Saul Rosenthal, PhD


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Guest: Dr. Kelly Wawrzyniak
Links of Interest: Tufts Craniofacial Pain Center
Link to Show: Episode 9

Saul: Welcome to episode nine of Life in the Time of Corona, a podcast exploring the many ways to stay healthy and sane in these strange times. I’m Dr. Saul Rosenthal, a developmental and clinical health psychologist.

After many weeks the day-to-day impact of the pandemic remains. Travel is limited, businesses remain closed or restricted, workers may be laid off or at home. Among those who are particularly affected are people with chronic pain and illness. Without access to ongoing treatment, conditions and lives worsen. In episode three of this podcast we talk with Dr. Katie Fleishman about chronic pain and illness in children. Today we focus on adults. According to the CDC, more than 20% of adults in the United States experience chronic pain. It costs hundreds of billions of dollars in medical care, disability and lost productivity.

Today we are joined by Dr. Kelly Wawrzyniak, a health psychologist who specializes in treating chronic pain. Currently she splits her time between private practice and the Craniofacial Pain Center at Tufts School of Dental Medicine, where she works with patients with temporomandibular joint disorders, chronic facial pain, headaches, and sleep apnea. Kelly, thanks so much for joining us today.

Kelly: Thank you for having me. This has certainly been a challenging time for so many patients and just people in my life that I talk to. I’m glad you’re doing podcast.

Saul: Well, thanks. So given that, what are some of the biggest changes that you’re going through both in your work and in your life?

Kelly: Yeah, I think one that’s notable for me is that I had time to transition with work actually leaving Boston Pain Care Center where I had been almost seven years to transition over to Tufts and to grow my private practice and you know, I think for many of us, saying goodbye and being welcomed to a new place in a time of transition is important to celebrate and processing and to have to do that alone without those has been a little challenging. But I must say that I’m more an introvert at hearts and tend to be more on the quiet side and have things slow down in life and to be able to hunker at home has had moments of pleasure for me as well.

Saul: Some people are saying that this is sort of the perfect situation for introverts. And how about your clients what you hearing from them about the biggest challenges that they’re facing?

Kelly: It’s been interesting. At the start, some people, I think, were more stressed with all of the rapid changing information and uncertainty and now that they have their game plan in place and some information on how to operate daily, their distress has gone down, the anxiety has settled a little bit for them. Whereas other folks, it’s in the opposite, where to be able to react to information early on and make their plan gave them something to do and they could kind of work more in that realm and now that it’s just on repeat, all of these weeks, seeing more depression and anxiety in them, so it’s been surprising, it’s not a one-size-fits-all reaction.

Saul: Yeah, I’m definitely finding the same thing. The first week or so people had the news on all the time and then the first thing people started to do coming into weeks two and three, was shut the news off, and that seemed to at least help that anxiety a little bit.

Kelly: Uh-huh.

Saul: Now you do a lot of work with chronic pain and I wonder if you could talk a little bit about how chronic pain differs from acute or everyday pain?

Kelly: When we have an ache or a pain or an injury, you know, pain is a really helpful adaptive process that we are all for the most part able to respond to. You know, there are few people in the world that don’t have that pain response and they struggle in different ways going about daily life, but we’ve all pretty much learned how to feel our aches and pains and respond to know when something’s new, what to do in that case, to stop, rest, seek treatment and hopefully recover.

But with chronic pain it’s quite a challenge because the signal that is supposed to be helpful to protect ourselves and kind of recover from injury, continues to signal beyond the point where it’s helpful in terms of alerting us to tissue damage or injury and so a lot of the work is how to cope with this constant signaling of this distress signal and not… to continue to have a full life even with that. So a lot of it is overriding this kind a natural signaling that we have and trying to kind of continue to engage in daily life or work or relationships, all the while feeling this very strong alert signal.

Saul: So the pain is a signal that’s actually telling us something useful about damage to the body or potential damage. Whereas with chronic pain it’s a bad signal… the signal continues to come through but it’s not really telling us anything, and so trying to live our lives with that signal going on, that’s the challenge for folks who have chronic pain. That’s certainly part of what makes it difficult to treat. Are there other issues around chronic pain that make it particularly resistant to the treatments we have?

Kelly: Yeah, so among people with chronic pain conditions, those folks have higher rates of depression, anxiety, past trauma, and PTSD, as well as sleep disorders. Those are kind of the big categories. And so over time those areas are all playing off each other so it ends up being this really complicated web of symptoms fueling other symptoms and other disorders and struggles so really when you’re working with someone who’s had chronic pain for a number of years, you really need to be checking all areas and trying to work on all at the same time in order to make progress across all of those areas.

Saul: And given that there is certainly a lot more anxiety and depressed mood and sleep problems with the pandemic, it must be even particularly difficult for folks with chronic pain to find relief. What are some of the unique challenges for these patients given the restrictions and limitations and the uncertainty of the times we’re living in?

Kelly: Yeah, I think from a medical perspective, some folks have found that a mix of behavioral self-management strategies and medical strategies could really come together in a good plan for them to keep the pain managed and more importantly, help them function at the best level possible. So for folks who maybe relied on injections or acupuncture or maybe a group exercise class, to have that suddenly on pause for an unknown period of time, maybe for a long time in some of those treatments, it just takes some of those pins out of your carefully crafted treatment plan that you’ve been working on for so many years and it’s hard to really make up for what those sorts of treatments can do, you know, the physical movement and exercise, the social gathering and social support and interaction, or you know, some non-medication techniques where you can’t go to an office, you can’t get together in your group exercise class, it’s not safe to do that. So I think a lot of the strategies that folks have crafted over time to be their treatment plan, very quickly, you know, maybe 50% or more of the strategies were taken away.

Saul: So the ways that folks with chronic pain have been able to manage a lot of those strategies as you put it, don’t exist and at the same time all of these symptoms are playing off each other so it’s almost a perfect storm to make this condition worse.

Kelly: Yes exactly. I think this sort is recalibrating of how you’re trying to manage the negative pile or the symptom pile with your coping strategies… this is something that I’ve worked with a lot of folks when they first would come to the pain center, about how life before the chronic pain, you know, they had ways to manage the stress, maybe go for a run or just grab their things and et coffee with a friend to help cope with stress.
But when you have chronic pain, you’re not able to do all of those things, so you already have gone through one round at least of trying to rework how do I cope with everyday stress, or keep myself healthy now with chronic pain in the equation. So you’ve come to this new recalibration already and now here we are in a situation where another big recalibration needs to happen and I think at the same time, less access to the providers and helpers who might help you craft that.

Saul: So with less access to providers and to strategies, that’s got to make dealing with chronic pain even worse, because I know the folks that I work with who have chronic pain, they really need to plan their days and it may be that the days kind of revolve around things like their daily physical exercise, daily meditative or relaxation work, cognitive work, the health care provider appointments that they all have to go through. So given all of these factors are sort of thrown out the window or certainly mixed up, how can somebody with chronic pain really continue to manage themselves these days?

Kelly: Yeah, I find with the folks that I’m working with who are kind of in this quick scrambled to gather up any other strategies… things that they may have found even slightly useful in the past… to bring that to the forefront again and like you’re suggesting to really be planful and have some routine and structure. That goes a long way. Pain likes to hijack that. It likes to say, hit the stop button… stop, rest, recover… There’s tissue damage… Like we said with chronic pain you’re kind of overriding that so to have some plan, some schedule including to the extent that we can be creative, those social interactions are pleasurable activities, even though it doesn’t feel like it’s in a treatment category, those things do help in even some small ways and are important right now to kind of gather up, and come up with any sort of daily plan that one can but it’s certainly difficult. The first tier strategies that people want to use are not always accessible.

Saul: So it becomes even more important to be deliberate, to find the routine and structure… you may have to rebuild a routine and structure… but it sounds like it’s even more important now to try to apply that, because given all of the factors that seem to be making chronic pain potentially even more powerful these days is folks need to sort of balance that off with an even more powerful approach to overriding what feels like that demand to rest and recover, because in chronic pain that that makes it worse.

Kelly: Yes, exactly.

Saul: Do you have any thoughts, or have you worked with folks around how to get that routine together or how to be a little bit more mindful about their schedule?

Kelly: Yeah, it’s really been a brainstorming process with a lot of people. Some are stepping into older roles that actually virtually they’re able to step into again. For example, one person I work with used to love being, kind of, the hostess and gathering friends and having them come over and that’s really been on the back burner she hasn’t had the energy to do that… the physical energy to plan and host and do all of that in a long time. But with the Zoom technology, she actually recently hosted a Zoom party and kind of, had the energy level to plan an activity for a group of friends to do virtually, a trivia game.

So she was actually surprised at how much benefit, compared to the energy it took, it kind of presented itself as an opportunity to be that hostess again and a part of herself that’s been on the quiet side for a long time because of pain… to bring that back to the forefront. And, you know, the cyclical effect that that had on her mood and kind of connection to herself and quieting self-critical thoughts that we can have so it helped the cognitive work. It was a big win but it surprised both of us at how much that helped.

Saul: So that’s really interesting, that Zoom has allowed your patient to have social experiences which she was not really doing as much face-to-face. It was a sort of I guess “good enough” social experience that she was able to get a lot out of it.

Kelly: Yes exactly, and I think pain you know, was not part of the topic, that can be a theme for a lot of folks with chronic pain is, they are not sure what they have to say in a conversation… they don’t want to just be talking about their pain or have people asking them about that, so for her to be able to take an active role and plan something structured. People wanted to know how everyone was doing, but there is less risk that it would turn to, “Oh how’s your pain? Are you getting better yet? Let me problem-solve with you. This back surgery helped for my friend,” you know, a lot of those sorts of things that come up in conversation, typically, pain patients find are not so helpful.

Saul: Right, and there is a way in which the chronic pain and everyone’s advice does become a big part of the lives of people with chronic pain. Are there any particular chronic pain conditions that seem to be… I don’t know… particularly at risk for getting worse during this time?

Kelly: Yeah, I think some of those with… like we were talking… that need that physical movement, so your classic back pain where moving is better even though it hurts, but the more that we’re sitting or laying down, even though it might feel better in the short term, in the long run that’s going to be a big setback for folks.

And then any of these where really a medical intervention was really helpful you know, chronic migraine, some folks rely on Botox every three months or other injection therapies, medications, on a monthly basis and to be cut off from access… it’s going to be a while before people return to the gains that they had made to stop some of these treatments… to return to them after one injection or getting back to your exercise routine one time you’re not gonna be back at the level you left off.

Saul: Yeah, I’m definitely finding that my clients who have migraines and headaches are reporting an increase and I think that’s partly because as you’re saying, they just don’t have access to some of the medical interventions, but also everyone’s much more stressed out and that’s triggering a lot more of these episodes.

And with the lower back pain and other skeletal muscular… that just do so much better with exercise… that’s also been really hard for people feeling very stuck in their homes. Although that’s slowly beginning to change and I’ve been pushing a little harder with my clients to at least get out there and do some walking. They say “motion is lotion” with the joints. Hopefully as the weather improves which it’s now doing around here anyway… and as restrictions get lifted they’ll be able to return… folks will be able to return to some… maybe some kind of exercise.

So I really like that idea of using Zoom as a way to actually increase social interactions which may even be more than people were doing before we were all stuck at home. Any other interesting strategies that that you or your clients have come up with?

Kelly: No, I think it’s been an opportunity to talk more about the interconnectedness between mind and body and sleep… so without as much focus on the medical interventions it’s allowed maybe some deeper psychotherapy to occur with some folks in terms of exploring kind of, past trauma, anxieties, you know, those other experiences from, you know other times in their lives where we can kind of clean up sleep or work on anxiety in a more targeted way.

But like I said before it’s been this collaborative brainstorming process where we can both get creative together. Often it’s going back to older things that might’ve worked before and just bringing those back up to the forefront. There’s another client I work with, you know, she’s very focused on her business and that’s… as you can imagine… a small business owner with a lot of extra stress right now and worry… so we’re just talking through, okay what could you do at the office in terms of taking those breaks… she would take an hour for meditation each day, she was walking to and from the office, all of those things were very helpful. So we’re just trying to craft that into this new set up including just getting a change of scene and environment so when we have our meetings she actually leaves home and drives somewhere peaceful and nice to take a look at the scenery around her and have some time for that meditative moment.

Saul: Well, they say that crisis is also a moment of potential opportunity and it sounds like at least some of your clients are doing that, whether planfully or not. Whether folks can use new technologies to improve or increase social interactions, and maybe take the time to go deeper into some of the issues that may not seem directly related to chronic pain but certainly will affect trauma and anxiety and depression. But as you said, in general it may be a time or an opportunity for all of us to be more creative whether we’re more creative with our patients trying to figure out how to help them, given all these restrictions, but also for our patients and our clients themselves to be creative about, “How do I go beyond just managing this chronic pain to something that extends my life or is a more positive experience?”

Kelly: And I think actually that folks can approach this as an opportunity in that way. Many people are struggling. Symptoms are worse and like we talked about, this cutting off of strategies that were helpful, but the literature and the research on Western medicine interventions for pain… it’s not that overwhelmingly great data comparing it to if you have an infection… a bacterial infection… then an antibiotic is the prescribed treatment and most people would do that course. With pain, we don’t have that level of evidence for so many of our medical treatments and yet it’s the avenue we pursue to feel better. So I think to see this as an opportunity to maybe give it a longer trial for some of the behavioral, psychological, routine strategies… to see if they can really work a little bit better than someone might’ve tried… you know, that meditation a couple of times didn’t feel that great, but to give these things a longer trial, they might actually see some good benefit… more than they had experienced trying it in the past.

Saul: I always like to end on positive notes or at least things that we all could be doing, so taking these as opportunities to try new approaches or to retry approaches that may not have worked as well but may improve with practice.

As we wrap up, there are some “One thing…” questions that I like to ask. And so just starting, what is one thing that people should take away from our discussion.

Kelly: I think that this is a challenging time and people… so many people are feeling that with chronic pain the upheaval of what folks have been working towards for a long time to try to get at their best possible management of chronic pain and so just this compassion, including self-compassion, that it’s okay to feel that you’re struggling right now and if your pain is worse, it can get better, you’ve experienced that before and there will be a path forward, and to just be kind to yourself and to others around us who are struggling with chronic pain. That this is just a really difficult point in time and point with pain, but things are likely to improve.

Saul: And what is one thing that you’re doing to take care of yourself?

Kelly: So gardening and smelling the dirt and feeling the sun on my skin or even if it’s a little rainy out there… I decided to buy some small seedlings… I don’t try to grow them from seeds myself, but some seedlings of some lettuce and tomatoes and peppers so I’ve been tending to my garden each day and as we’re talking… it’s that routine, that connection that I’m still a human being in the world around me and can touch the dirt and feel the sun on my skin.

Saul: So, again, taking the opportunity to maybe try something new, but using that to build routine.

Kelly: Uh-huh.

Saul: And finally what is one thing that you think the coronavirus experience has changed forever?

Kelly: That’s a tough one… In a pause, maybe because I’m just reflecting now, maybe I haven’t wanted to think that far ahead quite yet. I hope that this has allowed folks to take advantage of an opportunity to reconnect to more of our human qualities and the interconnectedness to each other, and to get out of the kind of rushing routine and in part because coronavirus will force us to have to perhaps, wear masks or stay distant, or change how we operate in the world. But I hope that that leads to some slowing down or taking advantage of some slower pace, and I hope that that actually leads us to feeling better in the end in many ways.

Saul: So hopefully we will find ways to come out of this crisis building on the potential opportunities perhaps to become a little bit more kind and careful and a little bit more aware of each other and ourselves.

Kelly: Yeah.

Saul: This is Life in the Time of Corona. You can subscribe to the show at iTunes or wherever you get podcasts. Please rate the show and leave comments. Find out more at my website, and follow me on twitter and Instagram at DrSaulRosenthal.
Dr. Kelly Wawrzyniak is a health psychologist specializing in helping her clients manage chronic pain. She has a private practice and is part of the Craniofacial Pain Team at Tufts School of Dental Medicine. You can find out more at Kelly, thanks so much for joining us.

Kelly: Thank you Saul, this was a great experience and great that you’re offering the podcast to so many folks.

Saul: And thank you listeners. I look forward to continuing the conversation on Life in the Time of Corona.

June 9th, 2020

Posted In: Chronic Pain, Coronavirus, COVID

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