In Your Pants with Dr. Susie G - TENS for Pelvic Pain Relief

Episode Date: November 17, 2020

The most up-to-date information on pain science from the researcher! Taking new research advancements and implementing them in the clinic. Researchers found that TENS increases the body's inhibitory pathways and reduces their excitability in the nervous system. After years of research and understanding how it works: researches tested it to find out if TENS can help reduce pain in movement. TENS is a safe way to activate your opioid system (using your own body's pain killers), and is what Dr. Kathleen Suka  recommends is in everyone's medicine cabinet. Everything in the nervous system is moldable, and once you have a concern going on, it doesn't mean it's set it stone! Pain can change

And it does help reorganize the nervous system and the immune system. That's the best part. The consistency will help you change that system, bring it back to where it was before the pain began. You're listening to In Your Pants with Dr. Suzy G, the physiotherapist for your private, helping you get in the know down below. Hey guys, it's Dr. Suzy G here and welcome to another In Your Pants podcast. I'm so glad that you're here. Thanks for listening. So on today's show, we're going to be talking

about the analgesic effects of physical activity and exercise on chronic pain. We're also going to be talking about the use of TENS, which means Transcutaneous Electrical Nerve Stimulation. And what that is, is a modality that sends electrical pulses through the skin that helps to jumpstart your body's own natural pain killers. So that's pretty amazing. And we're going to be talking to the researcher who actually has done extensive research to show that it is quite beneficial. So we're going to go into detail on how it works. And we're also going to be talking about neuroplasticity and how our bodies and our cells are constantly changing and that pain isn't permanent and there's ways to navigate out of it. So very

interesting conversation. Again, up-to-date information on pain science and pain biology from the researcher herself, which is Dr. Kathleen Sluka. Dr. Kathleen Sluka is a professor at the Department of Physical Therapy and Rehab Science at the University of Iowa. She's a neuroscientist and physical therapist who does extensive research on chronic pain, exercise, and pain analgesia. Her research focuses on mechanisms of musculoskeletal pain and non-pharmacological treatment options. She's actively involved in developing physical therapy pain education. And when she's not doing all that, she's an avid artist translating neurobiology into art. As you can tell, I have one of her pieces actually hanging up in my office. And that is her artistic

depiction of nerves. It's so beautiful. So without further ado, let me introduce our guest, Dr. Kathleen Sluka. I hope you enjoy the show. Hi, Kathleen. Thank you so much for being on the show today. Well, thank you for having me, Susie. I'm really excited to be here. Yes. And let's tell everyone how you got into this work of chronic pain research in general. So it goes back a long ways. Back after I got my physical therapy degree, I spent a lot of time in the clinic treating patients with chronic pain. And we knew that we didn't have very good choices back in those days. We didn't know what we were doing with them. That was back in the 80s. So I'm dating myself a little bit. And we really didn't have good

answers. So I went back to get a PhD and learn how to do better research and to get to learn how to research at all, really. And I got a PhD in anatomy and neurosciences. And then I've used that to apply over the years to our research. Oh, that's amazing. And you're also an artist. I would just like to point out that we both have your artwork hanging up on our walls right now. that's right it's what i do in my spare time when i'm not doing research or university do you sleep kathleen i sleep eight or nine hours a night can't live without my sleep that's right and this research says so too especially for pain especially for pain oh my gosh well let's dive right in into it let's talk about your research on exercise hyperalgesia with or our analgesic

effect. I don't want to say hyperalgesia, although some people do experience pain with exercise and others experience a decrease in pain and exercise. Can you elaborate a little bit on your research and your findings? Right. You bring up a really important point. There's a number of people that when they exercise, they talk about an increase in pain. And that is a real barrier because regular exercise actually decreases pain if you do it for a long period of time. And so patients have a really hard time or people with chronic pain have a really hard time maintaining an exercise program if every time you go out and walk, it's an eight out of 10 and I can't possibly do this. And so we've been looking at a basic science level at the underlying mechanisms for why somebody might

have pain with exercise? And then also, what are the mechanisms by which regular exercise reduces pain? And it turns out that we think these mechanisms are kind of opposite of each other. They seem to be using similar pathways, but they're doing the opposite thing. So if you're really not, you're kind of a sedentary person, you kind of don't do a lot of activity, you're more likely to have pain with activity and activate kind of pathways within your nervous system that make you more excitable. And if you can do that regularly over a couple of weeks, that will go down and it will turn to an analgesic effect. And we've looked at the mechanisms in the central nervous system and the immune system that really promote that regular

exercises will actually reduce pain and your system changes with doing it, which is so great. We can take away some of the things that are happening in your pain condition and switch it to an analgesic mechanism and reduce your pain just by doing exercise regularly. Oh my gosh. I love that because that brings hope to the table for people, right? Like I can do something for myself. If there's a willingness to, I don't want to say endure, but explore with activity and have a different relationship with one's pain. Whereas like, if I keep doing this, I will start to feel better. Now, my question is, and I'm sure everyone else's is, well, how much, how much do I have to do? What's the difference between pushing through it and listening?

you know there's this fine yeah that's a really hard question but after digging through the literature for a lot of time and i've read almost every paper on exercise and pain in people i've looked through that turns out that what you think of as exercises for health benefits the centers for disease control and people are always talking about you have to get your 150 minutes of moderate to vigorous activity per week in order to have health benefits, I don't think those are the same as what you need to have pain-relieving benefits. It turns out that most of the clinical studies, or a great majority of them, people don't do it every day, right?

So you go in and you dig out those studies. They're having people come in two to three times a week to do their exercise program. And they're having effects. So we do think there's a minimal amount. It's not real clear what that minimum amount is, but as little as 30 minutes of walking can reduce pay, right? And you don't have to do it every other day. So I like to tell people that if they could commit to something like an every other day program or give me three days a week, you can do that. Just pick three days and we'll just make a deal and do those three days at 30 minutes of

walking, you will be much better than doing nothing whatsoever. And then I do think there's a little bit about pacing yourself and you need to understand your body well enough to know how far you can push it. And so there are days and everybody has them in which you're not going to do your 30 minutes because it's too hard. And you know, when that happens and you'll be done for a couple of days, but there's most days are not like that. So you need to be aware of your body well enough to know when those days are, and maybe it's okay to take that day off, but don't do it three days in a row. Try and keep a regular schedule. Right. And do something in between. Right. And have a recovery plan or purposeful rest into the day. And I think you're just coming down to,

it has to be individual, you know, collaborate with your health professionals, know your body, um you know the term sore but safe you know how do we you know mitigate some of the fear and anxiety that surround pain and activity which is a lot um and kind of work with that person to know you know let's build up confidence because the more confidence you have and the more that you stick with and i think you're hitting on some key points here is consistency i tell my people all the time like you can't learn a language by having a class once a month like it's going to take you a very long time and it's not really going to stick. But what you're talking about is providing consistent sensory input, just input, exercise, some sort of integration that helps to reorganize

the nervous system. And you've seen that. You're absolutely right. And it does help reorganize the nervous system and the immune system. That's the best part. The consistency will help you change that system, bring it back to where it was before the pain began. and then that's that's really what it does it does the opposite of what the pain does to your body it does the opposite so we can reorganize the nervous system everything within your nervous system is moldable which i think is fantastic and i think people need to understand that once you have something doesn't mean it's set in stone you can change it back yay thank you so much for saying that yes nothing is permanent and there's plasticity bioplasticity neuroplasticity

and we are constantly changing, right? Kathleen, like we're always changing. Our cells are always changing on a moment to moment basis. That's correct. So that's evidence right there, but I can see how for someone it could be a bit abstract, right? To think about like, even like the picture on your wall or mine to be like, wow, these are actual processes in my body. Like I can see my hand move and I know what, you know, I can see cause and effect, but we can't really see that happening inside our body, which I think kind of, it makes people think that we're saying like, what were you saying? It's all in my head then? Yes. And what do you say? What do you say in response to that? I hate that statement actually. Well, technically it might be true that it is all

in your head. I think it's just a terrible statement to say. I think the connotation is that you're making it all up and it's not true. Your nervous system has this incredible capacity and it goes from, you know, out where your injury is all the way up to your brain. But there's all these little molecules and chemicals and pathways all across there that change and are released and mediate not only the pain, but they also modulate the analgesia you get with all of our treatments. And all of those treatments are meant to kind of put them back and shape, bring those synapses back, bring the chemicals back, put things back in order. But I really hate that term. It's all in your head. I don't know how you feel about it, Susie, but that's

the same way, the same way, the same way. And I think it's the only way that people can make sense of like what we're trying to explain perhaps. And maybe these are past experiences from other providers or other people who've actually told them directly, like, well, it's a cycle. It's all, you know, it's all in your head. You're making millions of psychological problem. Right. Right. Exactly. And you know, the psychology piece, the emotional learning that happens with pain, obviously there's a, there's a connection, but it, it's not just a mental health matter, although it does impact one's mental health, right? Like anxiety, catastrophizing, depression, social isolation, you know, all those things, the interpersonal and social cultural

context of someone experiencing pain at any moment in their life, right? That's right. And the other important thing to keep in mind, Susie, is that depression and anxiety are our neurochemical as well, right? And they're using some of the same chemicals that mediate pain and analgesia. And so it's all an overlapping system. And so some of the reasons we have an emotional component and a depression or an anxiety may be related to that we're using some of the same pathways and some of the same receptors and some of the same parts of the nervous system to do that. So it's not all that problematic if you think about it from the bigger picture. And so when people say, yeah,

I'm anxious, well, you're anxious maybe because you've got some of the same things being overexcited in your nervous system. Oh, that's beautiful. That's great because it you know people feel like oh my gosh i'm not crazy no i just had a patient the other day say this all makes sense to me i was starting to think that i'm going that i'm going crazy and that's just not fun like internally to be holding and carrying around with you and then engaging in the world thinking no one knows what's going on with me i can't even explain what's going on with me like it's like chicken little the sky is falling do you know that movie that book. Yeah, I know that book well. Yeah. The sky is falling. The sky is falling.

Well, and if you're like that sometimes, and I totally understand that because you don't know what's going on. You know, for me, I've been studying this for 20 or 30 years. So, you know, it seems simplistic in some respects, but when you start talking to people who don't have that background, how would you expect to understand all that? It's a pretty rough path. It's a pretty rough pathways and mechanisms. So I do understand there's a lot of fear of the unknown. So talking to somebody who knows what's really going on can really help, I think, get people over that hump of where you are and what you need to do next. I totally agree with you. And having these types of conversations with the people who are doing the research behind pain and saying like, look,

we're not making this up this there's actual changes that are happening and the best part is is they're not permanent and you can do something to help yourself out of this situation right so that's correct that's awesome well i'm so glad i just i'm like geeking out over here i have you here because this is phenomenal this is a message that i try to portray every day to just put hope back on the table for people um it's really well it's a great message to give out to people and, and you see people on a regular basis. So being able to do that is really important. Absolutely. Well, thank you, Kathleen. Can't do it without you. So you can take what we do back into the clinic. That's the, that's the hope.

That's right. That's right. That's right. Cool. Well, let's shift gears here. Cause there's another interesting bit that I want to chat with you about is the TENS unit. So you're, you just had a research article come out. It was the randomized control trial of TENS for movement evoked pain in women with fibromyalgia. And that came out in early or late 2019, November. Tell us about that study and what you found, because there's not a lot of good research out there. And yours is the first. That's actually awesome. Yes, I think so. So there hasn't been a lot of good research on TENS. And we did this study. It's kind of a culmination of many, many years of research. We started out trying to figure out how TENS produced its analgesic effect in animal models and looking

at all the little mechanisms, the neurotransmitters and the receptors. And we figured out that it was increasing our body's own endogenous inhibition, our own inhibitory pathways, decreasing our body's pain-producing pathways and reducing their excitability in the nervous system. and so after years of doing that we decided well we know how it works what would be the best condition to test this in we wanted a condition that has a loss of of inhibition and is a little hyper excitable in the nervous system and fibromyalgia has both of those and so we decided to test it in that condition alone so that we could see whether or not it would reduce their pain. But we particularly looked at movement pain. So we already talked about this. Movement

pain is a big problem. Pain with exercise, pain with activity, it's particularly problematic in this population. And a lot of treatments don't work for it. But we found in some preliminary studies that TENS did a really good job on reducing movement about pain. So we decided to test that as our primary outcome whether or not it would reduce movement of bone pain so we spent five years collecting this data it was a long haul um there was 300 women in three divided into three groups someone who got an active a placebo or a no treatment and it turns out that in the end after we got done we unrandomized it our statistician did all the data analysis that they do, we got a really nice effect, nearly a two-point decrease on

pain during activity with an active TENS. It was different from placebo or no TENS. So we're very happy with that because it was really the first time that we've shown this kind of positive effect. And we think part of the reason is because we really addressed all the concerns of the previous literature um in this one we've been looking at the literature for years like you said it's really not very good um small numbers of subjects not well thought out sometimes they'll measure the effects a week after the tens unit is off but it's releasing all these chemicals they don't last forever in the nervous system right they have a short window just like a drug, you wouldn't take a drug like an ibuprofen and expect it to have an effect a

week later. Good point. You'd expect to have an effect during that time. And we measured it during the window when they would have that effect. So that was one of the things. We picked the right condition. We gave it to the patients and gave them home usage and we turned it up. So the other big problem is intensity people don't use the right dosing it was not enough right right so it's really important when you use any treatment that you take the right dose of that treatment if you take if you take a half a pill of ibuprofen you don't expect it to work and that's kind of what a lot of the studies had done with tens and we discovered over the years before we started this that you had to turn it up to a strong but comfortable intensity for that

person for that person that person can decide what that is but it's basically as high as you can tolerate it and it should not be painful right right so putting all those factors together then we were able to show a positive response that is pretty amazing because that is encouraging for people who are afraid to move right to help with movement now the type of movement that they did Was it, correct me if I'm wrong, was it two hours a day of using the 10s and moving or? We just suggested that they could use it, that they should use it a minimum of two hours a day when they were active. Whatever they were doing, whether they were doing their chores, whether they're going to the store, whether they're doing an exercise program, we didn't

really care as long as they were active. So that was kind of an important thing. And I think that's the same thing when we talk about exercise is we don't really care what you do as long as you do something. Something that you like or that you prefer to do. Exactly. Because the research in chronic pain doesn't say that one particular exercise is better than another. It actually says they all work equally well. Exactly. Right. So the most important thing for people to think about is what will i commit to on a regular basis that i like to do i will never swim i hate swimming i hate getting wet i have to dry my hair i hate having to go to the pool you're never going to get me to swim other people love it right so you just have to pick what works for you but if

somebody said that that's what i had to do i'd be a non-exerciser yeah likewise like and so many of us like, and I'm guilty of that too, telling people, you know, what to do and you have to do this and this without even asking like, well, where do you want to start? What do you like to do? What did you like to do for exercise before? Like, what are you willing to compromise here? Like we need to do something. So it's best if you could just pick what you'd like to do. There's no rhyme or reason. And that I think people trips people up as well, because they're like, well, I just want you to tell me what to do. There's some people that want it, you know? I know. Well, and I think that's where we have to, we have to get the information back out. We need

to let people know that it doesn't matter what you do. We need to pick something. And the most important thing is that you do something and we want you to make that choice. Right. And, and you make that choice. You're more likely to do it than if somebody else makes that choice for you. That's right. That's right. Now with the tens, is there like a, was there a specific type of tens that you were using? I mean, we actually also use what we call a mixed frequency. sometimes referred to as the SMP mode, but it basically goes between a low frequency of 10 Hertz or a high frequency of a hundred Hertz.

And we thought this was really important because when you give these two together, you get better analgesia for longer periods of time. It extends it. Oh, and is there, do we know why? Yes, we do. Of course, because we fixed, we, we figured that out at one point. If you give the same exact frequency every day for the same period of time, you'll get what we call tolerance to the effect. And that's because TENS actually releases our endogenous opioids. So our body has our own opioid system. You don't get addicted to

them, so they're great, but TENS is a way to activate that opioid system. But if you give that repetitively at the same dose for many days it stops working as well but if you give the mixed frequencies it stops that from happening because there's different mechanisms right and that's sort of like medications together yeah medications will have some of that effect too where you have right long-term opioids will will have that effect we're not promoting opioid use but this is a great way to actually use your body's own painkillers to reduce your pain enough to get you to move. So using it when you're active, using it when you're exercising, if that helps you get to work, it helps you go to the store. There's nothing wrong with it. You know, people, everybody has a

bottle of ibuprofen in their medicine cabinet, I think. I think I could go to almost every house and I'd see a bottle in it. But why don't we have a TENS unit in everybody's house where they could use that to manage their pain temporarily? Good question. Good question. That is, yes, because there's no side effects. Virtually no side effects.

There's a few people who don't like the feel of it, so they don't use them. But, you know, basically there's no side effects. It's quite safe and easy to use. User-friendly, for sure, for sure. So anyone could basically access this TENS and set this up. You can get them at Walmart. You can get them at the local pharmacy.

You can buy them online. They're readily available now. You know, Suzy, that 10 years ago, you had to have a prescription for it. Oh, yeah. But in the last five years, that has changed. And so it's widely available to people. So it's cheap. um we find units that are decent for under 30 dollars out there on the market that do what we

need them to do so that it's inexpensive it's cheap it's easy to access so it seems to me it should just be part of a self-management program some way that you can use to manage your pain right absolutely and does it matter where on the body they they use their tents so we think that the best effects occur at your site of pain okay if you can't put it there so perhaps you have pelvic pain then you can put it on your back that would be interesting right you know in in an area close to it but not in the same bit if you don't really know where to go and what to do your physical therapist can usually help you figure that out absolutely yeah it's troubleshooting sometimes again feeling comfortable and yeah safe and even like can i put it here can i reach that

spot right to put it on we also have made um a video for patients that's widely available um and we make it free it's on our on our university website that talks about the mechanisms of how TENS works and how to how to put it on and how to use it. Okay and I'll link that. There's also free information out there written documents as well and all you have to do if you know how to google is google UIHC and TENS and it'll pop right up. Oh that's great. And so if it also you know was developed by a whole bunch of physical therapists that work on our team and have treated patients for a long time, Dr. Vance, Dr. Daly, who worked with me for many, many years. And it's just meant to give the patients a resource. We used it in a study that we did to

try and improve the prescription and actually do a prescription for TENS by primary care providers. So when you go to your doctor for the first time, instead of them handing you an opioid pill we wanted them to hand you a TENS unit or an exercise program and so we were able to increase their usage of these kind of non-drug therapies by making them prescription driven and that was really cool and so we developed them for this but then we said well we should just make them free for everybody to use yeah and they should be widely available they were funded by some by company to, uh, funded the research. So, you know, as long as we have done the work, we feel like as much as we can get out there that people can use the better off we are.

Yeah, absolutely. Well, thank you so much for that. And I'm sure everyone's so grateful. I know I am, and I'll definitely be linking that in the podcast show notes for everyone as well, for ease of access. So thank you so much. Oh, that's wonderful. Well, what a great conversation. Are there any last parting words of wisdom that you'd like to tell us all? Like if you could tell everyone something, I know this is hard, but. Oh boy, that's a, that is a really hard question. For someone who's really struggling in pain, I guess. I think if somebody is really struggling and you hear all of these things and

all of these potential solutions and understand that you're not, you're not out there alone. There are people who will help you and you will for sure have days that are bad and days that are good. But understand that you just take it one step at a time, a little bit at a time. The main goal is for you to remain active and use what you have to. Don't feel bad about it to reduce your pain. I mean, everybody has pain occasionally. And I think it's really important to understand if you do have it long-term and you're going to have an occasional bad day, don't think that you failed somewhere. Know that that is going to happen and just take it easy for

that day and come back and look at it from a big picture. How am I compared to a year ago? How am I compared to five years ago? Not how am I compared to yesterday or a week ago? Try and keep the big picture in mind it'll help you get through that oh that's beautifully said thank you so much kathleen to all everyone there listening i hope that was helpful kathleen how can our listeners connect with you um i know you have again your artwork and cells of life but any other well i have an email address at the university um which actually if you just google my name it comes right up, but it's Kathleen-Sluca at uiowa.edu. I'm also on Twitter. And so I'll post the latest science and sometimes some artwork on Twitter as well. And it's always science-related

artwork as well. So it's kind of fun. I'll post a little bit about that. So feel free to follow me on Twitter because I try and put out the latest stuff, particularly related to a lot of the non-drug treatment options that are out there for patients, which I think is really important. There's so much more emphasis today nationally on the use of non-drug therapies because of the opioid crisis that we need to be out there getting those to patients, getting those to people with pain, getting them to providers so that they all know that those options are available. oh well you're part of the revolution kathleen and i'm so grateful that we had this conversation and we're stronger in numbers as i like to say right absolutely so thank you again so much for

being on the show and taking the time to share your wisdom and to all our listeners out there this is dr suzy g in loving wellness for your pelvis i'll talk to you later thanks for listening to today's episode be sure to head on over to drsuzyg.com where you can get more information show notes and related articles on today's topic also if you like what you're hearing head on over to itunes subscribe to the podcast and leave us a rating and review we'd love to hear feedback thanks again