Q&A with Amber RIchard (DPT)
Hear this former chronic pain patient's take on online physical therapy and pain management education for patients
Amber Richard (DPT) is a doctor of physical therapy who started caring for others as a little girl when she massaged her grandmother’s feet and made up “treatments” for her arthritis. Growing up as a dancer, Amber experienced her own fair share of injuries, including a 5-year journey with chronic neck pain! She is passionate about helping each patient return to the activities he or she loves and empowering them to be in charge of their recovery through education, guidance, and coaching. She feels strongly about working with clients in a holistic manner, looking at all factors that may impact health such as sleep hygiene, stress management, nutrition and hydration, posture and ergonomics, exercise, and social engagement:
Q: Hi Amber! Thanks for taking the time to chat with us. How did you get into the pain space?
A: Yeah, absolutely. So I started as an orthopedic manual therapist at a sports medicine clinic and did that for several years and I developed this right-sided neck pain that just became persistent. Even though I was a physical therapist, I really struggled to learn to manage it and recover from it. It's really a patient of mine, actually, who turned me on to the work of Greg Lehman because she was dealing with a persistent pain problem. And once I read his recovery strategies workbook, as I was reading it, I was thinking of all my patients that had chronic pain. And I was like, "Oh, I totally see this, and that, and the other."
Of course, never did it cross my mind that this stuff applies to me too! And then the next time that I had a flare-up of my neck pain, I observed myself catastrophizing and doing all of the things that a brain that's in pain does. And it clicked, I was like, "Oh, I have chronic pain. That's what this is! This isn't a mechanical issue in my neck. This is a neurological problem in my nervous system.” And that's really what catapulted my recovery and definitely put the fire under my butt to get this information out to all the people who are suffering out there, because I was shocked that I never learned this information in PT school.
And the reality is that the entire medical system and medical education system are still way behind. So we're really not giving people with chronic pain the right information. So it's definitely one of the things that made me very motivated to go out there and help other folks who are dealing with the same thing.
Q: It's great to have someone as motivated as you in the pain management space. And you alluded to some challenges that you've come across. Are there specific challenges to helping people in pain that stand out to you as you have spent more time in the field? And if there are, why are you optimistic about conquering those challenges?
A: Yeah, I think there are several challenges. The first is that, as I said, the current medical system is set up to deal with acute pain and acute illness, but not chronic pain and illness. So the systems themselves are not really there to support people who are dealing with those types of issues and people are really left to scramble for themselves and find the support that they need.
Secondly, we still have a very biomedically based model. So your doctors, the people that you'll usually initially interact with when you're having pain, don't have the most current information to really be able to send you down the right path. They're going to go down the orthopedic route, or they're going to send you for imaging, and they're going to take a very biomedically minded approach. And unfortunately, that's not the right approach when it comes to chronic pain.
I think the other thing that happens is that you're sent to a bunch of different providers, which is, again, how things are set up. You see your primary care doctor and then they send you to someone and maybe they send you to another person. When you see multiple care providers that all give you different answers, it starts to get very confusing and overwhelming as a patient. And because you don't know how to be able to interpret what exactly is happening, you start to think that no one really knows what they're doing, and no one really knows what's wrong with you. You must have some kind of crazy, rare, terrible thing going on that so many doctors can't figure out what's going on. So that is another hurdle that there's a lot of confusion that's added because of the misinformation that's part of our medical system at this time.
And then because it's biomedically minded there isn't the understanding that people's psychology and their social network is very much a part of having chronic pain. So they're often not referred to those services until it's at the end of the line. So once we've exhausted all of the options that are biomedical for managing pain, then at the end of the road, we finally go, "Well, maybe there's something going on in your brain that could be causing this," and we send you to a psychologist or something like that. And that's really, really dismissive when you're a patient and you've been dealing with pain for a long time and then you do all of the things that your doctors tell you to do and then at the end of it, they tell you maybe you should see a psychologist, it's probably all in your head.
So I think there's a lot of harm that's done to people because of the way things are currently managed and the care pathways that currently exist. The thing that makes me feel more optimistic about where we're going is that there is more and more good, high-quality scientific evidence to really show that chronic pain is a neurological disorder and that it can be treated by really focusing our attention on the central nervous system, rather than the peripheral tissues.
So the science is there and it's starting to make its way out into common knowledge. Just the other day, I had a patient of mine who brought up an article in the New York Times about pain reprocessing therapy and that really opened up the door for her to be open to me giving her a lot of information about that. So I think it's slowly happening. Of course, I wish it was a lot faster.
And another hurdle that I find is that because of the current medical system, the care providers that are very biomedically minded, like the primary care physicians and the orthopedists, they're seeing so many patients every day and they're so busy all the time that I think it's hard for them to be open to communicating with other healthcare providers and learning from those other healthcare providers. I understand, I have a lot of empathy for them. I think they're on that hamster wheel and just trying to keep up and they think they're doing the right thing, but they're really missing a lot of information that I think the allied healthcare field is actually much more current on. And certainly physical therapy I think is leading the charge, but even psychology is very aware of those connections between the mind and body. So I think there's a lot that we need to fight against and to work towards. But I do think that the right information is the starting point, we have to have the awareness and the knowledge first before we can actually change what we're doing with that. It's slowly, slowly making its way out there and becoming common knowledge.
There's one more challenge that I think is worth mentioning, which is that patients actually are part of the problem sometimes in the sense that we have been conditioned to think that for whatever health condition we come up with or have, we should be able to go to somebody and they should be able to give us a quick fix, a pill or something that will just take it away for us. That is something that we've been told since we were children growing up, and that's kind of how the medical system is set up. And fortunately for a lot of acute issues that works well, but that's not what works in the case of chronic illness and chronic pain.
So sometimes people are less likely to try the route that's going to take more work, more time, more of delayed gratification, versus wanting that immediate quick fix. Sometimes people really delay engaging with the treatment that would actually help the fmost because they're still looking for that quick fix or that person that's just going to "fix them". So I think there's a measure of autonomy and empowerment and accountability for yourself of taking care of your body that really has to happen before people can really get on board with doing what it takes to get out of chronic pain.
Q: You mentioned the need for providers to stay educated about the latest advances in treatments and science. And you also brought up how patients can be involved in their own treatments. One unique service you offer, which hits on both of these points, is patient education. This is quite different from the usual exercises that PTs prescribe patients. What does that have to do with helping people recover?
A: I'd like to think that every PT uses patient education, I don't think that's unusual actually; I hope not. But I think that in the case of chronic pain, the base level is, first, you need to understand the science because a big piece of the issue is that we have to actually unlearn a lot of what we have learned about pain. Chronic pain is a false alarm. But we only associate pain with real, true danger, or as a sign that something's wrong. So we assume that that's always what pain means. And if you don't have that basic knowledge of how the neuroscience of pain works and why chronic pain is different than acute pain, it's going to be very hard to get on board with working with your pain differently. Right? If you think that pain means there's damage happening, you're not going to be willing to work with that pain because you're going to think, "I'm damaging myself, I should not do this."
So just getting that basic understanding of the neuroscience of pain, the fact that chronic pain is not an accurate signal, it enables us to have the willingness to work with that sensation and learn to reprocess it. So I think that no matter what the condition is, knowing that condition is step number one, understanding what's going on, how does it work and how do we get out of here? And in the case of chronic pain, because we have to actually unlearn a lot of what's already been told to us, that educational piece is even more important because it really sets you up for success to be able to follow through and understand how to work with your symptoms so that you can find your way out.
Q: Another service your PT practice offers is not just treating people in person, like many of us are used to, but also doing online PT. How does that work? And how well does it work?
A; Online PT is something that probably sounds odd. And to be honest, I was very resistant to it. I'm not a tech person, that's part of why I'm a physical therapist! So I was very resistant to telehealth and I probably would never have done it if COVID hadn't happened. But it did happen and I did have to adjust and I have been really surprised at how effective it is and so have my clients. They have actually told me how much they like telehealth and how well it works for them. And I think that the strength of telehealth is that it really makes it very obvious from the start that I can give you the tools, but I can't do it for you. You are going to have to do it for yourself. You are going to need to learn how to work with your body, how to work with your mind, how to integrate these things into your day-to-day life.
I cannot fix you from across the screen. I can give you the information that you need, and then you have to put it into practice to get the results that you're looking for. So telehealth is really powerful for chronic pain and chronic illness. For acute injuries you usually do need to be seen in person to assess what's going on, to rule certain things out, and make sure that there's not other steps that need to be taken. But when you've had something for longer than three to six months, you're going to need a more long-term approach and a bigger picture approach that's going to really look at all of those pieces that are contributing to your pain. And telehealth is a really great way to do that because I can show you the things that you can do on your own every single day to help you take little steps forward every single day, because that's really what leads to progress.
So what I find is that if I see someone in person, they're much more likely to be very present with me in the session, do everything that I ask them to, but then once the session's over, that's it, they're back to their regular life. When it's on telehealth, I'm talking to them about what they need to be doing every single day and they understand no one's going to do this for me, I'm just going to have to do it for myself. And that's a really empowering place to come from.
So I think specifically for chronic pain, telehealth is extremely effective. And like I said, all of my clients have really offered me a lot of positive feedback on how that works for them. It's also just more convenient to not have to drive to the clinic to be seen by the 15th manual therapist you've seen who still can't fix your problem. Right? So I think it's just recognizing telehealth enables us to focus on what we really need to focus on to get better with a lot less inconvenience.
Q: When you are not working on helping people tone down their pain, what do you do for fun?
A: Primarily I dance. I've been a dancer my whole life. Dance is my medicine for sure. So dancing is my number one hobby, the thing that I most enjoy. I also love to go out hiking. Just being outdoors I find is really restorative and I'm sure a whole plethora of other things, but music, dancing and being outside are my top three, for sure.
Q: Awesome. And last question, where can people find more about you and your work?
So the best thing to do is probably to go to my website. There's a free resource there for a 50-minute lecture called the neuroscience of pain that I think anybody dealing with chronic pain should listen to. It goes over the basic science, but it also gives you some coping strategies and techniques. It's good reinforcement even if you're already sort of familiar with all of that. I think one of the key pieces of dealing with chronic pain is that the brain learns through repetition. So even just listening to the information again, it will let it sink in a little deeper. So I recommend to anybody dealing with ongoing pain, listen to that lecture, listen to it multiple times, revisit it at times. And then the third thing is that I offer a workshop called Empowered Relief. It's a Stanford-based program and it's a single-session, skills-based pain class that gives you an excellent framework to get started on the work of dismantling chronic pain in your nervous system.