Dr. Whittaker and Nick, CRNA discuss tips on better surgical recovery. Nurse anesthetists and physical therapists have unique training on pain, so they include practical tips to take charge of your health before and after injury or surgery. Transcript is below.

Hello and welcome to the Ascend Health Show. I’m your host, Nick Angelis. I’m a nurse anesthetist and the owner of Ascend Health Center and I’m here with Dr. Whitaker from Custom Care Rehab. How are you today? Hi, I’m good. How are you? I’m great. I almost started the show with “Ouch. Are you in pain? We’ve got Dr. Whitaker here.” But I always hate those gimmicky type of podcasts. So, I figured I’d be a little bit more normal. That’s fair. Too late. I’m not normal. This is terrible. Um, so why don’t we talk about post-operative pain? Because that’s something that at Ascend, we have this strange I guess streak is the right word where now that we’ve been in business for six years, there’s probably been about 40 or 50 of my patients who’ve had surgeries and all of them have had excellent postoperative outcomes. Now again these are patients who are getting IV infusions, ketamine, Spravato–different medicines that really help with inflammation. So that’s why their postop course has been uneventful. But physical therapy is of course something that people often think of of I had to get my shoulder replaced or had a knee operation and then you know I had to fight for my insurance and they gave me three visits with a physical therapist. Yeah. So with postoperative pain we can often control that really well with if somebody does what we call prehab. So, we have physical therapy before you actually have the surgery. Um, and so it just helps the muscles be strong. It helps the patient kind of understand what they’re getting into for after surgery, after the rehab. And so that you’re setting yourself up to have surgery at maybe a B rather than at the D that you feel. Um, so and it kind of gets them again in the same mindset of, okay, this is what I can kind of expect. It’s going to look very similar. And then and then so after they have the surgery, they’re in the right frame of mind of okay, I’ve done PT before. I know what it’s like and then they can kind of go back to the exercises maybe they have already done, but we’re starting from zero now. And so it helps with the outcomes very much. Wow. And it probably helps with injury prevention, too, because they know, okay, this is the range of motion that’s normal for me uh before I had this operation. Yes. And it’s really helpful so that we can teach someone how to use their stability muscles and their supporting muscles versus those big movers. Um so that we can support the joint itself versus um having to rehab that after surgery and kind of fix those habits then. Sure. So that way you avoid overcompensation where one muscle group is you being used all the time and then another one isn’t exactly which is fine until you need to make some sort of sudden movement. Like right now it’s winter in Ohio. This is the orthopedic surgeon’s busy time because everyone’s falling on the ice and breaking things. So, and a lot of times those falls are because the muscles aren’t stable. They’re not working together. One is overused, one is underused and you can’t catch your balance. Yeah. And so sometimes people are just surprised and everybody falls. Like you might not fall and then you hit that ice and then you and you slip. And so we do see a lot of people who um may be have concussions and so we treat them or if they’ve hurt their ankle or their shoulder from falling, we treat that as well. But then if it is a true balance issue, we can help them with their balance and and make that better, too. Yeah. I think this is my 64th show or so. And around show 30ish, I had your partner Amy on here and we talked about dizziness and balance uh and how useful that is because as a rehab place that can come to the patient. If you’re dizzy, you don’t want to travel to a physical therapy office to go work on your dizziness and your balance so that you don’t fall. So yeah, I’ve worked in I’ve worked in clinics where we have multiple people working at the same time. And often those vestibular patients have to have somebody drive them and they don’t want to leave their house or they’re worried about the ice. They’re worried about um what they can encounter or they don’t want to shower by themselves. They just always have to have somebody there. And so it’s helpful for us to just come in there and also kind of assess what their home looks like and help kind of fine-tune some things and of how to make things easier within their home, too. So you can actually do a home visit where you’re saying, “Okay, this could trip you in a week or let’s remove this rug or oh wow, that’s really useful.” Yeah. Yeah. Yeah. I’ve noticed that too when referring patients to you guys that it is something very helpful because a lot of times the mental health and the physical health are so intertwined and it may start with a vestibular problem, but then it becomes an agoraphobia or I just have to stay here where I’m safe. Absolutely. And the obsession of being safe can lead to a really unsafe place for their mind basically. Yeah, fear avoidance is a huge part of what we do. And so working with chronic pain, um I work with that a lot as well. And and just trying to teach someone how normal activity is okay to do, even if it was once painful. And trying to help them work through that. And sometimes it’s not even that they physically can’t do it. They just in their brain they’ve convinced themselves that they are unable to do it because they’re so fearful of what might happen. Right. So you’re saying the old idea of pain means stop. In some cases, it’s like, no, there’ll be more pain if this muscle atrophies because you’re not working through this pain. Yes. More pain, more stiffness. Um, I usually tell people um non-p painful range of motion versus like limiting their range of motion. Um, so go as far as you can, but if it feels just kind of stretchy, it’s a little bit uncomfortable, that’s okay. But if it’s a sharp pain, if it’s numbness, tingling, anything like that happens, we need to not go into that range of motion just yet. So, we don’t have to rehab more than what we need to. Oh, that makes sense. And that’s where my problem would be. So, uh, Monday for me was basketball. Yesterday was pickle ball. Today is volleyball. And unfortunately, the rule is that I’m not allowed to complain to my wife about how sorry I am since I’m in my mid-40s and playing all these sports like I’m still 20. Like, that was our agreement. Like, okay, you can play all these sports, that’s fine. You can pretend you’re 20, but except for the one time I got a concussion, but that’s a longer story. But I’m not allowed to complain about, oh, why does my ankle hurt? It’s because I played fullcourt basketball for three hours and I did no other exercises that week. That’s what it is. Yeah. The weekend warrior. I’m assuming you’re doing this through the week or are you doing it all on the weekend? Uh in this case it’s let’s see today’s Wednesday. So Monday, Tuesday, Wednesday. Okay. So yeah. Yeah. The weekend warrior. So when people just do exercise on the weekends only, we do get injuries from them too just because maybe they don’t warm up, maybe they don’t cool down and then they’re sore. But as healthcare providers, I think we’re often the worst patients. Sure. And you all watching thought this was so that we could learn some more about physical therapy. What a send us. No, this is for my own uh use in case I need the prehab and the postop and the intermediate-op. Well, we got you. Oh, good. So, I assume that insurance would not pay for any sort of prehab thing. Correct. Um, some of them do. So, Amy is mostly self-pay. Um, she does do some Medicare and then we can give a super bill so that we can have that paid for. Um, and you can just kind of see if your insurance will cover it. Um, sometimes if you have pain and then you are able to get that covered. Um, and then it might just be okay. We’re just trying to prevent surgery and so sometimes insurance likes that they have to pay a little bit less to do the PT versus having to pay for the surgery. Um, so sometimes you can get it covered. It really just depends on the insurance, but for my place of work, um, we mostly do self-pay and then Medicare, right? Mhm. And the advantage of that is uh what I felt cuz we did a show recently where we talked about the big beautiful bill. And the takeaway was honestly for a lot of our patients like maybe just look both ways before you cross the street and don’t get insurance cuz it’s not going to help you anyways which is a terrible cynical thing to say. In fact, I had a few patients say that was harsh. And then I had to think, oh part of the problem is that I’m here talking to another professional. So it’s not customer service patient speak. It’s like here’s how things work. Speak, right? Um I I enjoy the self-pay a lot. Um I have worked with insurance and I’ve worked in like a um a high volume clinic before and it’s really nice to know that if somebody has like for example low back pain, but over the weekend they fall, they sprain their ankle. If I were working with insurance, I couldn’t treat the ankle. I could maybe give them an ice pack, kind of tell them verbally what to do, but I couldn’t bill for it. I couldn’t treat it. I would have to have them either if we were in a place of direct access, we could then um I could then maybe open a new case and treat that, but then I wouldn’t be able to treat the back. And then if we then I could ask them to go get a referral, but then it might be two weeks and then I can treat the ankle. But with self-pay, I can just treat it and I don’t have to worry about it and I can tie it in with what we were already doing. So, it just helps me treat my patient with what they need and treat them like a person versus trying to play the insurance game of pleasing them but also doing what’s best with for my patient. Because to be honest, uh that scenario sound ridiculous. Yeah. No, it it breaks my heart every time they’re like, “Really? You can’t do anything?” I’m like, “I can. No, I can’t. I can give you some ice and I can tell you what to do, but I can’t treat it here. We can take it easy, not do standing exercises. We can modify, but I can’t actually treat the ankle.” And Bill for that, right? And at Ascend, most of what we do is insurance based, but the ketamine infusions, injections, that sort of approach is self-pay. And so that’s how we use it. So it kind of annoys my front desk. But there’s patients where I’ll just say, “Come in tomorrow at some point and then we’ll talk and we’ll figure out what we’re going to do and what you need and then we go from there.” So I don’t even know and they don’t even know what they’re coming for until we have a discussion, see, okay, what’s the most pressing concern, what needs to be treated today, and then we treat that. So yeah, cuz the other way is uh cuz it’s it’s really helpful now in Northeast Ohio uh once in a while either Cleveland Clinic or uh one of these hospital systems will provide ketamine infusions for patients so that we don’t have to, you know, take self-pay for that. But there’s a long way. It’s very specific. So the ability to get treatment exactly when you need it. And I I feel that most things you can put a price on and that’s how healthcare should work. Like when I go to a restaurant, okay, nope, this is too expensive. I don’t want these cheesesticks. Yeah. That I I just feel it empowers patients to realize, okay, this is what will happen if I pay this much and then we’re done with this transaction. There’s not four calls to an insurance company. Yes. And as a physical therapist, I think if you talk to anybody, we want you to be as independent as possible. So like my goal, I do a lot of patient education so that the patient feels empowered on how do I treat myself? How do I understand what’s going on? how do I do these exercises so that eventually when you feel ready when I think I’ve you don’t need me anymore you can do your home program by yourself and we’ll kind wean you off the therapy and then if you need like a once a month tuneup or every couple month tuneup of like dry needling or manual or whatnot we can help you out there or if you get hurt again and it’s not the same as what it was before we can help but I want them to be as independent as they possibly can because you can’t take me well I go to your house but you can’t take me home with you I’m not living with you 24/7 but again that is more empowerment the idea of you can see me more often or you can do your homework and see me less often and there’s no shame in either approach it’s just that you have a choice in this and that’s so gratifying I think for people in the healthcare system where so often it’s like nope shared said we could do that no we can only do this that hey this is up to you and it’s fine if you know you can’t do this part but at least this way you can see our faces less often yes absolutely wow that’s great so you mentioned dry needling uh what do do you use that for mostly? So oftent times it’s if somebody has a tight muscle um it’s it uses acupuncture needles. So it’s it’s I buy acupuncture needles to do it but it’s not surface level. We’re not doing chi anything like that. We’re putting the muscle or the needle directly into the muscle basically to hit almost like a reset button. It makes like a little bit of micro damage like you do with exercise. So when you exercise you have a lot of tears and then your muscle rebuilds stronger and that’s how we get the hypertrophy of the muscle. With dry needling, it’s like hitting the reset button, allowing it to kind of go back to the position that it is supposed to be in so that we can then re-educate it with exercise. Um, and then also we can use it for actual muscle re-education. So if someone has torn an ACL, they just had surgery. A biggest the hardest thing to do is get the quad back. And so we can do dry needling, put stem to it to kind of get that brain muscle connection back so that we can even use the quad properly. Wow. So, we can use it for a variety of things and sometimes with injuries, it does take several different providers to get that. Like we were just talking about peptides with a chiropractor and a nurse practitioner. Um, and a lot of what we do at Ascend is sending patients to various places so that cohesively they can get the full approach. Yes. It’s kind of ironic because a lot of times we’ll have patients who go to multiple specialists and there isn’t that cohesiveness. It’s just like, okay, we’re looking at your kidney. Okay, here’s how your eyes are doing. I think a lot of times when there’s a personal relationship between different providers, we can better curate, okay, here’s what the next step is. Yeah. I once had a um instructor say to a patient because it seemed like they’re getting so many different answers. They’re like, well, if you sit a chiropractor, a primary care, and a PT in the room, you’re going to get five different like things said, what’s wrong with you? So, it’s nice when we can all just communicate so that we can just take care of the person sitting in front of us. And I have noticed that a lot and it’s been wonderful. Right. Yeah. Because and sometimes it is a okay we to drill down to the root cause and sometimes it’s the other approach of like okay here’s a symptom that’s bothering you. We need to fix this before we can go anywhere else. And I think that does take a lot of conversation with the patient of okay what can we tackle most effectively. Yes it does. It does. And um so like and and of course there’s some things with PT where you just get at a standstill and maybe I do need help from another profession so that they can just take care of one thing so then we don’t plateau and then I can come back and like finish out the PT and so there has been cases like that. So it’s just nice to have those connections to kind of hand off and so that we can keep in contact with that person. Yeah. My classic example is I had a patient who uh had a lot of uh there weren’t neuropathic injuries, which is what we treat mostly with a ketamine infusions. So I was unsure if the ketamine or PT would work better. So I had him come to us have a ketamine infusion. Right after that, once he recovered, he went and did PT. And I said, “You won’t need both of these.” And we decided afterwards like, “No, I think the PT was actually more helpful than the ketamine.” So I didn’t see him again. he went to PT and got better that way. So, sometimes it is nice to uh almost have a rock paper scissors competition of what’s actually going to help you the most. Let’s go with that and continue that path. Yes. Cuz sometimes there’s too many options I feel for there are there are there’s almost like some I’ve have definitely had patients who have are on so many different medications, so many different seeing so many different people and I was like, “Okay, well, let’s try to cut down a little bit of this so we can kind of even see what is working and what is not.” because sometimes you just kind of muddy the waters a little bit and you can’t see what’s truly making the effect for that person. Are there common PT misconceptions? Because again, the American healthcare system is almost completely here’s a pill, take a pill for that. Oh, you’re you’re feeling that way. Here, here’s a pill for that. Yeah. Um, yes. I think one of them is that we just do a lot of like stretches and things like that. I um sometimes patients are a little bit upset that I ask them to do exercises or I have to really educate on the buy-in of exercises. They’re like, “Well, I’ve had this pain for 20 years. How is this even going to help me? All we’re doing is stretching and exercising. I’m up on my feet all day.” It was like, “Well, it’s exercising with intent.” And so, you may have been exercising up on your feet, but maybe you’re not targeting those little stabilizer muscles that maybe you don’t even know about because you aren’t a PT or you haven’t had someone educate you on that. Um, and then the prehab one is the biggest one. So, thinking that you can only have PT if you have an injury, and that’s not true. We get people who, um, for example, if you’re on a sports team and we want to prevent ACL injuries, well, then we can rehab you there, too. Um, if you do a very laborous job. We want to prevent you from having overuse injuries. So, we can prehab there. If you’re wanting to prevent surgery and this is like your last ditch ever, if you have a rotator cuff tear, I’ve had people who have come to me with rotator cuff tears and they didn’t have to have surgery because we got them to a manageable place. They were able to do everything they wanted to do and they’re like, “Well, I’m I’m able to live like this. I do not want to have surgery.” And so, we’re able to prevent that as well. And I think so a lot of times that’s the crux of it is the decision-m of am I bad enough for surgery? And it’s very difficult for our patients a little easier. I’m a nurse anesthetist, you know, I might work on them once a week for several weeks. Hey, you’re still not at a place where you’re comfortable. If I can’t help you, then you need surgery. And that way they also again these in many cases have anxiety, depression. They can go into the surgery with more confidence knowing, okay, I had somebody who knows this stuff work on me for a while. It did not go away. I can with more uh certainty go to the surgery knowing like, okay, this is it’s time for this. Yes. So, and and it it helps with that, too. It’s almost like you become a little bit of a like a mental health therapist versus like a physical therapist with people who had chronic pain. Um and and it does it gives them the confidence to know I did everything that I could. I but I am better than what I was off um but I do need that surgery. And so sometimes sometimes you just have to and um but we work together and then I’m I’m always very honest about it. if I think that you’ve plateaued, if I think that there’s nothing more I can do, um I help you get to where you need to go so that they can get you even further than what we got. Sure. and in in many cases. So we started in 2019, I did a lot of pain management at first with ketamine infusions and then I slowly realized you know if I use smaller doses and at least take care of the anxiety um then it’s a lot uh less work for the patient a lot fewer visits and then we can send them to PT to because now that the anxiety and the depression is gone they are actually much more enthusiastic about the parts that they can do where before I said no no I’ve tried that nothing helped but with that new mindset they can actually make some progress. Yeah, that’s definitely a really challenging part of our job is with people who have anxiety and depression because that intensifies pain and so trying to help someone have the motivation to do something when your motivation’s already decreased is very difficult. Um, but I always try to just educate that exercise is one of the best medicines for that going. It helps just get the endorphins flowing. Um, and especially with chronic pain and depression going hand in hand. Um, and then it’ll help with surgical outcomes, too, if we can get you moving a little bit more, um, and make them feel better. So, is there a specific way that PT helps with pain? I know you mentioned endorphins, which a lot of times, like you said, they won’t flow unless you’re moving, unless there’s some sympathetic nervous system response from the body. Yeah. So, PT and pain, we do a lot with that. So, it’s almost a lot of what I do is verbal education almost. Okay. Um when it’s pain cuz pain is very different for everybody. It’s very um a mental thing and and so there’s for example if you’ve ever like stubbed your toe and and you didn’t see an injury like you know you stubbed your toe and it was fine but then you looked down and you’re bleeding and then it hurts so much. Um you didn’t know that there was an injury there but there was and you didn’t realize it till you saw it. um we have to basically re-educate somebody’s brain on how to get their alarm system reset. So I like to use the example with my patients for the ring camera. People get those because they want to see intruders and but they also tell you when your spouse is there when there’s a squirrel. And so the spouse and the squirrel like the normal everyday things and so our bodies are registering the spouses and the squirrels or the normal activities as pain, as injury, as danger. And so we have to get them to understand that pain does not equal injury and re-educate them that normal activity is okay. Um, and so it’s a lot of talking through things and a lot of like coaching on tissue healing is 6 to 12 weeks. It’s already it’s already healed. Now we just kind of got to push through this and we have to understand that doing normal things is not painful. We’re not doing extreme things that’s going to put you at risk. I wouldn’t ask you to do that. Um, so it takes some guidance, a lot of guidance with that and educating on the pain system and that it does not mean injury. It’s just a warning. So sometimes it is, oh, I never healed from this. Well, maybe you did. You just didn’t realize it. Yeah. Yeah. So it’s it’s not that they never healed. They have healed, but their brain is still registering no sception from that area. And so um no sception is the signal that your body sends that what we register is pain. Um, and so it it’s just like your body’s just on high alert in that area. And now we kind of have to get it to remember like, okay, no, it’s actually fine. Like we don’t have to guard so much. We don’t have to make those muscles so tight to protect it. We can we can let it breathe, let it relax, and bring down that alarm system that we only register intruders. That’s just a squirrel. It’s fine. No, that makes sense. We deal with a lot of autoimmune disorders and for years a specialist said you cannot feel itching and pain at the same time like with psoriasis, psoriatic arthritis and then they realize no like both of those will simultaneously go up your spinal column into your brain and that’s how your brain will register it. So sometimes it is distraction. I mean, you know, I’ll put in IVs every day at the clinic and sometimes I’ll ask the patient, “What’s your second favorite color?” as I’m poking them with an IV needle and just that part of their brain like, “Well, wait, my favorite color is red, obviously, but my second favorite color.” No one’s asking that since I was seven. And then by the time they come back with an answer, the IV is in and they’re done. Yeah. So, and I feel that especially when we deal with mental health, it’s perfectly fine to trick your brain. Your brain’s trying to trick you and tell you you’re sad when there’s nothing to be sad about. So, return the favor. Yeah. Yeah, we do that a lot as well. So, um like different facilitation techniques or like like tapping on something if we’re working on it. So, like I’m working on your knee, so I’m tapping your thigh, trying to make sure that you’re focusing on that, not what I’m doing at the knee. Or, um if we’re doing balance stuff and somebody’s fearful, um I’ll talk to them and we’ll just talk about things that make them happy so that maybe they’re focusing on that versus the fear of falling. Um so, just trying to help them basically distract them to get them to a better place. It’s really fascinating how much the physical therapy you’re talking about is so similar to the psychotherapy. It it is. I have to draw the line sometimes cuz some people it’s almost like being like you always hear women talk about hairdressers and like you like you hear all the gossip, you hear all everybody’s secrets. It happens the same with physical therapists cuz we’re a healthcare provider that spends one-on-one time an hour with you. Um so we get to know our patients very well. We get to know their story very well. Um, and so being able to understand like, okay, this is now outside of my scope of practice. We’re not talking about pain. We’re not talking about um, fear avoidance. Now we’re talking about things that are serious issues. We need to get you to this person who can now help you. And I think that would be helpful. And so we also have that trust with them to where they’ll value our opinion very well cuz we’ve worked together like for weeks at a time, an hour together by ourselves. And they know that you actually know them. This isn’t like, okay, we talked for 3 minutes. Here’s another specialist. Yes. Okay. Wow. Cuz you’re right. So, emotional tapping technique or uh there’s a lot of different ways that even as we’re dealing with trauma that we can distract people as they go back into their subconscious or relive something. So, that is really fascinating. Yeah. It’s a new thing that is kind of coming out in PT schools because they didn’t used to really talk about pain neuroscience as much as that what they do. They did a class on it, but I know I went to Belmont University and they are very big on it because they teach us to treat our patients as a whole. Like we’re not just like, yes, we are musculoskeletal and that’s what we are experts in. Um, but our brain controls all of that. So, we kind of have to understand what that is doing and how depression and anxiety can affect pain and how lack of sleep and all these other things can affect our patients because they are people. They’re not just knees and shoulders. Well, that’s great. So if uh someone watching today is interested in contacting you or seeing if like it be the appropriate treatment for them, what steps should they take? Yeah. So I work with Custom Care Rehab. Um I believe my name and then the number is on the screen. So you can reach out there. Um and then I will kind of talk with you, see what’s going on. Um see how far you are cuz we are a mobile physical therapy place. So I come straight to your house. Um or I have come to people’s works as well. If they’re very busy and they have a lunch hour and they need me to help them and they have their office, we go there um and we’ll talk about what’s going on. I will likely send you to Amy McMillan who is my employer. She owns Custom Care Rehab and she’ll kind of help um get your account, everything set up for you so that I can come out and see you. And then if you’re not in the area that I work in or if you’re not close to me, we do have four I think it’s four other therapists that are in different areas that can come out and see you. Wow. Yeah. Yeah. And and I’ve sent patients to you guys many times and that is again we have the same philosophy of uh sometimes we need a long-term relationship with a patient but it’s nice to have that as an option and and often it is because okay insurance paid for four visits you need something else. So it is nice to be able to go to a place and then not feel that okay here’s where I’m going to be forever now. So that freedom I think is so important for patients to know I can go somewhere, get what I need, go back if I need it. Yeah. Yeah. So we usually have visits in packages. So we have like like we can just do an eval if that’s what it calls for. And I’m like, okay, I don’t know if this is necessarily appropriate. Um then I’ll likely like give you some treatment exercises and then send you on your way. But then we also have like three visits, six visits, nine visits, however you want to do it. Um, and then I give my recommendation off of what we talked about during the eval, what I think is wrong. And then, um, often will tell them I see my patients with this company like once a week. Usually I will have some twice a week people if they’re posttop patients. Um, and then I wean them off of their visits and let them know that at the time at this time you’re getting we need to space out the visits because you’re getting more independent. I think we’re in a good place. and then let them know we can just do like a once a month if you want to or we can you have my number if you need me. Wow. And for us at Ascend Health Center, uh we’re in Fairlon. We do some virtual visits but the first ones are always in office. So we do have psychotherapists who again do a lot of the same things you do just without moving quite as many muscles. And then usually the first step is you’ll see a psychiatrist or psychiatric nurse practitioner. often they’ll refer them to me the nurse anesthetist especially if it’s a complex complex case of anxiety with pain a lot of autoimmune issues because a lot of just again roll into each other into some sort of difficult to unwind tangle so yes yes we get a lot of people who have Parkinson’s or multiple sclerosis things like that and so it’s kind of just a teamwork effort on helping them get better for sure absolutely well thanks for coming on the show today thank you for having

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