For those of you who aren’t familiar with Ann Wendel, Ann holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy (MPT) from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT). Over the past two decades, Ann has continually developed as a health care professional. She started her career working with high school, college and professional athletes, and later went on to work at an area hospital treating patients with a wide variety of Orthopedic and Neurological conditions. In October 2011 she opened her private practice, Prana Physical Therapy and in May 2012, Ann joined the Consulting Team of Whole 9 Life. You can also find Ann on Twitter and Facebook. I asked Ann to answer some specific questions about the benefits of Physical Therapy for treating autoimmune disease.
1. How important do you think diet is for controlling autoimmune illnesses (AI)? I have a special interest in working with people who experience chronic pain.As happens with many people, it took my own experience to propel me to study and learn more about how to best help this patient population. In 2007, I became very ill with what was later diagnosed as Hashimoto’s thyroiditis. By the time I was properly diagnosed, I had gone from being a competitive athlete to being unable to hike a mile.I lost handfuls of hair every day and gained 20 pounds due to my thyroid shutting down. It took months of being on the right combination of medications to begin to heal and regain some energy. It took another five years of researching, asking questions, and trial and error to begin to regain my health. Those years of experimentation led me to the Paleo diet, and the knowledge that I needed to eliminate gluten, grains, and most dairy from my diet in order to prevent muscle and joint pain, mind numbing fatigue, mood swings, energy fluctuations, and gastrointestinal issues. After several months of my dietary shift, the majority of my inflammation was gone, my blood work showed changes in a positive direction, I began going days at a time without taking anti-inflammatory medication, and I was able to slowly begin bodyweight exercises and walking. From my own experience, I saw the direct connection between what I ate and how I felt. Naturally, I wanted to share this knowledge with my patients. I believe that proper nutrition is very effective as part of the whole treatment protocol for AI. Eliminating inflammatory foods from the diet helps to decrease pain, swelling, stiffness, aching, fatigue, and disrupted sleep. Proper diet, along with medications, gentle exercise, good sleep, and stress management can alleviate the symptoms that people with AI struggle with daily.
2. Many people battling AI get frustrated by how slow healing can be, especially when following the very restrictive Autoimmune Protocol. How can physical therapy help? I understand that frustration because I deal with it myself! I try to explain AI to my patients this way: the illness that you have been diagnosed with is like the tip of the iceberg – the years leading up to your “diagnosis” comprise everything under the surface of the water which we can’t see. The area of the iceberg which is underwater is HUGE compared to the tip, and your AI is really that huge area. During all those years while your AI was developing, you may or may not have been aware of being ill (your symptoms may not have been obvious because they often develop slowly and stay under the radar). It wasn’t until you got “sick” enough that the symptoms were obvious that you were “diagnosed.” We can’t expect something as big as an iceberg to go away after 30 days. We can and do see results in a positive direction after as little as 30 days; but, it may take months or years for the maximum effect to occur.
Then you have to factor in the often changeable presentation of an AI. Often patients feel pretty well for a period of time, but then suddenly start to have more bad days than good (a flare). Anything can contribute to a flare in symptoms: increased stress, lack of sleep, illness, going off plan with nutrition, environmental factors, and intense exercise. As time goes on, patients begin to learn what their triggers are, and can attempt to avoid the triggers, or provide extra rest and recovery time during periods of stress.
Physical therapy can be very beneficial for patients with AI. Your physical therapist is highly trained in the treatment of musculoskeletal (muscle and joint) issues. He/she will perform a full assessment of your posture, range of motion, strength, and functional ability in order to develop a personalized treatment plan for you. Your physical therapist may utilize stretching, range of motion/mobility exercises, energy conservation techniques, body mechanics training, and functional strengthening exercises as part of your treatment plan. Your physical therapist understands the need for slow progression of exercise and the need to adapt the day’s treatment based on your symptoms that day.
It is important to have some guidance when you are exercising with AI. I have learned the hard way that pushing through a “bad” day leads to paying for it with increased fatigue and soreness for days afterward. Even months and years into your healing process, you may experience setbacks because of the changing and unpredictable way that AI affects our bodies. Comparing how you feel on a given day to how you felt yesterday, last week or last month is generally not helpful. Having a good relationship with a physical therapist allows you to seek hands on treatment during times of a flare, and then return to independent exercise as appropriate.
3. What specific types of physical therapy do you recommend for people with AI? As discussed above, your physical therapist may utilize stretching, range of motion/mobility exercises, energy conservation techniques, body mechanics training, and functional strengthening exercises as part of your treatment plan. The focus is on restoring your ability to move your joints and develop strength to perform your activities of daily living, as well as any leisure activities you enjoy. Patients with AI need a combination of hands-on manual therapy and a gentle, progressive exercise plan. The exercise plan may include things like aquatic therapy (mobility and strengthening exercises performed in a therapy pool), walking, stationary biking, elliptical machine, bodyweight exercises, light weight training. These activities can be progressed as appropriate to avoid increasing inflammation and pain. The hands-on treatment may include soft tissue and joint mobilization, instrument assisted soft tissue mobilization (using tools and/or dry needling), stretching, and neuromuscular re-education to retrain the body to move in more efficient and effective ways.
4. What is trigger point dry needling and how is it different from acupuncture? A physical therapist with specialized post-graduate training uses Trigger Point Dry Needling as part of their treatment protocol with appropriate patients. A solid filament needle is inserted into the skin and muscle directed at a myofascial trigger point. A trigger point consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle. When the needle stimulates the trigger point, the muscle twitches in response. The twitch response is both diagnostic and therapeutic, as it is the first step in breaking the pain cycle.
Trigger Point Dry Needling is not the same as acupuncture. It is based on Western medical research and principles, whereas acupuncture is based on Eastern Chinese Medicine. The main similarity is that the same sterile, disposable solid filament needles are used. Licensed physical therapists in a number of states can use Trigger Point Dry Needling under the scope of their practice. I am one of a handful of physical therapists who has met Virginia’s stringent regulations to practice dry needling as part of their physical therapy treatment of patients. I am not a licensed acupuncturist and do not practice acupuncture. I use dry needling as part of my manual therapy treatment of many patients, along with other appropriate treatment techniques, to restore range of motion and decrease pain.
5. How does physical therapy/dry needling work in conjunction with diet and lifestyle changes to promote healing and reduce inflammation? Your physical therapist works with you to develop a treatment plan to work toward your personal goals. Whether your goals include being able to sit on the floor to play with your grandchildren, gardening, biking 20 miles, competing in triathlons, or rock climbing, if you have an AI you need a comprehensive plan to be successful. I always tell my active patients that they can’t “out-train a crappy diet.” I help them to see that their daily activities and sports are being affected by what they eat and drink, as well as their sleep patterns and stress management. It is a simple fact (whether we like it or not!) that those of us with AI need to be more vigilant than other people when it comes to sticking with the plan. If we want to feel good and perform at optimal levels, we have to do everything we can to decrease inflammation and prevent fatigue. People with AI need to get all of the aspects of their lives in line to reduce the effects of the disease process.
6. How much faster can someone expect to heal by combining physical therapy with the paleo diet Autoimmune Protocol? Because we know that “healing” an AI takes time (and that time varies from illness to illness and person to person) it is difficult to put a number on the time frame. The way I look at it is that many people with AI have gradually become more ill, more sedentary, and more deconditioned. Often, any movement or exercise is painful, and folks with AI have no idea how to get started with an exercise program. A licensed physical therapist can help by taking baseline measurements of your joint range of motion, strength, and functional abilities to give you an idea of what you need to work on in order to reach your goals (weight loss, endurance, strength, etc.) Then, with a personalized plan, they can help you to gradually reach your goals while avoiding flares. Once a patient begins to decrease their level of systemic inflammation through avoidance of certain foods and other lifestyle changes, physical therapy complements the approach by increasing function. For optimal results, the combination of lifestyle changes and physical therapy speeds up the journey to the person’s goals.
7. Who should consider physical therapy? How many sessions might be required? I recommend physical therapy for anyone who has restricted joint motion (such as inability to reach overhead or behind their back or inability to put on socks or shoes because of hip and spine stiffness), loss of strength (inability to open jars or carry grocery bags), difficulty with walking and climbing stairs, disrupted sleep due to pain, or inability to enjoy fun activities with friends and family because of fatigue. We can help in all of these situations. It is important to have a plan to reach your goals, and to work with someone who understands the disease process. Physical therapists have a minimum of 7 years of education (4 year undergraduate and 3 year graduate program) where we learn about not just the musculoskeletal system, but also every other aspect of human physiology including nutrition, neurology, pharmacology, differential diagnosis, and cardiac conditions. We have the training to address every aspect of your health safely and effectively.
The number of sessions required will be different for each patient, depending on the results of the initial assessment we perform. Our goal is to get you to reach your goals in the safest, most effective timeframe possible. In my practice, I spend an hour one-on-one with each patient during every appointment. I work with my patients for the entire hour and do not utilize techs or aides, so I provide not only the hands-on portion of the treatment, but also the exercise/movement based part of the treatment. This allows me to maximize our time together, to watch how you move and function, and to give you appropriate home exercises to perform. Most of my patients come in once a week (some start at twice a week then progress to once a week). Because I am not just giving you mindless repetitions of exercises, we are able to focus our attention on the areas of deficit. The flip side of that is that my patients have a job, too! They need to commit to doing the necessary work outside of our sessions in order to see results (home exercises, proper nutrition, sleep, etc.) Obviously, patients who are more committed to the entire treatment plan will most often see results faster, and require less sessions.
8. How does someone who doesn’t live near you find a physical therapist that can perform these techniques? How much should they expect to pay for these services? Patients can access physical therapy services directly in 47 states and D.C. (this means that in these states, you can see a physical therapist prior to seeing a physician). Since the state practice act varies from state to state, it is best to call the physical therapist you are interested in seeing to discuss your state’s direct access rules. I always recommend getting recommendations from family and friends, to get a few names to start with, then going to each website to learn more about the therapist.
Robb Wolf maintains a directory called the Paleo Physicians Network, which lists practitioners by state (many MD’s but also some physical therapists)
If you are interested in working with a physical therapist that provides dry needling, you can see the directory of graduates from the program I attended (over 100 hours of training followed by a comprehensive written and practical examination) here.
Payment for services will vary from state to state and therapist to therapist. The best way to find this out is to ask when you call the practice. Many physical therapy clinics accept insurance, and can answer these questions when you call to make your appointment. Because of my desire to treat patients with highly specialized techniques while spending one hour with each patient, I opted not to participate with insurance companies. What this means is that my practice is “out of network” with insurance companies. My patients pay at the time of service, and I provide them with an invoice to submit to their insurance, so that reimbursement comes directly back to them. I provide an insurance worksheet for patients to use when they call their insurance company, so that they get their questions answered.
9. Any last thoughts? One thing that many people don’t know is that physical therapists often provide Wellness services in addition to traditional physical therapy. In my practice, we offer Wellness appointments for people who don’t necessarily require “hands-on” work, but do require supervision and program planning for safe exercise. In many practices when patients are discharged from formal physical therapy treatment, they are given a sheet of exercises and told to find a gym to continue their program. Over the years, I have seen that this creates a situation that makes it difficult for many patients to maintain the gains they made in physical therapy. We encourage our patients to continue to see us for Wellness visits, so that we can safely progress their exercises. This also allows for continued supervised exercise for patients with AI, or Medicare-age patients who have chronic conditions that no longer qualify for physical therapy (strengthening for patients with chronic illnesses is often viewed as “maintenance” and not covered by insurance). Our Wellness visits are not covered by insurance, but are less costly than physical therapy, and can be paid for with money from Flex Spending Accounts.