Welcome back to the Healing Pain Podcast with Evelyn Hecht, PT
Emotional or sexual trauma, these two are just some of the contributing factors for people to suffer pelvic pain. By understanding the effects of the overall body to the small pelvic region, Dr. Evelyn Hecht is able to correct orthopedic issues as well as pelvic floor issues. But she also believes that modern pain care is revolutionizing the way physical therapists see their patients in therapy. Aside from developing a teamwork between the doctors and the patient, Dr. Hecht also reaches out to psychotherapists to help manage the psychological aspects of the healing process. Learn why pain science is both old and new and how allowing patients to find a healing path for themselves can also speed up the healing process.
I’m bringing someone who’s a colleague of mine and a friend here in New York City. Her name is Evelyn Hecht. Evelyn has a really incredible story. She is a pioneer. That would be the word that I would use for Evelyn. She’s been a pioneer in a certain aspect of physical therapy and pain care that we’re going to talk about on the podcast. Evelyn has worked as a physical therapist for almost three decades specializing in pelvic floor and spine and chronic pain of all types. What’s interesting is she designed one of the first public health courses for both New York University and Stony Brook University’s Department of Physical Therapy. She taught that course for seven years. She’s on to some interesting and informative and high tech ways to help people with pain.
How to Revolutionize The Healing Process Using Modern Pain Care with Evelyn Hecht, PT
Evelyn, welcome to the Healing Pain Podcast.
Thank you so much, Joe. I’m thrilled to be here.
I know you, as a clinician, working here in physical therapy and pain care. New York City, even though it’s a big city, we have a very tight-knit community of physical therapists that have been here in a long time in private practice, very successful and have really served New York City’s need as far as pain care goes. Take me back probably almost three decades now before you ventured into pelvic floor rehab and women’s health physical therapy. Now women’s health and pelvic floor is known, it’s arrived and people are well-aware of it. Three decades ago when you first opened your first practice and before that, I’d like to know what your journey was. When that first started, people were like, “Pelvic floor physical therapy, what is that? How does that work?” There was a lot of mystery around it.
Actually my answer to this is through patients. I was working at a large orthopedic hospital treating lower back pain and hip problems. We’ve treated kings of Saudi Arabia, all these dignitaries would come through, and I would get a lot of these dignitaries because I used to live in Lebanon and traveled to Norway. I was the international physical therapist. Because we have international clientele, I would get questions naturally from these patients and my American patients. They would ask me questions in a quiet way, “Evelyn, do you know anything about having pain during sex? I don’t know how I’m going to have a baby if I’m having pain with intercourse. I’m going to the bathroom so often. Do you know anything about this? I don’t have a nerve compression injury, but I still have to go to the bathroom too often. I’m leaking a lot and I’m also constipated.” These are different patients would tell me and ask me my opinion.
As a new therapist and I was an athletic trainer prior to going to physical therapy, I didn’t know what to say. I would meet up with my colleagues because we usually would have some time to write notes and talk about our patients, not about to gossip but about the situation. I would ask them, “Are you getting these questions because I would get them at least a couple of times a week?” Three or four times a week, I would get a question about that and I would research that myself but there wasn’t much out there, so I’d ask my colleagues and they all would look at me with blank stares like, “No, we don’t get these questions.” Because I kept getting these questions, I had to try to start the process of figuring things out. I would ask them questions, “Did you talk to anybody about this?” “Yes, I’ve seen a specialist and one older doctor.” This is for a female patient. “One of my elder doctors would pat my hand and say, “When you have your first baby, everything will be fine.”” She looked at me and I looked at her and I said, “No. We must do something about understanding how the floor, the bottom of our pelvises work.”
As physical therapists, we treat and understand mechanics of the spine, of the abdominals, of the hips, knees, shoulders. We’re really inundated with great information about movement and injury and rehabilitation, but zip-a-dee–doo-dah about the pelvic floor. I think it has to do a lot with because it has to do with sex and it has to do with going to the bathroom, and that’s embarrassing and shameful in this country for sure. I decided to look into that as a specialty.
What I love about your story is that you listen to your patients. Just through the conversation, you listen for the places they were having challenges, and pain is a challenge, and from that you have developed a specialty around it. At that time, there wasn’t a plethora of continuing education courses to go to. There weren’t people like yourself who developed courses and brought it into universities. The professors, they had no idea how to treat this. Where did you go and what was that journey like of starting to piece together the knowledge that would empower you so that you can empower your patients?
As a physical therapist, at least I think I’m taught to seek out answers if you can. The first thing I did was go to the anatomy of the pelvis. I actually started reading and looking at it and studying some of the anatomy and trying to understand how does pelvis muscles have anything to do with sex and where do the nerves exit from the sacrum that innervate the pelvic floor? Just around that time, about a year or so after that, Herman & Wallace just started their new company and I was one of the teachers there. In fact both of them, Kathe Wallace and Hollis Herman, were giving a course in Boston which is where they were located. That was in the early ‘90s. I went and took a first course, one of their first ones. It was a weekend course. Because I had been studying this prior and hadn’t delved into treating a patient yet, I felt more confident. I have some more tools and it’s okay to actually start to treat. I had asked questions and felt very comfortable talking about the issues to patients and giving some ideas to what they can do, but now I felt I know how to treat. I’m able to go intra, into the body, where the muscles are located. I have tools like biofeedback to start to measure the electrical activity of their muscles. I know simple exercises to help open the pelvic region.
You found some other people like you who were venturing into this new space, and you partnered with them. It’s so interesting to me how it started out as women’s health and now we’re finally saying, “Men have a pelvic floor too. Men have similar challenges with their pelvis.”
They may not be as open as women. Even the women were embarrassed to talk about it. We do give birth, I think we’re a little more comfortable with that area. Men were way more taboo, don’t talk about it. I find that a lot of men start having issues in pelvic regions if they’re not sexually abused. That’s a big component to this. The ones that have emotional health but have gone through college where now they’re sitting for hours a day under high amounts of stress, that’s when a lot of men start to develop pelvic floor dysfunction. They’re also starting to foray into sex. They’re free and are not with mom and dad anymore. That’s when they start having some challenges. Because they don’t know what to do or so embarrassed about it, they don’t say anything and things get worse.
What’s interesting with women is you have a gynecologist that you typically see at least once a year. You’re starting to develop a relationship with someone examining you. For men, we don’t have someone who examines our private parts once a year the way a woman has.
I didn’t put that together ever. Just the regular GP who hardly even ask any questions about their privacy.
When I go for a yearly physical all the time and in the last couple of years, they have not done a testicular exam on me. I know how to do one myself but that’s an important thing to do. They very rarely ever ask questions about your sex life or your elimination process, things that are really important questions for all your patients.
These are the core of a person. If you’re a male and you can’t have intercourse, can’t get an erection, have pain with that, can’t sit more than twenty minutes during your studies or during your work, you start to become dysfunctional and depressed and anxious and worried and spiral even further into a dysfunctional person. It’s so, so sad. If there is help in there, there is return into function which is awesome.
How has studying pelvic health made you a better musculoskeletal physical therapist? You’re not just treating the pelvis. You, at times, treat feet, shoulders and necks. As we say, everything is all connected. How does venturing into that part of your career helped the rest of it?
It was my extensive experience working as an athletic trainer and a physical therapist in orthopedic work that made me a wonderful pelvic physical therapist because I understand the small tiny group of muscles that sit at the bottom of the pelvic area. They are affected by the larger gluteal muscles, the hip flexor, all the muscles in the external, how the sacrum, the pelvic bones sit if they’re twisted or torqued. Understanding how the larger body affects the small pelvic region made me able to correct both the orthopedic issues as well as any related pelvic floor and pudendal nerve issues.
A lot of the contributing factor to those with pelvic pain is a history of some trauma, whether it’s emotional or sexual. I’m sure when you first started out, you knew that would be a factor but I’m sure as you matured in this, you realized it was a large factor. I’d been a PT since 1996. I’d been around quite a long time. You and I probably have been practicing a similar amount of time. Back in those days, they didn’t really talk about the psychosocial factors at all in PT school. Now, we get it through continuing education and if you’re reading the researches there. I always say to people, “How did you learn about this?” I tell them that, “If you’re a therapist that’s listening with open ears, whether or not you learned this in school, there are little clues that your patients are leaving for you as to what the cause of their pain is. Sometimes those clues lead you down a path where it’s one of trauma.” How did you start to integrate that into your practice and take care with patients?
Dealing with a big strong aspect of trauma for most people’s pelvic pain and then into the chronic pain world, I started reaching out to psychotherapists and to healers that can help my patient manage the psychological aspect of their physical treatments. I would ask patients to, “Seek out, go back to a therapist while I’m working with you because that might trigger some memories or some issues for you that you can handle much faster if I can help relax and help you become more in touch with your muscles and how you feel about these areas, as well as you’re doing some cognitive or some psychotherapy behavior.” As the world in pelvic health expands, it just doesn’t stay in the pelvic floor muscles. Now, we started to look above the diaphragm. The diaphragm has a big component with how the pelvic floor functions. Let’s say for example, women. They’ll suck that stomach up tight as anything because they don’t want to show any convolute proof in their stomach. When they suck their stomach up tight and hold it like that all day long, then their diaphragm cannot lower. They don’t have a good deep belly breath. When the diaphragm doesn’t lower and a good deep belly breath occurs, then the pelvic floor can’t lower. With each breath in as you inhale, the diaphragm lowers, the belly expands, and the pelvic floor is able to drop. As the diaphragm moves back up as you breathe out, the pelvic floor comes up. All day long, there’s an inhalation-exhalation and the movement of the pelvic floor.
As we’ve learned in more expanding knowledge about fight or flights and heightened sensitivity of our nervous systems, I’ve also learned that the diaphragm and breathing and pelvic floor are right integrated with the sympathetic and parasympathetic activity. I think it was more of a process, of a journey to, “Let’s see what works for you. Let’s have you do some deep diaphragmatic breathing in a happy baby pose, which really widens and opens the pelvic floor. How does it make you feel emotionally?” I ask them to imagine themselves feeling safe and supported and surrounded by love. It sounds so weird for me to say this to a patient when I was younger. Now, I say it all the time. It allowed them to expand into, “My emotions has a lot to do with my pain. I’m going to imagine and bring that together in a safe way and a slow way.” I would see results with that. It grew from, “It’s your pudendal nerve. It’s your right levator ani. It’s your sacroiliac joint too. It’s related to the way you relate to mother or father figure when you were growing up. You still have that fear pattern, etc.”
I’m a big fan of psychology, psychotherapy, pain psychology. All that definitely has its place in the world of multi-disciplinary pain care. Physical therapists and psychologists are such a beautiful marriage of specialties. What you’re saying is what I found in my career. As you continue and you treat patients that you start to weave these things in naturally. If you told someone to sit in a happy baby pose twenty years ago, you would think that would be really weird. Now, we have people do things. It’s not psychotherapy but it starts to combine the mind and body, and we see patients get better more rapidly from it. In early stage, they don’t necessarily have to see a psychotherapist, however, there may be a case for that also. What we’re doing reinforces what’s being done with let’s say a pain psychologist.
The work is exciting because what we’re seeing is that patients are getting empowered because they’re seeing that they can heal themselves. They just need, “What do I do and how long do I do this?” Is the research there to justify this type of approach? Which is really so exciting about the new pain science that’s out there.
When you start to look into pain science and modern pain care, how does it start to inform your practice and change you as a practitioner?
It actually revolutionized the way that we see patients through their therapy. Not all patients are going to automatically embrace the new pain science because it’s not given to them as information in any of their prior medical care or the current medical care. It’s still not filtered down yet into our society. In five more years, it will be every day. Right now because they haven’t heard it, the information is not given in a, “Blame you. You’re the one that created your pain so you have tough bogeys.” It’s given in a way that’s empowering. The information is given in a way that has proof that there is measurable changes within the brain that occurs with chronic pain and the fact that our brain has the ability to change and to adapt and to grow new pathways and to really change a pattern. That’s the beauty of this new pain science. It’s revolutionized the way we treat patients and we’re giving them the information, education about what is pain now, what’s the science of pain, and how could they incorporate that for their own healing journey. We’ll guide them and they’ll learn themselves some things as well. We may not know now, but it made it more beautiful and more a teamwork with patients and therapists and doctors.
As a practitioner, it’s been interesting to watch this pain revolution develop. I think those of us that are practicing 30 years ago, we knew this innately but we didn’t have the science yet. I tell people, “Pain science really isn’t new. The proof behind the science is new.” The techniques that you use in modern pain care are really centuries old.
We’re going back to India, China. We’re doing our breath work. We’re looking at the studies of Buddhist monks and seeing how their meditation has affected their growth of the pre-frontal cortex, the gray matter there. All this is finding the proof. It’s wonderful to have the proof and now we’re all in. There is no stopping us. There’s no stopping you in this.
Tell me about some of the great new innovations you’ve been working on in your clinic and outside your clinic.
Since the pain science has now proven that one can grow brain cells, one can change their homunculus, one can improve the ability for the brain to send the happy chemicals, the brain-inhibiting endorphins and dopamines, it’s proven by these techniques of breath work, of meditation, of movement. Physical therapists are amazingly trained to help a person guide themselves through, “What’s the right movement for you now? What can you tolerate?” and being a coach on that. I only can treat how many patients a day. My staff can treat how many patients a day. The pain science needs to come out. There are books on pain and your book, Heal Your Pain Now, is amazing, it’s so comprehensive and empowering for people to go. I refer to your books all the time for validation of what we’re teaching. I’m big on tech. I think tech is the next level of reaching people. It’s affordable, it’s accessible. What I decided to do because I’ve had some experience developing an app for pelvic issues a couple of years ago, I want to design an app for this new pain science and a program to help a person learn the techniques and track their techniques that they do every day, and then see their metrics change. Either improves target activity whether it be to sit for longer or have sex better or to be able to lift up their grandchild, whatever it is, they can track their metrics and also to see numbers of pain lower as well.
What is the app called?
It’s called re.lieve. It’s a chronic pain solution program, self-help. I wrote an eBook as well with pictures. Really easy to read and understand, not overwhelming science, and then a very simple backed, all-science based techniques of what one can do every day to start to heal themselves as they’re getting treatment by the physical therapist or their medical doctor and continuing their pain medications. There’s no, “You have to stop one thing to do another.” I’ve learned in life that whatever a patient’s healing path is, they’re going to find it if they’re almost given the opportunity or feel that they’re allowed to find their pain team, whether it be an acupuncturist, a physical therapist, whatever medications. Find your team and also do this self-help program as well. This is not a quick fix. There are no silver bullets that will help decrease or lower pain. It’s our work together and their work at home.
I love the idea of using the word opportunity because there are so many people that have gone to certain types of practitioners and they’ve hit the end of the road of the opportunity and whoever the practitioner is. There are a lot of practitioners to this day who still are not sure how to treat pain effectively and they say, “I didn’t really have anything left for you. You’ve tried all this. You just have to go home and live with it or manage it.” I think giving people that hope and reinforcing them to look for things that will help them because it’s not just going to be this one magic tool. It’s a combination of a couple of different techniques that are really going to help.
It’s this consistency of doing this. With my program, I ask people to do this for three months. A lot of people are like, “Three months? No.” “It took you months and years to get to where you are.” Given this is not invasive, it’s not risky, it’s simple. Measuring your sleep, that’s easy. Did you drink enough water today? We can do that, whatever you wrote in your book. Did you do your stretching? Every day you do a stretch or a couple of stretches. It’s every single day whether you like it or whether you feel better or feel worse, you do it anyway. We’re not going to do an exercise that creates huge amount of pain. Unless you might need, and therefore you need some guidance by a physical therapist. It’s something you do every single day and you’re not expecting an answer, “Did it make me feel better or worse?” I think a lot of people, that’s where they get stuck. “I did this yesterday or I did this for four days, and nothing happened.” It’s not enough time. Three months for me is like a drop in the bucket in terms of a long-time of pain that people experience.
It’s interesting to me because when I think back to 1996 when I first started treating patients, we used to get 60 visits, which pretty much was a year’s worth of therapy at once or twice a week. It was wonderful because when you had chronic pain patients, you’re able to develop a relationship with them. They were able to develop a relationship with you. It takes them time sometimes to get to know you and like you and trust you. Fast forward now, a lot of physical therapists struggle to get six or nine visits for the year. Now, you come with this app and you say, “I want you to do this for three months,” and people say, “This couldn’t possibly work if it’s going to take three months.” The truth is insurance companies have almost brainwashed not only the patient but also in some ways the practitioners.
I trained a lot of new therapists in my career, and they say, “It’s going to be six visits and then we put them on a home exercise program.” I say, “For some people that may be true. For some people, they may not be ready for home exercise program. You don’t let the insurance company dictate your care.” You give people the care they need and then say, “Unfortunately, your insurance ran out. We’re going to write that appeal letter. Hopefully, we’ll get more visits. If not, we have a program where you can continue coming once a week or once every other week for continuity of care.” I think that’s really important. A lot of times that’s missing from healthcare because in a lot of ways, people come into therapy or not just physical therapy but other types of therapy as well. Sometimes psychotherapy has the same challenge. They come in, they only have eight visits, insurance stops covering and the process stops and people say, “Therapy didn’t work.” This plasticity that we’re talking about is wonderful and incredible and amazing, but it takes repetition on a daily basis and it takes a couple of weeks, typically somewhere between six to sixteen weeks.
How do we get this information out to patients that they’re not done when the insurance company says they’re done?
The answer to that is I have always written appeal letters and I’ve always advised the patient to participate in that process and write the appeal letter also. The insurance company ultimately wants you to forget about it. They don’t want to hear from the therapist with more documentation. They don’t want to hear from the patient. It’s a combination of working and trying to appeal with the insurance company. It’s a combination of, in a lot of ways, looking at what’s going on in healthcare today and looking at who might be in office near you whether that’s on a local state level or a larger federal level, and see what their beliefs are about healthcare. What’s going on right now is people are starting to look at their health insurance plans for the end of the year. They’re starting to see deductibles going up to the thousands, some people $10,000. They’re starting to see that their monthly premiums are higher. All these things are really important conversations to have. When I think of being an advocate for people with chronic pain, I think about them not having insurance or having insurance that is not affordable for them, knowing that they need to have care for a period of time. That’s also why I think things like this podcast, things like your book, things like the re.lieve program that you have are really great tools for people because they’re easy, they’re accessible, and they’re affordable.
We want to reach the masses, Joe. That’s really what we’re interested in doing, reach the people, give them the information now, and they can take some of their healthcare into their own hands. It’s really in their own hands. It’s not just up to the magic doctor or the therapists. It’s there.
I have been speaking with Evelyn Hecht. She’s a wonderful physical therapist who specializes in chronic pain, pelvic pain and musculoskeletal pain. Evelyn, can you please tell everyone how they can learn more information about you?
My website is EMHPhysicalTherapy.com where my re.lieve eBook and program can be purchased. My email as well is connected with that. I’d be happy to talk with anybody who has any questions, help you out, give you information. Please contact me. Thank you.
Please check out Evelyn Hecht at EMH Physical Therapy. At the end of every podcast, I ask you to please hop on to iTunes. Give us a five-star review. Share this information now with your friends and family. If you are someone who’s seeking natural pain care, please check me out at DrJoeTatta.com. If you’re a practitioner, check me out on the Integrative Pain Science Institute. There are going to be tons of great courses and information for practitioners so they can learn many of the skills that Evelyn and I talked about on this podcast. I’m Dr. Joe Tatta. It’s been a pleasure being with you. We’ll see you next week.
About Evelyn Hecht, PT
Evelyn Hecht, PT ATC, is the owner of EMH Physical Therapy, specializing in pelvic floor & spine and all chronic pain for over 25 years. She designed the pelvic health course for both NYU and Stony Brook University’s Department of Physical Therapy and taught for 7 years.
In 2014 she designed and launched an app, PelvicTrack, currently free on iTunes store, to help anyone suffering with pelvic floor dysfunction learn some basic exercises and track symptoms.
In 2017 she authored an e-book: “re.lieve: solution for chronic pain, self-help program” based on the modern science of pain with a guided self-help program to guide people suffering with chronic pain on their healing journey.
Education: She earned her BS in Physical Education with a minor in Athletic Training from Brooklyn College and received her BS in Physical Therapy from Hunter College
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