Lifestyle Changes and Therapies to Manage Chronic Pain with Dr. William Welches

Podcast Transcript

Cassandra Holloway:

My name is Cassandra Holloway and I'll be your host for this episode. Today, we're discussing lifestyle strategies for pain management. Dr. William Welches is here with us to talk about changes we can make and some therapies we can try instead of turning to medication. Dr. Welches, thanks for joining us and welcome to the podcast.

Dr. William Welches:

Thank you.

Cassandra Holloway:

When you live with chronic pain, you know that it can affect nearly every aspect of your life. And besides just the physical discomfort that the pain can cause, the pain can also affect your mental and your emotional health as well. Today, our goal of this podcast is to shine some light on some lifestyle strategies, some adjustments, and even some self-care that can help you manage your pain instead of your pain managing you. Dr. Welches, to start off, will you tell us a little bit about your practice at Cleveland Clinic and the types of patients you see?

Dr. William Welches:

Well, I am an osteopathic physician. I was recruited by the Cleveland Clinic to perform my particular specialty, osteopathic manipulation therapy. In addition to that, I've become a certified acupuncturist. So my practice revolves around those two protocols: manipulation and acupuncture. Those are designed for the relief of pain; that's why I'm here. Basically, I'm the alternative. I'm the doc that gets used when we don't want to use medication or when we don't want to use procedures like neuro blocks. Both of those are very important in pain management, but they're not the only things that we should be thinking about.

Cassandra Holloway:

So sounds like osteopathic medicine is really the holistic approach to managing pain?

Dr. William Welches:

Yeah. I want to spend just a second talking about what holistic means. Holistic means everything; so it doesn't mean all the alternative. It means the alternative and what we've come to think of as regular medicine. The department includes specialists who perform the procedures. They also use medications when those are important. Every so often we do send a patient up for surgery because that's the best solution. But holistic means all of that and osteopathic manipulation therapy and acupuncture, and other therapies as well.

Cassandra Holloway:

So truly that team approach that you often hear about in medical settings. It deals with everyone. Obviously, pain management, surgery, medication, lifestyle strategies, the whole big picture it seems.

Dr. William Welches:

Absolutely. That's absolutely correct.

Cassandra Holloway:

I'm curious. What types of patients do you treat? Do they have certain diseases or conditions?

Dr. William Welches:

Oh, God! I see everything. Everything from patients with low back pain or neck pain to headache. Occasionally, I get a patient who's dizzy and we work with that. We get shoulders and knees, and ankles, everything. Across the range of chronic conditions, I have fibromyalgic patients as well as osteoarthritic patients, and so on.

Cassandra Holloway:

So the full gamut of conditions?

Dr. William Welches:

The full gamut. Yes.

Cassandra Holloway:

Will you walk us through an example of when a patient comes to see you maybe for the first time, complaining of pain from maybe one of the conditions that you just listed? What goes on at that first appointment? Are there typical exams or questions? Walk us through your first evaluation.

Dr. William Welches:

My initial visit is 45 minutes and we go through everything. We do a standard history. We go through a standard physical exam, in addition osteopathic exam. Now, an osteopathic exam focuses in on musculoskeletal considerations; so that is a big part of the exam. But I listen to their heart. I listen to their lungs. We do everything at that first visit so that we get a total picture. The history is detailed because again we want a total picture of where the patient is at, and in addition to just quizzing them about their pain and what causes it.

Cassandra Holloway:

Are there any general recommendations or first-line treatment that you typically recommend when a patient first comes to see you that you try first?

Dr. William Welches:

The first visit is a full history, a full physical exam. But then, I also do get to an osteopathic manipulation treatment that first visit. Most of my patients come knowing that, at least in a general sense, what manipulation is about. Hopefully, the physician that referred them has given them some warning about what that means. I don't have patients who don't want that treatment that visit. They're looking for something to relieve their pain as soon as possible. Then, invariably, there will be a plan at the end. I will discuss with them what the plan going forward is. But I cannot remember the last time I had a patient who wasn't appropriate for a manipulation.

Cassandra Holloway:

You've mentioned manipulation a couple of times. I'm curious. What is the difference between osteopathic medicine and chiro practice?

Dr. William Welches:

Boy! There's a question. I've never studied chiropractics; so I can't answer that question legitimately. I know that some of the techniques that chiropractors used, osteopaths learn as well. For example, cracking is something that have taught in both schools of manual medicine. However, I used cracking very, very seldom. I never would use it without the patient being on board. It's not an appropriate technique for so many patients. Some of my patients are in their 90s. These are not patients that you would crack. But it goes beyond that. There's other patients who are afraid of it, and so forth. Those are not good candidates for cracking. I do know that that's up. But that is a technique we're taught. Aside from that, I don't know. Patients who have gone to both chiropractors and osteopaths, tell me that I am different. Most common term is gentler. But again, I don't want to paint all chiropractors with the same brush because like osteopaths, it can vary from practitioner to practitioner.

Cassandra Holloway:

When a patient comes to see you and you have that overall physical evaluation, and you talk about their pain, do you recommend that they come back for three, four, five treatments to see you? Or is it just once every couple of months? How often are you meeting with these patients?

Dr. William Welches:

That varies. There are patients who are sent to me that I might recommend a run of four visits as a trial period. There's other patients where I follow-up with them on a monthly basis. But there's no set rule with regard to that. A lot has to do with their response. No technique works for everybody. When I bring them back, the first question we get to is: How did that first one work out for you? I would not make a decision about whether we would go forward or not on a single visit. I would need to have, like I said, some kind of trial period. Every technique, this is really important. Whether it's a procedure like a neuro block or medication, has to have a grade associated with it. At some point you have to be able to decide: Is this a useful therapy for me or not? That is a discussion that I do have with patients.

Cassandra Holloway:

Talk to me more about some of the techniques that you use for this manual manipulation that you keep talking about. You obviously said sometimes it's not the serious cracking that we hear about in chiropractics. Is it stretching? What do those techniques involve?

Dr. William Welches:

We generally divide osteopaths. We do this kind of work. Generally divide into direct and indirect. Indirect would be what most people would consider very general. In fact, I've had patients asked me if I've done the thing. Those are methods that move into a point of ease rather than away from the restriction. When you move in to a point of ease, you're really re-queuing the body on how it should align. It's really quite a remarkable set of techniques because without using very much energy at all, without using very much of my own effort. I do get a little bit of energy from the patient taking a breath in and letting it out. But aside from that, that's all we need. I do use some direct techniques if the indirect techniques don't work. I will use something like muscle energy, which you would think of as isometrics. We're pulling against each other, but we're doing it in a controlled fashion.

              A crack occurs all at once, but muscle energy occurs in stages. So we would go through a couple of different stages. Additionally, I do craniosacral. I've done some visceral manipulation. There's a couple of different things that I can bring to bear if they seem to be appropriate. Myofascial release is another one. It's somewhere in between direct and indirect. I use myofascial release a lot as well.

Cassandra Holloway:

Do you combine some of these manipulation with acupuncture? Is it common to combine those two treatments when treating a patient?

Dr. William Welches:

Medicare and insurance companies won't let us. The problem is this. They are synergistic, I believe. One plays off of the other. But the best that we can do if we hope to get it paid for is set up appointments, but they can't be on the same day. I have worked with patients back and forth. I have a few patients who are comfortable enough that they can pay for one or the other out of their own pocket. Then, they can't have it on the same day. But only one payment can go in to the insurance companies. This is shortsighted, but it's the world we live in.

              There are some similarities between acupuncture and osteopaths. Then, there's also some differences. We're still in the process of working out the best methodologies. Now, what everyone talks about is dry needling. There is a school of acupuncture that we can think of as potentially dry needling. But dry needling actually comes out of Travell and Simons work. Those are two physicians who developed the trigger point theory for how pain radiates. Actually, Janet Travell was JFK's personal physician; so she was very eminent even before she started with this work. They produced this anatomy charts that many people have seen with the red dot at the center and then the pink area around it that indicates how the pain can radiate. They are the ones who popularized dry needling using a needle without steroid in it to release a trigger point that you can feel.

Cassandra Holloway:

I often hear about how pain and stress can feed and play off of one another. How often are you counseling patients to get their stress under control when it comes to their pain management? Is that involved in your holistic approach?

Dr. William Welches:

Oh, boy! This is something that I'm working with Dr. Teresa Dews. She is a colleague of mine in Pain Management Department and also incidentally the president of Euclid Hospital. In her spare time, such as it is, she and I have worked on this very question. We identified four, what we call, pillars of pain. They are diet, exercise, sleep and stress. Probably of those four, the hardest to do is diet. The one that's impossible is stress and here's why. We live in a stressful time. So I try, when I talk to my patients about stress, and you can give them good advice. Meditation... Exercise is a good stress reliever for a lot of people. But stress relief is also idiosyncratic. There isn't a one method that works for everybody. What I try to guide them in and spend some time thinking about how they relieve their stress. Most of us don't even spend time thinking about stress as a problem. It is probably this single, biggest trigger for the patients that I see.

              One of the things that was a surprise to me in medical school and then beyond is stress is more than just a volume control on pain. When you have stress, that makes the pain worse. But how does it make it worse? I had always thought along psychological lines. It's not accurate. Stress actually causes physical changes that I can measure in the room. When they come in, I can feel the musculature. I can look at their alignment. I can see how they're out of alignment. I know it was triggered by a stressful incident or stress in general. I would get phone calls, "I have to come in and see you right away." They were in the emergency room last night and they were having a hideous time. Usually, this is coming from the low back and pelvis, which I can help them with. I can re-align it. Then, I ask the question, "Have you had a stressful incident recently?" The typical answer is, "Well, no."

              Why is that? Because most people eat their stress. I don't see a lot of people who come in who are hysterical and crazy about their pain. I see a lot of people who come in, who've been living with chronic pain. Then, when something triggers it, they fail to recognize it. This is very common in the caregiver field. No matter how you are related, but it can happen in other places as well, a lot of nurses, a lot of high seat physicians. They're supposed to be strong, first responders. They don't have time to spend time thinking about their pain and certainly not about stress. So it never happened.

Cassandra Holloway:

How often do you recommend one of your patients see a mental healthcare provider or a therapist to work through these kind of stressful feelings?

Dr. William Welches:

A lot of my patients come already having them referred. It's not as big a problem. Psychological counseling is definitely very important. A lot of the patients I see, it's not so much that they need that kind of professional. Sometimes what they need is something more like a life coach to help them. We do use psychologists freely in pain management. It can come up. Obviously, something like depression or anxiety are important components. If they're not being treated, then of course that would be the time that I would recommend it. One of the things that every pain management specialist will tell you you have to be careful how you bring the topic up because the first thing is, "Well. You don't believe me. You think I'm crazy." We don't, but that's one of the things that we have to be prepared to discuss. When we recommend this is because this is one more piece in your therapy.

              In my particular case, I have an advantage in that I can actually measure this up. I can tell them what's going on and point out to them how they're holding themselves loose. I can tell them, "This is not normal." And I know it's not normal. "You're not crazy. You're holding yourself like this 24 hours a day." It's a problem.

Cassandra Holloway:

You mentioned exercise and being active as one of those four pillars of pain management and wellness. I'm talking a little about just being active in movement. How important is it stay active especially when you're dealing with chronic pain?

Dr. William Welches:

That's essential. Now, one of the things that I recommend at every first visit is the 30-minute low intensity walk. This is 30 minutes walking, casual walking on a level surface and nothing else going on. So walking the dog doesn't count. Walking at work doesn't count. Carrying a backpack, you don't want to do that. All of those things are fine. You can do that. But that's not the 30-minute walk. In the 30-minute walk is a very low grade of exercise. In fact, what it’s designed to do is to work the joints. I'm not trying to get them to lose weight. I'm not trying for them to build muscle with that. What I'm trying to get is that their entire spine is used the way it's supposed to be used. Hominids have been on this planet for six million years of their about that we know of. When you go back to the first one that we know of, and you look at their pelvis, and you look at our pelvis. Then, you look at a chimp's or gorilla's pelvis. You see the differences instantly.

              We've been standing up and walking for millions of years. That is our most comfortable position. What are you and I doing right now? A chimp can do this easily because they're bent in the middle. They're designed to be bent in the middle. They walk on their knuckles. We're not designed for that, but we spend most of our day sitting. In fact, worse than that, we're pulling our heads into our computer screens and we're flattening up this curve as well as the lumbar curve. So, getting up, walking 30 minutes a day is a small price to pay for all of the amount of time that we're putting in to our spines that is not just bad for us, but painful. It'll ultimately result to pain.

Cassandra Holloway:

With that 30-minute walk, how many days a week do you recommend? Or is that every day that someone should be doing this?

Dr. William Welches:

Every single day. I don't deal with patients who have a little bit of pain here or there. I deal with patients whose lives have been transformed by pain. This is one of the big things. Lifestyle change is just probably the next big health explosion, bigger than antibiotics, bigger than all the surgical advances we've had recently. The only thing standing in our way is our commitment to it. I relate thoroughly because these are hard things to get a handle on.

Cassandra Holloway:

How often are you recommending to patients that come and see you that they also try physical therapy in addition to some of the treatment that you've recommended for them?

Dr. William Welches:

Not often. That's because usually they've already tried physical therapy and it hasn't helped. It does come up sometimes and I do use it in those cases. There's nothing wrong with it. It's a good adjunctive therapy. I think oftentimes it works best when both things are happening together.

Cassandra Holloway:

I want to talk about sleep since you mentioned that was one of the four pillars of this pain management and wellness. How does the quality of sleep often affects our pain levels?

Dr. William Welches:

It's a question of stress relief. To me, at least counterintuitive. People who don't get enough sleep put on weight. Would anybody have expected that result? There's a number of studies now that demonstrate that this is the case. Sleep is terribly important to a total healthy lifestyle and in ways that we're just now beginning to figure out. The stress one makes sense to me. I have to be honest, I was surprised when I found out that not getting enough sleep can lead to an increase in weight. Actually, it motivated me to take a look at how long I'm sleeping and make sure that I'm getting enough sleep.

Cassandra Holloway:

Do you have any strategies that you counsel your patients with about sleeping better in spite of their pain?

Dr. William Welches:

I really don't. The hardest thing to overcome is the amount of time they spent sleeping. That is what I run into as the biggest problem. I can't get them to give themselves adequate time for a good sleep. What people consider enough sleep... At least I know many of my colleagues think six hours is enough. They survive on that. Of course, that takes at some toll. But there are certainly recommendations. In those cases where patients are interested, we can discuss them. One of the questions I get over and over and over again is mattresses and pillows. There is no scientific evidence about the best mattress of the best pillow. It doesn't exist.

              This is a second career for me. My first career was as a scientist. I can tell you that any time you try to set up an experiment as complex as what would be the best mattress or the best pillow, this is why. Number one, not everyone is the same. We don't have the same anatomy. Number two, how would you test it? Well, you would go head to head: Beautyrest versus Serta, and so forth. You would have to test mattresses. And you'd have to do it with thousands of people. Same with the pillows. Can you imagine the complexity of those experiments? Now, who would pay for it? Well, mattress companies and pillow companies are not interested in paying for that kind of research. In fact, they would rather say that scientific research demonstrates which it doesn't.

              You can normally tell whether you're getting good information or not by looking for the reference. If you see with an ad or whatever that they've referenced several studies from John Hopkins or the Cleveland Clinic or Mayo... They're in journals like New England Journal of Medicine or JAMA, you can be relatively sure that research has been done and is reasonable. If you don't see that, then right away you need to be suspicious of any claims that are made on the internet especially with regard to that. So I have to tell people, "No." When we don't have any evidence, what we recommend is for...

Cassandra Holloway:

Sounds a lot like trial and error, figuring out what works best for the patient than when it comes to sleep position, pillow, mattress and all that stuff.

Dr. William Welches:

Absolutely.

Cassandra Holloway:

You mentioned diet and nutrition as being one of the most difficult aspects of this four pillars of pain management and wellness. What types of diet or eating patterns are best for someone suffering with chronic pain? What do you counsel your patients about when it comes to nutrition?

Dr. William Welches:

The diet we recommend is the anti-inflammatory. There's a number of diets out there. Even the anti-inflammatory has many different formats. It's really impossible. Actually, this is something that Dr. Dews and myself are working on right now with a group of student researchers, trying to put together the best advice. What I tell people in general is if you have something that gives you joy, it's off the diet. Everything you like isn't there. Everything that's been difficult, for most of us, is. Right now, I'm in the middle of my breakfast, which is about a pound of raw vegetables. This is what I eat everyday for breakfast. I don't eat a pound of raw vegetables because I enjoy them. This is a case of I do this because it's good for me. This is a hard part of this and I don't try to sugar coat that.

              In fact, I believe in telling people, "You're not going to be able to do this all at once. You're going to have this in stages because it's difficult to give up the things that we enjoy." You don't give them up totally, but pretty nearly. People ask me about steak, beef and pork. And I say, "We should be eating those the way we eat turkey: twice a year." That's a hard thing to look at. I don't know anybody who can follow that perfectly. But what if I could get rid of 90% of the red meat that I eat? That's big. That's what we should be going for is that sense of commitment to improving our diets.

              It turns out, I think, probably in the long run, we'll come to the conclusion that the vegetarians were right, or at least mostly right. We should be eating a lot more complex carbohydrates than we do. We need to stay away, like I said, from everything that is really quite enjoyable to eat. I often tell people when they offer me this or that thing that looks wonderful, looks delicious but I can't eat it. That's part of dealing with a healthy lifestyle. Chronic pain patients do have motivation.

Cassandra Holloway:

I like how you mentioned, though, that you don't have to make all of these changes all at once. Just factoring it into your lifestyle and starting off slowly, and adding things a little at a time. You don't have to change it overnight like you said.

Dr. William Welches:

Yeah. I started interestingly off with our diet, my wife and I. We started with fish because neither one of us cared that much for fish. Could eat it, but didn't care for it. Started introducing that to our diet a couple of times a week. Now with fish, age is important. There's always a mercury contaminant component. The wild fish as opposed to the farm fish are better about that. What you want to do is pay attention to the age distinction. If you're under 50, you probably should be careful. Maybe once a week, even a little less. If you are over 50, then two to three times a week is probably fine. That's just has to with the way that mercury goes up in your system.

Cassandra Holloway:

Are you the one who's often counseling patients on diet and nutrition? Or do you out source that out to a nutritionist?

Dr. William Welches:

We have never been able to successfully set up a program. We've tried several times and we've never done that. That's one of the projects that we're working on right now is how to introduce this to patients. Of course, one of the biggest problems we have is buy in. Patients are very reluctant to make these kinds of changes. Again, I'm not going to pretend I don't understand what they're talking about. These are hard changes to make in your life.

Cassandra Holloway:

You often hear about the importance of staying hydrated. What are your recommendation for water intake? How much water should a patient be drinking everyday?

Dr. William Welches:

There is no correct amount. The science behind eight glasses of water turns out to be... The original report turns out to be misunderstood. Between what we normally drink and the food that we eat, we get about eight glasses of water. But there's nothing important about eating and drinking an additional eight of glasses. Now, having said that, there are certain people in my age group who need to be careful. We don't always get as much fluid as we should just in the normal course of things. Elderly people need to pay attention to that. I have a group of runners, very athletic people who need to pay a lot of attention to how much fluid they're getting because they use it up a great deal. People who do manual labor who do any kind of activity where they're working. They need to pay attention to how much fluid they're getting. So I don't give them a number as much as... If you're in one of those groups where you may not be getting enough fluid, be working in a bottle of water. That's pretty much all day.

Cassandra Holloway:

When should someone seek care for chronic pain? What type of doctor should they start off with?

Dr. William Welches:

The rule of thumb I give is when it begins to interfere with your function. You can no longer function normally. Then, you need to move it up to a physician. That varies for various people. A lot of people I see put it off too long. I view that as just the different kind of people that we are. That some people are ready to withstand more pain to keep doing things and not have their lives interfered with. Then, other people who are ready to recognize that, "Yeah. This is gotten too far." But everybody hits that point usually, somewhere along the line. I don't have a good piece of advice for people. If you can do it sooner than later, that's probably a good idea. It's always easier to handle it when it's sooner. But I also understand what it means for a lot of people who have to work, have to hold on a job, and have to confront their realities.

              The person I recommend, and this is partly my training. They also trained basically as family practitioners. We specialize. But we start off as family practitioners. That's where I would start. Start with your family practitioner. There's nothing worse as a family practitioner than to be surprised by a program that the patient is involved in that you never knew about. You're finding out about it maybe under less than ideal circumstances. So start with your family practitioner so that they know what's going on, and that could even include a phone call to your family practitioner, "I heard about this doc. I think he could help me. Can you give me are referral?" That kind of thing. It can happen that way. If the family practitioner's comfortable with that, there's no reason why it shouldn't. But at that point, he or she already know that you're going to be getting involved with the pain management department at Cleveland Clinic despite of whomever you choose to help you with your problem.

Cassandra Holloway:

Why is it important to seek care for chronic pain even during a global pandemic when some people might not feel comfortable coming in to health care? Why is it still important to treat that pain?

Dr. William Welches:

First reason is that'll get worse. It'll begin to interfere with your function, even worse that it is now. We see that. That could happen rather suddenly especially in my field. I've seen patients come in when things got very much worse in just a month or two. Starting from a problem they may have had for 10 or 20 years. The COVID question is legitimate. Now, I want to start off by saying how much care the Cleveland Clinic takes in preventing any spread of the COVID. I wear scrubs. I used to wear coat and tie, but that's no longer appropriate. So I wear scrubs. I wear face mask. I wear a shield, so does my nurse. We're very careful. We wash our hands obsessively. We have the patients wash their hands, too. We go through a lot of trouble. But I can sympathize with people who are worried.

              I really do think that we're doing a really good job. I'm really impressed with all of the clinic facilities. We are in a position now where things are getting better. I think that part of what we need to understand is the massive vaccination that's been going on is really having a powerful impact. I think that things are much better than they are. I don't want to diminish anyone's fear about taking care of themselves or being concerned. But I do think that we're doing adequate job and really taking care that we don't spread this terrible disease.

Cassandra Holloway:

The last thing I want to ask you about today is just for your general advice to someone listening to this podcast. Maybe they're suffering from chronic pain and at their wit's end. What parting advice do you have for them about just the importance of trying to figure out this pain so that they can back to their lives and stuff they enjoy?

Dr. William Welches:

I think that thing that I would start off with is get help. I have patients who we're getting to a place where we're beginning to get them to help manage this pain. But it interferes with your life and there's the potential that that will increase as time goes on. When you hit the point that you're beginning to think about it, that's when you begin to need to think about, "Where am I going to go with this?" I did recommend primary care, but also there's nothing wrong with you being aware of that fact that there are pain management departments out there. All of the major hospitals in the Cleveland area have programs. Of one I'm most familiar with, of course, is the Cleveland Clinic program which I could vouch for. No matter who you see in our department, you're going to get a thorough examination and a plan of action that will begin to separate out those things that can be helpful and those things that aren't.

              Management means just that you're going to be presented with many options. But those options need to be ones that work. That's part of that process. I know that that's not something we like to think about, but it is a process that requires thought and care in collaboration between the physician and the patient.

Cassandra Holloway:

Absolutely. That's wonderful advice to end on. Dr. Welches, thank you so much for joining us and sharing your insight today. We really appreciate it.

Dr. William Welches:

Thank you.

Cassandra Holloway:

To learn more about pain management, visit clevelandclinic.org/pain. Thanks again for listening.