Integrative Ways of Dealing With Chronic Pain with Guest Dr. Michelle Dang, MD

Michelle Dang, MD is a board certified anesthesiologist and pain management physician who is fellowship trained in Integrative Medicine. On today's episode, she is our honored guest as we discuss the wide array of modalities and therapies that could be used for natural healing of chronic pain. If you're tired of dealing with your aches and pains and want to do something about this, make sure to listen to this episode as it's not something you want to miss!

1:00 - Michelle Dang's Integrative Med Journey
4:45 - How to do integrate Integrative medicine with Pain medicine
5:30 - Select Chronic Pain Patients ready for integrative Medicine
8:45 - Low back pain
11:05 - Tips for Musculoskeletal Complaints
13:08- Water Therapy
15:50 - Mind Body Connection in Pain
19:25 - Injection Use
21:53 - Supplements for Pain

Find Dr. Michelle Dang at www.michelledangmd.com, IG @michelledangmd, or her podcast: The Wish Well.

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Transcript

Dr. Carrie Lam, MD: 0:06

Hi, I'm Dr. Carrie Lam and today we have a very special guest who's a Board Certified anesthesiologist and pain management physician. Her name is Dr. Dang. I've had the privilege of being on her podcast, so I asked her to be a guest on our podcast. Her podcast is WISH Well and she specializes not only in pain management, but in integrative medicine, in addition to the pain. Today, we're going to be really talking a lot about how she integrates integrative medicine in her practice and how she helps her patients with pain. Welcome to The Dr. Lam Show, Michelle.

Dr. Michelle Dang, MD: 0:47

Hi, everyone. I'm Dr. Michelle. Dang. I actually interviewed Dr. Lam a few weeks ago, so hopefully we'll be able to get her episode posted soon. I am super excited to be here.

Dr. Carrie Lam, MD: 0:59

Why don't you tell us a little more about how you came on this journey of yours?

Dr. Michelle Dang, MD: 1:05

It's a little bit of a convoluted journey, so I'll try to summarize it. As you mentioned, my background is an anesthesia and pain management. Anesthesiology residency after medical school is four years, and we have the option to do a subspecialty or fellowship training. In anesthesiology, you're in the operating room for the most part, doing very important things, they keep patients asleep for surgery and monitor them. There's a whole lot more that goes into it, but during my residency training, I did miss the continuity of care, I missed seeing patients, I missed being in clinic. So I decided to do a fellowship in pain management. In pain management, what we primarily dealt with is chronic pain, any type of pain that is greater than three months, and we utilize different modalities, medications, as well as injections in order to help patients feel a little bit better. That fellowship program was one year. After fellowship, it's been almost a decade, and I started a practice. Being in private practice for a period of time, it gets a little bit overwhelming, just because chronic pain is a very challenging thing to treat. In my practice, I started going through some personal issues and in my personal journey, I discovered yoga. I utilized yoga more for emotional healing and things like that, but I also felt physically so much better. I was feeling the little feelings of burnt out in private practice. That was when... I mean it was burnout for a variety of reasons. But like I mentioned, chronic pain patients can be quite challenging. During that time, I remember I was googling different types of fellowship programs or different education because I thought if I felt better by doing yoga, surely there's something out there. This was back in 2013-2014, when I started kind of looking into integrative medicine. That was when I discovered that there was such a thing. That was when I discovered integrative medicine. I looked into various... I know nowadays, there's a lot of different fellowships out there. But at that time, I think the big ones were integrative medicine and functional medicine. Because of my background, I did complete a yoga teacher training. I decided that integrative medicine was calling to me more just because it incorporated a lot of movement therapies. I really wanted to go through the fellowship program for myself as well as to utilize those tools for my patients. I completed my integrative medicine fellowship in 2018. That's kind of my long story, short story of how I discovered integrative medicine.

Dr. Carrie Lam, MD: 4:10

Wow, that's really cool. You went through it, I feel like most people that end up in integrative medicine have a personal story of some sort, and that's how they get into integrative or functional medicine. That's a very common thing that I hear and that's great that you're able to use your knowledge even from before and integrate it with what you are practicing now. How would you say that you're using your pain management skills currently and how do you integrate it with the integrative medicine?

Dr. Michelle Dang, MD: 4:46

My story now is a little bit changed and I'll share with you. I haven't really talked about it a whole lot on my podcast, but I actually took a break from clinical medicine recently during the pandemic. Right now, we're kind of in the early 2021, but I decided to leave clinical medicine for a period of time. I had been in practice for quite a while, and like I mentioned earlier, was feeling really burnt out. So I left clinical medicine in October of 2020, and now I'm getting back into it on my own terms, but that's probably a different podcast on burnout. When I was in practice, I really enjoyed the chance, the opportunities that I had to incorporate some integrative medicine techniques for a select number of patients. I say'select' just because when it comes to chronic pain, there's so much that goes into it. Not just the organic reason of why a patient is experiencing pain, but also there's such a huge emotional behavioral component to it. Many patients, or I won't say many, but some patients are just not ready to hear what other things are out there to help them feel better. Because sometimes an injection or a medication is just really not going to help them if there's other issues that are contributing to them feeling the way that they're feeling. But for the ones who were open, they've tried so many different medications, they can't tolerate it, or it doesn't work or it's not effective. They've tried injections, but it just keeps coming back just because they're not addressing the underlying issues. Those patients when they come to me, and they say, "I'm ready to hear about anything else, what else can I do?" Then, I can talk to them about cognitive behavioral therapy. I can talk to them about water therapy. I can talk to them about movement therapy, like yoga, or even Tai Chi, which is really great for the muscles and for the movement and for the spiritual emotional component. So at that time, I can really talk to those patients. But I think in my experience, I have to just meet those patients where they're at. i think going through the integrative medicine fellowship has really helped me because one of the very first things that we learned about in our fellowship program is motivational interviewing. It's kind of letting the patient take the lead. I also completed a health coaching certification recently, as well. That was part of it, too. It's just you want to empower the patients to have a little bit more control over their health.

Dr. Carrie Lam, MD: 7:17

That's great. To work with the patients, that's what most most of us try to do with integrative medicine, to come to a meeting point. They might not go from having so much pain to pain free right away. But definitely going step by step is a very important thing that you're dealing with, I think, little by little.

Dr. Michelle Dang, MD: 7:43

I tell people.. like I said, my specialty is chronic pain, so one of the things I tell a lot of my patients is that, I ask them what their expectations are in terms of their pain issues, or their pain concerns. If they tell me that they want to not be in any pain, you have to at that point, kind of be realistic that pain is a normal response. To not be in pain is just not a normal thing. I mean, if you stub your toe, that's going to hurt, you expect that to hurt. So I think shaping the patient's expectations is helpful as well. Just to let them know that inflammation and feeling the pain is a normal body response.

Dr. Carrie Lam, MD: 8:28

Managing expectations, that's great. What would you say is the number one type of pain that you see, or the thing that is easily fixable or more easy than compared to others? I don't know if there's a way to say that. Something that you see very

Dr. Michelle Dang, MD: 8:49

What I see a lot, just in my practice is just your standard often, I guess. kind of, "I pulled my back", so a lot of spinal pain is what I see. But many times what ends up happening is, the patients get advanced imaging, and their imaging shows up, "Oh, I have this disc herniation, oh my gosh, that's why I'm having pain". But when you examine them, a lot of times, it may not necessarily even be that disc that's causing the issue. It may be something like a muscle strain, or they slept wrong, or they have myofascial or musculoskeletal pain, so it's not necessarily the issue of what's on their image. I do have that discussion with many patients who come in having already had imaging done and then they're very focused on the results of their imaging. I tell them, "I've never had any imagin done I kind of think that I'v hurt my back a couple of times, but it's fine, you don't fixate on it". I've had some patient who go and have underlined an circled every single bit o their MRI report and they'r just like, "This is why I' having pain". When in actuality their pain is in their lowe lumbar spine. Then the issue i the MRI is actually in thei higher L-1, L-2, so it' completely different. I tel them the MRI and the images hel us with our diagnosis, but jus because something shows up o your image doesn't mean that yo'll actually have symptoms. S we treat the symptoms, and not ust the image, which I find.. I mean, everybody pract ces differently. But there are t mes where I've had patients who I've come to me from other physic ans who've had every single gle injection based on that im ge, and it's really not even the issue.

Dr. Carrie Lam, MD: 10:36

I love that. Trying to really not treat just the labs or the imaging, but really your clinical diagnosis and helping their symptoms along the way. That's really great. What are some simple tips you would give to someone who might have a musculoskeletal, kind of like a strain or a sprain in their lower back? It's not like the imaging needs to show anything, but if you think it is more of a musculoskeletal, are there any simple tips that you would recommend?

Dr. Michelle Dang, MD: 11:08

Yes, I would recommend... I mean, it sounds counterintuitive for many people who are in pain, but to move. A lot of times, what happens is that if you pull something, and I am guilty of it myself, if I pulled something, the last thing that you really want to do is to really move but in actuality moving and getting those muscles going, will help the healing process. Even if I've pulled something, sometimes depending on obviously what it is, I can roll it out, or I can do some gentle stretches, yoga is great. There's so much out there I think available nowadays, that's free and accessible. YouTube videos on specific yoga poses for whatever specific type of pain that you have. Whether it's in your neck or your back, you can do very gentle exercises. The important thing is to listen to your body and that's, I think, really challenging. I know many people have problems with that, knowing when it's too much, and also knowing when it's not enough. Stretching and feeling that stretch is good, but pain is obviously not good. Sometimes it's a very fine line. People who are not used to really moving their body may have difficulty in the beginning with really recognizing when it is a good stretch, when it's a good type of stretching sensation versus when it's painful, and they need to stop. Getting someone to help them might be the next step to get that fine line between too much pain and just stretching? Yes, it's that and also just getting to know your body. I think that just takes a lot of practice. But in the beginning, there are a lot of gentle moves you can do that will not cause any injury or cause any pain and you can definitely start there,

Dr. Carrie Lam, MD: 12:59

That's really good. Are there any other... I know you talked about water therapy. Can you kind of go into that a little more?

Dr. Michelle Dang, MD: 13:09

In my training, we learned a lot about fibromyalgia, which is kind of like the disease that nobody ever wants to talk about it because it's kind of like the disease of exclusion where everything hurts. Nobody knows what's wrong with you. "Oh, you have fibromyalgia." I learned about it just because.. well, we learned about it in order for us to treat it. One of the great tools to help manage the pain of fibromyalgia is water therapy. I do recommend it to many of my patients who may be morbidly obese, who aren't able to even do any kind of gentle stretching. Their body is just not used to moving in that way. I recommend water therapy. It may be challenging now in the time of COVID, but it's great just to have people who aren't used to moving their body who can't really tolerate land physical therapy, which I love physical therapy, but to be able to do something inside of a pool. The reason why is because you can do basic physical therapy exercises, but inside of a pool, which allows people to do a lot more than they're able to do on land, or in general. So I think it's a great stepping stone for people who are not used to moving their body. Even if... we used to have it, it's funny in my fellowship program, we had this Xerox copy of aquatic therapy exercises, I can still picture it in my mind. It's literally very basic exercises like a picture, like a stick figure of a person walking in a pool and doing lunges in a pool and it's the most basic handout but it was one that I photocopied a zillion times. I even had it at one point when I first started private practice. I don't have it anymore, but it's really funny because I would hand it to a patient and say "If you have access to a swimming pool, do these exercises". It looks silly because it's basically just somebody walking in a pool and doing walking lunges, but it's just something you can hand to patients. Anyways, I do tell patients if they can't get into aquatic therapy, if they do have access to a pool, preferably a heated pool because that feels nice, just basic walking inside of the pool, obviously in the shallow end, walking up and down, just getting your body moving. Because they likely wouldn't be able to or wouldn't do that on land.

Dr. Carrie Lam, MD: 15:32

That's great. Less gravitational pull and maybe in the actual pool too and less joint aching. That's really water therapy. Just basically working out in a pool, right? Then you talked a little about cognitive behavioral therapy. Can you kind of also explain how pain and how the mind and the psychiatric part of it works together? What's the connection? How do we help people with their pain if we think that yes, they have some underlying emotional or behavioral issue?

Dr. Michelle Dang, MD: 16:09

I'm not a psychologist, but I do recommend for patients who do have a lot of fixation or a lot of anxiety associated with pain, to see a psychologist. Preferably somebody who has experience with dealing with pain patients. The reason why I say that there's such a psychological or emotional component to it is that besides the organic issue of pain, if there are other issues going on in a person's life, it can definitely affect their pain, and make it a lot worse. I will ask some of my patients what their support system is like, and more often than not, for these chronic pain patients, they have a really poor support system. Because they don't have a good support system, they feel very overwhelmed. That one issue is just too much for them to handle, and then it causes them to kind of go into this spiral. For that reason, I think, for many of these patients, they can really benefit from talking to somebody to see what types of tools they can utilize in order to reduce some of those extraneous issues that can contribute to them experiencing such a high level of pain. Also related to just pain psychology is what we learn about in integrative medicine as well. What we learn about with medicine, in general, is the benefit of something like biofeedback. So things like if you feel very anxious, if you feel like you're having a panic attack, your heart rate is elevated, doing something simple like taking big, deep breath, a really slow big deep breath can reduce your heart rate, and then thereby reduce your anxiety. The same thing can can be the case for pain. Like I mentioned the stubbing of a toe, if I stub my toe, my heart rate will immediately spike up, I'll feel that pain. If I stop for a moment, take a couple deep breaths, that pain will subside a lot quicker.

Dr. Carrie Lam, MD: 18:12

I love that. I do tell my patients a lot about breathing and how even the Yogi's in India are able to control their heart rate just by slowing down their breath or increasing their breath, but they can control their heart rate just like that.

Dr. Michelle Dang, MD: 18:27

It's that sympathetic response, I think that you get from when you stub your toe, and now you're trying to bring back up that parasympathetic to calm your system down, say, "It's not that bad, right?" So, you don't have to make a big deal about the anxiousness or the pain that you're going through and rewire that to somewhere more productive, which would be like the breath and the vagal nerve response. I think we have more control over our body than we think we do. I mean, of course, there are a lot of issues we don't have control over. But things like your breath, you have control of your breath. I tell my son whenever he gets super anxious, to take slow, big, deep breaths, and he feels a lot better, even though he says he doesn't, but he does. In that sense, I want to empower people and my patients that there are certain things you can control and your breath is one of them.

Dr. Carrie Lam, MD: 19:25

Like you said, you came out of the previous practice where you did shots and meds. How do you view those nowadays and who would you recommend those for? Are they more acute or what is their long term effects in patients? I definitely think that there is a place for Western medicine, meaning injections and medications, but there's a place for everything, I think. I think what we learn about a lot in current medicine is multimodal approach. I think if a patient comes in with an MRI, big herniated discs, ridiculopathy or pain going down the leg. They tried resting, tried movement, tried everything, tried medications, and they're still in a lot of pain, they're not able to move because of the pain, there's certainly a place for injections. There's a variety of injections that we do with chronic pain management. There's epidural steroid injections, which many people have heard of, and that's for pain going down the leg or going down the arm. There's joint injections, there's just a whole variety of different tools that we have. I think the benefit in seeing a pain management physician is that we have all those tools in our arsenal to help manage some of the pain whenever it spikes up. That being said, I still think that there is definitely a place and I think every patient should definitely do some sort of conservative management and active component. Meaning some sort of movement therapy, whether it be physical therapy, or yoga, or chiro, or anythin that allows or helps patients t move. I think, despite all th technology we have, in terms o all the different types o injections that we can do, if patient gets an injection an they're not addressing th underlying issue, they're no moving their body, they're gonn just go through that cycle wher they're just constantly doin medications or injections. think in the long run, it' really not that beneficial fo that patient I love that. It's more of like an acute, right? Conventional medicine is really good for acute treatments and helping to hide your pain. But what is the long term root cause? It would be to move or to get that underlying issue resolved, maybe with the cycle part of it, or the emotional part or even the the pain or the trauma that you've had in the past. Going back to just integrative medicine, are there any alternative, like supplements or nutrients that you use to help people with pain if they don't want to be on medication?

Dr. Michelle Dang, MD: 22:05

Yes, I always recommend... I think, in general, many of us are low or deficient in vitamin D. So I would recommend to help reduce some of the inflammation, to help with their chronic pain, to supplement with some vitamin D, supplement with some fish oil. I think those are two of the ones that I recommend, just because I also take them. There's a lot of other things you can do. You can do turmeric, and that helps with inflammation as well. I try to, when patients ask me about supplements, I don't try to overload them with every single supplement. I mean, there's probably, I don't know, 10 to 15 different supplements that people can take and I worry sometimes just because I feel like we're going from one end to the other. On the one end was all the traditional Western medicine, all the medications you would take for pain. Like neuropathic pain medications, maybe even narcotics, NSAIDs, all those. So you have patients who come in with taking five different medications, prescribed medications. Then you go to the opposite end now, "I don't want to take any of these medications, but I'm willing to take like 10 to 15 different supplements". Many of them are not regulated or anything like that so you kind of run into all these problems. Or then you have the patients who do both. So I try to caution patients, "Just do a little bit, if you want". Like I mentioned, vitamin D, I think is always great. Fish oil is good, just with omega three fatty acids helps to reduce the inflammation, and we definitely don't eat enough in our diet. But the one thing I tell people is a lot of these patients don't have the best diet. That is the one thing that, like I mentioned, they can control. You can control what you're putting into your mouth, and you can control what you're cooking, what you're eating. That is probably the easiest, yet seems to be the hardest thing to change for many people is exactly what they're eating. It's easier, obviously, to go to McDonald's or to Jack in the Box. It's harder to really sit down and think about making healthy choices in terms of what you're eating. That's so true, diet and lifestyle. That contributes to the weight and then that contributes also to the extra, the pain that might be building and the inflammation, definitely. I think we learned so much about pain management, and also how you practice and how you can use integratively. What's your favorite yoga stretch? I guess I would say is there any thing that's easy for someone who's just getting into it, that you would recommend? The number one stretch that you would recommend. The number one, oh my gosh, there's just so many. I don't know if you've heard of the Cat-Cow stretch. I think just getting your body warmed up and getting your core warmed up is great. Cat-Cow is.. the cat pose is when you round your back and then the cow pose is when you extend your back. It's so great. It's a great warm up pose to core work. You can do that actually sitting. Most people think of Cat-Cow as you're on all fours with your knees down and your hands down. But you can actually do that sitting just cross legged or however sitting poses are comfortable for you. You can just do that while you're sitting. For people who think, "Oh, I have to get on the floor, I have to do this and that", no, you can just do that sitting down and it feels so good. The best is after you do the Cat-Cow where you're extending and then rounding your back, you can do Cat-Cow rolls, where you're just kind of rolling your body, and it feels good. You should try it.

Dr. Carrie Lam, MD: 25:44

That sounds really amazing. I'm going to definitely do that. Thank you so much for educating us. How do people, if they want to find you, where would they find you? Why don't you let us know?

Dr. Michelle Dang, MD: 25:56

Excellent. Like you mentioned, I am Michelle Dang. You can find me on my website, it's michelledangmd.com. I am on social media. I'm on Instagram@michelledangmd as well. I do have my podcast which is the WISH Well. It's the Women's Integrative Summit on Health and Wellness. I have to figure out a way to shorten it a little bit. But the podcast is available on iTunes and Spotify, Google, everywhere. You can find that on the Instagram pages which is@wishwell.health and you can look on any podcast platform to find to find it.

Dr. Carrie Lam, MD: 26:34

Thank you so much. We really learned a lot from you. I just really welcome you to our Dr. Lam Show and we hope that everyone can continue to subscribe, both to WISH Well and also to The Dr. Lam Show and stay tuned for our next episode. Excellent. Thanks for having me.

Disclaimer: 27:00

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