There’s no one-size-fits-all approach to chronic-pain management. Each person’s story is unique and requires individualized care that often includes non-opioid therapies. Sara Hall, a clinical nurse specialist in pain management at Regions Hospital, shares how a 2020 grant helped her team develop a yoga program that’s more accessible for Spanish-speaking patients with chronic pain.
There’s no one-size-fits-all approach to chronic-pain management. Each person’s story is unique and requires individualized care that often includes non-opioid therapies. Sara Hall, a clinical nurse specialist in pain management at Regions Hospital, shares how a 2020 grant helped her team develop a yoga program that’s more accessible for Spanish-speaking patients with chronic pain.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Sara Hall
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Programa NeuroWell/Dolor
Manejando Mi Dolor con Yoga
¿Tiene dolor crónico? Está pensando intentar el Yoga, ¿pero preocupado que el Yoga pueda ser demasiado desafiante o que empeoraría su dolor? ¡Este curso podría ser para usted!
Yoga puede aliviar la tensión y mejorar el dolor
Enseñado por instructores certificados de yoga con capacitación adicional en el dolor crónico, este curso le mostrará los fundamentos de cómo crear su práctica de yoga y ayudará a entender porque el yoga ha sido demostrado que reduce el dolor crónico. Sara Hall es una enfermera que ha trabajado en el campo de manejar el dolor por más de 15 años y combinado la ciencia del yoga haciéndola accesible a aquellos con dolor crónico.
Ofrecido en formato digital en linea, este programa le permit progresar a su propio paso, y le ofrece el beneficio de que pueda participar de cualquier lugar y a cualquier hora que desee enfocarse en su bienestar.
A medida que yoga se vuelve más popular, también aprendemos más de sus beneficios de salud
Mejoramiento de:
También incluidos en este programa hay contenido y recursos adicionales.
Manejando Mi Dolor con Yoga lo dejará sintiéndose empoderado con herramientas para mejorar su bienestar, aliviar tensión, y controlar su estrés.
**Patrocinado por HealthPartners y MDH**
Visite https://myneurosciencecenter.com/MyNeuroscienceCenter/learnabout/10062 para registrarse.
Email: myyoga@healthpartners.com
Manage My Pain with Yoga
Do you have chronic pain? Are you thinking about trying yoga but concerned about it being too challenging or making your pain worse? This course might be for you!
Yoga can relieve tension and improve pain
Taught by certified yoga instructors with additional training in chronic pain, this course will take you through the basics of building a yoga practice and help you understand why yoga has been shown to reduce chronic pain. Sara Hall is a nurse who has been working in the field of pain management for more than 15 years and has blended the science of yoga with making it accessible for those with chronic pain.
Offered in an online format that's self-paced, this program has the benefit of being able to participate anywhere and anytime you want to focus on your well-being.
As yoga is growing in popularity, so are the known health benefits
Improved:
What to expect
Each module includes:
Also included in this program is additional resources and content as well as the option of meeting live with health care providers who are also trained as yoga instructors (for an additional fee).
Manage My Pain with Yoga will leave you feeling empowered with tools to improve your well-being, relieve tension and control your stress.
** Sponsored by HealthPartners and the Minnesota Department of Health**
Visit https://hprfstudies.org/redcap/surveys/?s=RKXN8YE3E3 to register.
Email myyoga@healthpartners.com for more questions.
Kari Haley:
He is a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Dr. Haley and Dr. Jackson:
And this is "Off the Charts."
Steven Jackson:
Hello and welcome to "Off the Charts," where we ask candid questions about what equity means in health care. Our guest today is a clinical nurse specialist in pain management at Regions Hospital here in St. Paul. Sara Hall, welcome to the show. How are you today?
Sara Hall:
Thank you. I'm doing really well. Thanks for having me.
Steven Jackson:
So we're going to be talking chronic pain. We'll be talking about more specifically improving access to yoga for chronic pain in the Spanish-speaking community. How did you get into chronic pain, just to start?
Sara Hall:
Yeah, so my career goes back over 20 years and when I was in school to become a clinical nurse specialist, I had a mentor who worked in pain management. And originally I just wanted to work with her because she was a really good clinical nurse specialist. And I quickly became really passionate about chronic pain because I realized we have very little training in the health care field about chronic pain, and oftentimes people approach it with a very cookie-cutter approach and each person's story and how they manage and maneuver and navigate through their chronic pain is very, very different. And what they really need is an individualized approach.
So I found it to be much more complex and also kind of a hot potato in health care. Some people really find it challenging and don't want to deal with chronic pain. So over the years, that's kind of how I got started and I've been doing that for 20 years now.
Kari Haley:
Was there any particular piece when you were being mentored or a particular patient story that really stuck out to you that were like, this is why I want to do this, or this is a change that I saw that really made a big impact on me?
Sara Hall:
The common approach in the hospital setting where we want to treat pain aggressively and treat it with primarily medication focused, which in the acute setting, if there's a trauma or a serious illness, that's very appropriate. But a lot of people want bigger, broader options than that for pain and really appreciate when you talk to them about things outside of it.
Steven Jackson:
Here on this podcast, we talk a lot about trust and making inroads into the community and meeting people where we are and a lot of themes and topics in that area. Is it similar in this case as well?
Sara Hall:
Yeah. Thanks for that. I appreciate it. It all kind of came about serendipitously when the Neuroscience Center opened in 2017 and that allowed multiple, different departments under one roof to work closely together and collaborate. And so the department of pain management is there, the department of rehabilitation and neuroscience research are all housed under one roof. And we started talking about ways that we could approach pain in different ways, and that really led one thing to the next.
So in 2020 we had the opportunity to get a grant from the Minnesota Department of Health, and it was to explore non-opioid therapies for pain management. The state said, "In light of the opiate epidemic, we really want to put a spotlight on what are we doing other than opioids for chronic pain across the state because there's little silos here and there, but as a health care community, we really don't know."
And so that led us to develop what we had been doing in person with patients with chronic pain where we had a yoga program and look at how can we make it more affordable, more accessible, and reach a broader diverse audience. So we took our in-person yoga program and transformed it into a free, web-based program with the dollars from the grant. And then we also said, what population other than white English-speaking could we reach? And doing some research and looking at the Hispanic community, it's the largest minority community and growth in the Twin Cities between 2010 and 2018 was over 28%. So we felt it was a really good opportunity.
Again, at the same time, we had a partner upstairs in the Center for Memory and Aging, and she was a Care Ecosystems program coordinator, and she was the one that really connected us with a community site within the Twin Cities that was already offering free programs for their Spanish-speaking community, and they wanted to be sort of our pilot or satellite site to offer this.
Steven Jackson:
Nice.
Sara Hall:
Yeah.
Kari Haley:
How did you go about then creating a program within the Spanish community if there was any opposition or if there was any barriers that you had in it and how did you overcome them?
Sara Hall:
Yeah, the beautiful part about it was with that connection to the site coordinators at this community site, they were already offering free programs for their seniors, their Hispanic seniors, based out of wellness and well-being so it fits so nicely and with what they already offered.
Another partnership that formed out of this was I was working with the University of Minnesota School of Nursing and I had a doctoral nursing practice student or a DMP student who wanted to do a project. And so she acted as that liaison to be on site with the community's clinic that was already offering programs for their Hispanic seniors. And so she would go and show our program once a week and the site coordinators were bilingual so they would serve as translators. And out of that, there were very little barriers to them receiving this and we collected paper surveys pre and post for that community site.
Steven Jackson:
I love that. Like what you're doing, what you're talking about is just so in line with not only the theme of this podcast, but also just a lot of the work that we've been privileged to hear about just sitting here and facilitating. I'm hearing a lot of things just meeting our patients where they are, meeting our community where it is.
And even something you said earlier about how maybe people that are Hispanic, maybe they deal with chronic pain or even acute pain differently. And I just think there's something to be said about that because the well-intended, you often hear people say, "I treat everybody the same." Well, you can't treat everybody the same because you're going to miss something. And so just that theme of figuring out what it is this population needs and then being able to provide that is just the epitome of what we're trying to do. I think in health care with a focus on equity and making sure people have what they need. So yeah. That's great.
So Sara, you often hear about in different cultures, individuals deal with pain differently. In some cases there's a stoicism where you don't talk about pain or your feelings or your mental health, and then others talk about it a lot, and then there's a lot in between. So just wondering how those factors have impacted your impact in the pain space and what are some aha moments or even some learnings that you or your team have come across?
Sara Hall:
Yeah, it's a great question because I think everywhere in health care we're seeing an increased diverse patient population, and it's up to us to understand and really meet their needs. And especially with chronic pain, there's a lot of cultural and ethnic backgrounds that strongly influence how people not only perceive, but how pain is manifested and then their management of pain. So that comes up on a daily basis, I would say.
And there's been some great, great studies that don't have really great results. There's reduced access to care. You guys have talked about that many times on this podcast, and they're all too familiar with that.
Steven Jackson:
Yeah.
Sara Hall:
Unfortunately, chronic pain is more highly prevalent among the minority populations. They often work manual jobs. They might have higher histories of traumatic events or poorly controlled mental health and trust issues with the health care system. So there's a lot there. Not to mention the stigma around opioids and reflecting even with my colleagues, unfortunately, I'll still see it where people are afraid to give opioids to a condition that would warrant aggressive treatment based on a race.
I think of the one population that we repetitively will see is sickle cell patients. Right? I wish I had more solutions, but I think at least building that awareness then reflecting on our own biases as health care providers.
Steven Jackson:
Yeah, that's awesome.
Kari Haley:
This is just springing up a few questions in my mind, too. Like I know, so as an emergency medicine physician, I mean, we often have people come in. Most of the time it is truly an acute pain, so we treat those with our normal methodologies, but there's not an insignificant amount of people who do come in with chronic pain. It's either a flare or it's just not well controlled. And from an ED perspective, it's like how, I don't really have a lot of tools in the toolbox to give you pain management. And you've come in and oftentimes that leads to dissatisfaction I think on both sides where we are not going to give opioids necessarily to help manage the pain, but then we don't really have anything else to offer other than a lidocaine patch or over the counter type medications.
So the patient still leaves in pain, and as the provider, you don't feel good about the fact that you didn't help the person and/or it could lead to some misunderstandings between the expectations for the visit. So hearing a little bit about how outpatient chronic pain is managed is really interesting to hear, and I'd love to hear your thoughts on maybe even what that could mean for more in the acute setting.
Sara Hall:
Yeah, that's the tricky part. I mean, it is chronic pain, right? So it's been going on a long time. And I think part of the disservice that our medical system sometimes sets up, and part of how we got into this and the opioid epidemic is we have fewer minutes to see patients and higher expectations out of patients. And so people are looking for quick fixes and that doesn't work with chronic pain. And oftentimes if you're seeing someone now who's had chronic pain for 10 or 20 years, they might've been treated more aggressively with opioids during the late '90s or early 2000s, and it might've worked for them, and now there's fewer and fewer of those available due to the guidelines and just the transition of care.
And so really, I mean the International Association for the Study of Pain and what the guidelines are all saying is we want to treat it with an individualized, multimodal, multidisciplinary approach. So it takes much more than one ER doc that's going to help them.
Steven Jackson:
Right.
Sara Hall:
So it's finding things that they have or haven't tried and opening that perspective of also empowering them that they have a piece of their self-management. I think that's what's been really powerful for me to see with yoga is there might be this mentality of, you're a doctor, you have the tools to "fix me", but I think you guys both know, you see patients with chronic pain. It's a very challenging condition with ups and downs and a lot of emotional overlay, too.
So as far as treating it in the acute setting, usually what we do is kind of go through a list of what have you tried and what haven't you tried? And then offering programs such as one that we've developed that is free and accessible and getting them connected to the right people who can help them navigate what's going to work for that individual.
Steven Jackson:
Has it been difficult to navigate and how have you navigated some of the landscape that we're all kind of faced with now?
Sara Hall:
Yeah. Well, and that's part of what I go back to is we have very little training about this in medical school and all health care disciplines that see patients. And in the late '90s and early 2000s, there was this big push to treat pain aggressively. There was patient satisfaction scores that was big pharma pushing to use opioids and all of this based on very little evidence that they had minimal risk. But now we know, unfortunately, they carry a lot of risk, and opioid use disorder has become a huge conundrum in our community as a result of it.
And so from there, you find yourself in this place of this pendulum swing. And at least now we know and we have evidence saying opioids don't make chronic pain better, it makes it worse. And over time, really to differentiate between acute and chronic pain and how I explain it to people is, if you're exposed to pain over and over and over again, your nervous system changes. And so the usual customary treatments we use for acute pain, they just don't work for chronic pain. And so we have to think outside the box and using medicines that may have worked initially, like opioids, we know down the line can cause you more harm.
And many people are very educated about the opioid epidemic. They're terrified. They've known someone either personally within their family or circle of friends that have been impacted by it because it's had a huge impact. So oftentimes people are more accepting now of trying to find ways to manage without opioids.
Kari Haley:
Yeah, I would say anecdotally, I would a hundred percent agree with that. I know when I first started in the ED, I felt like there was a lot more people who would come in specifically requesting a narcotic medication to help with a chronic and/or subacute type pain that they were having. And I feel like just anecdotally, it seems much less because there is, I think you're right. I think people know someone who knows someone at a minimum who has died from the opioid crisis that we have.
I do want to delve a little bit into the yoga specifically and asking a little bit how does that help? How does that manage people's pain? Because I don't know if I really quite understand it myself and just to hear a little bit more about how it could be beneficial for people.
Sara Hall:
Yeah, I'm so glad you asked that question. So I'm going to ask you back, have either of you done yoga before?
Kari Haley:
I have.
Steven Jackson:
Yes.
Sara Hall:
And what was your experience when you did it? Even living without chronic pain?
Kari Haley:
I mean, I feel, I usually try to do it after doing a different workout and then using it as the stretching afterwards. And/or a day where it's just I'm not going to do anything super hard, but I still want to move my body. And I think just moving your body and having that definitely helps in terms for me with mental health even. Just keep things going, re-levels things because that's been my experience. It's just kind a nice subtler reset kind of opportunity that you can take.
Sara Hall:
Perfect.
Steven Jackson:
Yeah, my exposure and experience with yoga is pretty limited. I've done yoga as part of other workout programs, but one thing that I realized or re-realized that's a word is that I'm very stiff. So it's like, "Hey, surprise, I remember this. I'm stiff. I can't move." And also, it's harder than you think. It's not just you're stretching a little bit here and there. I mean, you're holding poses and when you're done, you feel like you just finished a workout. So yeah, much respect yoga people out there.
Sara Hall:
Yeah. Well, I love both answers because Kari what you had said was kind of around the centering or balancing piece that yoga can provide for people. And Steve, what you said was it can be challenging, which is the number one reason we created this program is people living with chronic pain usually have a fear of movement or exercise because they might have done a series of physical therapy or just plain hurts to move. And so they develop this fear avoidance cycle with movement and exercise because most of the guidelines say for chronic pain, the number one thing we want them to do is move their body. And so yoga's a beautiful application for that.
Yet in our U.S. culture, it's made to seem like it's this exercise that only fit and flexible and maybe young people can do. I mean, there's whole clothing lines devoted just to looking good while you do your yoga. And that's the U.S. spin on it. But really truly that the whole program we developed is based on making it accessible for people living with chronic pain because it helps balance their nervous system.
So most of us are living these days in this sympathetic overdrive. I mean, we work in health care, we definitely know that. Right? Think back to your residency is that you had to go through. Yes. The little sleep that you got, you weren't probably eating that great and you were awake but... Yeah. So same thing with chronic pain. They're typically experiencing sympathetic overdrive. And on top of that, there's a lot of limbic system arousal with the emotional component, whether it's based because they have a history of trauma or they lost their job because of their chronic pain and they're having financial issues with their chronic pain. So it's all intertwined is what I'm saying, which is why we really try to approach it through a biopsychosocial lens to better treat chronic pain. And it takes multiple disciplines.
So yoga is one piece of that and bringing the nervous system into better balance because you're usually providing some movement and then stillness and interoceptive reflection of how am I feeling inside? Which for people living in chronic pain, that's huge. Usually they're trying to escape their bodies and they don't want to connect to their bodies. So the program we created is a gentle way for them to become reconnected to their bodies in a way that's not fearful for them. So those are some benefits.
There's a lot of focus lately on the vagus nerve, which is part of the parasympathetic nervous system and how yoga can help tone the vagus nerve just through stretching and deep breathing and expanding the lungs more. Like you pointed out, great benefit for mental wellbeing. It helps bring your stress level and cortisol levels down. So all of that has a great impact.
Steven Jackson:
Well, I feel like we're being educated here, and I feel like our listeners are being educated. How does one take advantage of this program? And I know we were specifically talking about the Spanish-speaking community, but what would be the first step or the next step in saying, "Hey, I'm interested and I deal with chronic pain. How can I take advantage of the program?"
Sara Hall:
Yeah. So we have partnered with our colleagues over at the Neuroscience Center that developed the NeuroWell program in the department of rehab, and anyone within HealthPartners can enter a NeuroWell consult. And right under that is our free web-based yoga program in English and Spanish. So we tried to make it incredibly easy and accessible, so it's already there for you as a tool. We also have in-person classes where we continue on after the pandemic and we're back in person. Those are offered both at Neuroscience Center and at TRIA in Bloomington.
Steven Jackson:
And do they have to wear a certain type of clothes so they look good while doing it? Just curious.
Sara Hall:
They can if they want to, and sometimes they do, but whatever they're comfortable moving in. And I would say the greatest benefit out of those groups is that social connection that's quickly formed with in-person programs and that community of I am in a room with other people struggling with chronic pain and they really get it.
Kari Haley:
That has to be huge.
Sara Hall:
Yeah, it's been really rewarding for the groups.
Kari Haley:
And again, this is maybe a little off-topic, but thinking about the future, too, you have this web-based program. You have programs that are centered at clinics, but knowing there's a large piece of the population who maybe don't have access or reliable access to internet and/or transportation. Are there any thoughts about other ways to get this type of program to people who maybe can't get to clinic or don't have reliable internet who would benefit from the program?
Sara Hall:
Yeah, that's the tricky part. We thought, well, in-person is hard. You have to be there at the right time. You have to get transportation. So that's why the web-based program was so nice, bigger and broader. We're hopeful to develop platforms, but they would need internet access for that.
I feel like that's maybe one silver lining of COVID is people got much more used to doing things on the internet and have more accessibility. I'm not saying everybody does, I realize there's still disparities there, but that's one hope. And then we have aligned with TRIA Well, and so we're offering multiple programs throughout HealthPartners to do in-person if that's an option.
But we're just trying to also raise awareness. And this podcast is perfect because we want our medical colleagues to understand that there's real true scientific basis for using yoga for chronic pain and multiple metabolic conditions that can help improve health and wellness, but know that it is steeped in science and research, and I think we're finally making gains. They're looking at finally developing a CPT code for yoga therapy.
Steven Jackson:
That's awesome.
Kari Haley:
That's great.
Sara Hall:
Yeah. Some of my colleagues are getting trained to work with them people one-on-one for that.
Kari Haley:
That's awesome. Is there a way for providers to refer either from clinic or from the emergency department or on discharge from the hospital for this program?
Sara Hall:
Yeah, so TRIA offers both one-on-one services and group classes, and then we have availability for our yoga program at the Neuroscience Center.
Steven Jackson:
On behalf of all our listeners, we're very thankful for just everything that we've been educated on today. Similar to things like mental health, and we have the initiative of making it OK to talk about and to discuss. We want things like chronic pain to not be this taboo, hot potato, as you said, which is perfect. Hot potato type thing that, "No, you take care of it. No, you..." I think for something to be successful is going to take teamwork and education, us working together. And so thank you for just being another building block towards that. We are better for it. And thank you for all your hard work.
Kari Haley:
Yeah, thanks for one, taking care of the patient population that you do, cause I think that's so important. And to know that people do have a resource I think out there that may not have all the solutions, but has some solutions in the way that you described. Chronic pain, I think maybe will hit home for a lot of people too. I think it's just great that we highlight this piece of health care because I don't think it is highlighted enough and it is a huge problem in, I think, across all of the people out there, all of the patients that we have. So thank you for that. And also thank you for being on the podcast today.
Steven Jackson:
Yes, thank you.
Sara Hall:
Well, you're welcome. Thank you for your interest. And I always say at the end of the day, I am just thrilled and delighted that I get to call this piece of it work because it gets so much enjoyment for me out of it too. So appreciate your interest.
Steven Jackson:
Yeah.
"Off the Charts" is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.