[00:00:00] Thank you guys so much for having me. Let me go ahead and, pop up my screen here. Okay. Thank you so much for having me here today. I'm really excited. I've actually never had anybody asked me about how I've been brought into the chronic pain space.

[00:00:29] So it's kind of a treat to kind of think of it. It took me a really long time to think about how to put these slides together because I'm so used to talking about other people's brains. I don't often talk about mine. As, as you mentioned, I am a scientist for both Interocept Labs, which is my practice that I use to help startups that are coming into the space of digital health and especially chronic pain make things that actually work in the real world.

[00:00:56] I'm also a sensory scientist for the U. S. Army Aeromedical Research Laboratory, where I help apply neuroscience concepts to therapies and technologies that help out Army pilots. So today I thought I would share with you a couple of things with my story, how I came to have a pain story of my own.

[00:01:13] The first one just being how I found chronic pain, which is sort of unique. probably not what's generally expected. I started on this journey as an R and D scientist for United Health Group, and that's really brought me into this world. And then I also would really love to talk to you about some of the things that I've learned as an R and D scientist that help make some of these brain-based therapies for chronic pain really stick and help them to be as effective as possible for folks that are using them.

[00:01:38] I think it's important that when I start out, I clarify what it is exactly that I do. Because most people, when they think of a pain scientist, they're probably thinking something really serious and very cool and impressive with lots of lab equipment. In my case, it looks a little bit more like this, but I mean, if we're really being honest with ourselves, it looks like this.

[00:01:58] But the best way to describe it is that, you know, a clinical scientist's job is to make sure a therapy works in a lab, which is very, very important. It's sort of the first step. So making sure therapy has legs, but an R and D scientist job is to make sure that the therapy works in the real world. Sometimes I like to say that my clinical scientists, colleagues, their job is to build a therapy or to build a therapy or to build a product. And my job is to try and break it.

[00:02:24] So, how did I come into chronic pain? This story really kind of comes into play in four acts, but I promise they won't be very long. Spoiler alert, I didn't find chronic pain, chronic pain found me. So over the past 20 years, neuroscience has really been going through a very huge shift in how we understand the brain to work.

[00:02:45] In general, and no matter what the topic, we went from believing for many, many years that the brain was in this constant state of reaction, stimulus and response, you might have heard it called before. But over the last few years, there's been growing evidence that the brain is actually in a constant state of prediction.

[00:03:04] And so that really explains why our automatic reactions to things are so quick and so fast, because frankly, on a reaction-based model, we know that we should have been extinct. And you know, millennia ago, we would have been eaten by dinosaurs or saber-toothed tigers. So, this predictive concept not only explains why our automatic reactions are so fast, but it also has a very important fact for, you know, chronic pain and other things in our body.

[00:03:30] Our brain creates these perceptions that to us are very real. We're experiencing them in the exact same way we experience anything else that comes to us in the world. However, because it's predicting and it's trying to beat the real-world data to the punch, sometimes the things that we perceive don't match the data that come in.

[00:03:51] Now, to us, there is no difference, but to the outside world, there may be. So, When I realized this, I realized that in general, working for UnitedHealth, that it, my job really needed to be shifting our approach to healthcare to match this new realization, because it has a very serious impact for all kinds of conditions.

[00:04:14] So I had shifted UHG's mental health portfolio into this predictive brain body medicine focus and all of the things we could do with this. And the executives brought me a huge challenge. They said that chronic pain was costing the company billions of dollars. And no matter what we were doing to try and fix it, all of these things, surgeries, injections, all of these different interventions that should work, weren't working.

[00:04:37] And in some cases, they were making people's pain worse. They had no idea what to do. So, they brought me this issue. So, talking a little bit about this, just to give you guys a sense of how big this problem is, and how not alone any chronic pain patient is, 21 percent of the entire population will deal with chronic pain in their life.

[00:04:56] That's a very large number. And on average, it costs about just over 8, 000 to treat a person who has chronic pain per year. And that adds up since chronic pain tends not to be cured or remedied, but managed over time, those costs balloon up to 553 billion annually on total health care costs for chronic pain.

[00:05:19] So this is a huge and very expensive problem. And so, in the mainstream, in these commercial health care spaces, it's considered to be a very serious problem. It's one of those situations where we're seeing a lineup between people's needs and thankfully, the needs of these businesses, they need to save money, but we want to just get people better because chronic pain can be so debilitating.

[00:05:44] So, you know, executives and surgeons and physicians, they were very resistant to the idea of mind-body medicine for pain, even though, frankly, in the scientific literature, those were the kinds of things that we were seeing had the best results when I first started digging into what actually does work for chronic pain.

[00:06:02] I didn't see anything that told me that surgeries were the answer, injections or medications. I saw a lot of really great results from things like yoga and acupuncture, things of that nature, meditation. When I first started talking to people about this, you know, guys up there in the top brass, they had a hard time with it.

[00:06:18] However, luckily for me, even though they weren't open to traditional ways of talking about mind-body medicine, they were open to neuroscience. Now, chronic pain is a very perfect example of the predictive brain at work. You know, if our brain predicts damage, it creates real pain in response. Even if that damage isn't there, it's trying to go as fast as it can.

[00:06:41] And just like anything else, when you rush things, sometimes you get them a little bit wrong. And the brain will always err on the side of safety. So, it can rush to this idea that there's damage and create the exact same pain response in your brain that you would feel if there was real damage. So, to the patient, there is no difference in how these things feel.

[00:07:00] And so when I was trying to teach this, to all of these guys who, you know, needed to learn a little bit more about what I called brain-based therapies, as opposed to mind-body, even though, realistically, they're pretty much the exact same thing. Here are some points that I pulled out that were very helpful in making this point clear to them.

[00:07:20] The first is that chronic pain is not significantly correlated with bodily damage. We've known that for a really long time. There's been MRI studies that go back as far as 1994, this one of the really big ones that showed up in the New England Journal of Medicine, that showed that just about the same number of people who have no back pain at all have the same number of things like, you know, herniations and disc issues, as people who do have pain.

[00:07:43] And a very recent study that came out by Dr. Howard Schubiner, who I think you've had on the show, and I think you're gonna play one of his recordings after this, his team just found recently that upwards of 80 to 90 percent of chronic pain has no clear structural cause. So, we're not talking about a few people here, we're talking about the vast majority of people are dealing with something that is not as structural as we used to think.

[00:08:07] Now, chronic pain is strongly correlated with trauma and other phenomena that cause pain predictions. So, people who have PTSD are actually ten times more likely to have chronic pain. And brain scan research shows that there's a hyperactive connection between a part of our brain called the amygdala, which is sort of like our alarm system, that looks for threats and harm and damage and danger in our environment or in our bodies and the pain processing areas in chronic pain patients.

[00:08:33] So that alarm, and our pain processing centers share a really, really, really strong connection in chronic pain. So, we're seeing that that alarm is maybe getting a little too touchy. Sort of like a smoke alarm whose battery is about ready to die. It just goes off, right? And so, you have folks who, you know, at the, at the belief or the sensation of, of what they fear to be damaging, will have a very real pain response.

[00:08:59] And lastly, the big one that came up in my work is that therapies that target that amygdala connection, instead of trying to fix something in the body, are the therapies that result in huge effects. So, two thirds of long term chronic pain patients were pain free after the PRT randomized control trial that they did out in Boulder.

[00:09:20] And the fMRI scans they did on those patients showed that reduced activation in the amygdala and a weaker connection with the pain processing centers. And all those things I mentioned earlier. Things like yoga, meditation, acupuncture, all of those things are well known therapies that help calm down that amygdala part of our brain.

[00:09:38] So it helped to kind of get a sense and how to explain this to folks who weren't quite sure how to get on board with these brain-based therapies. And that was step one for me. So after many, many, many, many meetings with these folks, I finally got a green light to start testing a neuroscience based approach.

[00:09:57] And so my portfolio really shifted towards being very strongly aligned with chronic pain, and I set out on this journey to just change the status quo as best as I could. So we started what we called the brain first pain clinic experiment out of my work. We were at Las Vegas, Nevada, which had really high rates of chronic pain at the time.

[00:10:18] We were looking at an adult medicine population. These were totally just your everyday folks coming into their doctor, had any complaints about pain, they were sent our way. And the therapy we used was pain reprocessing therapy. However, there are lots of brain-first therapies out there. Howard Schubiner uses something called EAET, which is emotional awareness and expression therapy.

[00:10:40] There's a lot of really great brain-based, what are called manual therapies, like through chiropractors and massage therapists, where they're using sensation to help dull that hyperactivation in that amygdala part of our brain. So, this was the one we landed on, but there are others. So, what did we learn?

[00:10:57] Well, first and foremost, I should say it worked. And that was the biggest finding, PRT patients in the sample, even though we're in the real world where things were messy, things weren't perfect, like they were in the lab or an RCT. We saw reduction in both pain and costs in the people who got our PRT program.

[00:11:13] I should also mention that my experiment kicked off in the month of March of 2020, which you may recall was a, hectic time for everybody. And even though we had to do a lot of crazy pivots at the last minute for COVID and all of our therapy had to be done through telehealth. We actually still got really great results.

[00:11:34] So that was very exciting. Some of the things that we also learned is that time in practice was very important. So newer docs were way more open to PRT, whereas some of the docs who have been practicing longer were much more resistant to it. In fact, I had one physician who abjectly refused to send anybody to our PRT condition, and I ended up having to use him as a control, because he just didn't, he just could not be led to believe that pain, in any case could be brain based or top down. So that was an important thing for us to consider.

[00:12:09] The other thing, and again, probably one of the most important findings for us, was that it needed to be scaled out. We found this great therapy, and it worked, but one on one therapy was way too small to meet that huge demand I talked about earlier. So, at that point, there are a lot of other brain and body therapies that needed to scale out to work, and that was a big moment for me where I realized that there were all of these opportunities, and what we really needed were ways to turn them into something that could get to lots and lots of people at once.

[00:12:40] And so that's become my mission. And that's my story today is fueling this global paradigm shift. And that's what I do with my work at Interocept Labs and what I'm also trying to do with the army. So, I'm trying to get promising brain based therapies into the mainstream healthcare system. That is my absolute goal in life.

[00:12:59] And so how do you do that? Well, there's a lot of things out there that I have found to be very helpful in my studies that I, I think would be really helpful for folks listening in to hear about as well. So, when I'm trying to make something go into the mainstream, what is often referred to, I mean, usually my lab colleagues have made sure that the therapy works.

[00:13:21] We know that it's what's called efficacious. It has good efficacy, but we don't know if it has good effectiveness, which is when something works even when all of the conditions aren't there to make it work. When you're dealing with a therapy, it's important that it has all the clinical elements, but when you take it out into the real world, there are some things that are really common, no matter what the therapy or intervention or practice is that need to be there in order for it to work really well.

[00:13:49] That piece of what we talk about, that piece of effectiveness is often referred to as engagement. And in order to have high engagement, you need to have something that sticks and that somebody actually does the way that they're supposed to do it for as long as they need to, to make the change. So, one of the things that's tough with brain-based therapies is that it's not always instantaneous.

[00:14:10] You're trying to change neurons and their pathways and the way they talk to each other in your brain that have done something a certain way for sometimes, you 10 or 20 years, depending on how long you've been in chronic pain. So, we need to find a way to get in there and we need to make sure that you're doing the therapy long enough where it actually has time to start moving those pathways around and work.

[00:14:34] So some of the lessons I've taken away, there are three big ones that I like to stick to no matter what, when I'm putting a therapy into a scalable model to try and get people to do it. And my first and foremost, like. If I had a list of commandments on what to do when you're making a therapy that will do well in the mainstream, is that it has to feel good to do all by itself.

[00:14:59] So, this can mean that it's fun, it can be interesting to you, it can be entertaining, or it can also just feel really good physically. Whatever it may be, the details have to be that it has to just feel good all by itself. You have to enjoy it no matter what. Now some people will argue that this is a nice to have and not a need to have, and I would argue against that.

[00:15:25] Whenever you're trying to change something, and it's a really big journey to go through and change chronic pain, you need to have something that brings a smile to your face whenever you're doing it. It makes a massive difference, and it also really boosts how open your brain is to changing in regards to that thing.

[00:15:42] So when you're pairing those fun, good, happy feelings, you're releasing things in your brain, neurotransmitters, chemicals in your brain that help make that learning stick and make it more strong. It has to be important to you. It does not matter if it seems important or it seems like something you should be doing.

[00:16:02] It really needs to be important to you as an individual person. And so, in this busy world, you know, you don't have free time. Let's be realistic. People talk about that, you know, oh, you can just do this in your free time? I would love to meet a person who just sits around every day and has like an hour of free time.

[00:16:22] So what is realistically happening is that you're carving out time in your day in order to fit this new thing in. So, it needs to be more important than whatever it is you have to carve out in order to make time for it. And so, in order to do that, I always tell people you have to define specific values for each user.

[00:16:41] What that might mean for you as a patient or a user of a therapy is you need to find that specific value for you. So, it's not a matter of, I just want to feel better. What are specific things that get you going? What is important to you during the day? Is it, you know, playing with a child? Is it being able to do a hobby that you love?

[00:17:01] Is it getting out into nature? Whatever it may be, it's important. And usually writing that down and really reflecting on it on a regular basis is very, very helpful. And lastly, you really need to find a way to blend it into your daily routine as seamlessly as you can. So, convenient things are just easier to try, and they're easier to maintain.

[00:17:21] So if you can just pick something up and go with it, you're much, much more likely to stick with it. And that's why so many therapies are starting to be on your phone. Because you have a phone, it's there, it's easy to pick up, it's very convenient, and to do things on it all in one place tends to be really easy for people.

[00:17:40] So accessing whatever therapy that we're trying to do, it needs to be as fast and as simple as possible. It should be built into something that people are already doing every day. There's some really great research that's been done on building new habits that I like to borrow from in this particular area.

[00:17:57] So for anybody who's interested in this one in particular, and I should have written this down, and I didn't, so I apologize, but, there's an author named James Clear who has a book called Atomic Habits. And it's one of my favorites and he has an entire book dedicated to how you can make things more convenient for yourself so that they're more likely to stick and it's very very reasonable. There's also a book called Tiny Habits.

[00:18:21] I believe that one's by BJ Fogg and it's a similar kind of concept, how do things really convenient and sticky so that you stay with them for a long period of time without feeling overwhelmed?

[00:18:32] Now, because I'm a neuroscientist, I feel compelled to tell you that the first thing I kind of talked about about those brain chemicals making things easier to move around is really very important.

[00:18:44] So,, I wanted to give everybody some bonus tips around what is called neuroplasticity. So, if you pair something with something that helps you with plasticity, you're getting like a huge boost from that as well. And there are a few things in general that help anybody in any condition, in any age, in any shape to really help their brain boost the ability to form new pathways.

[00:19:11] I always like to say that when you're talking about neuroplasticity, think of it like this, you've got a freeway. That you've built up in your brain. And what you need to do is go around that freeway through the woods. And the first time you do it, you're going to forge a little path and you're going to break some twigs and make some room and you're going to see those signs. And so, you're going to take that path again.

[00:19:32] And the more often, the more consistently and the more frequently you do, that freeway is going to start to degrade and fall apart, and you're not doing maintenance on that, but that path you're making through the woods is going to get stronger and stronger and easier to follow and more concrete every time and so neuroplasticity is the process of your brain making those new paths and of getting rid of the old ones. And so the number one thing that is generally shared in helping out with neuroplasticity is exercise has actually been shown at all ages to help your brain make new neurons, new brain cells, which really help a lot with neuroplasticity and making new pathways.

[00:20:12] So, the more, the more workers you have on that new road, the faster it'll get built. So, any kind of exercises, does not have to be hardcore weightlifting or running a marathon, just going for a walk. Especially in the mornings, and outside if you can, are all really, really helpful and helps boost your brain cells.

[00:20:30] The next one of course is meditation and mindfulness, which everyone has probably heard by now. These things really can help boost plasticity and reduce stress so they have a nice two way punch. But the more you sit with your mind, and kind of accept it and understand it and see what its patterns are, the more you can work with it and come up with new ways of thinking and new belief systems that will help you on your way.

[00:20:55] And the last one, I think every doctor has probably told you. On every one of these interviews is sleep. Sleep is super critical. And I know it sometimes feels a little bit like a chicken or the egg thing, because if you're in chronic pain, sleep can be very difficult.

[00:21:11] And I just recommend that you do the best you can to work towards it. Do little things that help you get a little closer every night with the goal of trying to get to that eight or nine hours each night, because again, the more you do it, The easier it will become, not just because it becomes habit, but because your brain gets a little bit healthier every time and it'll get you where you need to go.

[00:21:32] So with that, I. I'm all finished with my science part of the presentation. I've got my information here. If anybody has anything that they want to reach out about or have any other questions about, my email address is just bethany@interoceptlabs.com. It looks like intercept, but it's actually got an ‘O’ in it, interocept.

[00:21:54] It is related to the sense of how your brain can keep track of how your body is doing Interoseption. And I also have a blog that I write in. Usually, I get an article out every week and it's just a neuroscience blog for folks that are interested in how their brains work and getting all of that technical information out there to an audience, as best as I can.

[00:22:15] So the blog is called 'Firing and Wiring', and you can access it through 'Medium.com'. And I've got the site here listed on this slide for anyone that might be interested in checking that out. And so, with that, I will turn it back over to you guys.

Author/author image: Dr. David D. Clarke MD

Credentials: Asst Prof. Emeritus of Gastroenterology
Oregon Health Sciences University

Employer: President, Psychophysiologic Disorders Association

Location: Portland, Oregon

Story title: ‘Discovering the Psychology of Pain Relief’

Presentation Date (mo/yr, two digits each):  110923          (6 digit date code)

Type resource: (video, slide show, book, paper, ..):   Video

Length (X m/Y pg, or Z slides):    41 min.

You Tube URL:

SKU elements

Summary:

In his final phase of gastroenterology training at UCLA Harbor Medical Center, a 37-year-old woman was referred to him for specialized testing after other universities had found no cause for her ailment of a single bowel movement per month.  Their test also found no cause and he was designated to do her exit interview.  He had never encountered anything like her situation.

He asked about stress in her life, expecting all prior doctors had also inquired, and she revealed her father molested her hundreds of times up to age 12, but she was otherwise happily married with two children.  It seemed improbable that stress 25 years prior could be a factor in her ailment, but he referred her to Dr. Kaplan, a psychiatrist he heard might be interested in this unusual mind and body problem.

Two and a half months later he inquired about the patient and Dr. Kaplan said she had met with the patient one hour a week for 8 or 10 weeks and she was cured with her bowels back to normal.  Thinking he might encounter a few such cases in his career he asked her to train him on her framework for evaluating and treating patients, i.e. the questions to ask patients to uncover the stress in their lives.  With that background he planned to send any similar unsolvable cases to a local mental health provider where he was practicing.

He actually encountered 5 – 6 such cases per week (7000 in his career) but only Cognitive Behavioral Therapy was available in Portland, Oregon. So, to serve his patients, he eventually learned how to uncover the stresses that caused ailments in patients referred to him with various illnesses that had no structural or disease cause.  He published a book in 2007 titled "They Can’t Find Anything Wrong” describing his approach and the key factors in about four dozen widely varying cases.

In 2011 he co-founded the PsychoPhysiologic Disorders Association and has served as President of the Association since then.  He refers to the illness as a PPD and shows statistics that 20% of the population suffers from the disorder, or about 20% of the adult population. The PPD population is 80% larger than the diabetic population and absolutely can be diagnosed.  PPD symptoms range from dizziness, to coughing, rashes, irritable bowel, migraine and a long list of both pains and non-pain symptoms.

He shows results of a randomized controlled trial, the Boulder chronic back pain study (published in 2022) where 150 patients with 10 years average chronic pain, showed that 8 hours of Pain Relief Psychology treatment produced reduced average pain scores 50% compared to standard treatment or placebos, and was sustained for the 1-year duration of the study.

He then describes how a disorder is diagnosed, citing blushing, physical discomfort prior to public speaking, and phantom limb pain as common examples of physical changes produced by emotions.   Adding an example of a nail in a worker’s boot that produced agonizing pain, but no tissue damage because the nail passed between his toes.

His 6-step evaluation process attempts to: discover the chronological relationship between stress experiences and ailments in a patient’s life story; then explore current stresses in their life; possible stress from adverse childhood experiences; and finally, three mental health factors; depression, post-traumatic stress, and anxiety.

Having patients make a list of all stresses in their lives, past and present, is a very useful technique.  Then start working to reduce some of the stresses on the list to discover those that relate to their symptoms.  When symptoms change that is encouragement to continue the process.  Reduction of current stress may yield to changes in personal boundaries or improving self-care like adequate sleep, nutrition, and personal time.

For previous stress experiences, revealing past emotions in secret, through writing or verbally   recording, elevates the emotion that causes a symptom into consciousness which relieves the brain from producing the symptom as a protective notice.

He recommends reading the resources available in the PPDA website, including a self-assessment questionnaire and his 2007 book ‘They Can’t Find Anything Wrong!’

He cites studies from Harvard, the Boulder Back Pain study and a West Los Angeles VA study, that showed 30% or more long term improvement in symptoms compared to normal treatment or Mindfulness practice as ‘nothing comparable in pain relief literature’.

Three doctors in a medium-sized city in New York were so enthusiastic they said the insights put the joy back into their practice and it then spread to 72 doctors in the community.

Key Ideas:

1. Six common assumptions about pain or illness not due to disease or injury, are taught to health professional, buts are all not true.
2. Stress related symptoms range from pain of various types and location, including migraine headache and fibromyalgia, to digestive irregularities, skin issues, hearing tinnitus, dizziness, and others.
3. Stress symptoms can be diagnosed and reduced.
4. ‘Gold Standard’ trials have shown dramatic, long-term improvement in stress related symptoms.
5. Twenty percent of the population suffer from stress-related symptoms.

Unique Aspects:

1. Patients who had adverse childhood experiences are Heros to have survived.
2. Recent scientific evidence shows that the symptoms of stress-related illness can be dramatically reduced or eliminated.
3. Awareness of the cause and treatment for stress-related illnesses is expanding.
4. A doable path for patients and professionals is outlined.

Transcript PDF:

Approved Date:  February 14, 2024                 by:  jrk

Video link….xxxx-story-title-with-dashes:   1030-Discovering-the-Psychology-of-Pain-Relief

Transcript #: 1030

Video name: Discovering the Psychology of pain Relief

Original Recording Date: November 9. 2023

Author name: David D. Clarke MD

Credentials: Asst Prof. Emeritus of Gastroenterology, Oregon Health Sciences University

Organization: Psychophysiologic Disorders Association

Location: Portland, Oregon

Transcript text:

1030 Clarke 110923

[00:00:09] Thank you, Rolly. It's a pleasure to be with you and I really appreciate being invited tonight to share my story and share some of what I've learned. Let me go ahead. So tonight we're going to discover the psychology of pain relief and it's basically a journey that I started very early in very early in my career.

[00:00:28] I was actually doing pretty well. Early on, I got an award for excellence in medical school. I was passing my board exams with excellent scores. I got into a top training program at Harbor UCLA Medical Center, and I was seven years into it, just starting my eighth year, which was the first year of my gastrointestinal specialty training.

[00:00:55] And I was completely unprepared to run into a patient that I didn't know the first thing about diagnosing or treating. This was a 37 year old woman who had been referred to us by another university because they could find nothing wrong with her. The symptom that she had was that she was averaging one bowel movement per month.

[00:01:17] And I'm sorry about that symptom, but, you know, if you invite a gastroenterologist to come and speak to you, this is the kind of stuff you're going to hear about. And she was taking 4 different laxatives at double the recommended doses. And it wasn't helping her at all. All the tests had been normal from a regular doctor from the other university.

[00:01:39] And she was coming to us for some very specialized testing of the neuromuscular contractions of the large intestine. And my department chair and I were absolutely certain that that test would show what was wrong because no other explanation for her condition was possible. Or so we thought.

[00:02:00] Because that test also turned out to be entirely normal, which completely perplexed both my department chair and I, but at that point, we had nothing more to offer her and it was left to me to do the exit interview and tell her that she basically was just going to have to live with this. But I asked her, you know, just to make the conversation not be too abrupt and final with her.

[00:02:26] I asked her about stress in her life, knowing full well that all her other doctors had asked her about stress in her life, and she didn't have any. She was happily married. She had two kids whom she adored. She loved her job as a bank manager. There really wasn't anything. So again, not wanting the conversation to end too abruptly, I asked her about stress earlier in her life, thinking, well, maybe something happened two years before at the time her illness began, and she interpreted my question to mean the more remote past and began telling me about her having been molested by her father.

[00:03:11] And I had never heard anything like that from a patient before, even after 7 years of training. I had no information about how to respond when a patient says something like that to me. So, I was very worried, that if I asked her too much about this, that it would have all kinds of difficult emotional repercussions. So I was reluctant, but at the same time, she seemed fairly calm about the whole thing, and I thought, well, you know, this is for the best.

[00:03:43] Kind of a surprise that she's mentioning this. There's no way it has anything to do with her bowels, but I might as well at least get the story because that's what I've been trained to do. You get the history. You find out what happened. When and where did things occur? When did it start? How frequently did things happen? I asked her all of that, and it turned out that Her father had molested her hundreds of times up to the age of 12. But nobody, including him, had touched her after that.

[00:04:15] Nobody had touched her against her will for the last 25 years. So it seemed completely improbable that this terrible suffering that she had endured could in any way be linked to her gastrointestinal problem. But, it gave me an idea for passing the buck, which was that there was a psychiatrist at UCLA named Harriet Kaplan, who was also board certified in medicine as well as psychiatry, and whom I had heard might be interested in these unusual mind and body problems.

[00:04:50] So I thought, great, I've got something positive I can do. At the very worst, it might help her live with her condition a little better. So I made the appointment and forgot all about her until about 2.5 months later, I ran into Dr. Kaplan in an elevator. I barely knew who she was, but I did know, so I asked her, what, whatever happened to that patient that I referred to you? Did, you know, were you able to help her at all?

[00:05:22] And she replied, well, Dave, I haven't seen her in a few weeks. And my first reaction on hearing that was, oh, you know, it didn't work out. It wasn't helpful. It was a waste of time as I expected. But then she goes on to say, she's cured now. She's fine. Her bowels are back to normal. She's not taking the laxatives anymore.

[00:05:45] And I was absolutely thunderstruck that you could alleviate a horrible, serious, physical condition. Just by talking to somebody because that's all she did. She didn't prescribe any medication. She saw her once a week for an hour for about 8 or 10 weeks. And at the end of that time, she didn't have a problem anymore.

[00:06:09] There was nothing in my 7 plus years of education that even hinted that such a thing was possible. So, as I got off the elevator, I turned around and I said, Harriet, how did you do that? And I thought, you know, if I'm going to be a complete gastroenterologist, I should know how to take care of a situation like this because if it's happened in my practice once it'll probably happen, you know, maybe even a couple times a year that I'll see a patient like this. I should know what to do.

[00:06:42] So I prevailed on Dr. Kaplan to sit in with us in the outpatient GI clinic at Harbor UCLA Medical Center. And give us the benefit of her perspective on this condition, how she thought about it, what was her framework for evaluating and treating patients. And I gradually absorbed a basic set of concepts about what to do, never thinking I was going to use most of it.

[00:07:11] My plan was that if I didn't find anything wrong with a patient, I would ask him a few questions about stress, send them off to mental health. and whoever the Dr. Kaplan was in Portland would take care of the problem. Well, I was wrong again and again in my early years of working with this, and I was wrong that there would be Dr. Kaplan's in Portland. There weren't any.

[00:07:36] When they went to mental health, these patients got cognitive behavioral therapy, which for most of them, just simply isn't good enough. And I was also shocked that the patients that didn't have anything wrong on diagnostic testing ended up being five or six a week, 250 or 300 a year, over 7,000 in the course of my career.

[00:08:05] And when I asked them the questions that Dr. Kaplan had taught me to ask, even, you know, though most of them did not appear any different in terms of their mental health than anybody else you might know or meet, they had serious stresses that they were struggling with. Sometimes shockingly serious stresses like my first patient with the hundreds of episodes of molestation.

[00:08:32] But it turned out that if you could uncover these issues and related impacts from those issues, there was usually a fairly straightforward method for treating them for alleviating the stresses for bringing the stress level down. And when you did that, people got better. And even as a bumbling beginner back in the 80s, I was getting better outcomes with these patients than they were getting from the rest of the health care system.

[00:09:04] And that encouraged me to keep going. And I got better and better at it. I was climbing a pretty steep learning curve, but with every additional patient, I was learning more. And after four or five years, I had reached a pretty decent level of proficiency. And I was working for Kaiser at that time. And about a year after I felt like, okay, I've, I feel like I've really learned how to do this.

[00:09:31] About a year after that I unexpectedly won the doctor of the year award for this work which was, you know, I was much younger than most people who won that award. So that was, you know, additional confirmation that I was on the right track basically.

[00:09:49] So I kept going with it, ended up writing my first book in 2007 called "They Can't Find Anything Wrong".  And when that came out, I started getting a lot of invitations to give speeches and to be on television and radio. I did over a hundred radio and television broadcasts. I was giving speeches. All over North America and Europe including in the UK at the Royal Society of Medicine and a famous psychotherapy institute called the Bowlby Institute.

[00:10:22] And that has just accelerated. I became a Co-founder and President of the Psychophysiologic Disorders Association in 2011. I've been the president ever since. We've written two textbooks. We've got an online webinar based course in this for professionals that patients can also take because it's jargon free.

[00:10:45] We have a really nice self-assessment quiz for people. It's only 12 questions, but it's set up so that the more questions to which you answer yes, the more likely it is that a psychophysiologic disorder is responsible for your symptoms. I've been a producer of three documentary films in this field.

[00:11:06] We have a new even more advanced course coming out in January (2024) that's going to be on the endchronicpain.org website. We have held four international conferences, the last two of them online. The most recent was just two weeks ago and it's all recorded so that you can view the course.

[00:11:27] And most of it is a jargon free and for professionals, they can get up to 12 continuing education credits for it. We have a new membership program at the PPD Association where people can get substantial price advantages and discounts for all of these resources that I've been mentioning and more that are offered by our allies.

[00:11:52] And we have monthly meetings that are international that are open to all of the people who are members to come and ask questions of experienced experts in the field. Starting in January, we're having monthly Zoom webinars just for professionals where they can ask questions of people who've been doing this for decades.

[00:12:14] So lots and lots going on and it's, it's accelerating. 15 years ago, we had almost nothing in this field that reflected the science. And now we've got more and more and more that are resources for both patients and professionals. So, with that is a long-winded introduction. Let's go on to the slides.

[00:12:37] And this one goes back to what I was taught in those first seven years of my medical education and training. These are the assumptions that are taught to health care professionals and mental health professionals for that matter, both implicitly and explicitly, even to this day about pain or illness that is not found to be due to disease or injury: that it doesn't affect many patients; that the symptoms are largely imagined and not real; that the patients themselves are neurotic, they just can't handle their own normal daily stresses; that diagnosing a cause of this condition is not possible; that the best achievable outcome is living with the; and that it's not really manageable by physicians; that when the physician has done their job of looking for organ diseases and structural damage and not found any, then doctor's job is done, and there's really not much more they can offer.

[00:13:41] It turns out and this was what I learned in the early years after first meeting Dr. Kaplan, that not a single one of these assumptions is true. Let me give you one example. This is a 50-year-old-woman with undiagnosed attacks of severe dizziness and vomiting for 15 years. The attacks would last anywhere from 1 to 4 days.

[00:14:05] She would have between 6 and 10 of these attacks every single year. She was having them severely enough to put her in the hospital four times a year. So about half of the attacks over the 15 years, she was in the hospital 60 times. And the hospital she was in was Stanford University Medical Center because she happened to live in Palo Alto.

[00:14:31] So she got very good care from a dozen different specialists who put her through every test you can think of and did not find why she was having this condition. So in the third year of her illness, they had a psychiatrist evaluator and he was confident that she did not have any sort of mental health condition.

[00:14:53] And he sent her back to the doctors and said, keep looking. Well, she ended up in my hospital here in Portland and she was in such despair that she said, doctor, don't waste your time with me. You'd be better off seeing your other patients. And she had very good reason to say that after all that diagnostic evaluation.

[00:15:14] It wasn't likely that any tests I would order would show anything different. But I said, you know, I've kind of been making lost causes a specialty of mine here in the last few years. This patient is someone I saw when I was still early in my experience, probably around 1987. And I said, if you'll give me 30 or 40 minutes to tell me your story one more time, we might be able to come up with something.

[00:15:42] And sure enough, we did. I found the stress that was responsible for her attacks. We talked about it. We brought the stress into her conscious awareness because like so many patients, the stress is unrecognized the magnitude of it, even the nature of it is not part of the patient's awareness.

[00:16:04] So if you can find it and help the patient to see it. That starts their healing journey. And in this patient's case, she was cured on the spot. She went home from the hospital the next day. She called me a year later when she was back in Portland to say she'd gone the entire year with no episodes.

[00:16:22] We'll talk about her a little later about exactly how she was diagnosed after I go through the process. But as usual with my talks, I put way too many slides. But we'll get there. My colleagues and I like to call this psychophysiologic disorder. We drop the A L at the end of psychophysiological because it's already got enough syllables to it.

[00:16:44] The abbreviation for this is even better. We call it PPD. And that is, you know, obviously a lot easier to say. This is just, this term is a blend of psychology, the processes of the mind, and physiology, the processes of the body, because that's exactly what's going on in this condition. It's a blend of the two, and it's defined as pain or illness caused by past or present psychosocial stress, not associated with abnormal organs or structures.

[00:17:12] There are millions of people who suffer from this. This is a review article of 32 different scientific papers from 24 countries, showing that on the average, 40 percent of people that present to outpatient primary care are suffering from PPD. It's approximately 20 percent of the adult population or 50 million people in the United States alone.

[00:17:36] This is not rare. This is 80 percent larger than the diabetic population for comparison. So the truth is that PPD affects about one in five adults. The symptoms are absolutely as real as from any other form of illness. The patients are actually quite resilient. They're just carrying levels of stress that would bring any of us to our knees.

[00:17:59] It absolutely can be diagnosed if you know what stress to look for. It often can be completely relieved by treating those stresses. People don't have to live with this. And the best outcomes are when a physician and a behavioral health consultant collaborate with each other, ideally in the course of the same office visit.

[00:18:22] So it's complete turnaround from how I was originally trained, these patients can get symptoms literally from head to toe, certainly pain anywhere, but also non-pain symptoms like: ringing in the ears or dizziness or visual disturbances or non-epileptic seizures, trouble swallowing, trouble breathing, trouble coughing, certain rashes, bladder spasms, genital symptoms numbness and tingling in the extremities complex regional pain syndrome, fibromyalgia, irritable bowel, migraines, the list just goes on and on and on.

[00:19:02] The only common denominator is that patients tend to have more than one symptom at a time; they don't always, but they tend to. And not only do we have my 7, 000 patient experience to share with you, but today we have randomized con­trolled trials, gold standard science that is showing that these outcomes are extraordinarily good.

[00:19:29] This is a study that was done at the University of Colorado in Boulder of 150 patients with chronic back pain for an average of 10 years. Their pain scores are on the vertical axis and the 1 year duration of the study is on the horizontal axis. And you can see that the pain scores plummeted during the first month of the study, which was when they got their pain relief psychotherapy.

[00:19:56] The other two groups were the control groups. One got an injection into the spine of a placebo and the other got their usual care, nothing special. This is a huge drop in pain score. You have to imagine these are patients who'd been in pain for a decade on the average. So imagine the timeline, the horizontal axis extending for 10 years to the left before they get this 1 month of pain relief psychotherapy, just 2 sessions a week for 4 weeks. And the pain score is plummeted. This is by far the biggest drop in pain from a psychological treatment that had ever been published up to that point.

[00:20:35] Alright, how do we diagnose this condition? We've known how to do this for a hundred years. This is one of the most famous speeches in American medicine. Francis Peabody, professor at Harvard, speaking in 1925. "In all your patients whose symptoms are of functional origin, the whole problem of diagnosis and treatment depends on your insight into the patient's character and personal life." The approach that I take is just a rigorous, systematic form of exactly what he's saying here.

[00:21:05] When he talks about functional origin, he means no organ disease or stress. Or structural damage. So, the first step is to address the skepticism that everybody has, myself included back in the day, "merely stress could make people physically ill". And so we clarify that symptoms can originate in the brain.

[00:21:24] Anybody who's ever blushed with embarrassment has had a psychophysiologic symptom. Anybody who's ever felt a knot in their abdomen when they were in a tense situation has had a psychophysiologic symptom. And this is just a more severe and long lasting form of those normal, common, everyday human experiences.

[00:21:45] Another example is phantom limb pain in which someone who's had an amputation feels pain at the place where their limb used to be. Obviously, the missing limb, whether it's an arm or a leg, can't be doing that because it's no longer there. It's the brain that is generating that symptom.

[00:22:02] Why is the brain doing that? It's because of stress, and we just need to find what the stress is in each patient's life. Here's another example from the British Medical Journal in the mid-1990s. A construction worker who impaled his boot on a nail, and as you can imagine, was instantly in agonizing pain, rushed to the emergency room, given morphine intravenously to alleviate the pain. And then the boot was carefully cut away only to reveal that the nail had passed neatly between his toes and didn't cause a scratch. And as soon as he saw that, the pain was gone. It’s a great example of how the pain can be generated in the brain.

[00:22:40] So in evaluating the patients, I go through a six-step process, which may take several office visits to complete, but that's okay. There's no law that says you need to do all of this in one visit.

[00:22:52] I start with the chronology. When and where did the symptoms begin and what's been their pattern over time. Later on, I'm looking at the stresses in the patient's life and looking for any chronological links between when and where stress was happening and when and where the symptoms were happening. I'm going to skip this, but, people can pause the recording and look at it. It's particularly for physicians who are interested in what some of the clues are to the presence of psychophysiologic disorders.

[00:23:22] Second part, very simple. Are you under any stress at the moment? Is there anything going on in your life right now? Or did anything of a significant stress happen right before your cannot symptoms began that might have triggered them? Or have the symptoms, stresses in your life been fluctuating up and down and your physical symptoms fluctuating in parallel with those stresses? All kinds of things we're looking for there. Another one is, do your symptoms go away when you are in a less stressful situation, such as being on vacation or being in a safe place? That's another clue.

[00:24:01] A subset of the stresses in your life right now is a very common one, not having enough personal time, spending your days, taking care of everybody else in your world, but not having the time or the inclination even to put yourself on the list of people you take care of.

[00:24:20] If you do that for too long, it's going to catch up with you and your body can start to protest in the form of symptoms. Many people with this issue grew up in difficult home circumstances as children where they didn't get sufficient opportunities to play. They had to instead pay attention to whatever difficulty was going on around them.

[00:24:43] And if you don't learn to play as a kid, the outcome from that can be you don't know how to play as an adult and you're on that treadmill. This was the biggest shock of my medical education, finding out that stress when you were a child could make you ill. as an adult. That was what happened to that very first patient with the severe constipation.

[00:25:03] There's research now, a lot of research, that shows the association between what are called ACEs, Adverse Childhood Experiences, and symptoms later on in life. This is one of those studies. I won't go into detail, just to say that in the pelvic pain group, The incidence of childhood sexual abuse was three times higher than it was in the group that did not have pelvic pain.

[00:25:30] This is a study of the outcomes of lumbar spine surgery, basically surgery on the low back. And it shows that in the group that had no adverse childhood experiences, that surgery was 95 percent successful. But if you had, up to five adverse childhood experiences, three, four, or five out of five in the categories that they used, the success rate of the surgery plummeted to 15%. Why? Because the ACEs can cause stress, which can cause your brain to generate back pain. And if you operate on the spine for back pain that is generated by the brain, It's not likely to help.

[00:26:12] When I'm asking a patient about these issues. I start with a very general open ended question. Did you experience stress as a child? And we start the conversation there. And I find that patients are quite willing to discuss it, even though I might be only the first or second person they've ever shared it with.

[00:26:31] At the same time, many of my patients will minimize what they went through, they'll tell me about something very bad they went through and then at the same time they'll be saying it wasn't that bad. Or they'll tell me that I know other people have been through worse, or they'll tell me "I think I'm pretty well over that right now".

[00:26:49] So my response to that is to ask them to imagine their own child growing up exactly the same way, or to imagine being a butterfly on the wall of their childhood home. And having to watch a child of their own or another child whom they care for enduring that same childhood experience, how are they going to feel about doing that?

[00:27:09] I asked this in my written screening questionnaire. We have it as one of the 12 questions in the self-assessment quiz on our website. On my written screening questionnaires, I give people four choices: you'd be happy if you watched a kid growing up the way you did; you'd be neutral about it; you'd be sad or angry; or you'd be very sad or very angry. And I correlated that with a standard 10 item adverse childhood experience questionnaire, and you can see the results here that people who said they'd be happy to watch a kid growing up the way they did, they had an ACE score of only a little over 1 out of 10.

[00:27:49] But when you get to the very sad and very angry end of the spectrum, the average ACE score was over 7 out of 10. So with just this one question, we're capturing a huge amount of information.

[00:28:01] The ACES themselves can't be changed. We can't, as much as we would like to, go back and change the past. But what we can do is have a therapeutic benefit to the long-term ACES impact, which comes in three major categories: stressful personality traits that have resulted from the ACES; repressed emotions; and triggers which are people, situations, or events that are in the present day.

[00:28:31] But they are in some way linked or reminiscent of the ACES of the past. But all three of these are subject to therapeutic interventions that can make a huge difference.  And when we make that difference, physical symptoms, whether pain or otherwise, improve.

[00:28:49] The last three parts of the stress evaluation are mental health conditions. They are: depression; post-traumatic stress; and the anxiety disorders. And here the key is to evaluate those in detail because they don't always manifest in an obvious way. The majority of patients with these conditions actually present to the health care system with physical symptoms rather than mental health symptoms.

[00:29:17] So you have to ask detailed questions about the patient's, situation and about secondary symptoms of these conditions to make sure that they are not present or to confirm that the y are present. For my medical colleagues, a very useful technique, but also for patients is to make a list of all the stresses you've had in your life, both at the present time and in the past .

[00:29:41] For patients who want to tell the doctor their life story for the next 2 hours, this is a great way to honor the patient's willingness to disclose this information. But also to let them know that you don't have time in a 15 minute office visit to give this issue the attention it deserves. But patients will go to work on these lists.

[00:30:02] They'll bring them back for their follow up visit. And in many cases, they'll actually start working on some of the stresses on the list, which will have potential benefit to their symptoms. And that makes it clearer to everybody what's going on. For patients that are working hard on behalf of everybody else in their life, but don't know how to put themselves on the list of people they take care of they need to learn self-care skills.

[00:30:28] They need to take a regular block of time with no purpose, but their own joy. They need to use that time for trial and error, and they need to find a way not to be guilty about doing it. And if they can learn this essential human skill of self-care time, they will have that skill for the rest of their lives so that whenever their stress level gets up to the point where they're starting to have physical symptoms, they will now have something enjoyable that they can do that will bring the stress level back down.

[00:31:03] For my patients who've survived childhood stress, I like to point out that that experience is analogous to being born on the far side of Mount Everest or in a dangerous jungle. And they deserve tremendous credit for the heroic perseverance that was needed to endure those situations. And they should give themselves that credit.

[00:31:25] They should think of themselves as heroic. They should recognize that what happened to them was through no fault of their own. And when they do that, it gives them a foundation for further healing.

[00:31:37] Another good exercise is writing. We won't go into a lot of detail because I know I'm already running short of time, but a great technique here is to write a letter, not to mail it, just to write it to anybody who mistreated you as a child.

[00:31:52] Put down all your thoughts about that person, which may be some good thoughts, but all the thoughts and feelings that you have, to put them into words. Because if, if they go into words, they may not have to be expressed via your body quite so much.

[00:32:07] This is my screen for the, whether the patient can read or not. I just ask them, do you like to read? If they say no, we move on. If they say yes, there are today a lot of evidence-based books that can help patients to recover from this.

[00:32:23] This is my book it's been out for a number of years now, it has approximately four dozen stories in it about my patients that illustrate the very broad spectrum of different kinds of stresses that can make people physically ill. And most people with a psychophysiologic disorder will find at least one and often more stories that resonate for them personally and can start their healing.

[00:32:49] I donate all the royalties from this to the nonprofit. In fact, I donate all the earnings that I have from any connection to this work to the nonprofit, because I don't want even the appearance of a financial conflict of interest.

[00:33:04] There are just too darn many companies out there that are exploiting PPD patients by selling them supplements or devices that have no better than placebo benefit. And we can do way better than placebo for people who have this condition. This is the textbook that Rolly mentioned earlier but it's written without jargon.

[00:33:27] We wanted it so the medical professionals could read the mental health material and vice versa. And a nice fringe benefit from that is that people who aren't healthcare professionals at all, if they're interested in the science, they can get a lot out of this. And I know a number of psychotherapists who are prescribing this book for their PPD patients.

[00:33:48] Once again, all the royalties are donated. Same with this book. This one's more for professionals. It's got a table of almost 500 different diagnoses in it and describes the contribution of PPD to those diagnoses. The diagnoses were selected because they're common in PPD patients.

[00:34:07] There's also a longer version of our 12 item online self-assessment questionnaire that's a full 37 items. Same structure, the more questions to which you answer yes, the more likely it is that you have PPD.

[00:34:22] More evidence based resources. I'll point you particularly to the App: Curable. They charge for it, you know.  About the same amount you'd pay for a half hour of psychotherapy, for a year subscription.

[00:34:34] The founders of that company took the best ideas from my colleagues and myself and put it into a wonderful user interface. The other app up there is to teach healthcare professionals these ideas. Several other books, evidence-based, that I can recommend, each one has something to contribute.

[00:34:53] Pain relief psychology, there are several subtypes, but they're all closely related. And what they share is that they focus on brain generated pain. Their goal is relief of pain or illness, not merely helping people to cope with it. And they address, most of them address adverse childhood experiences or ACEs, trauma, and emotions.

[00:35:14] And when they do that, they get these kind of results huge changes in pain scores in fairly short spaces of time. This was the Boulder Back Pain Study.

[00:35:24] This was a West Los Angeles VA study of older male veterans with chronic pain. Two groups, one got cognitive behavioral therapy, which I mentioned earlier, the other got pain relief psychology of a specific type, happens to be the one that I practice the most, and you can see the huge difference in achieving their goal of at least 30 percent pain relief.

[00:35:47] Nothing like this has ever been seen before in pain relief literature to have an eightfold higher success rate.

[00:35:54] This is a study from Harvard showing similar striking results.

[00:35:58] I will skip over since we're so short, telling you the stories of some of these patients. But I will say that the doctors who have learned how to do this have seen their practices transformed. One of these doctors who learned it a few years ago, took me aside at a conference and said, these ideas and put the joy back into my practice, and they were so enthusiastic about it that it spread from these 3 doctors to now a full 72 doctors in their community, which is a medium sized city. They took the online course at endchronicpain.org.

[00:36:30] Here's the information about the nonprofit and we've got lots of resources on there that are growing all the time. I'm very enthusiastic about the advanced course that's coming. It's going to be jargon free. It's got actors in it. It's got graphics in it. It was filmed here in Portland with a video production company that I'm very excited about. And that's going to be released in January. So I'll stop there.

[Question period begins]

[00:36:58] Yeah, that's great. Thank you. so much. Kathleen, go ahead.

(Kathleen) You know, in the pain science group, we discuss all different methodologies, and there's so many different answers, it seems, but it sounds like you've found the secret sauce on that. Can you explain that a little bit more on why mindfulness, there's just so many options that pain sufferers go through and trial and error. So, do you suggest all of those or do you have, a little bit more of a state straightforward path?

(Clarke) Let me, let me show you mindfulness.

[00:37:38] Here it is. This is this study from Harvard with the vertical axis showing the percent of their subjects who were completely pain free and the horizontal axis shows the 6 month or 26-week duration of the study. In the pain relief psychology group, which is the brown line, they all start off with zero are completely pain free.

[00:38:07] Six months later the pain relief psychology group has 64 percent are completely pain free. And the reason I'm showing this slide is that the magenta line there is mindfulness, which achieved, 25%, pain relief after six months. So it was better than nothing, but not much. If this was a football game, the score would be 64 to 25.

[00:38:38] And so that's why I didn't talk, and you didn't hear me talk about mindfulness tonight because it's a little better than placebo, but not a lot. And if you're going to be working on this, you should devote your energy to the technique that's the most effective. it took me years to, I mean, I was on a relentless pursuit of the root causes of what was going on because I had seen Dr. Kaplan cure this profoundly ill woman, with just talking to her. So, I knew it could be done. And I was determined to find what was necessary to achieve those kinds of outcomes with everybody who came my way that had this problem. It took me five years of almost 300 patients a year before the pieces of the puzzle finally came together.

[00:39:35] You know patients who have this condition, when I, when they don't know anything about it, and I first see them in the office, and they're telling me their story, it is as if they are randomly throwing jigsaw puzzle pieces at me, and I don't have the box to show me what the picture is supposed to look like.

[00:39:54] And sometimes a piece that they throw at me in the first five minutes, and a piece that they throw at me after 35 minutes, fit together and it makes sense, it just, took me a long time. And like I say, probably close to 1500 of these interviews, before I could, make these pictures happen on a regular basis.

[00:40:18] You'll see some of the results of that if you take the advanced course in January. In that course, I am teaching the most advanced stuff that I possibly can.

(Maureen) Wow! What was the brown line again, doctor?

(Clarke) That was the form of pain relief psychology. Okay. They had a fancy term for it, but that's basically what it was, is everything.  They called it psychophysiologic symptom relief therapy.

Brain Man: Understanding pain and what to do about it
https://www.youtube.com/embed/qEWc2XtaNwg
Everyone agrees that pain is a universal human experience. We now know that pain is 100% of
the time produced by the brain. This includes all pain, no matter how it feels–sharp, dull, strong,
or mild–and no matter how long you've had it. You might have had it for a few weeks or months.
This is called acute pain, and it's common with tissue damage, say from a back injury or ankle
sprain. And generally, you'll be encouraged to stay active and gradually get back to doing all
your normal things, including work. Or you might have had it for three months or more, and this
pain is generally called persistent or chronic because in this type of pain, tissue damage is not
the main issue.
What's less clear, though, is when you're told you have chronic pain is knowing what's best to
do about it. Well in Australia chronic pain is a really big problem. In fact, one in five people have
it. Having a brain that keeps on producing pain even after the body tissues are restored and out
of danger is no fun. Some people say it still feels like they must have something wrong, but
that's just it. Once anything dangerous is ruled out, health professionals can explain that most
things in the body are healed as well as they can be by three to six months. So, ongoing pain
being produced by the brain is less about structural changes in the body and more about the
sensitivity of the nervous system. In other words, it's more complex.
So to try and figure out what's going on, you need to retrain the brain and nervous system. To
do this it's helpful to look at all the things that affect the nervous system and may be contributing
to your individual pain experience. What can help is to look at persistent pain from a broad
perspective. And by using a structured approach and a plan, it's less likely that anything
important will be missed.
Let's start with the medical side. Firstly, taking medication can help but only to a limited extent. It
is the more active approaches that are necessary to retrain the brain. So using medications to
get going is okay, and then mostly they can be tapered and ceased. Some people also think
surgery might be the answer, but when it comes to a complex problem like chronic pain, surgery
may not be helpful. So if you're thinking of surgery, it's best to get a second opinion and
remember to consider all the things.
Next, it is helpful to consider how your thoughts and emotions are affecting your nervous
system. Pain really impacts on people's lives, and this can have a big effect on your mood and
stress levels. All those thoughts and beliefs are brain impulses too. But you can learn ways to
reduce stress and wind down the nervous system. This helps with emotional well-being and can
reduce pain as well.
The third area to consider is the role of diet and lifestyle. Now it turns out that our modern
lifestyle might not be so good for us. In fact, what we eat and how we live may really be
contributing to a sensitized nervous system. Looking at all the things like smoking, nutrition,

alcohol, and activity levels, and seeing if there are any issues, is a good beginning. And these
things can go on your plan.
Then there's often enormous value in exploring the deeper meaning of pain and the surrounding
personal story. By stepping back and looking at all the things that were happening around the
time the pain developed, many people with pain can make useful links between a worrying
period of life and a worsening pain picture. For many, recognizing deeper emotions can be part
of the healing process.
Last but by no means least is physical activity and function. From the brain's perspective,
getting moving at comfortable levels without fear and where the brain does not protect by pain is
best, and you'll gradually restore your body's tissues.
So to sum up pain, it comes from the brain, and it can be retrained. And when looked at from a
whole personal broad perspective gives you a lot of opportunities to begin. So get a helping
hand if you need it. Set a goal, and begin.
Credit:
“Brain Man: Understanding pain and what to do about it,” HNE Health, Hunter New England
Local Health District, 2019. https://www.hnehealth.nsw.gov.au/

[00:00:10] I guess I'll start with my history and just kind of give you guys a little rundown of my story. I was sexually abused starting at the age of three. It went on for a couple of years, also suffering, emotional and mental abuse. I was raped at the age of 14, lost my fiancé at 19, was married to a mentally and emotional abusive husband. Got a divorce then was in a long-term relationship with a physically abusive boyfriend. I was getting really sick all the time and in a lot of physical pain. I became really, really sick and could barely function in everyday life. It took five years of nonstop doctor appointments to finally get a diagnosis of lupus. But by that time I was already on 16 different medications, and life was miserable. I had started taking some classes, and one of them I took was Lianne's [Dyche] with the hopes of learning how to manage my pain because life was all about pain. But I started to learn so much more.

[00:01:30] The biggest turning point for me in my life was being up at OHSU [Oregon Health Sciences University]. I was up there for more testing. My blood pressure was skyrocketing, even though I was on two different medications for that. My heart was beating irregularly, and it was hurting. They rushed me in for an EKG and also gave me some kind of shot to try to help with whatever was going on. As I lied there, I thought, "If I die, what is going to happen to my animals and my rescue?" You see, I started Linn County Animal Rescue to help animals in 2008, and at the time that this happened, I was responsible for over 40 horses and 17 dogs. So I decided then and there I was going to change this.

[00:02:20] I was released to go home and immediately went home and looked up my medications and their side effects, and I was shocked. I could not believe how bad some of the side effects were and how bad they affected my other issues like my PTSD, my anxiety and my depression. I immediately stopped taking some of them. I do not recommend anybody do that. Please talk to your doctor to get off medications the right way. Don't do what I did. So I got myself off all of them, but one. To this day, I only take one medication and it's for my blood pressure. And it is the lowest dose that you can take.

[00:03:05] That was about five years ago. I continued to take classes. I learned how my trauma was affecting my perception of pain and how that affected my body. Pain was not what I thought it was. So my opinion of my pain and my lupus diagnosis changed along with other things in my life. I learned the pain science, and how my brain was trying to protect me because of the past. I learned that when my brain perceived something as a threat, it sent out signals to protect me. But there was no real threat. It was just the past. But I had to put that piece together to where I understood that this was my past. It wasn't actually anything that was happening now.

[00:04:04] The perfect example of this is I used to not even be able to walk a half a mile without running out of breath and almost having a panic attack because I felt like I couldn't breathe. Then it came to my attention through learning all of this, that my brain was perceiving that as when I was under threat. Somebody had stopped me from breathing by choking me, and so my body thought that's what was going on. Once I figured that out, I would talk myself through it. "I'm safe, I'm fine. And everything's okay."

[00:04:40] Now I can jog without stopping, can jog and do all that stuff without any problems and breathe just fine. So I started focusing on other things that would ground me. As I like to put it, get me out of my own head. So I stopped focusing on my pain and my sickness.

[00:05:04] One of my biggest allies in this was the animals. In one of the classes I was taking, we would set goals for ourselves to try to help us grow. I decided with help and encouragement from my teacher and other classmates to set two big goals. One, was to be around people. Two, was to have my horses help other people like they had helped me.

[00:05:31] You see, I totally isolated myself from most everybody. I couldn't even handle going to the grocery store. It was just too stressful. I set small goals like hanging out with one friend off my property, so I'd actually have to go somewhere. And I didn't realize that the second goal was going to also help with me being able to learn how to be around people.

[00:06:00] Because my second goal is having my horses help other people. That one was a big one for me to actually let people be in my space and be around my creatures. That was hard, but it was a good one. But I realized how much they had helped me with my PTSD, anxiety and depression. The calming peace that's being around them is so healing to me, it would be so healing to others. I thought. So I started the Healing Hearts with Horses program to help people with PTSD. This program is where we invite people who have PTSD to come out and spend time with our horses. And it works great. They get to spend time with these amazing animals.

[00:06:48] It was so amazing to see the connection that the people were making with these horses and the connection the horses were making with them as well. You see, our horses that are here have been abused, so they have been through trauma themselves. They have such an understanding of pain, especially emotional pain, because they have emotions as well. Horses are extreme empaths. They feel emotions so, so immensely. They know the difference between someone who is suffering from PTSD and other disabilities like autism any, anything like that. And they know somebody that doesn't have any of those issues. The horses that are here, a lot of them, didn't even like people to start with because of what they had been through. But they started loving on these people and showing them compassion and kindness. And the people were loving on them. And it almost still brings tears to my eyes just to see that happen. Because it's amazing, and it makes people feel so great. And it makes the horses feel great.

[00:07:57] So we have expanded the program to extend to people with physical and mental disabilities and other issues. We have also started working with several other groups like Kids Northwest, who works with kids with mental issues such as autism, things like that. Youth Build, who work with troubled youth to try to get them to be successful in life. And the Oregon Farrier School, to get kids to learn how to do horses' feet and deal with them. And we are setting up more groups to try to start coming out, to help as many people as we can.

[00:08:29] And we use cows now too. We do have some cows that are helping out with the program also.

[00:08:33] So what I have learned has been huge for me in my life. I still have work to do. You know, life's not all roses all the time, and sometimes you have to put your tools to practice. But I do because I have an understanding of it, and I have an understanding of what tools I have that I can use whenever things get hard.

[00:00:00] Well, thanks for having me, everybody. It's nice to be around like-minded people and kind of sharing our stories and learning from everybody. Let me pull up my PowerPoint here. So when initially was approached to talk, I was excited to share my story but then also thought I don't want to be redundant and repeat what has been repeated before. Because I know a lot of this has been talked about by people, more expert than me in the field of pain neuroscience and its application.
[00:00:49] But, at that time, there had been a question I had been kind of pondering myself about why this practice hasn't been accepted as widely into healthcare. This knowledge about pain science isn't brand new, and I hadn't seen that it had really changed healthcare practice. So I, in thinking about my story, thought about how this information had been presented to me in ways that were helpful and ways that weren't helpful, and how I think as healthcare providers, we could message this to other healthcare providers. And I think from a patient standpoint, this is very applicable, too, because patients that have come to understand pain in a more complex and nuanced way, I think can become excited, and passionate, and very knowledgeable about it. And sometimes I think we try to pass that information along to other providers, friends, family, things like that, in a way that isn't subtle and in a way can be such a drastic shift to their understanding that it almost causes them to recoil in the other direction.
[00:01:53] At the time of this, too, I had a doctoral student who was working with me, and she was very surprised at how I practiced because it was vastly different than anything she'd ever seen or anything that they had learned in PT school. And, you know, we had one moment early on in the experience where I kind of sat down, and I just dumped pain neuroscience on her. And I think she left the room with her head kind of spinning, thinking, "This guy's kind of crazy. This is kind of nonsense. And this is nothing that I learned in school." And so from that, I kind of had to step back myself, you know, and had been almost evangelizing this to her because I feel like, you know, we've had this awakening and needed to approach it with a little bit more subtlety.
[00:02:32] And so anyway, in coming up with this, I didn't want to be too redundant and just repeat some of the concepts that had been repeated before. But I think this may be helpful in thinking about how we can change beliefs of providers, and how we can ultimately have providers speaking to patients about pain in a different, and hopefully a little bit more helpful way.
About Me
[00:02:51] A little bit about me. I grew up on the Oregon Coast in Bandon. I went to Oregon State University for my undergraduate and studied exercise physiology. I'd always been interested in healthcare and wanted to be somewhere in the medical field. Unlike a lot of people that end up in physical therapy, I've actually never been a patient of a physical therapy clinic in my life. But I was always fascinated by anatomy and biomechanics and the capacity of the body to heal itself. And so I was pretty naturally drawn to the profession.
[00:03:24] I did do some observation in my high school education in a physical therapy clinic, and I really appreciated the length of the sessions that therapists had, working with patients. And that seemed a bit unique in healthcare. And so that was another thing that kind of drew me to that profession. So throughout my undergraduate education, I had the goal of becoming a physical therapist and going to a graduate program.
[00:03:46] I ultimately decided to go to school at Eastern Washington University. I liked a lot of things about the program. I, at the time, was highly interested in orthopedics, and they had a pretty strong orthopedic background in their teaching. And they had some clinicians that were pretty well versed in manual therapy, which was something I was really interested in at the time as well. So that played a role in why I ended up there. And now as Rolly mentioned, I work at an outpatient orthopedic clinic within Samaritan called Rebound Physical Therapy in North Albany.
My Journey With Pain Neuroscience
[00:04:19] Going through my story, I, a couple days ago spoke with Rolly, when we were kind of getting this all set up and I don't know that I had ever rewinded in time enough myself to truly appreciate what I thought pain was. And so in the last couple days, I had gone back and edited these slides a little bit and kind of tried to break it down to when I was a kid before any formal education and biology, and anatomy, and physiology, what did I think pain was? And at that time I truly, one, I don't know that I had ever thought about pain. Pain just seemed to be part of the human condition, right? As a kid, you fall down and you bleed, and it hurts. So pain was just pain.
[00:05:01] But if I had to think about it, I, at that time would've thought that pain was something that lived in our tissues, right? That it was a quality of our body. I don't think that I had had probably a recognition of the influence of the nervous system in any capacity. If you banged your knee, the knee hurt because pain lived in your knee. So it was kind of interesting to go back and think about that understanding of pain prior to having any sort of education about the anatomy, biomechanics, neurology, all of that stuff.
[00:05:33] So ultimately I went to undergraduate at Oregon State University. So that's when I was kind of introduced to human anatomy and physiology. I started to develop a bit of an understanding about the peripheral nervous system and the central nervous system, and how we had different sensory receptors that transmitted signals.
[00:05:54] Though I don't recall at any point in my undergraduate training, even though I was specifically in a kind of pre-physical therapy track, I don't know that we ever talked about pain, specifically, aside from maybe noting the differences between different sensory receptors in our body. And we certainly talked about nociceptors, which to me were pain receptors. But beyond that, I don't think that we really specifically talked a whole lot about pain. So I would say in my undergraduate education, I still had an understanding that pain was kind of a one-way signal, but that the nervous system did play kind of a role in that.
[00:06:28] My physical therapy school was largely kind of trained under a biomedical model. So again, at that time, similar to undergrad, I had a understanding throughout my education that pain was something that was arising from an injured or a damaged tissue. Again, we talked a lot about a nociceptive fiber or what we would call pain receptors at the time. Through of modalities class, we were introduced to the gate theory of pain, which is a understanding of pain that's quite ancient at this point, but still has a fairly firm grasp, I think in how we train medical professionals, particularly within physical therapy.
[00:07:05] Essentially the gate theory of pain and pain management is that we have these kind of small diameter, nociceptive pain fibers that send a signal up to our spinal cord. A way that we can block pain or essentially shut the gate, is to heavily activate these larger myelinated large diameter fibers that are sensory receptors.
[00:07:27] And so that was kind of the baseline understanding of how we talked about pain and pain management. If we can adequately stimulate these large fiber sensory receptors, then essentially we can partially shut that gate to the pain receptors at the level of the spinal cord and block that signal from being transmitted up to the brain.
[00:07:46] And so that was kind of the theory and the understanding behind the use of inferential current and different types of electrical stimulation. Even the application of heat and different kind of topical modalities, biofreeze and things like that, was we overwhelm the skin with this robust sensory stimulus. That will essentially flood the spinal cord, which will block the input of pain. So again, it was very much a one-way signal from the tissue up, and that was really the only level at which we had control of managing or blocking pain.
[00:08:20] It was very much assumed, at least by me, and I would suspect most people in my program, that pain equaled damage. I had never even challenged that idea. I didn't think about the idea of having pain in the setting of no damage or conversely having no pain in the setting of significant damage. I didn't, in my training in physical therapy school, have any psychosocial training or education. So we had very little understanding of psychology or its influence on pain or the human condition. To the degree that we maybe talked a little bit about psychology was more in the realm of sport psychology, and motivation, and things like that. But was largely left pain out of that discussion. Again, I didn't have any pain neuroscience education, so my understanding of pain was purely bioanatomical, and I was well-versed in the different tracks in our spinal cord, all the different receptors, fibers, things like that. But didn't have a understanding of the pain neuroscience behind that.
[00:09:22] And certainly we didn't talk, and I hope this has changed now, but about trauma and ACEs, or the adverse childhood events, and how early childhood can affect our neurobiology and psychology and certainly our pain response later in our life.
[00:09:37] In my clinical training. So as part of physical therapy school, we have clinical rotations or internships. I was introduced in my very first rotation to Explain Pain, pretty well known book, by Butler and Mosley. At that time, because I was so heavily focused on orthopedics and manual therapy and was still working largely under that biomedical model, I largely wrote off that understanding. It didn't resonate with me and any of the experiences or training I'd had at that time. And so it just didn't really stick.
[00:10:07] The remainder of my clinical rotations, somewhat by my choosing, were highly biomedical, and they had a pretty heavy focus on orthopedics and particularly a focus on manual therapy. So utilizing largely my hands to try to make people better. So muscle energy techniques, and joint mobilizations, and spinal manipulation, soft tissue mobilization, all of those fairly passive interventions.
[00:10:33] Kind of moving forward to the start of my clinical practice. Again, just coming out of my schooling and my clinical education. I, in the clinic had a pretty heavy focus on manual therapy. I kind of, at the time thought that I had magic hands that could fix anyone with the perfect manipulation or just the right amount of pressure on a trigger point. I certainly still had that understanding that. Pain was something that was arising from the tissue level.
[00:10:58] And so my applications at that time were derived solely at, at the tissue level, whether that be exercise, manual interventions, et cetera. With my patients, I utilized Very medical language, talking about tissues and anatomy. And in a way, I think at that point in my career, I almost did it because I was so new. I wanted to show people I knew what I was talking about, and it would've felt somewhat elementary to me to use much more basic language. So at the time, it was very much about the tissues and what I'm going to do at that specific joint level and utilize language at that time that, ultimately now I know is quite harmful, but the time was what I did.
[00:11:38] And again, at that point in my career, I still hadn't had any really formal training any of the psychosocial aspects of health in general. So my awakening, if you will, I would say within probably my first year of practice or within at least the first two years of practice, I certainly, as I think many providers do, became frustrated by a lack of progress or improvement with patients, particularly patients dealing with chronic and persistent pain. It was a a common theme amongst colleagues and other providers within the profession that you just have some of these patients with pain that we can't get better. And there was almost a probably an air of judgment about it and a air of blame on the patient. But I became frustrated with the fact that we weren't helping these people, and that they were somewhat stigmatized within healthcare as a profession.
[00:12:32] And I have always enjoyed about PT the fact that we spend so much time with patients, and we really get to connect with patients on a human level. And what I ,started to notice, that was the most profound impact that I was having with patients struggling with persistent pain, is when I just connected with them, and really met them as a person and connected with them on a very human level. I attempted to become very good at listening, and again, had some pretty big breakthroughs with patients just by being a good listener, and being empathetic, and allowing them to tell their story. And over and over I would have patients that were moved by that and oftentimes brought to tears by the fact that somebody just listened to them. And it might have been a half an hour of them telling their story. And some of it was about pain and some of it was about the injury they were seeing me for. But I think more importantly than anything, somebody had finally listened to them and didn't try to shove them somewhere else, or give them a medication, or push an intervention on them, but the let them tell their story and just tried to approach those patients with empathy and compassion.
[00:13:39] All of this led me to want to better understand pain. And so I started to do a little bit more research. Having been exposed to it a little bit, I kind of started to realize, man, there's maybe something to this because there's a lot going on that's affecting these people's pain and a lot of it's not happening at the tissue level.
[00:13:57] And so I started to research a little bit more. During that time, my wife had began her graduate education in a clinical track as a social worker. And so she became my resource for the psychosocial everything. And I think up until that point in my life and my career, I was very passionate about anatomy, and biomechanics, and kinesiology, and the stuff that I could really grasp. But this whole realm of psychology in the brain, and human beings as something hard to even put in a box was just so fascinating to me. And a lot of what she was studying and learning, there was just so much carryover into some of what I was seeing in the clinic in terms of what my patients were struggling with. And so through that I kind of immersed myself a little bit in what she was learning and became much more intrigued and curious myself about the psychology of pain and the human condition. Through that too, I was exposed to the idea of trauma, early childhood experience, and how some of those could have such a profound impact on health outcomes later in life.
[00:15:07] There were several books at that time that I just devoured and I think grew a lot from, one of them being, The Body Keeps the Score. That was kind of what got me into understanding trauma and becoming more trauma informed in my care. That's a book by Bessel VanDerKolk that's just incredible, talking about how trauma, particularly early childhood trauma, can essentially live in our body and show up in all kinds of manifestations later in life. Another book that was quite profound in how I practice was The Boy Who Was Raised as a Dog, which again was written by Dr. Bruce Perry, who talked a lot about different stories of trauma and some of the later impacts that it has on people. Another author that at that time was really influential was Robert Sapolsky, who's a neurobiologist at Stanford, who has a great book about stress physiology called Why Zebras Don't Get Ulcers. He has another really thick book about the title Behave, which is about just the complexities of human behavior. And then another kind of profound book was When The Body Says No by Gabor Mate, who's a author, has several books. But again, really diving into trauma and its effects on our health, and our physical bodies, not just our psychological bodies.
[00:16:18] And then certainly in the pain neuroscience realm, you know, books by David Butler and Mosley, Explain Pain Supercharged and Pain Neuroscience Education by Adriaan Louw, about how we can teach patients about pain. I think all of that together is really what was the capstone of my change in practice and my change in thinking about chronic pain, but just pain as a concept.
[00:16:44] Post awakening. So I had just had all that knowledge, but I still felt a bit siloed and isolated, practicing under that kind of model because it wasn't something that I was exposed to in my clinic, specifically. But healthcare in general didn't seem to be applying that approach that seemed to me like the answer. And then I met Sharna Prasad, brilliant, kind, compassionate, and very high achieving PT that many of you know and have been touched by. And so that kind of got me plugged into a community of providers locally here who were like-minded and understanding pain, and were taking a more holistic approach to just patient care in general, but certainly in management of chronic pain.
[00:17:26] She teaches a class called MAPS in Lebanon, and so as part of that, I attended the class and learned as much and absorbed as much from her as I could. During that, I was introduced to ACT or Acceptance and Commitment Therapy, which is a psychotherapeutic intervention. It's kind of the third wave of the behavioral interventions. And it really changed how I not only practice with patients struggling with pain, but also with any unpleasant sensations, thoughts, emotions, which oftentimes go along with pain. Essentially, it's a modality by which we don't try to get rid of those unwanted thoughts, emotions, sensations in our body, but we allow them to exist. We identify our values and who we want to be in the world, and then we allow those things to be there with us.
[00:18:14] So for patients struggling with pain, it was really, I think, a helpful modality for me to have because it got us over this idea of, well, when I get rid of my pain, then I can do all of these things. It was, I can have pain and I can do all of these things. And so it was a nice way to very quickly empower patients to take a little bit more control of their life and allow pain to be there as part of that journey. So that's something I've applied both as part of teaching the MAPS class myself, as well as just working kind of one-on-one with patients.
[00:18:44] So that kind of leads to today, what my current practice looks like. Vastly different from the start of my practice, which again was very biomedical, heavily manual therapy approach. I very much try to treat patients now as a whole person rather than a body part or a diagnosis, but see them as a whole. I've attempted to become much more psychologically informed and trauma informed in how I care for my patients.
[00:19:09] I've tried to become fluent in what I see as the languages, both of bioanatomy and medicine, as well as pain neuroscience, but psychology as well because they're all different languages. Pain neuroscience resonates with that part of my brain that's very rational and loves the deep dive into the science of it. But human brains and psychology is just a different language than that. And so I think it was important to me to not get too hung up purely on that because that can, just like talking about different tissues, we can become so wrapped up in the nuances of pain neuroscience, that I think we lose a little bit of the human element with that as well. So I tried to become as fluent as I could in the language of psychology. I've shifted, certainly. The majority of my interventions now are active rather than passive. So, the majority of what I do is either exercise based or functional movement based. I still do practice manual therapy in certain situations and it's something I still have a bit of a passion for. It's something I do, but I certainly use different language around that intervention, and that's something I'll talk about a little bit later in this presentation.
[00:20:17] I've very much shifted the patient to be the center of their healthcare team, and so I'm constantly checking in with patients and want them to be the one who's leading their care, their goals, what their expectations and hopes are out of their experience in working with me.
[00:20:32] And then again, in all of my interventions, I've changed my language significantly to be less biomedical in treating all pain, whether it's acute pain, chronic pain, postsurgical pain as being a kind of complex biopsychosocial phenomenon, rather than speaking specifically to the tissue. Again, we'll talk about this a teeny bit further down the slides here, but I think we need to be utilizing these interventions and this language with all patients because we, as healthcare providers, often create chronic pain patients by the language that we use. And so I think this doesn't only apply to working with people who've struggled with pain for years or decades, but if we can talk about pain in this language for somebody who just twisted their ankle yesterday, I think it's going to start to change their understanding and hopefully prevent people from developing chronic pain.
[00:21:20] And then I very much focus now on patient education and empowerment and doing as much as I can to make the patient less reliant on me as a provider, but giving them the resources that they need to take control of their health. So, you know, pain neuroscience, understanding about exercise, some of the pillars of health, sleep, nutrition, mental and emotional health. And then just the benefits of general movement and activity.
PNE Isn't New: Why hasn't it changed Healthcare?
[00:21:45] Okay, so that's a little bit about me and my journey. It was kind of fun to go through that in a little bit more detail myself, to better understand what I believed and what I believe now, and to see the pretty large delta between those beliefs and how those beliefs have changed how I practice.
[00:22:01] So this leads me to the meat of my presentation here. And it's the question of, you know, pain neuroscience. Isn't new, and pain neuroscience education as a intervention isn't that new, but it doesn't seem to have really changed healthcare throughout the time that I've been practicing. And just on a more global scale.
[00:22:22] So this idea about trauma and ACE scores, things like that, have been around for decades now and it doesn't seem like it's really changed how we practice healthcare. And, I think that's because when we're talking about pain, and we're talking about somebody's belief system about pain, we're also talking about emotions, and we're talking about values. And those are things that are pretty deeply held by patients, but also deeply held by providers within healthcare.
Pain Neuroscience--Integration into Clinical Practice
[00:22:51] So this brought me to the topic of how do we integrate this information into clinical practice. Again, this is a pretty drastic paradigm shift from the traditional biomedical model under which most clinicians, whether that be physical therapists, or physicians, or anybody within healthcare, were educated. So I think the majority of people's education was probably similar to mine in a very biomedical model. This biopsychosocial model is vastly different, and I think we need to recognize that. And knowing that, I think that we need to, with providers, introduce some of these concepts slowly and cautiously because again, we're challenging the foundation of not only their just intuition about what pain is, but essentially their entirety of their training, which could be, you know, decades of their life spent learning about this. And coming in with such a drastically different understanding, I think can be quite challenging to hear.
[00:23:46] I think that we do a better job of doing this with patients, right? If we have a patient who comes in with struggling with chronic pain, we don't dump a whole book's worth of pain neuroscience on them. In that first session. We just kind of start to introduce topics, right? We ask questions, we're curious. I think we're really good at doing that with patients, but I don't think we often afford that same grace and understanding when we're talking to our colleagues.
[00:24:13] And, and thinking about that, I kind of recognize, I think it's probably easier to teach and introduce these topics to patients because they don't have a biomedical model to fall back on. Right? They have their life experience, they have their interactions with different providers, but they don't have a vastly different biomedical model that they were trained under so it's almost harder, I think, to introduce these topics to people that have been educated in that in the past.
Changing Providers' Closely Held Beliefs: Key Tips
[00:24:39] In doing that, I started to look a little bit more into how we change beliefs in general. And this isn't specifically to someone's beliefs about pain, but this could be beliefs about anything that somebody kind of holds close to heart. And through doing that, there was four really big things that jumped out that were common amongst all of the behavior change research that I looked at. One was that we need to listen and rather than constantly, try to educate and preach about this, just listening to our colleagues, listening to our patients, and trying to better understand their views, understand the reasons behind the belief systems that they have, and really approach that with curiosity.
[00:25:24] It's important also, I think, as we're trying to change beliefs of providers to come to a conclusion on some of our shared values, right? Providers are doing the interventions they're doing because they want to make patients better. I think we all have that shared common value. And so I think connecting on that shared value of how do we, how do we help patients get better? How do we help patients who are struggling? And leaning into that shared value can be really important.
[00:25:53] Again, evidence and logic are important, but beliefs are often motivated by our emotions. And so I think it can be really helpful in talking with colleagues and trying to change how we practice in healthcare to use stories and to use anecdotes and examples that you've had. Because those play a little bit more on our emotions. And, like we talked about earlier, our beliefs are heavily tied with our values and our emotions.
[00:26:17] And then this is possibly the most important thing from what I've seen and heard from my colleagues. We don't want to force it. We want to respect people's boundaries and don't push too hard, too fast. Because I think often in doing that, people kind of recoil in the other direction. In doing this, I've spoken to several of my colleagues who I know have been to classes, who've taken courses on chronic pain, and it hasn't really changed how they practice. I asked them why, and they felt kind of across the board like two things. One, that they were being told that everything that they learned and knew was totally wrong and that they were essentially being asked to completely change how they practice overnight. And that I think information was just too much to take in too fast. And so I think they all kind of shared the sentiment of it would be nice if this were just presented in a way that felt less forceful.
Cognitive Dissonance
[00:27:09] Again, in doing a little bit of research into behavior change, there was this common theme of what's called cognitive dissonance. So I think about this as we're just planting seeds, right? We approach them with curiosity. We ask questions. We're respectful of their beliefs. And then we tell some stories. We talk a little bit about the complicated nature of pain, and we kind of plant those seeds. And that leads to what's called cognitive dissonance, which is essentially a mental discomfort or tension that people feel when you hold two or more conflicting beliefs or values. So they have their old belief system. We carefully present a different belief system, and that causes a little bit of mental tension and discomfort.
Cognitive Restructuring
[00:27:52] And then the hopeful outcome of that is that they have some sort of cognitive restructuring. By reevaluating their beliefs, they start to adjust them to align with some of the new information and some of the new experiences. That is kind of an internal process, and it often involves seeking out new information, and considering alternative perspectives, and reflecting on the reasons for their prior beliefs, and updating their current beliefs.
Two Big Problems
[00:28:18] So thinking about PT specifically, again, talking to some of my colleagues about, "Why hasn't your practice changed, even though you know about pain and you know about pain, neuroscience?" Two big things stood out.
[00:28:30] One of them was that clinicians become defensive of their skills and their training, and our ego kind of gets in the way, right? It doesn't feel good to go to a class or go to a conference or interact with somebody where they say, "Hey, everything that you know, everything you learned in school is wrong. The foundation of the entirety of your training is built on faulty ground. This is the truth. This is the gospel. This is what you need to do." People just recoil away, largely because I think the ego kind of gets in the way a little bit.
[00:29:02] And then the other one, I think that's particularly in an orthopedic setting that I think clinicians struggle with that I've encountered is that oftentimes pain neuroscience education is seen very much as a educational approach and very much a hands-off approach, which is quite different from the traditional framework of PT, where we're doing manual interventions, we're prescribing exercise, and we're using our hands to move people through exercise. This idea of talking and being instructors to patients, I think is something that therapists in particular struggle with.
Solution
[00:29:37] So again, my, in thinking about this kind of solution is that I think we need to be better at empowering practitioners to integrate pain neuroscience education into their current mental framework and their current interventions. Right? We don't need to tell them everything they're doing is wrong. And that you need to practice just like this. We need to say, "Hey, you're doing really good things, but can we integrate some of this information into what you're already doing?" So it doesn't have to be this or that. It can be kind of a both and situation.
The Power of Our Words
[00:30:12] Again, I think the most important thing, and in talking to my colleagues, I think the most important way that we can start to integrate pain neuroscience into our intervention is just to recognize the power of our words. Patients listen to healthcare providers, right? We're the source of their information. And so the things that we say, whether we're thinking deeply about the words we're using or not, they stick with patients, right? And so again, we don't need to radically change how every provider practices in regards to pain, but I think we can educate clinicians about how profound the influence of their words is.
[00:30:48] And if we can start to gently reshape the language that they utilize with patients, I think that's probably one of the most important things that we can do. And again, very simply, when talking to some of my colleagues, I often just tell them, "Here's some things to avoid, and here's some things that we essentially want to do." We want to avoid language that reinforces fear, that reinforces uncertainty and helplessness, that feeds into a pattern of patients feeling threatened, subjugated, and dependent on us, which is the majority of the language that we utilize under the biomedical model, right? We talk very much about anatomy and talk about very specific tissues. And in doing so, I think a lot of that starts to instill fear. Patients aren't totally familiar with what that might mean, so it leads to a sense of uncertainty.
[00:31:39] We often, as providers, make patients feel like they need to come to us to get better. And so we utilize language like, "Yeah, well just come back in, and we'll do that, and we'll put your pelvis back in place." Right? And patients have a sense of helplessness with that.
[00:31:52] What we want to promote in working with patients and changing our language is language that fosters a sense of safety, and control, and understanding. This is going to feed into a pattern of patients feeling less threatened and feeling more empowered.
[00:32:06] Again, I think if we can start to get providers to change the language and the words that they use, that is going to have a profound impact just on how we manage patients who are struggling with persistent pain.
Examples in PT Practice
[00:32:21] Just again, this could be a somewhat exhaustive list, but a few of the kind of main areas where I see examples in PT practices in practice, but in medicine in general where we utilize language that's harmful. And not only are we using neutral language, but kind of one of the main mottos in medicine is "First, do no harm." And I think a lot of the language that we use in healthcare does harm. Right? And this can be something as simple as the diagnoses that we give to patients. You know, have patients that come in with a PT order, and it's got eight different diagnoses. Because they have chronic knee pain, and the diagnoses are you know, osteoarthritis of the knee, and patella femoral pain, and medial meniscus tear, and all of this language that the patients have access to. And even just utilizing those diagnoses is something that patients see and that feeds into patient's pain experience.
[00:33:19] The importance of this slide is we need to be careful with the language that we use. There's lots of examples I could use. X-rays is one area where I know we often use language that does a lot of harm for patients. In exercising, again, a lot of times the go-to, if a patient says, "Ooh, that hurts when I do that exercise, " we say, "Okay, let's do a different exercise." Rather than say, "Oh, you feel a little bit of tension when we do that stretch. That's great, right? We're hitting the right tissue. That's perfect. You're going to be more flexible."
Passive vs Active Interventions
[00:33:45] Okay. I will skip past this slide. Not super important. This leads to a little bit of how we integrate this into our current practice. So again, oftentimes pain neuroscience education is seen as a somewhat educational approach only. And so we could think of that as kind of passive pain neuroscience education, where it's provided to patients purely through educational resources. What we should shift towards, and what I'm kind of proposing that we do is that we have active pain neuroscience interventions, where we're involving the patient actively in their therapy with exercise, with manual interventions, while we implement the pain neuroscience education.
[00:34:26] These slides will be available. This was just a little literature review that had looked at, I believe it was eight different studies that had compared either manual intervention alone or exercise alone versus manual intervention or exercise in combination with pain neuroscience education in treating patients with chronic low back pain.
[00:34:47] Again, we often see this as an educational only approach, but what the conclusion of essentially all of the studies were, was that, the patients did better when they had pain neuroscience that was applied in combination with either manual therapy or with therapeutic exercise. And so it doesn't have to be a educational only hands-off approach, but it's something that we can integrate into the practices that we're doing currently. And again, I'm speaking as a PT and speaking to PT interventions, but I think this would be very applicable to anybody practicing in medicine, just changing our language and the applications.
Big Picture Take-aways
[00:35:23] So anyway, to summarize, these are just kind of some of the big picture takeaways from how I think we can start to change the beliefs and practices of providers. Again, we need to recognize that it's a big shift in their beliefs. So we need to introduce these topics slowly to our colleagues. We need to recognize that beliefs are intertwined with emotions and values, and so we need to approach our education and our conversations with curiosity, kindness, and without judgment. So we need to listen. We need to identify their shared values, and we need to utilize story, which plays heavily on emotion. And we don't want to push too hard and want to respect their boundaries. Again, we want to introduce these slowly and just create that sense of cognitive dissonance, which allows those providers to do the internal process of cognitive restructuring and changing their beliefs.
[00:36:11] Again, we want to respect their professions, their training, and their interventions, so we're not triggering their ego and the associated defensiveness that kind of comes along with it. And then again, I think the takeaway from what my research led to, and what I'm trying to implement with my own colleagues is that we want to try to educate providers to implement this into their current practice model rather than drastically shift the way that they're practicing.

00:00:10] Thanks Rolly. It's really good to be part of tonight's session and to meet you all. And I love sharing stories. And my passion in talking about my story, in particular DIM/SIM Therapy, is to help to encourage others to take a fresh look at how they do life and how changing how they do life can make a real difference.

[00:00:41] I just loved what Russell was sharing about. And I think we'll probably touch on a few of his concepts as well. And for a bit of context, I lived with chronic pain for 20 years. And it was quite debilitating. And if I shared all the stories that I have about those 20 years, we'd be here to well over midnight.

[00:01:02] So I'm just gonna skim right over that with a couple of reflections. To cope with my pain that started in my lower back and eventually spread all over my body, I reduced movement. And, out of fear I laid down and kept still. My hope was that that would stop flare ups and reduce the pain that I was feeling.

[00:01:26] I sought medical advice from lots of different clinicians and specialists. And what they did: they prescribed pills, and then they prescribed bigger pills, and then x-rays, and then CT scans, and MRI scans. And I've had injections into my spine and all sorts of different treatments over that 20 years.

[00:01:48] What I did was I saw anything that had "therapy" in its name, like myotherapy, physiotherapy, osteotherapy, massage therapy, I've been there and tried the whole lot. And I had a standing joke with my massage therapist, and when I went and saw her, she'd ask me, "How are you today, Trevor?" and I'd say, "Well, my nose is all right today." That just really gives a little bit of a snippet of what my mindset was, that I was in quite a lot of pain. And the other thing that I'd joke with her was I should design a t-shirt that said, "I can massage concrete."

[00:02:26] And you know, I had a mindset that was problem centered. And I said to myself, look, if it's good enough for clinicians to come up with "failed low back surgery syndrome," I'll come up with a couple of my own syndromes. And so I had TRMS, which really relates to Therapy Resistant Muscle Syndrome because, you know, I'd have my massage and I'd feel all right for a couple of days, and then bang, I'd be back into severe pain. So that was my TRMS. And the other thing I had going for me in chronic plague proportions was PMS. And that stands for Poor Me Syndrome. Everything was a problem to me.

[00:03:11] And over those 20 years, I was really left just lying down most of the day. I ended up being unemployed. I'd spent well over a hundred thousand dollars on chasing treatments that left me in more pain and no real answer as to what the root cause of my pain was. And as Russell mentioned, pain is complex.

[00:03:33] I ended up having lots of falls from opioid use. And I needed surgery for hemorrhoids, which is a side effect from the opiates. And my relationship broke down. My marriage was over after 30 years, and I was on my own. And for anyone that lives on their own, it's a vulnerable place. And what I was planning to do was to sell up and move into a retirement village with a nursing home attached. And that was my Plan B after the medical treatments just failed me.

[00:04:08] When I was at that point, sorry to say Russell, but I took a sideways look at my situation. And I spoke to a friend who was in far more pain than myself. And he mentioned to me that he went to a pain clinic and that it helped him a lot. And the short story was that four months later I got into that pain clinic, and they taught me about my oversensitive pain system. And over a three-week live-in intensive program we didn't, not only "educate," we did.

[00:04:42] So I put into practice everything that all has been taught over that three-week period. And I came off my opioid medication over that time with medical supervision. And 12 months later, I took my last pain pill. And six years later, I don't take any pain medication at all. So pain really over that time went from being a rock concert level volume in my body right down to how it is today, which is just a background noise, quite, quite okay for me to handle.

[00:05:19] And look that really is just a sneak look at my life prior. And I'd like to jump forward to today, which is six years later. I'm employed full-time. I've remarried three years ago, and this room that we're in that you can't quite see is an indoor rainforest. And I built this room myself. And I fixed up the roof panels and got it all built. And really that is such a big difference from my expectation that I'd end up in a nursing home or a retirement village.

[00:05:54] When I did the program, DIM/SIM Therapy hadn't been rolled out into practice. I found out about it six months after I left the program, and I heard David Butler talk about it at a Pain Revolution event. And it really grabbed my attention, got me thinking about what I can do. And, it really has changed my life, as I began to put into practice some very simple principles across all aspects of my life. And in the time that we have remaining, I really would like to talk about DIM/SIM Therapy and how to do it.

[00:06:34] DIM/SIM Therapy stands for "danger in me" and "safety in me." And pain is intensified when we're stressed. When we're worried, it goes up. When we're in danger, it goes up. And the opposite is true. Safety in me calms me down and calms down that oversensitive pain system. And it dials down pain levels that we experience.

[00:07:06] So, what do we do with the DIMs in our life? The dangers in me? It is possible to reflect on what they are and just think about what they are. And in my case, I was able to change one of my DIMs, and the DIM was "move, and you'll be in a whole lot of pain." So that kept me still. That kept me on edge, worrying about any movement. So I've changed that into a SIM by understanding that moving is good for me, that I'm safe to move.

[00:07:43] The other way of handling a DIM is to ditch it altogether. We don't need to have DIMs.

[00:07:50] It's interesting. I just think about moving and you'll hurt yourself. What that did, it not only helped me to lie down, but my other behavior was putting everything at bench level so I didn't have to bend. And then slowly over time I started putting things under the bench. So I had to bend down or bend up and extend the range of my movement. So that was looking at safety in me.

[00:08:18] I got back into the shed. I slowly started to do woodworking and started to enjoy life a whole lot more. And that sort of moving across into SIMs, safety in me, starting to incorporate SIMs into my life is really important.

[00:08:36] I think that when we look at what are our DIMs, the danger in me is often related to other people's stress. If we find ourselves overloaded with worry and stress, it's very easy to ask yourself, "Whose problem is this?" And to have a think about how many of the problems that I'm worrying about in my life are related to my situation. How many of them are other people's? Describing that is you just, you know, ask myself, "Whose problem is this?" And if it's not my problem, I can leave it alone and stop worrying about it. A bit like me sitting here at the moment, and I've forgotten to go to the toilet before and, I said to Rolly, "Hey, Rolly, I haven't got time. I've gotta talk to these fine folk here. Why don't you just go off to the toilet for me?"

[00:09:32] And so it, it's really important to have a clear idea about whose problem are we talking about here, and to handle them. And safety in me is really anything that gives me a calm, safe, fun, joyful time. What I did, was I started to write down what are my SIMs. And I've got a very long list of what are my SIMs. And you know, I'm sitting here in this beautiful rainforest. And just coming out here at the end of the day and having a cup of coffee or tea with my wife and, and unwinding and relaxing is a big SIM. Going to the pool, warm water exercise, walking, going to work, helping people, volunteering. There's lots of things that we can do that are SIMs.

[00:10:21] I think family's a lovely big SIM too. I'm a granddad, and you know, during COVID we were, we were separated from family. I just went over to Perth, which is about 4,000 kilometers west of here. And spent a couple of weeks with my family and my granddaughters. And the night that we arrived, my five-year-old granddaughter said to me, "Granddad, can you stay forever?" And it was just a beautiful thing. Just warms your heart really to hear those things.

[00:10:52] The practical application of DIMs and SIMs really works on calming down our oversensitive pain system in a very practical way. And stress blocks the production of our happy hormones and calm releases.

[00:11:11] And I have a very, very funny story that I'm gonna slip in here. And when I was touring Tasmania with Pain Revolution and talking to groups, we went down to Hobart, and David Butler was about to talk. And we were in a aged care center. I was looking at this myself, really. This is where I might end up. And, and thankful that that wasn't the case, but there was about 60 older people in wheelchairs and the like, just sitting around. And David Butler was talking about DIM/SIM Therapy and how our fun, enjoyable activities, release happy hormones. He named all of the different happy juices that our pharmacy in our head can release. And then he said to everyone, "What do you think releases your hormones?" And it was really quiet. And then he threw his arms out and he said, "What about sex?" And all of a sudden, this group of older people were just sitting there nodding their heads with big smiles on their faces. And Trevor, sitting in the corner, tried to keep a straight face, really, because, you know, I hadn't been in relationship for a while. And it got me thinking, got me thinking about possibilities, and here we are.

[00:12:29] The other thing that I wanted to talk about is how do we incorporate SIMs and not just for patients with a lived experience? They're for all of us. How can we incorporate SIMs into our life so that they become part of what we do, and how we treat our staff in the clinic, how we treat our patients in the clinic?

[00:12:53] You know, what are the ideas that we can have to generate SIMs? And I'll provide a practical example of that. Just leading up to my wedding three years ago, my right leg just decided to stop working. And I was in incredible pain, and I was really worried about it because I couldn't drive my car and couldn't use the brake pedal. So I rang a friend. And a few of you might know Visanthia. And I rang her, and she said, "Trevor, do you think you might be a bit stressed?" And I said, "Oh, duh." You know, there's a lot of stress going on. So we dealt with that, and my leg got better quite quickly.

[00:13:42] And in the meantime though, I had gone off to a physio just to check out was there any tissue damage here. And I walked in, and they welcomed me into the clinic. Called me by my name, helped fill out the intake form. And the lady on the reception area offered me a cup of coffee, cup of tea. There was fruit on the top of the bench. I was made to feel like part of the family. And it was safety in me just coming out through every part of that clinic.

[00:14:13] And I'm sitting there filling out the intake form, and I look across the reception desk, and underneath it, there's this big board with all the brochures from the local community groups: walking groups, chess playing groups, free lunches, card groups, all of those sorts of things. And when you think about pain, not only being issues with our tissues, but having a psychological and a social component to it. This clinic was modeling what SIMs are to their patients, and that was, you know, fantastic.

[00:14:49] And then just a week after then, I had to get two fillings, one in each side of my teeth. And we're only two weeks away from the wedding. And the dentist said to me, "Well, we can do one side at a time with anesthetic, and there'll be about a six weeks wait in between or we can get them done now without anesthetic." So I'm sitting there and I'm thinking to myself, "Well, let's give this DIM/SIM theory a real redhot go." And I'll just say, "Right let's do it. Here we are. Let's, let's do it. No needle."

[00:15:25] So I'm sitting back in the dentist chair and I'm thinking to myself, "This bloke knows what he is doing. He's alright. This is safe. I'm okay. And this is good for me." He starts to drill my teeth, and I just feel a gentle rubbing. I mean, you think what Russell said about pain having a danger element to it. There was no danger in what was happening to me, and I didn't need to know that this was gonna hurt because yeah, my tooth was getting drilled. And I just felt this gentle rubbing, and then halfway through getting drilled, bang my mouth exploded with this lightning bolt of pain. And it was just a flash. And I think it was just a joke on myself, my brain telling me that, "Yeah, we know something's going on here." Got it all finished, and that side of it really worked out well for me.

[00:16:16] Yeah. So look, we've got a couple of minutes left. And I just thought I'd tell you a bit about my mindset prior to going into the pain clinic, where everything was a problem, PMS. And this is my two-year-old granddaughter. She's now five. And here I am over in Perth after leaving the clinic and stretching the calves. And look, look at what happened. She threw her leg up and was stretching at two. And you know, just beautiful to see her modeling, learning from Granddad. And people learn from what we do. So keep that in mind. Yeah, that's one of my favorite photos actually.

[00:16:57] Now I was going to do the assessment for the pain clinic. And in my PMS state, everything was a problem. I couldn't bend. I couldn't move. I was in so much pain. And I was failing all of the assessments in my mind. And then the person said to me, "Well, what I want you to do is I want you to throw your arms out and hold them up for as long as you can."

[00:17:21] And I just winked at him. I said, "Here we go." So 10 minutes later, I'm still holding my arms up. And he, he looked at his stopwatch and he said, "Well, I meant to keep you here till you drop. You're not breaking out in a sweat. So let's move on to the next thing. And you've broken all the records." And the reason why I could do that was that I play the flute. I've been playing it for 45 years. And holding my arms up is normal. And that just told me, you know, it countered the Poor Me Syndrome thinking and gave me a concrete example that, yeah, I can do things. If you use your body then that's real good.

[00:18:10] So what I did as a result in going into the program is to say, "Well, I've tried everything that doctors have told me to do, and look at where it's got me. So despite all of this stuff about the program being rubbish in my mind, I'm gonna give it a good redhot go, and we'll see where it takes us."

[00:18:32] And what I learned was that by applying some self-management to my situation, taking responsibility, getting support, calming down that oversensitive pain system, it really makes a big difference. And my encouragement to people living with pain, but also clinicians is to take a really good look at DIM/SIM Therapy and enjoy life.

[00:19:03] Getting into the shed and doing all those things I thought was gonna cause me a whole lot of pain. What it gave me though was the experience of having a life with a whole lot less pain by having a life and not being isolated and not lying down still like I was. So just great to talk with you.

[00:00:09] Hi, my name is Cindy. I have a pretty short story, but it's caused a lot of chronic pain in my life. About 46 years ago, in 1976, when I was 26 years old, I fell off of a two-inch curb. I hit the curb with the bottom of my foot at an odd angle, then twisted and bent my foot backward. It hurt like the dickens, but I didn't go to the doctor.

[00:00:36] Ace bandages, pain-relieving rub, and Tylenol got me through the discomfort while healing. At later times the same treatment would again work when the pain reared its ugly head. Now fast forward to 2015. I went home to Illinois to take care of my dad, who died in 2017. The pain in my ankle kept getting worse while I was there, and my rheumatologist suggested an x-ray.

[00:01:05] Turns out there were fractures across the top and side of my ankle that had developed lots of bone spurs from improper healing. My rheumatologist said I might consider an ankle replacement. "Yes. Yes, of course I will," I thought, "as soon as I have the time." I came home to Oregon and checked with Samaritan orthopedic surgeons, who all said the same thing, due to primary lymphedema in my lower legs: "Wouldn't touch that with a 10-foot pole." They felt the replacement would never heal. The pain became even more debilitating, and I needed a walker to get around. Not quite knowing what to do next, I asked for a referral to Lebanon Samaritan's physical therapy group and was offered a chance to participate in their MMAPS [Movement Mindfulness and Pain Science] program.

[00:01:56] As a group, we learned about mindfulness, movement, and modern pain science, and how trauma contributes to chronic pain. It all made so much sense. We also learned about the life-changing Pain Triangle developed by Dr. Kevin Cucarro. Exploring his triangle led me to understand that I was anticipating what I should feel every time I put pressure on my ankle.

[00:02:24] This realization made me feel safe, and I knew that I didn't always have to hurt every time I stood up and tried to walk. MMAPS also introduced me to some existing members of the Oregon Pain Science Alliance. I believed in what the organization was doing and what it hoped to become. And so here I am today, a proud member and secretary of OPSA, hoping we can help others to achieve pain mastery on their chronic pain journey, just as our members have done.

[00:02:59] Thank you.

[00:00:10] So tonight, I have a presentation that I'll be sharing with you
the title being, "Controlling the Narrative." And this may be a bit of a
change in pace from the usual. It's not as heavy on concepts, and
treatments, and data, but more along the lines of sharing pain
experience from a patient perspective in a clinical window.
[00:00:39] So we'll start by confirming that I am sharing my screen. Here
we go. I will introduce that "Pain: Controlling the Narrative." My name is
Russell Wimmer. I'm a physician assistant. I work in internal medicine,
family medicine, as well as addiction medicine, addiction recovery in
Lebanon, Oregon, predominantly, so not as prestigious or exotic as
Australia. But I am local.
[00:01:06] So, my disclosures: I'm a member of the Oregon Pain
Management Commission. That is an unpaid position, and it is a public
advisory commission. And I have no conflicts of interest for today, and I
am not being paid for my time or presentation.
[00:01:20] The agenda for tonight and this presentation will be a couple
parts. First of all, establishing that pain, as many of you probably know,
is not that simple. Starting with, "I hurt," transitioning that into, "Tell me
more," and then hopefully getting to, "What I hear you say is..." And
then, if I've done my job, at least one of you will have your mind blown.
That's the goal.
[00:01:42] This is a bit of a transition from what I'm used to. And this
would be great for a lot of participation, audience kind of interaction. I'm
just going to have to tell myself that you're laughing when I think I'm
being funny. And that there's head nodding when I ask what are
essentially rhetorical questions. So with that in mind, I'm also going to do
a lot of cliche things that I always make fun of presenters for doing in
their presentations. I encourage you to laugh because they are funny.
[00:02:07] We'll start with, "Pain: It's not that simple." So the goal is to
find out how to listen and how to be heard in the context of the personal
pain experience.
[00:02:16] So let's start with that first and foremost cliche, which is, let's
define pain. So pain: physical suffering, or discomfort caused by an

illness or injury. I can't see your faces, but here's where I would really
look to see how many people are nodding and how many people are
squinting in anger. Because this is an absolutely terrible definition.
[00:02:36] It is not simply physical suffering. It is not a physically simple
discomfort caused by injury or illness. It is far more complex and
nuanced and multifactorial.
[00:02:48] So let's get into a better definition. We're going to go with the
tried and true Merriam-Webster definition. I apologize. But it is "a
localized or generalized unpleasant bodily sensation or a complex of
sensations that cause mild to severe physical discomfort and emotional
distress, and typically, results from bodily disorder." now, there are a
couple things that I underlined and highlighted because I think that
they're on the right track. This is not a perfect definition, but it's better. In
the way that we are now understanding the pain experience. This is
much better. It is unpleasant. It is a discomfort, and it is often linked with
emotional distress. And I think that there's more to it than this, but it's a
good start.
[00:03:34] And the best word in that entire definition in my word is
"typically." Because the most important part in my mind about a pain
experience is that there's nothing really typical about it. It's unique, it's
individualized, and it's different. Everyone experiences pain differently,
and that experience is modified by a number of things that we're still
identifying.
[00:03:58] And so starting with this as a general jumping point, this is the
idea of pain. It's complex. It's motivated by external and internal factors.
It's modified by things like thoughts, fears, beliefs about pain and about
the source of the pain.
[00:04:15] So I'm going to use this picture. I kind of stole this story from a
previous Pain Summit, but I use it a ton with patients. And I think it really
lays some great groundwork. So I will be brief. There is a very well-
documented case. Construction worker on the site doing his job,
stepped off of a step, and stepped down, and wearing proper, attire, and
safety gear, and work boots, and everything, stepped on a very large
metal spike.
[00:04:41] And that metal spike punctured the bottom of his boot, and
went through the boot, and punctured all the way up through the top of

the boot. And the moment he realized, of course, did what everyone
would expect the typical response would be, which is a very painful
reaction. You know, took the weight immediately off the foot, fell to the
ground, grabbed the foot, starts calling for help.
[00:05:01] So his mates do exactly what they're supposed to, they pick
him up. They get him into a car. They get him transported to the
emergency room. And they come him into the emergency room with his
foot in a boot with a huge metal spike saying, what now? How do we fix
this?
[00:05:14] And so in the emergency room, they immediately do what
they do. They triage. They put on a blood pressure cuff and a pulse ox
and all the things. And they start monitoring his vitals and they see that
he's hypertensive, and he's tachycardic, and he's sweating, and he's
clearly writhing in pain. This man is in really bad pain. And as clinicians
we're taught that's how we know he is in pain. He looks like he's in pain.
His blood pressure, his body's compensating for these huge excitatory
signals being sent from the foot, right? He's got this metal spike.
[00:05:41] It's got to be terrible, so they give him pain medication to try
and stabilize him enough to start assessing and dealing with the
problem, which is his foot, right? And the first dose doesn't really work.
And then they give him a subsequent dose. And after a couple doses,
multiple doses, and a patient with no historical desensitization and
intolerance of these strong medications, he's "opiate naive," as we would
call it. He starts calming down. It starts working. Right? The pain starts
decreasing.
[00:06:09] And so they talk to him. They've got him stable. Then they
say, what we're going to do is we're going to cut the boot off, all right?
We're going to hold and stabilize this metal spike. And we're going to cut
the boot off around your foot so we can see how bad it is. And he goes,
okay. And cut off the boot. And what they found was that the spike had
gone between his toes. It hadn't touched his foot. It hadn't punctured
tissue.
[00:06:33] So the question that I have for you is, "Was he in pain?"
Another great opportunity for audience participation that I will visualize in
my head. And my answer is absolutely yes. That man was in pain. He
was in pain because the pain is processed in the brain. His body used
the mechanism of safety and avoiding danger and saw this metal spike

and did what it was supposed to do, which is a protective sense, and
said, I'm in pain. Try and stop what's causing it. Try and get away from it.
Stop the source. Remove it. Run! Whatever you gotta do. Fight or flight,
the adrenaline. And that's what caused the hypertension and the
tachycardia is his brain's response to survive this perceived danger.
[00:07:20] And so the tissue damage wasn't real, but the pain was very
real. He lived the pain. He experienced it the whole time. From the time
he stepped on it into the hospital, despite multiple doses of potent
narcotic medication. The pain was very real to him. And so the idea that
I really want to impress upon this point in the presentation is that we
know that pain is complex, and pain is also not the body.
[00:07:46] You can have pain without damage. And you can have
damage without pain. I fairly recently had a 90-year-old patient, and this
is very true, 90-year-old patient come into me who said her hip had been
bothering her for two weeks. And her daughter was tired of her kind of
slowly ambling around and kind of rubbing at her hip and made her
come in to see me. And she walked up to my second floor office to come
see me and said, "Well, they just, they made me come here."
[00:08:11] I said, "Well, let's take a look at your leg." And I start
examining her, and it's pretty clear, pretty quickly that something doesn't
seem right. And I convinced her to let me get an x-ray. And when I get
the x-ray, I found that her femur, her big bone in her leg had fractured
just below her hip and was completely misaligned. Huh? It was pushed
to the side of where it should be. It should be like this. It was like this. It
was completely broken. It had been for two whole weeks, and she was
still walking around. She walked up to my second floor office, and she
only came in because she was tired of getting nagged by her daughter.
[00:08:48] She had very real damage. She was in surgery within a
couple days and has some new hardware she hadn't planned on. But
she really wasn't in a lot of pain.
[00:08:57] And so this old concept that we've kind of married to for so
long, and we've really meshed into how we've previously approached
pain is that if you have damage, then you have pain. And if we can
address the damage, then the pain goes away. And that's just not true.
You can have damage without pain. You can have pain without damage.

[00:09:17] So I'm going to keep doing the cliche thing and I'm going to
go through a couple more stories. Disclaimer, this is not my toddler. I do
have a toddler. This is not mine. It was just a great picture online and
this one's actually funnier than mine. Don't tell my wife. She will get mad
about that. So I have a patient whose kid is right now she's just about
turned four. And about a year and a half ago, so she's two and a half,
we're talking about our kids in communication and stories. And she said
the most prophetic thing that I have seen and experienced in parenting,
and then it has translated into a lot of my practice and communication.
And so the scenario was that her two-and-a half-year-old daughter, she
has words and she has some language, but she's, she's two, you know,
she's got a two year old's language. Mom understands it, Dad
understands it, mostly, and no one else does.
[00:10:04] And her daughter is trying to communicate that she really
needs something that's by the fridge. I want it. I need it. And she's using
words and she's using motions and Mom is not understanding it. And it's
something that she doesn't just want, it's something she feels she needs.
And so she starts getting more and more upset, and she starts melting
down. And any one of you that have had kids, hopefully, have ingrained
in you the trauma that I live with every day of having a toddler meltdown.
It's terrible. And the kid starts melting down, and Mom becomes more
desperate to try and fix it and finally connects the dots of what her
daughter's trying to communicate.
[00:10:36] And she gets, I think it was just a cup of water. It was a sippy
cup of water and hands it to her and says, honey, is this what you want?
And her daughter hugs it and says yes. And just maintains eye contact
with Mom. And totally stops the meltdown. And it was at that moment
that she said, "It was like my daughter has been doing everything in her
power to communicate with me for two and a half years. And I've been
doing everything in my power to understand anything that she's trying to
say. And at that moment it was like I finally got her, finally heard her for
the first time. And this is what two and a half years of struggle for this
tiny little human being who's so dependent on me. It's finally paid off,
and we were both relieved." And she said, "I have been chasing that
moment and it's finally getting easier."
[00:11:24] And that really struck home with me with how difficult some
patient experiences are to describe, how difficult they are to explain, and
how important communication and just feeling heard can be in every
context.

[00:11:42] This is the brain of a six year old. They did an amazing study
through Brown University. They called it the baby imaging lab. They're
really smart people. They're not good at creative titles, clearly. A child's
vocabulary grows from the time that they're about two years of age until
the time that they're four at an even growth. That part of the brain
doesn't go up and down based on how much vocabulary they're
exposed to or how many words they learn. It just keeps growing at the
same rate, at the same speed. They're constantly absorbing, no matter
what.
[00:12:15] And at about a year they have 50 words in their vocabulary.
At six, two years after that growth has stopped, but they're starting to
really make more complex connections, they have 5,000 words. In five
years that part of their brain. I guess you can kind of see me pointing,
but not at the screen, so that's less helpful for me to do. But each one of
those colors represents a different measurable timeline along that one
year to four years that they scanned. And it just keeps growing and
growing in as a 100-fold increase, which is just massive.
[00:12:53] And that really hits home to me how important it is for
communication to exist in us as human beings as early as possible. I
mean, they're barely walking at 12 months old, and they're already
starting to communicate. And then by the time they're six, I mean, they're
not driving, they're not voting, hopefully, possibly. I don't know. But they
have 5,000 words. It's incredible. At the age of two, they have the
intelligence of most dogs, and I know a lot of smart dogs. But four years
later, they have this massive amount of communication skill.
[00:13:26] Last story, probably, I have a patient that I see in addiction
and recovery. And let me start by saying she's not an addiction patient.
She had a number of abdominal surgeries. And after those abdominal
surgeries, which were merited, there was real reason to do them, she
developed chronic pain. And that pain continued to evolve, and despite
more surgeries and interventions specifically to fix her post-procedural
pain, it didn't work. And her function was affected, and her life was
affected. And it went from, "I was pain free, but I had some stuff that
needed to be addressed surgically" to "I have some pain", to "I live with
a lot of pain." And so eventually the determination was made to put her
on opiate medication. It helped. It helped her function better. It helped
her feel better. She, she was able to regain some of her function.

[00:14:18] But, after a number of years on that medication, she had
changed clinicians a few times because practices had changed or
someone had left. And at some point, one of her clinicians decided to
put her on methadone. And methadone is a really potent opioid
medication that is classically reserved for substance use and
dependence. It's used because it has a high potency. It's very titrateable.
It's difficult to abuse. It has a lot of good benefits for that cause, but can
also be used for pain, largely because of its potency. And it has a long
duration. So you can dose it once per day, and it'll last for a 24-hour
period. But there aren't many people that will prescribe it, even though
it's available for clinicians that can prescribe controlled medications.
Methadone is perfectly within our rights to prescribe. Not many people
do.
[00:15:05] And so she was put on methadone and it was okay. It wasn't
better than what was before. It was probably not quite as good. But she
was told by her clinician, "This is a better option." And so she stuck with
it. And then once again, after about a year, her clinician left the practice.
And she inherited a new clinician for her primary care. And they said
well, "I've gotta send you somewhere else for your pain." And she didn't
understand. And she said, "Well, why? I mean, you've been managing
my pain in this practice for, for years. I, nothing's changed. I don't
understand." And they said, "Well, I don't deal with addiction." And she
was very confused and said, "I don't understand. I don't have addiction."
And they said, "Well, you're on methadone. And the only reason to be on
methadone is addiction."
[00:15:44] And so she ran into an impasse. She said, " Can you review
my history? I've never had addiction issues. I've never had dependency
issues. I just have chronic pain. And, I didn't ask for this. I was put on it. I
don't know what to do." And they said, "Well, I can't help you. You need
to find someone else who will prescribe for you."
[00:15:58] And so now I manage her. And I have for about a year and a
half. And so despite the fact that she has persistent pain through no fault
of her own, and she lives with that experience. And she didn't make the
choice to initially become a patient that was managed on that level of
medication, and she definitely didn't make the informed decision to start
methadone. She was following the advice that she was given and kind of
doing what she was told. She has been labeled a pain patient, and she's
been labeled an addict, and she's neither of those things. Hmm.

[00:16:32] And so to give you a bit of a happy ending for that, and it will
segue into what I'm hoping to achieve here, one of our audience, who
I'm going to put on the spot because she's the one that got me here,
Sharna Prasad, has worked with this individual. And I will tell you that it
took a number of appointments with this patient. And I would say
probably six, and I see her once a month, six appointments. And the first
appointment or two, I just got to know her and let her know that my job
was to help whatever she needed. I acknowledged that she was not a
patient seeking addiction and recovery services, that that is not what she
needed, and that's not why she was there. She was there through no
fault of her own. She was there to be managed, to have her medications
maintained. And she had accepted that that was the best it was ever
going to be.
[00:17:20] And so I asked her to tell me about her pain experience, her
story. And she told me her story. And over 4, 5, 6 months, I was able to
convince her that there may be someone else who'd like to hear her
story. And that person may be able to let her see her pain in a different
way that might be modifiable. And I was very clear. I am not trying to
send you to a new therapist that's new and awesome and a new
treatment. And I am not going to solve your pain and neither is she. But I
do think that you have been a victim of the classic model for a long time,
and that model has failed you. And I think that there are people that
understand pain the way that I do that are much more open-minded that
will see where you are at in your experience, and may be able to give
you some hope.
[00:18:08] And I will not disclose a whole lot of details, but I can tell you
that she is still a patient with a persistent pain experience, but her life is
very different. And she has a lot more influence on how she feels. And
she has a lot of good days. And she knows that there will be bad days,
and she's okay with that because she knows that she's got a lot more of
a part in it than she ever thought she did. And that all came from my
approach of, "I just want to know your story." And then her having the
courage to be vulnerable when we actually formed some trust.
[00:18:43] So with all of that said, why is pain so difficult to
communicate? And in my experience, there are two personal patient
experiences that if you haven't lived them, you can't explain them. If
someone hasn't experienced it, no amount of eloquence or token-esque
ability to write and paint a scene will be able to get them to experience
what it means to live that way and to feel that day in, day out. And the

nuances. These are both very lived experiences. And one of those is
substance use dependence, or what some people coin addiction. And
the other is chronic pain or the persistent lived pain experience. They're
both lived experiences. They're both things that include lots of factors
and nuance that occurred day in and day out. And if you haven't
experienced all of those nuances, you just have to accept it on face
value. And man, and that's hard.
[00:19:40] And the idea that it, yeah, it just hurts, and that's where it
ends is really hard to break. So there's the end of my presentation. I
hope it was helpful. I'm kidding. I basically highlighted the problem. So
here's the challenge. Here's the difficulty in all this. Now what, right?
[00:19:59] One of the simplest things is to be able to communicate "I
hurt" and hear all the nuances and seek care and support, but man is
that difficult. Right? And I want to get us to the point where I can
empower patients to go from, "I hurt" to, "Tell me more," from the other
side. The average patient with a lived pain experience has experienced
it for years. And many, many, many of the patients I've run into have
been living with this for a decade or more. And they've gone through
clinician after clinician. And every time they try and have this
conversation, it runs into a brick wall of someone saying, "I get it. You
just want pain meds." Or, "Yeah, you hurt. I can't fix you." Or, " Another
surgery's not going to work." And it ends the conversation.
[00:20:42] And so they just stop trying, and that is a horribly isolating and
disempowering feeling. So both of those conditions and both of those
stories, I was hoping to illustrate that that lack of communication, that
lack of feeling heard, it's a barrier to connecting with one another as
human beings. You can't form an alliance. And it is just this impassable
brick wall to improve the wellness.
[00:21:07] So my goal and my encouragement is to just start with what
your goal is. And rarely is that goal "I want to be fixed." So there are two
parts to this. There is the lived experience, which is the persistent lived
patient experience of pain, and that is a story. It's not simple. It didn't just
happen when I dropped the hammer on my foot, and my foot's hurt ever
since. There's a lot to it. Usually there's surgeries and there's years, and
there's things that were up and things that were down. And it affects your
sleep and your emotion, your fatigue. Those things are really hard to
communicate, and I know that that's not easy.

[00:21:44] It takes vulnerability, and that's scary. And so what I'm hoping
is to make it a little softer and to develop a better rapport with this, which
is I want you as a patient, if you live this and you're trying to bridge this
conversation with a family member or ideally you know, a clinician,
because this is where my peers and I have to be better. Start that with "I
want you to understand." And on the other end, we have to want to
understand, we have to want to bridge that gap. And it's difficult to
understand something we haven't lived, you know? How do you describe
color to a dog? How, how do you describe something that you've never
seen, you don't know exists from someone who has, it's very
challenging.
[00:22:29] So I'm going to encourage you to just start at the beginning. If
you're going to walk into that room, start at the beginning and view it as
a story, and you're going to start as simply and as comfortable as you
can by saying, "Today I'm hoping to tell you about my pain and have you
understand a little bit of what that means to me." It's not just the pain
exists. It's not just the hurt. It's what does that hurt do? What does it
mean? How does it affect who you are as a human? Because that's
really the origin of what a persistent lived pain experience is. It's all of
that profile. It's not just a back hurts. It's the feelings and the emotions
and all of the things that go along with the impact of that pain all day,
every day, and ebbs and flows and ups and downs.
[00:23:18] And, "I want you to hear how this affects me," right?
Communicating all those pieces. It's also okay to say, "This is hard for
me to talk about." And that may be helpful. It's okay to not know what
happens next. If you just start with that, it's okay because the provider
probably doesn't know either. The course forward takes a team
approach, and the team starts with one person, the person behind the
pain, and then it grows.
[00:23:52] So if you aren't feeling heard, it's okay to say, "I don't feel like
you're hearing me." Or, "I don't know that I'm communicating what I
meant to." It's okay to say, "This is challenging and scary, and I feel like
I've tried this a lot, and no one really seems to understand. I'm hoping
you can understand." It's okay to say that that conversation is failing.
Because if you do and you try and communicate that it's challenging and
difficult, and it's complex and you haven't been heard before, and there's
a lot to it. At some point, hopefully, the other person is going to, and that
other person in this context may be me, put down the pen, put down the

notepad, take their eyes off the computer screen, and go, "What do you
mean?"
[00:24:39] And that's the hook. That's the bridge because sharing the
story opens the opportunity for more people to be involved, more
characters to become part of that story. And then change the ending of
that story. And that's ultimately the way that we improve wellness for
anyone that deals with persistent pain experience. It takes community. It
takes people from multiple disciplines because no one has the right
answer.
[00:25:06] And that should be absolutely supported by the fact that many
people with persistent pain experiences have done this for years, and
years, and years. And they've seen lots of people over those years, and
it kind of all ended up the same. And in my patient with persistent
abdominal pain, the chronic pain, it was multiple surgeries. It was
multiple primary care clinicians. It was multiple physical therapists. It was
multiple, insert any level of provider you can think of.
[00:25:34] She tried it. It wasn't that she wasn't open to being better, she
desperately wanted to be better. No one had the right idea. And part of
that was that no one was really hearing what she was saying. And part
of that was that the old model is still prevalent. But the one thing that has
quite literally changed her life is one amazing provider that has laid a
seed in this community, who has taught me a lot of the vocabulary and
the terminology, and broken down my old beliefs of pain. And made a
change.
[00:26:06] And that change continues to sow more and more and more
productivity and more benefits through lots and lots of people. And that
program that I work with, and I'm still talking about Sharna, has grown.
And the first time that I met Sharna, she gave me a quiz. I asked to
shadow her, and her first day was that she gave me a quiz. And it had
20 different statements about pain. And she said, I want you to check
every one of these that you know, is correct. And I checked three of
them, and she turned it over and she said, well, you only failed a little.
There are none of them that are correct. And we talked about it.
[00:26:46] But it takes a whole team to start to make change when the
model that we've worked on for so long is so wrong. And so by sharing
your story in the beginning and breaking through some vulnerability and
opening up, even though it is hard and scary and challenging, and you

have no idea what comes next. And the person on the other side of the
table, myself or some of my peers, probably don't either. That's okay
because it starts by admitting we're not really sure how to move forward.
But we're going to keep looking.
[00:27:16] Sometimes the best action is nothing. Just listen. And that
has been true for me as a clinician ever since I started. Sometimes the
best approach is to just shut up and listen. When it's obvious that the
goals cannot be reached, you don't adjust the goals, you adjust the
action. And that is important for everyone.
[00:27:42] The goal is wellness. The goal is improved quality of life. The
goal doesn't change, but the way that we address it, the action, the way
that it's received, should and can. I'm going to use a mantra that is not
mine, that I have stolen from peers. Probably heard it before, but, "All
pain is pain. All pain is real. All pain can be modified." Not all pain can go
away, but it can change over time. And because it's individualized, those
modifiers are individualized, too. And it starts with opening up and
sharing what pain is to you, what it means to you, how it feels, and then
starting to work with people as you build alliance to identify them and
find ways that they can be changed.
[00:28:27] I'll leave you with one of my last quotes. I am a huge nerd, so
I, of course, quoted Tolkien: " Go back is no good at all. Go sideways is
impossible. Go forward is the only thing to do. On we go." And the we in
that statement is the most important. Many patients with this lived
experience have tried sideways, and they've tried backwards, and
they've tried everything. But if we are to move forward, starts with we,
and that starts with your story. And that is what I have.

[00:10:00] Hello everyone and thank you to the Oregon Pain Science Alliance for inviting me to speak tonight. My name is Dr. Katie Smith and I'm an occupational therapist, a Kundalini yoga teacher, and I'm a musician and a lover of nature and a student of life and a spiritual being. And tonight I'd like to share a little bit about my clinical practice and how I integrate the concepts of pain science and a bit about some of my own experiences with pain and the concepts as applied to my own life, to understand why pain science is so key in where we as a collective are moving towards, we need to understand where we're coming from.

[00:10:36] Way back in the 1660s, thought leader and influencer Rene Descartes theorized that the body and the mind are entirely separate and not made of the same thing. The mind was largely left to religion and mystery, and the body and the external world was measured and thought to be understood scientifically using the tools available at the time.

[00:10:58] And through a century's long game of telephone this dualistic, mechanistic model of who and what we are as human beings has contributed to the propagation of the false idea that is still largely alive and well, wherein an external stimulus over here creates pain in the body, and then our nerves tell our brain that there is pain over here. That's a simple cause and effect, and that's because that is the extent to which the science at the time could make sense of reality.

[00:11:32] And with this understanding, there's really nowhere to go. In this dualistic model, the external world, the stimulus is the independent variable; that's the thing that's calling the shots. And our internal experience is the dependent variable. So we will get pain when we encounter a "painful" stimulus, and there's nothing we can do about it. That's it. It's done, over, inert. So we're helpless.

[00:11:58] But in the new understanding of the world of human beings and of pain, through the application of psycho neuroimmunology, neuroplasticity, quantum physics, and epigenetics, we're actually discovering a return to power.

[00:12:14] We are not the helpless victims of our environment. We are actually creators of our experience in authority and dominion in our lives. So rather than an immutable cause and effect process, pain is an emergent process, which means it includes many factors, including factors from the internal world that combine together to create something different than the sum of its parts.

[00:12:42] Processes like fire, pain, and cake are emergent processes. So when you're baking a cake, it isn't just about combining the ingredients and expecting it to be a cake. All of the ingredients need to be present and it has to be baked. And in that process, that's when it becomes a cake. So without every ingredient being present in the right amounts at the oven, at the right temp, it wouldn't be a cake, it would be something else.

[00:13:10] So what I seek to target in my clinical interventions is that magical. process where experience including pain emerges. So let's bring some of that magic out into the light a little bit. So I am an Occupational Therapist and as an OT I address the whole person. So that's their physical body and also their mental, emotional, spiritual, internal aspects.

[00:13:37] This is, this is a, a diagram of the scope and focus with a person here, physical, spiritual, emotional, and mental. So as such, I employ a variety of research driven psychotherapeutic techniques, including Cognitive Behavioral Therapy or CBT and Rational Emotive Behavioral Therapy. REBT is a style of CBT, and it has a concept that's been really helpful for me personally and clinically in zeroing in on where change can happen and how to help foster that change.

[00:14:10] And this is the ABCs of REBT. So in the ABCs A is the activating event. So that's something that happens in the external world. So someone steps on your toe or cuts you off in traffic or breaks up with you, gives you a promotion, buys you a cup of coffee, and then the Beliefs. That's B, that's our interpretation.

[00:14:34] So that's the Beliefs that, they're a jerk, or I don't deserve this, or I'm actually better than she is, or it's all my fault, or this is a problem. And then C is the consequence. So that's the experience. So the formula there is if B, then C. So if they are a jerk, that's the B then I am experiencing anger , it's all my fault.

[00:15:03] If that's true, then I'm experiencing shame. So if B, then C. So, these beliefs, these nearly instantaneous, largely unconscious assessments of our own resources and the perceived threat of the stimulus. These are the areas where change can happen, and that's because our beliefs are in our dominion in our internal world.

[00:15:29] They are in our authority, that's in our lane. So if we're trying to focus on A, the activating event or the stimulus, then we're out of our lane and we're really trying to control other people or the outside world. So good luck with that. And then if we try to focus on C and try to change our experience without really looking at the B, the beliefs, that's like trying to deny that the cake is a cake.

[00:15:56] All the ingredients went in, you baked it, that's a cake. So you really don't get anywhere by, by denying the, the experience. And, I feel like that that risks some unkindness to self. So really the magic is in the B, in the ABCs of REBT, the beliefs that inform our appraisals of resource and threat and subsequently shape our experience.

[00:16:23] So what? What happens in the oven? What is B? What is it that creates and informs those nearly instantaneous appraisals, the instantaneous assessment of our perceived resources. So that's physical, emotional, temporal, relational resources that we have. So questions like, am I tired? Am I hungry?

[00:16:44] Am I stressed out? That happens instantaneously. And then also the perceived sense of threat. So, how does the thing that we're encountering, stack up against me if we are in opposition? So for those of you who are familiar of the work of Butler and Mosley, this is where Dims and Sims come in.

[00:17:01] That's the signals that create a sense of safety in me and the signals that create a sense of danger in me. So an example of this, going to a hospital can create a sense of safety in me. If I have acute appendicitis and I'm seeking medical attention, it could create a sense of danger in me if I have a history of uncomfortable hospitalizations.

[00:17:23] So, whether something is a Dim or a Sim, the safety in me or danger in me concept is an emergent process in and of itself. So our appraisals of ourselves and our situation takes into account so many factors, including personal history and experiences, trauma and our adverse childhood experiences, family patterns, cultural conditioning, and also the external voices of authority that are internalized voices that we're learning from schools, from our parents, from religions, politics, or even celebrities.

[00:17:57] So my intervention strategy is first to address more superficial mitigatable factors. I focus on boosting the internal sense of resource. So what I work on with my clients is we address their sleep. We're making sure that they're getting the rest that they need. We go through their whole, usage of energy throughout the day, and maybe we employ some pacing strategies or some energy renewing strategies.

[00:18:22] Also, things like physical exercise or. Mindfulness practice, these, these kinds of adjustments, to, to boost an internal sense of resource and then to reduce the external sense of threat. I work with my clients on sensory modifications to modulate the input that's coming in through their senses.

[00:18:40] We also might work on ergonomics or overall environmental modifications or modifying the tasks so that it's more achievable and more successful for them. So this was just a really brief overview of. Some of the interventions that I address with my clients first, and I do those more superficial interventions first to build therapeutic alliance so that they know me, I know them, and we've got some rapport. We can trust each other a little bit.

[00:19:10] I also address those things first to support an increased sense of self-efficacy so that life in general feels more achievable, more doable, more successful. And also going a little deeper in this process seems like it's something that could be successful.

[00:19:26] And then finally, I address these things to help bring the nervous system from a place of survival into a state of calm and coherence, where cognitive flexibility, creativity, and change is possible. And for those of you who are familiar with the HeartMath Institute or concepts of flow state during meaningful task engagement or limbic activation versus frontal lobe activity, or high beta versus alpha brainwave patterning, you know what I'm talking about?

[00:19:56] And we can talk more about it in the Q and A if you like. So. Working on these things first really helps set my clients up for more success. When we then take it to the next level we address the deeper stuff, we really take a look at the cognitions, the beliefs, the habits, expectations and assumptions, and where they come from.

[00:20:15] So we bring these subconscious assumptions into the light and first of all, own them. When they are seen and known as our own, then they are in our dominion, and then we have the power to make change beliefs. Our beliefs are in our dominion, but they are not the same thing as who we are otherwise. They're just another independent variable that we are subject to, that we would just be under sway of whatever it is we're holding in our mind as a belief.

[00:20:46] So they are ours, but they are not the same thing as us. So really understanding what our beliefs are, where they might come from, how they align with our values or not, how they serve us or don't, then knowing that they are ours, but they are not the same thing as us. So there's so much potential for really deep change here.

[00:21:09] And to get a little deeper into this, I'd like to share my own story. So, I'm the youngest of four kids, and when I was born, my mom, who's a registered nurse, stopped working mostly to take care of me. And as the smallest and the youngest, I was well cared for. Perhaps to the extent that I learned that self-reliance is maybe not my best survival strategy.

[00:21:34] I also, I got sick as a child that which required a brief hospitalization. And even though it was for such a brief moment, to my young sense of self, it was really pivotal to me. It confirmed that I was vulnerable and that I needed external protection to be safe. And I developed a medicalized perspective on myself, informed by, in part from my mother's medical background, and I went to see healthcare providers often throughout my childhood and adolescence for any strange experience that I hyper vigilantly scanned my body for. And in my twenties, I felt pervasive joint pain for which no explanation could be found. And after years of seeking answers, a physician tested me for joint hypermobility, and I met the criteria.

[00:22:23] And this became the diagnosis that I hung my hat on and I felt validated, like my experience, and therefore me could suddenly be more understood because there was objectified language for it, language that was validated by an external authority. So I started wearing joint braces. I started modifying my activities to protect my joints.

[00:22:43] I was lifting less, doing less physical activity, really focusing on keeping myself safe. And then I had three pivotal encounters that really changed everything. I saw my primary care provider and I presented to her all the evidence that I had gathered about my condition and how it proves that my experience means something.

[00:23:05] And she simply asked me, why do you want this diagnosis in your chart? And it had not occurred to me at all that that was optional. I thought that my medical chart needed to describe and define my physical body and all of its issues as though the point was the documentation and not, to support my experience of my wellness.

[00:23:30] So that was wild. And then I, I also saw an occupational therapist actually for some challenges with some fine motor activities due to small joint hypermobility. And I thought that CustomMade hand and finger splints might help me, and she agreed they might. And they might not, and there's a cost benefit to getting them and a cost benefit to not getting them.

[00:23:56] She said that we could build me an entire exoskeleton and maybe I'd feel a bit more safe and secure in the world, and would my life really be better from within the protective shield. So both of these encounters blew my mind. I was used to healthcare providers, always choosing to run the test, prescribe the drug, do the therapy, give the diagnosis, and both of these women were in some ways saying no to that, saying no to my request for that actually, in a way, returned my agency to me, returned hope to me and opened doors for me. I also went to a gym wherein I was modifying every activity and taking it really easy to protect my joints. And a very highly skilled trainer encouraged me to just just push a little bit in very specific ways. And I actually got stronger.

[00:24:46] And the stronger that my body felt, the more capable and strong I believed that I was and that I could be as a being. So as I went through these encounters, my self-concept began to open up and allow for some flexibility in who I believed I was. And as my beliefs about myself shifted, my experiences shifted to reflect and affirm my new beliefs, I changed my ingredients, and what I got was a different cake.

[00:25:19] And I still meet the criteria for joint hypermobility. And sometimes I experience pain, but it's nowhere near what I felt in my twenties, and I don't believe that I am feeble, vulnerable, and in need of external protection. I know that I am resilient. I am powerful. I am magical, and I am capable of meeting any challenge that comes my way.

[00:25:41] I'm returning to this slide because we've talked a little bit about the pain experience as an emergent process, and I'm suggesting that all of our experiences are emerging processes and all of our experiences are impacted significantly by our beliefs. And our beliefs are entirely within our domain, within our realm of empowered authority.

[00:26:04] And science is no longer limited to studying the body in the physical universe as a cause and effect machine. Our collective tools are evolving as our consciousness evolves and vice versa. So Einstein's famous formula directly disproves the separation of energy and matter. So that's the mind, the spirit, and matter, the body, the external world.

[00:26:28] This formula clearly indicates that there is a direct relationship between energy and matter. And even when we're talking about matter, physical reality is really less substance and there's more space in an atom than there is substance. What we're, what we're really interacting with is, is less matter and more fields of energy in vibration and electrons.

[00:26:54] What we're, what we know now through quantum physics is that electrons behave unpredictably. They could be anywhere doing anything until we give them attention, until we anticipate where they will be, and then that's where they show up. So what we focus on, where we put our energy and our attention informs what we encounter.

[00:27:18] And moreover, all of physical reality, including our bodies, is made up of these same particles and is subject to the same laws. So we know then how this applies clinically through the studies of neuroplasticity and psycho neuroimmunology and the impact of the experiences on our brains. So thought is energy and energy impacts energy and our thoughts impact our experiences collectively and individually.

[00:27:52] Moreover, through new science with quantum entanglement, it's really teaching us now that instead of the old paradigm of duality, These particles are impacting each other from across the universe. So really the reality is, is interconnected.

[00:28:08] It's more about oneness than it, than it is about duality. So we all impact each other because we are literally all connected. So where we stand now, I'm a healthcare clinician, and so where we stand as clinicians is at a crossroads and where we stand as healers we're all on our healing journey for ourselves and supporting others on this journey.

[00:28:36] We stand at crossroads now between the old paradigm of separateness and the emerging understanding of oneness. And we have an opportunity now to lean into that rising tide and facilitate widespread acclimation to this new paradigm, not just in healthcare, but in all areas of our, of our culture. So as clinicians and healers, we have the opportunity to heal the schism of the dualistic and mechanistic paradigm by first and foremost, truly embodying the new science and living its application and implications in our own lives.

[00:29:13] So when we not only step up to teach others this new understanding, but truly become the teaching itself, we are owning our power in our lane to make change and impact everyone and everything, including our patients and the systems that we're working in. And to step into this new way of being, we need to release the expectation that the old way of thinking is ever gonna take us where we're going.

[00:29:41] Because the old tools and the old assumptions are designed to look for old answers, and that's exactly what they're gonna find. So the task now is to step into the unknown, and it takes courage to step into the new and into the unknown, but we're at a precious pivot point right now where I believe it would be harmful not to.

[00:30:06] And as we look beyond what we've come to expect from what we've seen before and what we anticipate from an outdated false construct of our experience as being subject to immutable cause and effect, and into a new reality of our interconnectedness and the seat of power that is our mind and our internal reality, the real healing can begin, and we don't know where it'll go from here.

[00:30:33] But I do know that we're all in this together. No one is alone. And as each one of us makes the bold choice to step into our power, we together can be so much greater than we were when we believed that we were on our own. I think it's time to take the leap. So that's what I got for today, and thank you so much for joining me here tonight.

[00:31:02] Thank you so much for joining me on the planet at this time. It is an exciting time to be alive, and I am so, so grateful for walking this path with you.

[00:10:00] Thanks for that introduction, uh, Rolly. It's always good to see you guys and I just absolutely love what the Oregon Pain Science Alliance is doing. And of course, I do have some biases about that because, many of the, actually a lot of the participants here were fundamental in kind of creating that, and I'm seeing a lot of really cool names as well as faces, some of which I haven't seen in a while, actually haven't seen you for a while. So this was exciting to see you, um, but just really amazing. Amazing people doing some really, really amazing things in the Willamette Valley.

[00:10:36] And while there's a lot of work to be done, I just wanna kind of call attention to that. We are so lucky to have the number of clinicians that we have and the number of community members that we have that are really interested in this topic and have really gone forth and become advocates because there's a lot of hope here.

[00:10:53] So we're going to be talking about the Pain Triangle a little bit more. We're diving deeper into it and deconstructing this analogy of the fire triangle to the Pain Triangle. But most importantly, kind of my journey and how I created this model.

[00:11:06] So this is a brand-new presentation for me. There will be some slides that you have seen before, because I tend to use them. There's certain things that I use over and over again, but there's also some slides that have not been seen for almost a decade now from some very early presentations, that hopefully give sort of a, a little bit of a model on how my thinking changed. Because there's a definite process to this.

[00:11:30] So who am I? For the people who don't know me, I'm Dr. Kevin Cuccaro. Yeah. I went to Chicago College of Osteopathic Medicine. I got my, the residency training in anesthesiology at the University of Chicago. So anesthesia, we do a lot with consciousness and we do lots and lots and lots of things with peripheral nerves.

[00:11:46] Then I did a fellowship in pain medicine at the University of Michigan. Went into the Navy, well, they paid for medical school, so they told me I had to go into the Navy and, uh, served at Naval Medical Center San Diego. Very quickly there was associate program director of the pain medicine fellowship program there, and that's a long way to say is I learned how to put needles into people. And I bring that up because as a fellowship-trained pain specialist, there's theoretically nobody who has the training, who has the specialty knowledge involved with pain.

[00:12:16] And, and I kept coming to this thing as things aren't making sense. We're doing all these injections. People don't seem to be getting better. And so there was this huge disconnect there. I thought it was the model with the military because we had a group practice model, and my colleagues, all great people, we all practice very different ways.

[00:12:34] Sometimes I thought they were too aggressive. They probably thought I was too conservative with what I was doing. So I thought it was the model, rather than the science. And so when I left and came to Corvallis and I joined a medical group here as the sole pain specialist, I was convinced I had all this knowledge that somehow because I was really attentive to my patients and I was following very aggressively and I was following all the guidelines, like the medical guidelines that we had that said you would only do a procedure in this situation.

[00:13:00] This is how you do the procedure. And you do it very, very strict and you do these little micro doses of local anesthetic in these scenarios and you only use these medications in other one. I was convinced that I was going to see this dramatic improvement. And I didn't.

[00:13:12] And now I didn't have anybody else. I could say, Well, it's not the military model, it's not my colleagues, even though they're great. I had to look at myself and I had to come to this idea that, well, if you are treating something and you are not getting the results that you want, then you probably don't understand what it is that you say you're treating very well.

[00:13:28] And that was very humbling to me. It broke down a lot of beliefs and a lot of ego. And then I started this journey here. And that journey has really transformed who I am and what I do, and especially personally. So let's get into that.

[00:13:41] So, that first presentation that we did back in February, I talked about these kind of key transformation concepts. These are things that I think are absolutely critical to understanding pain.

[00:13:50] The first one is shifting the idea that pain equals damage, that somehow is a damage indicator. And really fundamentally to your core understanding there is a reason why we hurt. Pain is not this bad thing. If you did not experience pain, your body would be unprotected, would have no warning signals at all. You would have wounds. You would have basically infections in your skin that would rot pieces of your body off. So this is something that we want and we need. So the first thing is understanding, there's a reason why we hurt. And that reason is to protect us. So we need to make sense of how that applies then to us as the being.

[00:14:25] The second part was about pain and construction, and we talked a little bit about the Pain Triangle last time, and that's a very quick way to sort of bring all these concept complex processes together to recognize that pain is essentially irreducible. That requires at least three critical components coming together in order to construct a process. And that process is pain. And people have a tendency to get kind of stuck on that. They'll either gravitate and say, Oh, well, Dr. Cucarro, that makes perfect sense and kind of works here, but then they kind of stumble over it. That makes sense for chronic pain. We all know acute pain's easy, but here's all these weird scenarios, and this doesn't seem to apply.

[00:15:01] And it really comes down to truly understanding what it means when we say something is constructed versus something is caused by. And that took me a couple of years for sure of a lot, a lot, a lot of questioning and research and reading and thinking and looking at a lot of different sources.

[00:15:20] So Sandy sent me some questions. So some of the things that she wanted me to cover is: how did you come to design the Pain Triangle? That's the one I'm gonna focus on the most. How did you apply it early on? We kind of will try to intersperse that a little bit. And then through this process, I can't focus on this question as much, but hopefully that you learn some of the thinking as well as some of the reasons I do what I do in presentations for how I've learned to use this process and facilitate change.

[00:15:47] And then lastly in the Q & A, we may be able to get into, what I'm reading now and discovering and learning to further my understanding of the science of pain. Because the learning never stops. There's never a point where you know everything and what you end up finding, when you start learning and deep diving into pain, is it opens up like this entire universe of things that you never thought about. And it truly is one of the most amazing things, and I'm absolutely blessed to have these really early experiences where are quite traumatic that could put me on this journey.

[00:16:16] So I always use this [slide] lightly: pain or no pain? This is like the classic one, because this prevents this kind of conundrum that we have. You guys have probably all seen this. This is the person who has got the nail through the boot, had lots and lots of pain, got really strong opioid medications in the emergency department because he couldn't touch the boot without him screaming in pain. And when they cut it off, they found that the nail was between his toes.

[00:16:39] So lots and lots of pain, but no tissue damage. On the other one we have the person who I got from a YouTube video, who'd put a nail through his thumb with a nail gun. This was not the first time they did it because this is a very typical injury apparently with people who use nail guns and are building. He didn't get fentanyl in the IV. I'm not even exactly positive he went to the emergency room. He did experience pain, but what they were doing is laughing and joking with him and they're trying to cut this nail and pulling it through his thumb and basically so you can go back to work. So how is it that you have somebody who has tremendous amounts of pain but no tissue damage. And you have somebody who's got actual tissue damage but really moderate to minimal amounts of pain. And we very quickly realize that this idea that there is either physical pain or there is psychological pain or emotional pain is simply false.

[00:17:27] This is what we call mind-body dualism. It's a very reductionist idea that says you either you got physical pain or you got emotional pain. One is caused by biological factors, like a broken leg that's physical pain that's somehow fundamentally different. And then emotional pain, which we'll say is associated with trauma or repressed emotions or whatever. That's completely distinct. And that is simply not true because these two pictures, and the reason I bring this up in every single presentation that I give, these are both examples of what we would prototypically call acute pain. And if your model where it's supposed to work, where nociception is the cause of pain. And yet we have a clear example where it doesn't, there's something wrong here.

[00:18:11] So we know that mind-body dualism doesn't make sense. And it clearly doesn't make sense when you look at all these different patterns. You see people who have imaging like this middle one [slide] here, where you have scoliosis. And a lot of people say, Well, that person must have back pain. That person doesn't have back pain.

[00:18:25] This person has a normal spine radiograph, and this person had tremendous amounts of pain. You can have someone with a broken leg and no pain. Etcetera.

[00:18:33] So, this model doesn't work. And I want to make very clear, the way we typically present and talk about pain, even in some of the more advanced scenarios, doesn't make sense because it doesn't apply to acute pain.

[00:18:49] So way back when, and I started noting these sort of dichotomies, and these are literally slides that I had to do a couple little things to because I was a little bit embarrassed by them. I was like, Okay, well this doesn't make sense. I'm doing these injections, and we're blocking the so-called nociceptive generator, or we would call it the pain generator, which is total nonsense, and things aren't working.

[00:19:09] And we have people with a lot of trauma and a lot of people who seem to have a episode of pain and they come in from treatment and then we end up doing this whack-a-mole game where we're doing injections here, and that seems to get better, but then all of a sudden flares somebody else. And overall their whole experience has not improved.

[00:19:24] So I started focusing on the neurobiology, like most physicians would do. And I went back to this old papers, and I'm like, Okay, let's learn more about pain. So very, very, very far back, when Melzak and Casey published this idea that we have basically three dimensions of pain.

[00:19:38] There's the sensory-discriminative aspect, there's what they call the affective- motivational aspect, and the cognitive-evaluative aspect. And what these are: The sensory aspect has to do with localization and characteristics of a stimuli. Is something sharp? Is something dull? Is something electric-like or shock-like? And where in the body that would be: toe, hip back, et cetera.

[00:20:00] The affective-motivational branch, what they described, is that's the emotional coloration. What does that sensation mean? And then the cognitive-evaluative branch is the fore brain, the higher learning centers coming together and deciding, well, what do I need to do right now?

[00:20:13] And this was, this paper is amazing. Like I know we have a lot of clinicians on here, go back and read the original publications. Go back and really delve into it and see. Because those are really, really good. And what I found is actually a lot of times that they were translated, when people talked about them, or certainly the way I was taught about them, didn't actually line up with what Melzak and Casey was saying.

[00:20:31] So I'm looking at this, and I'm going, Okay, well there's three dimensions of pain. Well, how does it all fit together? And then I started looking at the neuroanatomy. You know, I'm an anesthesiologist, and I'm an interventional pain specialist, and I'm looking at the brain and I'm looking at all these nervous tracks. And they'll talk about these different pain systems.

[00:20:50] Listen to that language. Anybody who knows me now knows I hate what people call them pain systems. There's no such thing as a pain system. But in the medical literature they'll say the lateral pain system and the medial pain system. And what they're really referring to is these nerves as well as areas in the brain and where they fit, in the lateral area or in the middle, the medial area?

[00:21:11] And what they saw is there's different signals going up in these different aspects of your nervous system. And then the nerves that we're firing in this lateral pain system. And that, again, that refers to the actual anatomy. Those seem to be more involved with this sensory-discriminative aspect: the location, the timing, the physical characteristics, whether they're sharp, dull, et cetera, and prompt these reflexes that you have. So you touch a hot stove and it pulls back. What really fires is that lateral pain system.

[00:21:38] And then the medial pain system is much slower and provides this kind of unpleasantness, this emotional coloration there, and seem to be devised with defensive behaviors in the future. So you had an experience and now this kind of coloration, this medial aspect starts getting on here. Sometimes would call this the emotional component of pain. And this was providing kind of the slower information that provide meaning to that sensation.

[00:22:03] Some of the fascinating these studies did here though, is if you could go in, and what neurosurgeons would do is they would actually cut some of these nerves, they would cut these fibers in the spinal cord and they would do what was called the cordotomy. And when you cut that lateral pain system, what was really interesting is people couldn't localize a stimulus.

[00:22:21] So you cut that lateral cord or that little area where those nerve fibers were going, and then you can crush their toe and they would be like. You'd be like, Well, where are you feeling this? They're like, I don't know, but something's not right here. On the other hand, they would do a cordotomy in the medial pain system, and when they lesioned that, people now could identify things. Oh yeah, that's in my toe. But there was no unpleasantness associated with it. That whole emotional coloration would go away. And so what that was telling us is like, well, there's something different here when there's this sensory characteristic and then this meaning or this emotional coloration to it.

[00:22:58] Now, they used to actually use that as a therapy, by the way, where they would go in and do these cordotomies. Unsurprisingly, pain is much more complex than that, and the long term data wasn't very good. So don't go in rushing off. If anybody has pain and says, Oh my God, I have persistent pain. I need to have this neurosurgeon cut my spinal cord. Don't do it. It's bad news.

[00:23:15] But for, research purposes and experimental, and the data it gave us, it actually taught us that there's all these different fibers sending different signals throughout your body up to your brain, and the brain uses them differently.

[00:23:26] So, what that did is got me on this kick of, Okay, well I kind of understand that sensory-discriminative aspect, because that's where, you know, when we're looking at needles and actual anatomy and this peripheral stuff, that made a lot more sense to me at the time in my training.

[00:23:40] But the emotions was not something that I was well trained in. This understanding about trauma. And depression and all these emotional states and how this comes together. So I started going a little bit deeper there. I started looking at some of the theories about emotion. There's actually no clearly defined definition for emotions still in the medical literature, which I found really interesting.

[00:24:03] It's still kind of nebulous out there. And there's a lot of theories around it. And this also brought me into sort of the realm of John Sarno, if any of you guys remember that name? And John Sarno was a physiatrist at Columbia who had some very, very early observations in, I think the early seventies where he was like, you know, we're doing all the stuff, and a lot of these people that I'm seeing who have pain, and particularly back pain, seem to have all this like trauma.

[00:24:30] And what he saw a lot of was what he called it repressed anger. So what Dr. Sarno did is we'll say, Well, you know, we've done all the x-rays, we've done all the images, and we can't, "find anything wrong." Must be something else. So he got this theory about, repressed emotions, published very popular book, Healing Back Pain. Had a lot of very prominent people, in the media and entertainment world, who came out. And a lot of people got good results. But a lot of people didn't.

[00:24:57] And what was a little bit frustrating for me about Sarno is he said, Okay, well there's acute pain, but when we've looked through everything and we've done all the x-rays and we've done everything and nothing seems to be responding and we can't identify a physical cause anymore, then the cause of your pain is something that we're going to call that tension myositis syndrome.

[00:25:16] We're going to say that there must be something that's constricting the muscles in your back, that's repressed emotion, that's then causing that pain that shoots to your brain. So again, it was very reductionist. A lot of people got some really good results with it, but it didn't line up with what we knew about science, and it didn't explain these discrepancies when it comes to acute pain, how someone can have an injury and yet have no pain, right?

[00:25:41] You can't say, Well, you drop a hammer on your toe. Oh, you know what, that hammer, because it's not hurting now, is because I don't have any repressed emotions. That doesn't work. And it certainly doesn't mean if you have dropped a hammer on your toe and then all of a sudden you're gonna express your anger that that somehow is going to make a, it actually can make a little bit of a difference for different reasons. But it's not gonna have that fundamental shift that Sarno was describing.

[00:26:03] These transformative behaviors, where people would see Sarno, they would go through his presentation. It was like three presentations that he gave in the basement of Columbia, and people were walking out of there with no pain.

[00:26:15] The Sarno stuff didn't quite understand. I didn't quite, couldn't put it together. The science was incomplete, but I was really focusing on that emotional aspect to it. I really started buying into, very early on, this idea that there somehow is acute pain, and that there's chronic pain, and that these are fundamentally different processes.

[00:26:41] And people will still present it this way: that acute pain is adaptive. It's the good pain. It tells us where the quote unquote "source" of your pain is coming from. It's easy to treat, and it's predominantly that pain source (again, I hate these terms. I'm just going to use them because this is my old presentation here) was out in the periphery, meaning it's out in your toes, it's in your back, it's in your knee, or whatever.

[00:27:04] But chronic pain was this different entity. Chronic pain is completely maladaptive. There's no purpose for it, which always question if you have something in your body, even if it persists and it's unpleasant, that there's probably a reason it's there. You know, there's probably a reason there. Evolution does not like things that don't work for you. But chronic pain was also nebulous, poorly located. There's no signal treatment. Fibromyalgia being the prototypical kind of thing where your whole body hurts. But this was somehow brain pain.

[00:27:38] So we had acute pain that was somehow broken leg; that's out in your body. And then we had this brain pain here. And this is the most common way that I still see pain presented today. And so we have this dichotomy now where you have acute pain and chronic pain and we kind of say, acute pain's, focal, sensory, peripheral. Chronic pain is all over the place, emotional, kind of moves all over throughout your body. And then we proceed from there.

[00:28:02] And so I'm trying to take this information. Okay, well, if acute pain's different and chronic pain's different. How can we still make sense of chronic pain, then? With understanding that we have the sensory-discriminative aspect, we have the affective-motivational aspect, and we have this cognitive-evaluative portion. How does this make sense for chronic pain?

[00:28:22] And so I took this, and I was trying to make sense of it, and I was giving these presentations. And I'm like, Well, if we know that trauma in your emotional state impacts your pain, what's a model? What's an analogy that I could use to explain this? And so this was my very, very first pain model.

[00:28:42] This slide is actually what I said. Pain sensation, and Experience. Now, I know I have some people who are in a lot of my programs in here, who should be going Dr. Cucarro, Pain Sensation? What the hell does that mean? What does that mean? Because now we're saying that pain is predominantly a sensation, and then there's this experience that's associated with this.

[00:29:09] And so in this model, what I was saying was, okay, the sensory-discriminative aspect is the microphone. That's the source. That's where the pain signals go in. And then this affective-motivational aspect is once those pain signals are going in, then this mixing board can either amplify, or change, or modulate those signals. And then the last part, this whole process where these signals are going down, these pathways, now comes out through the speaker system. And that is the pain.

[00:29:41] I struggled really, really hard with this. I knew that emotions, I knew the trauma, I knew that early life experiences impacted pain, but I couldn't put it together. And this was the model that I had. A very sequential sort of fashion where there's inputs, these pain signals that are then influenced by these bad, awful emotions, and then the end result coming out the speaker, this is where pain comes from.

[00:30:12] And what I was really trying to do though, and this I'll tell you basically this model kind of works as well as anything out there. And it kind of makes sense, just enough. But what I was really trying to do is make sense of the science with the concepts that I knew. That my brain in many ways, because of the way that we both perceive the world and the way we're taught, sees things in a cause, a stimulus and effect, result fashion.

[00:30:42] And so I really focused on my early talks about this mixing board idea: that how trauma and childhood adversities and adult conflicts and victimization post traumatic stress really is just affecting the quote unquote "pain signals". Be either amplifying them or dimming them down. And I see this often in a lot of ways with the current ways people say mind-body integration.

[00:31:06] In fact, my biggest kind of thing, I think Sarno did a lot of great things, but I think he stopped learning at some point, and he just stopped being curious. And I call this kind of the stage two thing where people identify pain as a sensation that is then influenced by biological and psychosocial factors.

[00:31:27] So we'll say biopsychosocial, but that pain sensation. If we're equating a sensation as the same thing as pain, as the input that then is being worked upon, this is really what I call stage two. And I see most people in the pain science world are usually about this place. But this still doesn't make sense. Because you can see all these contradictory examples again, particularly in the acute pain entity world.

[00:31:58] Where we have this thing and we're like, Well, okay, you can have acute pain, you can have the same sort of stimulus, and you may not have any experience associated with it, depending on the day. You can have chronic pain that we can say is purely emotional. And yet it has different responses on different days.

[00:32:18] And for different people who have the same different experiences, they may have completely different pains. We have situations where people have, a lot of people say these are learned pathways. Very, very commonly "learned pathways" or "learned patterns." And yet this is where I somewhat disagree with a little bit about, Dr. Mosley's stuff, is, these are learned, learned, learned. Yes. But then how do we then explain on the Sarno side, these people who have gone to a presentation, seen something, read the book, and their pain goes away? How does that make sense?

[00:32:58] So I was straddling these two worlds. You got Sarno on the full emotional stream. You have the interventionalists going purely after whatever they can poke needles into. That's all sensory-discriminative. And then you have Mosley, who is, without a doubt, one of the finest pain researchers in the world, but really is in this kind of cognitive-evaluative space, really into this thought and this patterns and this learning thing.

[00:33:17] And I'm going, all these people are saying super, super amazing things, except for the pain specialist poking at the sensations all the time. But none of them are actually making sense consistently. And most of the time, people just throw out the acute pain. And they're like, Well, acute pain is easy. It's always nociceptive, and we don't really have to think about it. Let's just talk about the chronic pain stuff.

[00:33:40] And I was really stuck on this. That doesn't make sense. And if I can't explain it, I'm not understanding this whole pain thing. So there was obviously something missing. And so I started looking, and I was reading, and reading, and reading.

[00:33:52] And then Melzak, revised Gate Control Theory, because they, these really phenomenal scientists 50 plus years ago, even they recognize that something was missing with Gate Control this sort of sequential model here. And Neuromatrix Theory then puts together this idea, there's, all these things acting at once.

[00:34:14] Now I tell you, I read this, and I thought I understood it. But I still am like, okay, affective-motivational. Okay, well, which one? What kind of pains would be cognitive-evaluative? What kind of pains would be affective-motivational? What? Which ones would be sensory-discriminative? Like these are primary like pain signals. Again, I hate that term, but pain signals that somehow are being influenced by other things. But the primary source was whatever the input was.

[00:34:37] Until I was listening to a podcast. And for anybody who's interested in learning, Try to learn from as many different areas as you can because you'll always be shocked that you'll hear something in a different field, and you're like, Holy crap! This is completely relevant to what I'm doing.

[00:34:54] And I was listening to this podcast, it was a business podcast because I was an independent consultant at the time, and I was trying to figure out the stuff about marketing. And this marketer starts talking about a concept called emergence. And what emergence is, is the idea that you have enough contributions coming together that construct a process that is unable to be explained when you take away those components. And emergence is actually present all over the place.

[00:35:23] Your health is an emergent phenomenon. It depends on what you eat, how you move, your emotional state. Business in his example is a emergent process depends on your sales technique, your backend, all the stuff coming together in order to construct a system that is basically irreducible.

[00:35:45] And I went. I'm trying to remember the exact moment. I can't remember if it was in my car or if it was on my deck, because I was like painting. I was refinishing the deck, listening to these podcasts, like hours and hours podcasts, and all of a sudden I was like, holy crap! Pain is an emergent process. You cannot reduce it from three things.

[00:36:07] It's not one being influenced. It is all of them coming together. And that process then constructs an experience of pain. So there isn't physical pain or emotional pain. There simply is pain. What matters is how that experience is constructed.

[00:36:28] So I was looking at this paper, I'm like, Okay, we know that there's three major divisions to this thing. What's a model then that represents an emergent phenomenon? That represents something that if we take one piece of it away, we no longer have that entity? And that's where the Pain Triangle came from. Because what pain is literally, it's just like this thing where you have these three critical components.

[00:36:56] And I'm not saying there's only three critical components. I'm saying there's lots of different components, but there's three predominant ones that you can subdivide these different things into. But for fire, if you take any one of these away, the fire's gone.

[00:37:12] If you have an experience of pain, you have to have all three elements when it comes to pain. I think I put the fire triangle instead of the Pain Triangle, but you have to have that sensory input. You have to have that emotional oxygen to it, and then you have to have that cognitive-evaluative heat, the attentional heat to it. You take any one of those away, and the pain goes away.

[00:37:35] This doesn't mean it's permanent, but it can be. What are examples of this? Well, if you go in for surgery, as the anesthesiologist, if I do what's called a regional technique, and I go in and I inject and numb up the nerves that are going to your leg, where you're going to have say, neurosurgery on, what am I doing? I'm taking away potential fuel. The absence of fuel with that heat and oxygen. no pain.

[00:38:10] If you have even a broken bone, lots of fuel, and you know what that broken bone means, you can see the bone sticking out of the flesh. So you know there's something bad with it, but then there's something that grabs your attention. Maybe a Tyrannosaurus Rex is all of a sudden run down the highway. Something big enough, threatening enough, scary enough that it pulls your attention away from your broken leg. You take away the heat. What do you have? You have no pain because there's no heat. There's no attention there anymore.

[00:38:41] And then the last one was if you have say, sensation, and you're paying attention to it, but now we change the meaning, that oxygen supply somehow it changes. It is no longer threatening. The narrative changes. The meaning is no longer, there's something wrong with your back. But say that, "Oh, this is an example of repressed emotion, and I'm okay." You take away the oxygen, and the heat goes away. And finally I was able to start making sense of things like, how is it that someone with 40 or 50 years of back pain can get better in really short amounts of time?

[00:39:25] Some of the people who went through Sarno's stuff when he changed this narrative, changed the meaning of what that sensation was to them. And they were literally 40 years of back pain, and really no back pain. You're taking the oxygen supply away. So that business podcast plus that Neuromatrix Theory absolutely changed my mind.

[00:39:46] And changed my understanding of pain because I realized then that these are fundamentally different models. The idea of this mixer is seeing pain as a source that is being acted upon rather than recognizing that pain is the end output. It's the final summation of all this stuff coming together. And these are not the same thing.

[00:40:11] One is a cause and effect, which is how your brain wants to see things, and there's important reasons for that, for perception, and for safety, and for evolution. It's fast, it's quick, it keeps you safe and generally works pretty well. But our brains actually work in an emergent fashion, where we're constructing lots and lots and lots and lots of complex information in milliseconds in order to create a perception.

[00:40:36] So these are then different categories, and this was probably the biggest and most in where that podcast came in. Because I didn't have an emergent category for my brain. And if you don't have a category, it makes it almost impossible to learn a theory or to learn something new.

[00:40:55] And what categories are is basically if you don't know what a car is, so maybe you lived in the middle of the Amazon jungle and you've never seen a car, and you're presented with a car, you can't describe it. You will describe it in terms that fit your knowledge, the concepts and categories that already are in your brain.

[00:41:14] Until you learn and grow and actually develop a new category that contains cars. This was huge for me though, and it really made me go into the educational literature because this comes up all the time.

[00:41:24] And so if you guys, I'm seeing a lot of clinicians here. And this is by far the biggest problem that I think that we have when it comes to pain and pain education, is we're trying to teach people about an emergent process that either we don't know that it's an emergent process, or if we do, how do we build that category so it makes sense for someone else?

[00:41:52] And the Pain Triangle for me, has been the fastest way to do that without actually taking all the time to discuss and talk about what an emergent principle is. And a lot of you guys actually gone through the Pain Course, like the whole first lesson in the Pain Course is all about trying to build an emergent category.

[00:42:09] Because once we have that category, now we can start using it. And these different categories require different types of thinking. So people are saying, sensation, isn't pain, Dr. Cucarro? Well, yes, that's exactly what I'm saying. Sensation is not the same as pain. They say, Well, if you have nociception, how could you say that that's not pain?

[00:42:27] Well, because nociception is a process, a sequential process that's not the same thing as pain. So these are all fundamental, what we call ontological categories, categories of being. You have things like structural pathology. These are the physical objects. A broken bone, or a bone that is not broken, is structural. It is either there, or it is not there, right? So the thinking's really simple. Is the bone broken, or is it not broken?

[00:42:56] The second category or this process, the sequential process category is where nociception fits in. This is the cause and effect, stimulus response. So nociception being signals that tell you that there's been change in body tissues that go to the brain. So now you're looking stimulus and response. Where's it coming from and where's it going? That's not pain though. That's simply a process.

[00:43:20] But inflammation I've had people ask, "Well, what about inflammation? How's that work?" Inflammation is a process, sitting in the middle here, that amplifies sensory information. But it is not the same thing of pain. It fits right nicely in that sensory aspect of the Pain Triangle.

[00:43:38] And then finally, we have the constructed experience. In that constructed experience, we have to be thinking in a minimum of three dimensions. What's the sensory aspect, the fuel? What does that mean, that oxygen supply? And then how much attention are we focusing on it? And how threatening do we perceive it to be? And so we're thinking in three dimensions here.

[00:43:59] And so if we're looking at these, like when people are talking to me about pain, I'm always thinking in these... I'm categorizing it. Okay, broken bone, nociception, inflammation, what's the process and what's the experience here?

[00:44:10] And then it, but I know that they're not the same thing. A broken bone is not the same thing as pain. It's a different category. You can have a broken bone, with nociception, but you may or may not have pain. The thinking behind them is different.

[00:44:28] And again, so we're looking at objects. For treatment, this becomes a lot simpler, and particularly if you're working in acute care, because people are, "Well, how do you know whether or not something's wrong?" Well, you evaluate them! You're never ignoring the pain. But you are never also thinking that pain equals a different ontological category. What you do is you rule them out.

[00:44:52] Someone walks into the emergency room and they say, "Oh, I have horrible leg pain." What's the first thing that you do? History. Did they fall? Is there trauma? Is there impact? Mechanism, we would call that. What does your physical exam show? Is there an inflammation, swelling, etc. that suggest that the tissues are reacting, trying to protect that area? That's the process. Get the x-ray. What does it show? Does it show a broken bone?

[00:45:22] Now we could say, Well, okay, all these are positive. They come in, they fell down, their leg hurts. On exam, that leg is all swollen. The X-ray shows us a broken bone. Well, we have pain, we have inflammation, we have a broken bone.

[00:45:37] Let's actually address that broken bone, because that is actually associated with all of them. But there are other things that we can also do for the pain. Because that inflammation and broken bone are feeding into your sensory aspect. How can we treat that with the cognitive and emotion of aspects while we're in the middle of the emergency room?

[00:45:57] Well, you would use non-threatening language. You can do redirection. You can change the meaning of what that experience is. You can use humor to decompress the stress and the fear that's associated with it. And we also have medications, but we're not relying on medications alone.

[00:46:15] Now, on the other side, you have somebody who comes in with, in the emergency room with a horrible leg pain. And the same way we go, Okay, well what is, what is the mechanism? Oh, well no mechanism. I actually got shot in the leg 15 years ago. Okay. Hmm. That's interesting. So we got some past experience. There's probably some learning here. What does my exam show? Well, it doesn't seem to be actually an acute inflammation going on, but we're in the emergency room, and we do these things. Let's get a quick x-ray. There's nothing broken.

[00:46:42] Now we go, Hmm, this person has pain. But we know from that sensory aspect, we don't have any acute inflammation, we don't have any broken bones. This looks like there's predominantly heat and oxygen here. So what can I do now? And one of the worst things that you can do is say, "Well, you're faking it." Because what have we actually done by doing that? We've increased threat.

[00:47:04] But if you say, You know what? This is interesting. What else was happening? You know, you told me this experience that you got shot in Vietnam. What else was happening? Well, you know, I don't know, but my wife said that there was actually a helicopter, and it was as soon as that came over is when I dropped to the ground. Well, when did you get shot? It was in Vietnam. How did you get medevacked? It was a helicopter.

[00:47:24] So then we're seeing these contributors here now that provide insight into this experience. But we're not neglecting any one of these different categories. We've looked at the actions, we've looked at the structures. And we're servers. We're not telling people that they're lying or that their pain is not real, because it's a hundred percent real. It's just that the inputs are different than somebody who says a broken leg.

[00:47:47] And the key point being here is that a sensation is not the same thing as pain. This became very easy to gloss over. It's like once your brain switches and you're like, pain, all pain is pain. There's no physical pain and emotional. It's all pain. I actually forgot about this. And then a really good friend of mine who did a lot of work and a lot of training, and she's actually said she was struggling with this for a long time because she got stuck on this idea that, and I didn't explicitly state that a sensation alone is not pain.

[00:48:18] And then we were doing a presentation, and actually it was Mo, who I think is on tonight, who provided the epiphany for her, when Mo was asked in this early presentation. I don't know if you remember this, Mo. I think we're up in Dallas. And someone asked you a question about pain and you're like, Oh, you just don't feel pain anymore. And you go like, No. I still have sensations. They just don't mean the same thing to me anymore. And this is the thing that people get stuck on is they think the elimination of pain means the elimination of sensation. And that is simply not true.

[00:48:52] If you try to eliminate all sensation, A, you'd be non-functional. B, it's not going to happen. Because there are always sensations. There's all sensory inputs that are going to your brain all the time. And your brain is actually sending little inputs out trying to affirm that those sensations are true.

[00:49:11] So, sitting here, I'm probably talking too long and someone's going to ring a bell on me, but, you've been sitting here, How many of you are kind of shifting positions in your chair? Right? Because your butt's basically sending sensations up to your brain that's saying, Hey, you've been sitting on us a long time. The tissues are changing. This is not normal for us. Is this something you want?

[00:49:32] That sensation goes up, you notice it adding some fuel. The meaning though, is, "I've been sitting here for a long time. I need to change positions. I'm okay. Dr. Cucarro is going to shut up at some point. I'll be able to go out and do what I need to do."

[00:49:44] Imagine though that your associations are a little bit different. Somebody has told you you have disintegrating discs or a degenerative disc disease, which is a stupid name because everybody's got degenerative discs because I got wrinkles and bald head, and that's the same thing as having discs that are not 10 years old in your back anymore. But, someone's told you this. And so now you have sensations coming from your, You've been sitting here and you feel sensations coming up, sends up to your brain.

[00:50:09] You go, Oh my God, this is from my back. That doctor said, I have disintegrating disc disease. I've been sitting here for a long time. Whoa. So now we have sensations, the same sensation coming up, that still grab our attention, but now that attention is filtered through this lens of threat and the meaning is I have disintegrating disc disease.

[00:50:27] I guarantee you those same sensory inputs are going to have a very different experience for you. And that experience could be profoundly unpleasant to you? So a sensation though is not the same thing as pain.

[00:50:43] So this kind of culmination for me is when I understood construction, this concept and understanding of emergence, everything changed. Because a pain experience, now. We're not talking, a sensation is one aspect of that experience, but it's constructed from. It's not influenced by biologic and psychological factors. It requires them in order to construct this experience that is irreducible. Without those inputs, it would not be there. And this is emergent thinking. And the really fun thing about emergence is you start seeing it beyond pain.

[00:51:20] I have this saying, I've been saying now, "Pain science is brain science, and brain science is life science." Well, the Pain Triangle is about experience and how experience is constructed, but pain's not the only experience that you have, right? So then you start playing this like Rubik's cube thing and you start looking at what potentials there are, because everything is now this constructed process, at least for our brains and how they go: the sensory input, the meaning that we have, and that cognitive evaluation of it.

[00:51:51] So your perception of your health. Whether you think that you're broken or not. What fatigue you're experiencing, whether that's a threatening thing or simply saying that to you that maybe you have not exercised as much as you've had, that you have not developed enough endurance over time. That you're aching because, oh, my body is disintegrating versus, like me, you have horrible insomnia and sometimes your body and brain are saying, Whoa, you know, you haven't gotten enough sleep and this is a dangerous thing, so we're going to be really heightened to all sorts of information coming from your body in the periphery.

[00:52:27] And so for me, it's just fundamentally changed not only pain, but how I view life. And the recognition that when we diseasify things, that we emplace this implicit threat associated with them. We're not helping people. Very early in this presentation, I called out the fact that all these things that we call quote unquote "negative," we evolved with them for a reason.

[00:52:53] And so then when we start viewing them through this threatening negative, these are neither good or bad, but something that's inherent to living, it really changes how you think about them. So we look at depression. What's the root of depression? Depression actually causes us to withdraw. It causes us to slow down.

[00:53:10] And one of the reasons that they believe that this occurred is so that you would pull back, be less active, so it gave you a chance to heal. Obviously too much of that prevents you from doing things that keep you safe, but it doesn't help to say, "Well, it's major depression. There's nothing you can do. It's inherent in your brain, and the only thing you can do is drugs for it the rest of your life." Let's understand the process involved.

[00:53:31] There's a whole host of examples here, but I know I'm running out of time, but when you understand how emergence and construction fit together, then pain isn't scary and it also makes sense, including the scenarios when it used to not make sense before.

[00:53:49] So whether it's acute or it's persistent, or you know, whether there's lots of sensory input or not a lot of sensory input. What it all tells to me is, what are we trying to do? What are the threats that are involved in this construction? What are the sensory? We're never ignoring body, ever. We're never ever just saying that all you have to do is focus on your head. There's nothing else we have to worry about.

[00:54:10] No! If someone has a broken leg, whether or not they had pain, you're going to want to do something with it. If the pain is associated with a broken leg, you're absolutely going to address that broken bone, but you're not going to ignore the other things that you can do through your words, through the actions, through your medications, if you need them, through the meanings, through the pro empowerment that you're giving people to the safety, the active modalities that you're introducing. The sense of increased perceived control that people have over their lives and their experiences so that they understand why they feel how they feel. And they're empowered to take actions for themselves, to change those circumstances.

[00:54:47] And that's, I think, what's the power of the Pain Triangle is because once you understand how this stuff comes together, it is literally like a little Rubik's Cube, and it depends on what your strengths are, who presents in front of you, and then what you choose to emphasize.

[00:55:03] So Tina's here. Tina has taken this, and Tina has made it in such a way that she actually reforms and revises and helps people to process trauma in such a way that it makes sense, and that the meaning changes, and that they feel more in control.

[00:55:19] Sharna takes the same thing and she asks where the fear is, and then she helps them de-threaten through the fear.

[00:55:26] And all that you see is this, there's a story that's inherent to people's experiences. So how then can we take that story and help them to understand that in such a way that is more empowering to the individual rather than scary and that they're not under control.

[00:55:41] So I, you know, again, I'm a hundred percent biased cause it's my thing, but I, I just don't see anything else that works as well. But fundamentally is you gotta have a model that addresses emergence when it comes to pain, if you fully want to understand and really intervene in many, many different aspects.

References:

1965: Melzack & Wall: Gate Control Theory, 

1968: Melzack & Casey: Sensory, Motivational, and Central Control Determinants of Chronic Pain: A New Conceptual Model.

1999: Melzack: From the Gate to the Neuromatrix

1021 Betlinski Final Transcript 030623

[00:00:00] Good evening everybody, and thanks so much for being in and for the invitation to be a part of this group, at least for an evening, and perhaps in some other ways as well. I'm excited, I, in part because this is a little bit of a different format, we get to tell a little bit of our own personal stories as well here.

[00:00:25] My name is Dr. Jonathan Belinsky and I get to hang out with you for at least the next half hour or so talking a bit about my experiences and also what I've learned from the available science about trauma and pain and how they might be related.

[00:00:39] As always, we academics like to remind everybody whether or not we have financial conflicts of interest. I have no relevant financial disclosures for this topic. I do get to work for OHSU, where I'm a professor and the director of public psychiatry. I also work with a couple of statewide projects like the Oregon Psychiatric Access Line about Adults and the Oregon Echo Network and the Oregon Psychiatric Physicians Association. And I serve on a few nonprofit boards.

[00:01:04] I have shamelessly used lots of graphics from Unsplash in accordance with their policies. And as far as I know, everything that I'm showing you is available to be shared. I would like to take a moment to say a huge thank you to one of my mentors in the area of trauma and in just being a good human being, Dr. Maggie Bennington Davis, who currently works at Health Share of Oregon. If you ever get to hear a talk from her about trauma, definitely attend that. She's been doing work in this area her entire career.

[00:01:34] Here's what I hope we learn over the next half hours. I hope that everybody leaves this evening with three examples of the link between trauma and pain, at least three effects of trauma on brain development, and three ways to be helpful to those with a history of trauma and chronic pain.

[00:01:50] I will warn you, I'm going to fly a little bit fast, so if I do that, if I'm going too fast, please don't let me. The downside is we psychiatrists spend a lot of time listening in our work every day. And you've done something very dangerous this evening. You've given me a microphone and an audience, and I am perfectly capable of talking completely nonstop, almost without breathing about this. So, feel free to let me know if I'm getting carried away.

[00:02:16] Here, by the way, is how we'll get there this evening. We're going to just review a bunch of information and then talk about how to apply it. But first my story about trauma and pain. I'm gonna go all the way back to my teens and twenties to start this where I was of course involved in high school, in college, and my personal favorite sports were mountain biking and rock climbing and uh, softball. And I spent my summers working on the waterfront in summer camp.

[00:02:43] And a really interesting thing happened when I was 16 years old. I was up in British Columbia, in Hope, British Columbia taking off on a mountain biking trip with a couple of friends of mine, and we got away from the place where we'd spent the night we were bombing down a gravel road. We weren't even in the difficult stuff yet. And I hit a pocket of loose gravel and endoed, and came down, and I got scrapes on my shoulder blades, on my hips, on my knees, on my elbows, on my hands. Every point of contact that could get some skin taken off was taken off. And what didn't particularly hurt or bother me, it was a little bit annoying, and I decided probably I shouldn't finish the ride. And I went back and spent a long time getting cleaned up and things like that.

[00:03:30] Fast forward about four years, four years. I'm now in my twenties. I'm in college. I'm bombing down a hill, a dirt path, not a gravel road this time, bombing down a dirt single track on my mountain bike. And I endoed, which means I caught the front wheel, and I popped up in the air, and I started to flip through the air. And even before I hit the ground, it hurt.

[00:03:57] Nothing had happened to me yet. It was about to. Nothing had happened to me yet, and it started hurting.

[00:04:05] That same summer. I was water skiing and did not cross the wake wisely. And with the sensitive ski I was using, shifting your weight forward is like putting on the brakes. So essentially as I came across the wake behind the boat, whipping across the wake at somewhere near 50 miles an hour, I stepped on the brakes and of course that planted the front end of the ski and I dove into the water. It pulled me out of the ski. The ski then came shooting across the water and hit me right smack in the mouth as I'm diving into the water. Shattered two of my teeth, broken clean off, put a bunch of cracks in the rest of my teeth. Didn't hurt at all, aside from the thunk of the original. Whoa, something just rang my bell.

[00:04:48] And those incidents got me thinking about why is it that some things hurt and other things don't. Getting whalloped with a ski traveling, at near 50 miles an hour in the face ought to hurt. It didn't. Having pain before you crash your bike is just strange.

[00:05:09] Well long story short, I decided to go off to medical school in part because very curious about the human body. And I also wanted to be helpful to people on a very practical level. And I started medical school in 1998, and the world of pain changed in my first year of medical school because in 1999, as I'm finishing off the first year of Medical School, the Veterans Health Administration decided that they would include pain as a fifth vital sign. The rest of America followed over the next couple of years, and suddenly I'm learning to ask all of my patients, on a scale of one to 10, how much pain are you in? And then focusing the clinical visit on trying to alleviate that pain, usually with medications.

[00:05:48] By being here tonight, you know that as a national strategy, that did not work well for us. An awful lot of people ran into problems with medications and we didn't do a great job of actually helping people get their lives back and be functional.

[00:06:01] And I began to learn this, especially when I started my intern year in internal medicine. I went to southeast Ohio, and a really interesting thing that happened in southeast Ohio. Over the previous couple of years before I got there pain medicine specialists moved into town, which was really great and supposed to be really helpful. And then within a couple of years of pain specialists moving into town, heroin returned to the Miami River Valley for the first time in decades. And why did heroin come back? Simple and easy. People were dependent on opioids, and there was suddenly a market for it.

[00:06:34] And so I'm working in the ER, for instance, during my intern year, and I'm having people coming in with a respiratory rate of three because they've overdosed. And I'm treating people and I'm sending them into terrible withdrawals, and I'm sending them back to their pain medicine specialists, and I'm doing all sorts of things and none of it feels very satisfying. I feel like I'm keeping people alive. I don't feel like I'm helping them.

[00:06:53] I made a switch because I found out that what I really cared about, for me at least, what really helped me want to get out of bed and show up to work in the morning, wasn't so much the medical wizardry and all of the cool technology that we had, and all the ways that I was able to save somebody's life. But it was really how do people make sense of what's going on for them? Why do they make the choices that they make? Why do we do what we do? And why do we wind up where we wind up? And how can we as a healthcare community partner with people to help them get their lives back, not just keep them alive?

[00:07:25] So that led me into psychiatry. I moved down to New Mexico where I did a psychiatry residency, and all of a sudden I got to learn a lot about trauma. By the way, one final footnote, I moved to Oregon after my psychiatry residency back in 2006 uh, which was just right at the time that Oregon passed laws that decided that all healthcare providers needed to do a special six hours of continuing education in the treatment of chronic pain.

[00:07:50] So as soon as I got here, I did my six hours so that I could get my license. And I learned that I needed to aggressively treat people's pain with medications so that it wouldn't develop into chronic pain. And what happened after Oregon did that? Opioid addiction rates got higher, in our state, anyway.

[00:08:08] I will leave it to somebody else to tell us whether pain control in our state actually got better. But that led me down a journey of curiosity. And that journey of curiosity, I would like to take you along with me on that during the rest of our time together.

[00:08:25] First question. What do you see when you look at this picture? This, by the way, is the most famous version of this is by a comedian. Back in about 1915. I found earlier versions of this on postcards floating around Paris in the late 1800s, famously called My Wife and My Mother-in-law.

[00:08:39] I'm guessing when you first looked at this picture, you saw either an old woman or a young woman. For those of you who don't see both of them, I think if I use my pointer here if you're, if you wanna see the young woman, she's looking away from us. Here's her eyelash. Here's her nose. She has a beautiful cheek and jawline. She's wearing a fashionable choker. Do you see the young woman now?

[00:08:58] For those of you who only saw the young woman, the old woman is now looking a little bit more left out of the screen. Here's her left eye. This is her right eye. You can tell that she's kind of tired. She has a sort of a much larger nose. Her lips have sunken in a little bit, and here's her chin down here. Do you see the older woman now?

[00:09:18] I'm guessing if you're looking at this, now that you see both, your brain snaps back and forth between the two. But it's really hard to see both at the same time.

[00:09:26] Let's try this again. What do you see in this one? I'm guessing you see a beaver or a muskrat or a cute little rodent with an adorable little that's a, maybe a bow tie on his tail, or that's a butterfly in the background. It's a little hard for me to tell, but do you see the cute rodent? Alright, this is a similarly colored picture. But what do you see on this one?

[00:09:49] Most people tell me when they look at this picture that they see a donkey. . I don't know if that's what that looks like to you. But those of you who read German are in on this joke because it turns out that it's the exact same picture. Those two German words both mean upside down

[00:10:11] The point here is, in the words of Dr. Wayne Dyer, "When you change the way you look at things, the things you look at change." And that's what I'm hoping to do here tonight, is to change the way that we look at things.

[00:10:24] Let's look at some numbers. First I just wanna observe a couple of things about chronic pain in the United States of America. For instance, if you are older than 20, more than half of people older than 20 in the United States of America have reported pain in the last year, that lasted more than three months. If I bump up to 65, more than half reported pain that has lasted for more than 12 months. Chronic pain is a big problem here in the United States of America.

[00:10:52] If I want to look, instead of at pain, I want to look at trauma. I'll just remind all of us that the classic trauma disorder called Post-Traumatic Stress Disorder happens to about 6% of us over our lifetimes, about twice as often in women as it is in men.

[00:11:06] If I go just to a year it's a little bit less than 5% but still twice as common in women as in men. But notice that there's not really a big difference between those of us who have been exposed to trauma and get PTSD. And those of us who have been exposed to trauma, but do not get PTSD. So PTSD is not simply caused by exposure to trauma. There's something about us that makes us more vulnerable. If you want to decrease your risk, be Asian or Pacific Islander. Be educated, be wealthy, live in an urban area, and live with someone else. That, statistically speaking in our country, gives you the best chance of not developing PTSD.

[00:11:44] If I move to the primary care setting, now I'm starting to move trauma and pain a little bit closer together. I will just note that PTSD is pretty common in primary care patients. And also that people who have been traumatized visit their primary care providers four times more often. If someone happens to be a survivor of childhood sexual assault, and you do chart reviews, they're much more likely to have physical complaints, pain disorders, and general medical diagnoses as a whole. In other words, they have a longer medical problem list.

[00:12:16] And then of course, into our world, back in early 2020, came this beautiful -thistle-y looking little virus that sent our world a little bit sideways for a while. And you can see that almost overnight, the incidence of anxiety and depression in the United States of America jumped about fourfold just in the first few months of the pandemic.

[00:12:35] And that translates to PTSD for some people, to trauma for some people. During the COVID 19 pandemic, you were more likely to develop PTSD if you had lower income, if you had to quarantine for a long time, if you were exposed often to COVID or were around people who had COVID, if you were hospitalized for COVID, or simply if you were a healthcare worker, your risk of developing PTSD during the pandemic was much higher.

[00:13:02] I'm going to shift again back to chronic pain but to hold on to PTSD now and look at the intersection of PTSD and chronic pain. This is a study of about 5,000 folks who were either identical or fraternal twins and the researchers were trying to figure out what the genetic risk of developing PTSD is and what the genetic risk of developing chronic pain is.

[00:13:25] And what they found is that your genes account for about 43% of your risk for PTSD and about 34% of your risk of developing some kind of pain condition. Everything else is environment. Notice, environment plays a much bigger role in your risk of developing both PTSD and pain compared to your genes.

[00:13:45] But more importantly from the study, if you look at the blue and yellow boxes that I've highlighted here, if you have PTSD, that's the blue column, your risk of developing a pain disorder is at least double for all of these different pain conditions. And for things like tension headaches or chronic fatigue syndrome, that risk is about six times as great that you'll develop one of those if you have PTSD compared to if you do not have PTSD.

[00:14:12] The only pain condition that they checked that there was no difference between people who had PTSD and didn't have PTSD was prostatitis, and that one held steady across. But for every other kind of pain condition they looked at, your risk is much higher if you have PTSD than if you don't.

[00:14:30] The truth is that post-traumatic stress disorder and chronic non-cancer pain, often overlap. They share the same symptoms: anxiety, hyper arousal, avoidance of things that make it worse, emotional unsteadiness, and elevated focus on your body. And, they result in the same kinds of things over the course of one's life. People become hypervigilant. They watch out for things that can make their symptoms worse. They pay attention more to things that make their symptoms worse. Their bodies get more physiologically reactive, and they are wired to magnify pain.

[00:15:06] So let's talk about how that happens. Let's talk about how trauma shapes us. Now, when I say trauma, here's what I mean. I think Bessel VanDerKolk said it best in his, by the way, he even admits this, his very hard-to-read book: the Body Keeps the Score. "Traumatization occurs when both internal and external resources are inadequate to cope with the external threat." Let me put that in English. When whatever happens to you overwhelms your ability to deal with it, that can be traumatic, which means what's traumatic for you may not be traumatic for me, and what's traumatic for me may not be traumatic for you. And what's traumatic for you today might not be as traumatic next week or next year, and so on.

[00:15:49] I'm gonna tell you about this study that broke this wide open for us in the United States of America. So come all the way back with me to 1998, Felitti, Anda, and the rest of their team published, The Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.

[00:16:04] This is most commonly called ACEs, and who they studied in their first couple of groups of research were folks who all had health insurance in Southern California, mostly women, mostly white, mostly over 50, and mostly college educated. These were not the people that we traditionally thought of before this time as having high rates of trauma. And what they found is that trauma is pretty universal.

[00:16:29] Now they just asked yes or no. Did one of these 10 things happen to you? Did any of these 10 things happen to you when you were growing up? Were you someone who experienced physical, emotional, or sexual abuse? Did you experience physical or emotional neglect? Or did you grow up in a household in which there was significant mental illness, domestic violence, substance abuse, divorce or separation, or incarceration present?

[00:16:52] And what they found is that, these were really common things. At least two thirds of those 17,000 people had at least one adverse childhood experience, and if you had one, you almost certainly had more than one. They tended to occur in clumps.

[00:17:09] Now, what's particularly interesting to me is the reason why they decided to ask these 10 yes or no things. They noticed that some of their patients stayed really healthy through pretty much their whole lives. And we all know those people. They take one or maybe no medications, and they're really healthy, and they don't have a lot of health problems. And they stay that way pretty much until they die.

[00:17:28] And then there's the rest of us who tend to develop more and more chronic health conditions as we go through life. It usually starts in our forties, and then gets worse, and we get sicker, and we tend to die a little bit earlier in life. And they wanted to figure out why that was. And they had an inkling a hunch that it might be due to things that happen to us when they're younger. And sure enough, just those 10 questions predicted the 10 most common causes of death. In fact, those 10 things alone account for more than half of your risk of developing chronic diseases or the risk factors for them.

[00:17:59] If you had none of those, you almost certainly didn't have any of those chronic diseases or risk factors. And if you had four or more, you almost certainly had at least two of those diseases or the risk factors for them.

[00:18:12] When I talk about the leading causes of death, here were the leading causes of death for adults in the United States of America in 1999. And you can see overwhelmingly we're talking about heart disease, cancer, chronic lung problems like C O P D or emphysema, accidents, diabetes, infectious disease, and so on, all the way down to suicide. If you have an ACEs score of four or more, you're twice as likely to smoke, seven times more likely to be alcoholic, twice as likely to have heart disease, four times more likely to have emphysema or chronic bronchitis, ten times more likely to have injected street drugs.

[00:18:47] Long story short, it doesn't take a rocket shrink to realize that what happens to us when we're young has a profound impact on the way that our lives unfold and increases our risk of things like traumatic brain injury, fractures, post-traumatic stress disorder, suicide, alcohol and drug abuse, and even how far we are likely to go in our educational career.

[00:19:11] There's been hundreds of studies around this since then. And I wanted to just point out a couple around pain. Turns out the things that happened to you when you're young also have a profound impact on your likelihood of being diagnosed with chronic pain or even disabling pain later in life. ACEs are associated with at least a 1.2-fold increase in the odds of any kind of chronic pain, chronic back pain, headache, even dysmenorrhea or pain with menses.

[00:19:39] We don't yet have all of the links in this pyramid solved. But in general, bad things happen to us. That changes the way we develop. That leads to impairment in the way we function, which leads us to adopt risky health behaviors to cope with that, which then in turn leads to increased disease and early death.

[00:19:57] Let's dive even just a little bit deeper. Your brain, when you are being put together in your mom's uterus, forms from the bottom up or from the inside out. It adds more and more layers. You are born with about 50 trillion brain cells. That multiplies by 20 by the time you're six. You get another explosion of brain cells up in the front of your head during puberty. And thereafter you lose brain cells for the rest of your life. And the main reason you lose brain cells is because you're not using them. You keep the brain cells that you use and you keep the connections that you use, and you let go of the ones that you don't.

[00:20:34] Because your brain gets more and more complex as you grow up in childhood and adolescence. Again, it's not too much of a stretch to realize that the kind of environment your brain is in when you're growing has a profound impact on the shape of your brain. I want you to pay attention right now to just three areas of your brain, and we're going to look at the amygdala, this little almond-shaped structure. We're going to look at the hippocampus. And we're going to look at the prefrontal cortex up here in the front of your brain.

[00:21:02] Your amygdala is a threat detector. It's fully functioning when you're born and its job is to tell you thumbs up or thumbs down, this is safe, or this could kill me. This is one of the reasons babies cry so much because everything is a threat to them if they're not feeling safe. They can't really protect themselves.

[00:21:19] Your hippocampus, on the other hand, helps you with short-term memory, helps you begin to lay down long-term memory, and it doesn't really function very well until you're about four months of age. By the time you get to around two years of age, it's working pretty well and so your hippocampus allows you to take stock of your surroundings and say, I feel scared, but Mom looks relaxed and happy, so I'm probably okay. Or I'm hungry, but I can see Dad's fixing my bottle, so I don't need to panic just yet. Your hippocampus can agree with your amygdala or it can suppress your amygdala.

[00:21:50] And finally there's the prefrontal cortex, that part up front. It really doesn't start forming very well until you hit puberty, and its job is to really pay attention to new things in your environment, figure out where they fit, and to take advantage of all of the memories that you've formed and the way that you think to figure out how to make a decision and whether to agree with your amygdala and your hippocampus or to disagree.

[00:22:11] Your amygdala works instantly. Your hippocampus takes a couple of beats longer. Your prefrontal cortex, what's the longest you ever spent making a decision? It could take years to finally decide to do something about something, right? Usually it's, a few seconds or a minute or something, but it can take a really long time.

[00:22:30] So for those of you who like pictures. I'm gonna go this way. Stuff comes into your sensory thalamus. Oh, I should have changed the transitions on this. It very quickly goes over to your amygdala and your amygdala tells you to run away, or to fight, or to freeze or to do something to to stay alive. Your hippocampus on the other hand is a little bit slower. Allows you to take stock of your immediate surrounding and to either agree or disagree with your amygdala. And finally, your cortex can weigh in on the process as well.

[00:23:00] If you live in an environment where, when you're growing up, where things are traumatic, and you have to use your amygdala a lot to survive, that pathway really gets laid down. And the other pathways, not so much. Because you're not using them as much. You might be able to use them in moments when you feel really safe. But your default becomes your amygdala.

[00:23:24] And in fact, if things are really traumatic, we can see this with functional M R I. Your cortex doesn't get as thick. It doesn't get as robust. You don't develop as much ability to think and reason and be as adult-like as you otherwise would. And if it's really bad, we even know now that your hippocampus doesn't develop as much.

[00:23:42] Now most of us, are not living in our amygdala except when we're stressed we do. And when we live in stressful periods of time, oh, say a pandemic, we think a lot more with our amygdalas, and we find ourselves getting more and more irritable. By the way, your brain is wired to your body to all of your organs through the vagus nerve. And what's happening in our brains influences the way our organs function and the ways that they develop as well. We wind up irritable. We wind up on guard. We pay attention to threats, to danger. We feel a lot of anxiety. We are more programmed to act and less programmed to think. The thoughts that do get through tend to be more extreme in their nature. And we begin to in short, we're overwhelmed.

[00:24:25] Trauma overwhelms us. It overwhelms our ability to self-regulate. And when we can't do that, we stop being able to recognize our own emotions. We may disconnect from our bodies, and we begin to express our emotional distress as physical pain or as physical symptoms. That hyperarousal, that attention to threat, becomes our baseline and results in things like allodynia, which is interpreting things that are perfectly innocent or innocuous as painful.

[00:24:55] For example, acid reflux. A lot of us have it, but did you know that people with PTSD are much more likely to be diagnosed with acid reflux? Did you know also that people who have PTSD have no difference in the variation of acidity in their esophagus compared to people who don't have PTSD? It's just that their brains feel that and say, wow, that might be dangerous. You gotta pay attention to this. Whereas those of us who haven't been traumatized don't pay attention to that as much.

[00:25:23] Hyperalgesia, things that are a little bit painful get really magnified, and we think this might have something to do with migraines.

[00:25:31] By the way, SAMHSA says this about chronic pain. " Chronic pain often results from a process of neurosensitization following injury or illness in which thresholds are lowered, responses are amplified, normally, non-noxious stimuli becomes painful, and spontaneous neural discharges can occur." That sounds an awful lot like what I just said about trauma. It turns out that trauma and chronic pain are linked.

[00:25:57] But I promise you there is hope in all of this, and I think that hope starts when we change the basic question. Instead of when somebody has a problem, instead of asking, "What's wrong with you?" I and Bruce Perry, who gets credit for this question, think we do better when we ask, "What's happened to you?" Do you see the difference there? Not what's wrong with you? Instead, what's happened to you?

[00:26:24] When we ask somebody, what's happened to you? Or when we ask ourselves, what's happened to me? Instead of what's wrong with me, that allows us to reinterpret what's happened through the lens of exposure to trauma, to avoid overreacting, to avoid power struggles with our healthcare providers or with people who seek help from us, to lean into what's going on with somebody, to find that area of distress, and to try to open up communication about it. That is when healing can begin to happen.

[00:26:54] Other healthy responses involve listening to people, listening to understand what's going on for them instead of listening for our turn to talk, to focus on building relationships, to accept our own limits, and to learn to work within those, to intentionally enjoy things every day, to notice the progress that we and other people make around us, to pay attention to our breathing, to move our bodies every day, to pay attention to basic things like making sure that we stay hydrated, making sure that we protect our sleep and making sure that we avoid substances.

[00:27:25] There are all kinds of other ways that we can intervene in traumatized brains. That's how I earn a living and that's how a lot of other people earn a living as well. And it's probably beyond the time we have tonight to talk about a lot of those. I just want you to know that there are all kinds of ways that we can help people restore balance in their brains and develop pathways that are underdeveloped, and be able to damp down the amygdala.

[00:27:50] The short version, as Dr. Bennington Davis would remind us, recovery is very likely. Our job is to create an environment in which recovery can occur. We need to believe. People live up to our expectations. We live up to the expectations we have for ourselves. So it's important to be bearers of hope.

[00:28:09] In summary, trauma's common. It rewires our brains and bodies. Recovery can be our expectation. Change starts with us.

Final Transcript 1007 Cuccaro 02 22 091122

[00:00:09] Now, as Rolly said, what I'm going to be talking about is, um, is not necessarily a direct pain story. I will kind of interweave my own experiences with this presentation, but really it's to provide some concepts around modern pain science. And certainly what they did is the way I learned them in the way that they sort of impacted my practice is going to bleed through really, really, really quickly here.

[00:00:31] So we're going to talk about deconstructing pain.

A pain specialist

[00:00:33] And for those of you who don't know me, oh, there's a couple of people in here that I don't know. Most people I've at least have a little bit of familiarity with your name. So, um, I just see you, but for those who don't and you're like, well, why in the world should we even listen to you? I'm a fellowship trained pain specialist. So what that basically means is I did an anesthesia residency at the University of Chicago. I did a fellowship in pain medicine at the University of Michigan, uh, passed all my boards, did all that stuff. I was in the Navy, was associate program director of the Navy Medicine Pain Fellowship program.

[00:00:42] And what that ultimately came out is, is when you're looking at a modern healthcare system, a quote unquote pain specialist, such as myself, are supposed to be the people who have the answers.

Lessons from group practice in the military

[00:01:14] Now, when I went into practice, I had the privilege of, of practicing in the military, and in the military, we had what was known as a group practice model. So we see individual patients, which is very different than most of the way that, that, that practices go. Usually you have your patient panel, you see your patient panel, you're kind of are involved with them. You may cross cover and see other physicians' patients on the side, but they're not really yours. In the military because we had all these deployments, and we had people, other clinical responsibilities. I may see a patient, one of my colleagues also fellowship trained with may see them on a follow up visit, or maybe they're doing a procedure. And then somebody else might like see them after that. So it was really kind of discordant care, but it also meant you couldn't hide your results.

[00:01:57] And this becomes very, very important because I've seen lots of people, particularly in the pain world, talk about how awesome and fantastic their results are. But when you see their patients or you talk to their patients, that fantastic outcome could be very, very. different in the way it's being presented to you. And what I also saw is that there was this vast kind of change in the way that we treated people. Some of us were very conservative. Other people were very aggressive. Everybody had the best interests of our patients in mind, but we practiced very, very differently.

[00:02:25] And what the other part I noticed it was is you never knew exactly what was going to occur. You can have the same person with a, quote, “same” type of pathology, and you can do the same procedure on them, and you could have vastly different results. Different people could do the same thing on somebody else and have completely different results. And I found that very, very frustrating. So what I thought it was the military model. I thought it was this group practice.

Questions raised by solo practice

[00:02:49] So when I moved and came up to Corvallis, it was just me, the solo practitioner, very conservative in my approach, very standardly standard. I wasn't doing like crazy stuff. I was actually following all the evidence that we had. And what I found very quickly though, is that my outcomes in pain were the same that I was seeing in the military. Meaning you could do the same procedure on somebody on a different day and they'd have completely different results. You could see that, do something completely different and have a fantastic result. It was this inconsistencies that drove me crazy.

[00:03:20] And I also wasn't seeing people get better. The reason I went into medicine is I wanted to see people improve. I don't want to see them over and over and over and over again. I want them to get back out, out into their life, seeing their friends, their family, and not being, you know, if you're, if you know your physician by their first name, and they're a specialist physician, that's probably not the best thing because you're, you really want them out in the community. You want them out and kind of dipping their, their foot into the water to see you every once in a while, but not seeing you all the time or certainly getting worse and worse over time.

Looking at the data

[00:03:53] So I didn't, I, I now didn't have these other people around me. I couldn't say it was the military. And I'd asked her think, well, well, I'm a fellowship trained pain specialist. Let me look at the data on what I'm actually practicing with a critical eye. Not this idea that says, well, you know, I know that published story, but, but that's not true because I know in my heart, the procedures that I'm doing work. And when I looked at a little bit more critical eye, what I noticed was that all these high priced expensive interventional procedures that I did have very, very, very little evidence to support them. And you say no or none. And if you look at most of the way that we treat persistent pain in the United States, almost everything that we do, the surgeries, the injections, the, the whatever type of therapy you want to  look at, the evidence that support is pretty much minimal to non-existent. And that was very disconcerting to me.

Do I understand the problem?

[00:04:46] And the second part that I looked at, well, it's wait a second here. I'm a fellowship trained pain specialist. These procedures don't work. Do we actually understand the problem? Because if you are treating something and you are not getting people better and you're treating it all these different ways, and those don't seem to be working, the first thing that you need to do is take a step back and say, well, actually do I understand the problem that I say I'm treating?

[00:05:08] So I went back and started looking at the literature and research on pain and what I found. Was that there was vast amounts of good, good research in fields that were completely unrelated to what I had been studying. Lorimar Moseley, who became a mentor, you know, all this published data that said that there is something so much more to pain than what I had been taught.

Understanding pain changed my practice

[00:05:28] So that information, and when I really went deep into the pain literature and started exploring like how this stuff works, and what actually is the science of pain? And why is the neuroscience, the brain science that we're looking so critically important to the, to the science of pain? And that fundamentally changed my practice. I'd stopped doing interventions. I don't, haven't put a needle on anybody for over a decade now at least, and became very involved with clinical education.

Not scared of pain anymore

[00:05:51] But on a personal standpoint, it absolutely changed not only how I practiced, but it changed my own personal relations with pain. I'm not scared of pain anymore. I appreciate. I don't find it threatening. Instead, I find it a learning tool, and it has led me in so many different ways in my own personal life with how I experienced the world. I just can't tell you.

Four key topics

[00:06:14] So I have four key transformative topics when it comes to pain education, we don't have time for all these, and we're not going to be able to go into all, all of them in great detail, but I want to  briefly put them here just so I can start to plant some seeds for future discussions and plant some seeds for maybe to help you kind of think about this stuff.

[00:06:31] Once you're away from this presentation. The first one is this concept of pain and protection. And the second one is pain and construction, which is really this deconstruction process that Rolly led into, but you can't separate those too much. So I have to introduce them both at the same time. The other two are about pain and time, how different time perspectives, and past memory, and future prediction, and have a huge impact on how we experience pain.

[00:06:52] And the last one is what I call pain and power, in the sense of empowerment and control, this perceived control and how important that is to your personal experience of pain and what you talked with. And if you're a, a clinician, how you're working with your clients in order to help them to feel more in control of their bodies and over their experiences.

What is pain?

[00:07:11] So first we're gonna start with, "What is pain?" And I, and sometimes, and this audience is a little bit different. Sometimes. I, I feel like people like laugh at me and say, Dr. Cuccaro, what do you mean? We all know what pain is. We've all experienced. It. That's the stupidest thing ever. Just tell us how to treat it!

[00:07:26] But fundamentally, do we actually understand what pain is? And more importantly, what it is not? Because if you understand on first principles, what pain is, you should be able to explain it in such a way that it starts to make sense. And you should also understand how and why we experience it.

[00:07:43] And if I had a lot of time, these are two pictures I typically will use. And I'll say in the audience, I'll go, Pain or no pain? And I'll flash the first one, and people will say, well, that's a big old nail through going through someone's foot. Obviously they have pain. And then other side, they'll say, well that guy's got a nail through his finger. Obviously he has pain. And then most of you know, this, but that picture with the nail, through the boot, a person that was screaming in pain, taken by ambulance to the emergency department who received fentanyl, which is an opioid a hundred times more potent than morphine, another strong anxiolytic. And only after he got those medications, could they cut it off? What they discovered was that the nail was between his toes.

[00:08:19] And the other guy with the nail through his finger. That was a work-related injury. Wasn't the first time he did this, this is something that he did with a nail gun. And he did not go to the emergency department, and he didn't get fentanyl. This is a YouTube video I pulled off where him and his friends are joking around, and they're pulling it and he's going, “Ow, ow, ow.” And they're telling him to stop being a big baby, so that they can cut the nail and pull it through his finger.

[00:08:40] Now, we should be able to explain both of these scenarios, but the typical reasoning that we have, at least in the modern healthcare system, we can't. Because this person with the nail, through his boot. We should be able to call that acute pain. And almost everybody says, well, acute pain is there's tissue trauma, there's damage being done. This guy had acute pain. There's no tissue trauma. And yet, and if, unless we're saying he's lying, which I don't believe he was because if he was lying and he didn't experience pain, and we gave him a bunch of fentanyl, he would go into respiratory depression. We have to be able to explain that.

[00:09:17] On the same token, the other picture, which we would say, well, that's acute pain. He has a nail through his thumb. That obviously causes lots of pain. And there's a problem there. And again for him, he had minimal pain. So how can we explain both of these scenarios in a way that's aligned with the science that makes both times without saying that, oh, one person's lying, and one person's not. Or one person has real pain and one person has fake pain. And the only way that we can do this is to move away from the idea of thinking that pain equals damage or that some pains are equal to damage. And other pains are some, mysterious thing that we don't understand.

All pain is about protection

[00:09:56] All pain is about protection. And what we see then is if we understand that pain is a protective system, that is this complex experience that comes together with all these different inputs that, we'll get into this, start to make sense very, very quickly, because if you have that guy with a nail through his boot, and you're looking, and he's got a nail through the, through, through the middle of your boot, and you kind of feel something kind of on your foot, because if I put a pencil between your toes, you would definitely feel it, that your brain would see and go, holy smokes.

[00:10:28] Something could potentially be really, really wrong in my foot. There’s a lot of protection that I need here. On the other token, though, you got somebody with a nail through his thumb. If you’ve had an injury before and you’ve successively recovered from it. And that past experience wasn’t horribly traumatic in any way, shape or form, and a similar thing happens to you, there’s not a lot of danger in that situation. Oh, I’ve done this before. I need to pull out the nail. You know, what kind of sucks, but it’s not a big deal. So not a lot of need to protect. And so we see then that pain is all about this protective modality. And as we increase threat, we increase the experience of pain.

[00:11:06] Now, counter to that, a little outside this talk, then. If you know this and you know, pain is about protection, then safety becomes paramount. How can we increase a sense of safety? So if pain is about protection, how does it actually do this? What are the biological processes involved that allows this really complex system to keep us safe, to keep our limbs safe, to keep us from burning our fingers and then rotting off because of infections?

Plumber thinking: flow

[00:11:32] And the way that it does that is not this way. Most people, when they talk about pain, they talk about this ‘coming from.’ In fact, the language that they use will be well, “Where is the pain coming from? And very quickly though, you see that this fails to actually add up, because if you have somebody again with this acute pain in his foot and he has got a nail, but it’s between his toes, where is the pain coming from there? It can’t be from the foot. There’s no damage. There’s no significant inputs coming from the foot. The only place that makes sense for this person to be experiencing pain is in the brain itself.

[00:12:08] And similarly, the guy with a nail through his thumb, that is not pain coming from his thumb. If it was a directly one-to-one correlation that if we had input in the finger and the number of inputs in a finger directly correlated with the experience of pain, then all pain would be modulated by the amount of tissue damage that we experienced.

[00:12:27] And we know that's not true. You can have no significant tissue damage and extreme pain. You can have profound tissue damage and minimal pain. And the only place that makes sense again is in the brain that the, our brains are central to this experience of pain coming from thinking. I also kind of use is, I describe it as pain plus, because we want to believe that somehow there's this little pain pus particle, and that pain pus particle stimulates a little pain receptor.

[00:12:54] And then that pain receptor sends the pain down the pain pathways and into the brain almost unadulterated. And everything that we see in most healthcare systems are then designed to interrupt this flow. We think we can stop the flow of pain pus, or minimize the pain pus, or we can cut it out, or we can poke it, or we pop it, or we drug it.

[00:13:13] But if this was the case, if pain actually flowed down pathways like pus. Then when we cut, poke or drugged those pathways, we should have consistent and predictable results on how our pain is experiencing. We would have fantastic outcomes. We'd have fantastic data and pain would be amazingly easy to treat, particularly even the persistent pain, but this is not what we see.

[00:13:36] Usually I'll have a slide after this. We'll actually look at the actual data on how we're treating persistent pain. And it is absolutely atrocious. We do more surgeries. We do more injections. We prescribe more drugs than anywhere else in the world. And our outcomes with pain, particularly persistent pain are no better, if not worse, than anywhere else in the world.

[00:13:54] So this simply does not work. This idea that pain flows down these pathways, and the thinking here is very cause and effect. Somehow there's a stimulus. In a response, the pain is coming from and going to the brain. And again, we want to think this way. Our brains are actually designed to perceive the world in this way, but this simply does not work again.

[00:14:20] If it was cause and effect, every time you had tissue damage, then there would be a direct correlation between the amount of pain that you experienced and the amount of tissue damage that we have. That's not true. And if we had no tissue damage, we should not be experiencing pain. And yet from the vast amounts of persistent pain that we have in this country and in the world, we simply know that's true.

[00:14:39] And again, people do not lie about their pain. Their experienced pain, the pain is a hundred percent real, but is not associated with tissue damage. I also call this then plumber thinking, because we approach this idea of pain pus pathways, and this idea that we can somehow interrupt the flow of pain, same way that a plumber would look at your pipes. They're looking for a stop or a gap or something that they can kind of wizzle out so they can stop or start the flow there. But when we think in these linear processes in this cause and effect manner, it doesn't line up for how we can explain pain. It doesn't line up with how we see that treatments align with pain.

A different way to think about pain

[00:15:18] And it certainly doesn't line up when we're looking with overall outcomes. So we need to understand that there's a different way to think about pain and that's to understand what I saw, construction of pain. So when you look at the diagram on the left, which is uh, it's from Melzack and Wall, Ron Melzack's, neuromatrix theory. And it's a adaptation of that. What you see is when it comes to pain, you cannot think of cause and effect.

[00:15:42] Instead, what you need to recognize is there are multiple inputs. We have the sensory inputs that come from the periphery. We have this affective motivational component that comes from more long term memory in what we have learned. And then we have this cognitive evaluative input, which also comes from the brain, but is more forward thinking anticipatory, anticipatory, and is in a lot about threat and threat and danger appraisal. We also have immune modulators in there. We have endocrine factors in there. We have intrinsic neurosystems involved. We have simply exteroceptive and proprioceptive input, all these different inputs that tell you where your body is in the world and what are all the different stimulants is in the world. And what that you believe are important to how you navigate the world all come together to construct this experience of pain.

Firefighter thinking: dynamic process

[00:16:28] Now, this is very, very different thinking though. You can't just think again cause and effect. There is no single stimulus that directly correlates with an experience of pain. And this type of thinking then is not plumber thinking, but what I call firefighter thinking, because that process of fire is dynamic.

[00:16:53] All fire has to have three components in order for it to be constructed. You have to have a fuel source. You have to have a heat element, and then you have to have an oxygen supply. And it doesn't matter how complex or how simple the fire is. You always have to have these three elements in order to construct that fire. And these elements are extraordinarily dynamic.

[00:17:18] And the reason then that firefighters learn this is because they recognize that this dynamic process can change very quickly. Uh, and that how it is constructed is going to have very, very different treatments. Meaning if you have a big fuel based fire, there's lots and lots of logs of wood. You still have oxygen and still have heat, but you may wanna target most of your modalities against that fuel.

[00:17:45] On the other hand, if you have a complex fire that maybe is more oxygen related, there's just tons of there's a hundred percent oxygen. Maybe you have somebody with a bunch of, O2 tanks nearby. The thing that makes more sense is turn off the oxygen supply. And in other scenarios, if we can somehow stop that process of combustion from going on, that may be the best way that we can address this.

[00:17:65] And so firefighters who may not understand emergence, which is sort of the science behind this, but they've really quickly recognized with this model is that, Hey, if we can think in three dimensions, we can very quickly start to figure out how these fires are constructed in that way. Then we can start targeting our therapies very effective to treat this specific fire that might be similar to others, but is unique because these dynamic interactions are unique to what is occurring right now.

Pain is a constructed process

[00:18:38] So in the same way, pain is a constructed process and you can fundamentally then simplify without what I call "dummifying" pain into this idea that there's three critical dimensions that you have to be thinking in, in order to understand how we experience pain and how our patients are experiencing pain.

[00:18:59] There's the sensory aspect, which is sort of like the wood to a fire. There's the emotional aspect that has to do with learning and memory and past experiences. That's sort of the oxygen supply to a fire. And then there's the heat element. That's that cognitive element that's all about attention and appraisal. Does this matter right now? How much attention am I investing in that sensation? How much threat and danger am I experiencing? What's my environmental cues doing here in this moment? And so just like that fire then pain is a dynamic process.

Pain can change--and quickly

[00:19:31] It can change, and it can change very quickly. You can have acute pain, which we would call, which in, in, in a better terminology would be a greater amount of peripheral, nociceptive input. There is lots of nerves firing out in the periphery. This would be something like a broken arm, or a burn, or a cut, or a, a tear of your skin.

[00:19:52] When we have all of that fuel, all that sensory input coming in that sensory input alone is not pain. It is just fuel. That fuel then has to have meaning to it this past experience. What does this sensation mean to me? And then has to have that heat element that you're actually paying attention to it. And as we change, then the meaning, the oxygen, the heat, and those sensory inputs, pain can change dramatically.

[00:20:18] Now, one example is this, when you're thinking about, well, it's all sensation, Dr. Cuccaro. If it's something is burning, and that's my pain, then that is burning pain. No, you can have burning sensations with different meaning and have very different experiences from them.

[00:20:34] If you are an avid exerciser and you're moving around, what will happen is you're start getting, uh, your peripheral cells start to get tired. There's lactic acid and there's deoxygenation. And there may be a burning or an aching that's associated with that. But the meaning, because you're actively exercising, and maybe you're an athlete, doesn't mean that you're suddenly in a bunch of pain. That meaning, which is your body tissue saying, Hey, something's changing down here. You may want to pay attention that. We're gonna put some different information up. That meaning then becomes, Hey, I'm getting a very good workout, or I'm pushing myself hard.

More than just sensation

[00:21:11] So when we're looking at construction, and we're thinking in three different elements, we're not just thinking about what are the tissue saying? We're thinking about tissues. And we're thinking about past trauma and experience: the memory, the harm, the fear that's associated with that sensation. And we're thinking about how threatening the brain is focused on any individual sensation or input. Now all of these then can change both acutely and chronically, and I've sort of diagrammed things out here. About where I see different aspects of these fitting. So again, sensation is probably the easiest element to it.

[00:21:48] That's what if you're a clinician and you know about nociception, those specific, nociceptive inputs, which are not about damage. They're about change in the tissues. And they don't fire when tissues are damaged. They fire when tissues are changing. So if you jump and you feel a sting on your feet, that does not mean you damaged your feet, but what those little sensory inputs are telling you is they're telling you, “Hey, something happened down here. Something has changed in my tissues. Is this important?”

Attention

[00:22:18] You still then have to put that attention on them. And that attention where you're focusing, investing that attention is looking for threatened danger. If you have a lot of anxiety or you have expectations of harm, or you believe that pain or sensations equal to damage, guess what? You're gonna invest more heat. You're gonna burn your attention into it, like a laser beam and add a huge degree of heat element to that experience.

Meaning

[00:22:42] And then the oxygen supply, the emotional meaning, past, has a lot to do with what we've learned. Are we afraid? Do we believe that pain equals damage? In which case there's lots of data that shows the more you believe that pain equals damage, the more pain we tend to experience because there's more threat and danger inherent then within that meaning.

[00:23:01] What have you learned? What have your clinicians told you, have they told you that your spine is disintegrating? Have they told you that pain is dangerous and you should not move? Have they told you again, that you need to be very, very careful with all of your movements because you're so fragile? In which case you're gonna be very sensitive to different threats to your body. But all of these things then coming together in order to construct that experience.

All pain is constructed

[00:23:26] And when we start looking at things in a constructed manner. When we start looking at pain like firefighters and not plumbers, then the whole spectrum of pain starts to make more sense.

[00:23:38] So we have somebody who's got a broken leg. There's lots and lots of sensory input there. That sensory input. The pain's not coming from that broken leg though. The only thing coming from that broken leg is a lot of sensory input. The brain still has to say, am I safe? Is this important? Is there something else that's the matter right now? And those inputs then can either amplify or diminish that experience of pain.

[00:24:04] In the same way. On the other spectrum, you may have somebody who has horrible leg pain, but that leg may not be broken. There's still sensory inputs coming from that leg. If you are sitting in the chair listening right now, there's still sensory inputs that are telling you you're sitting in this chair. Sometimes they may even tell you, well, we're sitting here, we've been sitting here for 15, 20 minutes. Now you may want to shift your body around.

[00:24:25] Some of those are unconscious. A lot of them are conscious, but those are still sensory inputs. Those sensory inputs alone though, are not the same thing as pain. And so when we start moving away from plumber thinking, though, to fire fighter thinking, we start appreciating all the different potential inputs.

[00:24:43] When we're limited to cause and effect, we start thinking, well, how can I interrupt the pain pus? We start thinking, well, what is damaged? And if nothing is damaged, we start throwing up our hands and going, well, your pain's all in your head. I don't know what else to do for you. Well, all pain is in your head. If I cut off your finger, your pain would be in your head.

What else is happening?

[00:25:03] Allow. This allows us to do though, is if you're a clinician and you understand, then that pain is a constructed process. You can have somebody that maybe does not have tissue damage, that maybe doesn't have a big tumor, that maybe doesn't have an inflammatory process. And instead of saying, well, this is not real pain. This is something else. You can say, well, what else is happening with my patient? What else are the threats and dangers involved in their life? And then you start seeing things like what they've been told. You start seeing things like external stressors. You start seeing things that, including financial stressors, marital stressors, stressors, past trauma. And if we had more time, we could talk about how past trauma, traumatic experiences change, how your brain sees threat. Not because that's a bad thing, but because if you are in a dangerous environment, You want a brain that can see threats very, very easily so that you are on top of your survival.

[00:25:58] So ultimately when we move away from pain pus thinking, even in what I would call acute scenarios and start seeing pain as constructed, whether it is acute, chronic, persistent, whatever, you start to be able to explain pain in a way that makes sense, that is aligned with the science and helps people feel, feel more in control of their pain again.

[00:26:18] We're not into this thing where we're saying, well, there's nothing else you can do. The only thing that you can do is learn how to live with it or manage it because we don't have any therapies for you. Simply not the case.

Pain and protection

[00:26:29] So key transformation concepts just very early on, the first one is pain and protection. When you stop thinking that pain equals damage and you move into understanding that pain is about protection, then the key modulator isn't to find what is damaged or not. Instead it becomes, well, how can I feel safe? And if we increase a sense of safety, even if you're in the emergency department with somebody with a broken leg, you're using soothing words, you're soothing medications that may actually provide a sense of safety to them, or you're providing assurance or positive expectations for them. We can start modulating these things in ways that don't, aren't limited only to medications or injections or any sort of, uh, what they call passive or direct modalities.

Pain and construction

[00:27:17] When we then also understand protection and we move into construction and we stop viewing things in the sequential fashion cause and effect. And we start looking at things into what is involved in this construction. We start able to align things like what are all those past experiences? How important are they to this current experience? And more importantly, how can we start reframing these things in such a way to help people feel more in control, more confident, and more importantly, have a sense of self that they can heal. And we're gonna hear some of this actually in, uh, our community member presentation this evening.

Pain and time

[00:27:53] Then finally the last ones, pain and time and pain and power, are more of this little Rubik's cube. You start understanding how the brain operates in two, three different time perspectives that there's this past element, what we have now, and these future expectations. And we can start messing with those a little bit.

Pain and power

[00:28:08] And then there's pain and power about understanding if pain is about protection and then threat is what makes pain increase. That's the key modulator there. Well, how can we increase a sense of safety in individuals? What are the steps that we need to do to help people feel safe, to feel confident, and in control of their bodies again?

[00:28:28] Thank you everybody for having me.

1001  Ransdell Nov 10, 2021

[00:00:09] This, it contains elements of technical presentations that I've done. And I've tried to make it introduce the technical experience, the technical terms in a way that all of us can understand it. So I did run it by my husband this morning. And he's said this really, it he said, “Finally, what you're talking about makes sense! I know you keep on saying it's in the brain, but now I understand why you mean it's real and it's in the brain.” So I hope that this has a lot of impact. And so please slow me down and tell me, I've got to keep Sharna on my screen because she told me that she would pull her hair if I was talking too quickly. So you all are welcome to pull your own hair too, if I'm talking too quickly as well. So I'll look at everybody's heads.

[00:00:44] So we were told to talk about a personal story. My husband said this is boring, but I think it's interesting. So here's a visual to go with it. Graduated in medical school in 2008 where I learned all about pain. I learned about how pain is a marker of tissue injury, and how to dose opiates, and how that pain is a fifth vital sign. And I wanted that, it's an emergency that we want to get people on medicine, so they don't experience the sensation. That we weren't good doctors unless we were able to make people not experience pain.

[00:01:10] This is what I went out to thinking. Started my residency 2008. 2012, I was in residency, had my first baby. And this is 2012. My, my second baby, I was studying for my board exams, studying for my board exams. Felt like I knew everything, felt like I was ready to practice. I was. Ready to go into the world and save everybody. There was not going to be a problem that I wouldn't be able to solve.

[00:01:31] So started practicing in New Hampshire, and this is us in cold New Hampshire. Now this little baby is this little baby there. And the other guy was two and a half at this picture. And now he's this size. I realized that I was failing.

[00:01:42] I really felt like I didn't, I never felt like there was a problem that I couldn't solve here, but here I really felt like my patients kept on coming in. And the more they came in, the more I felt like I'm going to get on top of this; I'm going to make them not suffer. I'm going to dose their opiates. I'm also going to find out what exactly is happening.

[00:01:59] If a nerve is damaged, I'm going to find the person who can cut out that nerve, or I'm going to find out what's the tissue damage that's causing this pain (because there has to be tissue damage that's causing that pain). But my patients kept on getting sicker, and sicker, and sicker. And I started to feel more and more like a failure.

[00:02:14] I was failing these people that kept on coming in to me. I thought I could save the world. I'd worked so hard. I'd gone through medical school. I'd worked really hard through residency. I was, I thought there was nothing that I couldn't figure out, but then realizing that I just, I couldn't do it.

[00:02:30] 2019, I attended the Oregon Pain Summit and finally things started to make sense. I started to learn that pain is not a marker of tissue injury, and I started to learn how pain is constructed in the brain. Started to learn that despite markers of tissue injury or without tissue injury, every pain experience is real. I learned to start listening to my patients. I learned to start understanding more of their experience.

[00:02:52] And this is me in 2021. I'm still learning. I still don't have all the answers. But I feel like I'm closer to where I wanted to be back in 2008. So, thanks to Sharna.

[00:03:03] So let me talk about the topic that I, that I wanted to introduce you all to. So when I was talking to the OPSA board folks on Saturday, I was thinking about how could I best summarize the things that I've been thinking about that really I've been trying to explain this to all my friends and family for years.

[00:03:24] How do I explain it in a way that makes as much sense to them as it did, to me in the Oregon Pain Summit. Now the Oregon Pain Summit was two days of lots of intense information. How do I do this in a shorter period of time?  So, when I met with Rolly, Cyndee and Sandy, they said it'd be nice to talk about:

• What happens when I stub my toe?
• Then also taking that to the next level. How does pain become chronic?
• And then how does knowing about pain science help?

[00:03:47] So I feel like I'm preaching to the choir here. This is all those things that you all know when you've been talking about, but I just wanted to give my perspective on this. So, we'll start off with what happened when I stub my toe.

[00:03:59] So I, I think Kevin, doesn't like to share this picture cause it's so outdated. So outdated; this was in 1600. This is how we understood pain in 1600. And it really hasn't changed that much for the way we're taught medical school, that there is one signal that goes off one wire and it trips off a part of the brain. Descartes said the pineal gland. This is what we thought pain was, and this is how we're still teaching it.

[00:04:20] So much of medical sciences has evolved. And but this is the way we used to understand pain that it's just this one wire that when you touch the fire, you get this injury that goes up and sets off a signal that just turns off and on. It's an off and on switch.

[00:04:33]  It really isn't. And I want to prove to you guys that it really isn't this way. So how do we know that it isn't? How can you do an experiment or prove that this isn't the case? So let's talk about some experiments that kind of prove that this isn't the case. So this picture is wrong.

[00:04:52] So the danger signal. So talking about point ‘A’ right here. So the danger signals that, that get activated when there is tissue damage, become active when the skin reaches 105 degrees Fahrenheit. It was supposed to be Fahrenheit here. I changed this, all. This was originally in Celsius, but my husband said it's not going to make sense unless I change it.

[00:05:11] This experiment was done, where you take a lot of people and you take a heat probe, and you put this heat on the skin, and you wait until the person says, “Ouch.”

[00:05:20] Turn it up, turn it up, turn it up, turn it up. And you wait until they say ouch, but then you also have probes in their skin to see when those fibers are active.

[00:05:27] So you have a probe on their skin to see when the fibers are active. And then you're also asking them, does it hurt? Does it hurt? So they can see from the readings that the fibers start to become active at 105.8 degrees Fahrenheit. But the person doesn't say ouch until 111 degrees Fahrenheit. So the signal is coming in from the outside, but no one's saying ouch until it reaches 111 degrees Fahrenheit. So it's not that just the signal that it just turns off and on.

[00:05:54] All right. I maybe haven't convinced you. Let me give you another experiment. So let's take a sharp pin. This sharp pin wasn't actually pushed, didn't break the skin, but a sharp pin was pushed into the skin. You have one sharp pin that's hot; one sharp pin is room temperature. So you take the room temperature pin, and you put it on the skin, and it fires the C fibers, those major signal fibers start to fire really slowly. Beep, beep, beep.

[00:06:20] And then if it gets really hot, it fires really fast. Beep, beep, beep, beep, beep, beep, beep, beep, beep. But people can’t differentiate the two. So it's not how fast they're going. It's not like it's Morse code where it's just this is a signal, we're going to get the signal up to this part of the, it's not just that one signal. There's so much more to do than that.

[00:06:36] All right. I've got two more experiments. So you take warm stimulus. Remember we talked about the stimulus was 111 degrees Fahrenheit. When the person said “Ouch,” so 113 degrees Fahrenheit. Do you take 113 degrees Fahrenheit stimulus? And you put it to something one millimeter wide. So one millimeter is about a third of this three millimeter.

[00:06:56] So just to give you guys a sense of how big one millimeter is, it's described as a pricking pain. At four millimeters wide, so this size right here, it's stinging. At 20 millimeters wide. So even so all, probably this whole fingertip, it's a pleasant strong warmth. So it's not the number of the dangerous signals that are firing. It doesn't match what people are experiencing.

[00:07:18] One last experiment. So you take a 15, second painfully hot or pinching stimulus. You pinch, pinch, pinch, pinch, pinch, pinch, pinch. Those signals are going crazy for their first 15 seconds. Those fibers are just sending all this information out, but then they stop after 15 seconds. You keep on applying this painful stimulus. The person keeps on experiencing the sensation. So it doesn't really match what's happening. These signals are doing something and people are experiencing something different. So that picture does not make sense. So what is really happening?

[00:07:52] So I'm going to just show you guys some pictures. So this is what we look at for a nociceptor. This is the signal that, that are just hanging out in the skin. They just start to look for danger, these danger signals. So it's not like directly, you get injured and you feel this, it doesn't directly trip this off.

[00:08:08] This can be tripped off by any injury. And you have all these chemicals that get released that cause these danger signals to start to be activated. So this is what looks like. This is what it looks like, the danger signals start to look like. So when this danger signal gets tripped off, it releases a lot of substances outside.

[00:08:25] So right underneath the skin, a lot of substances outside of the skin that help the skin heal. So cause it has things that promote bone healing. It has things that make the blood vessels become bigger to let all the healing ingredients get to the part of the body that needs to be healed. So thinking about how important this danger signal is for healing. So when the, when this initially happens, when you have an injury, this dangerous signal needs to fire in order for the body to heal itself. So thinking about how important that is, that it needs to fire in order for the body to start healing itself.

[00:08:59] So then what happens is that this signal goes all the way to this spinal cord. And there's going to be a lot more information that gets transmitted, but it's going to meet another nerve. That's going to send information up to the brain before it even gets processed as anything.

[00:09:13] Those signals, that, the strength of that signal is going to change. The more you fire it, the more important this signal is, the more, the stronger this sensation gets. So this might never change. But if someone injures themselves, and this spinal cord may change in such a way that it remembers that injury and will be much more sensitive to anything that happens in that part of the body in the future.

[00:09:36] So you have this protection system that starts to get turned up based on any injury that you've had before in the past. And the same thing happens in the skin too, that any injury that you've had in the past. It can remember it. So all these injuries that you've had in the past, there's a potential for the central nervous system for these nerves to remember this injury.

[00:09:54] Now keep in mind that I'm talking about the nerves. It's not the tissue that's causing the pain. It's the nerves that are causing these signals to be sent up to the brain. This is the most important part. So you get these signals up to the brain. It's not pain yet. You have these, this danger signal being sent up to the brain and these danger signals meet up of this part of this brain. This part of the brain is called the thalamus. And so what this part of this thalamus does is it receives all of the signals from outside, from the, from throughout the body. All the signals are being received here.

[00:10:24] What's really important is that this thalamus sits right next to the hippocampus. And the hippocampus is where all of your memories are stored. So think about all the memories of any sensations that you've had before are stored here. And remember, this is really similar to what's happening in this spinal cord, too, that you have all those memories that are stored there too.

[00:10:43] This side sits right next to the amygdala, which can fire often off which mediates our fear. This is where our fight or flight responses, the faster this is firing, the more fight or flight we need to get out of here. This whole part of the brain is called the limbic system. This is all the emotional part of the brain. So all pain needs to be processed through here. So all pain, regardless of the cause has an emotional component.

[00:11:04] I want to also draw your attention to this, that the more painful memories that you have, the more, this dangerous signal's going to start firing. The more the thalamus is going to be sensitive to everything that's happening. So thinking about the set point of things that have happened to people. They're all stored in here and this amazing protection system becomes more sensitive because it has to be. Just thinking about how we've evolved, how every single organism evolves to protect itself. You can see that in the anatomical relationship here.

[00:11:32] But I also want to call into, to let you guys to talk about when we saw that first picture, that Descartes drew, that it was just that one part of the brain that they thought was causing pain. There are actually multiple parts of the brain that have to be involved to create a pain experience.

[00:11:48] So I want you to think about any activity that you're doing right now. So it's a matter of, oh, maybe even thinking about putting these headphones on. So you got, you want to put these headphones on, you have to know where's your head, how long and short are your muscle fibers in order to open up this, where are your ears? Do you need to open this first? Where do you put your head? All of these things have to happen to put this pair of headphones on. That's takes so much complexity, but you're not thinking about that.

[00:12:14] Same thing with the pain experience, you get all of these sensations that are coming up through the thalamus. It's checked against your memories. Does this ever happen to you before? Am I really scared? Am I in a horrible spot right now? Am I really stressed out? Did this happen to anyone else I've known before? What do I think about this? Where's my emotional state right now?

[00:12:31] The prefrontal cortex is the CEO of the brain, basically deciding what to pay attention to, what not to pay attention to, trying to thinking about how you're going to plan the rest of your day, the rest of your life. How is this going to impact my work? My physical activities? What else do I have to do for the rest of the day? Where am I feeling in my body? Did my parent experience this before? What does this mean to me as an organism? Then these parts of the brain can also communicate with the thalamus hippocampus, the amygdala, can turn down these sensations as well. I've experienced this before. This is not a big deal. I know it's my nerves it's causing this. I know it's going to get better. You can turn down these sensations.

[00:13:06] So all of this processing needs to happen in order for us to experience pain. All of this processing needs for us to do anything.

[00:13:13] Our brain does so many incredible things and it does it so quickly. So you think about a song that you listen to over and over again, you listen to the first note, you're going to hear the whole song again, in your head. Similarly, with chronic pain, you hear that first note of something, it's going to set this all the more you connect all of these experiences together, the easier it is to fire.

[00:13:32] So the more you do it, the better you get at it. You know how to ride a bike. You don't even think about riding a bike. You know how to drink coffee. You know how to eat a bowl of cereal. All of these things, you do it so frequently. You don't even have to think about it. You start putting the spoon up to your mouth, you open your mouth right away.

[00:13:48] Same thing with the pain experience. I twist my back a certain way. Oh no this exact same sensation is what happened before when my back started to really hurt and that meant that I couldn't work anymore. All of this is going to happen without you even knowing it. It happens fast.

[00:14:00] I put these headphones on without thinking about all of those things that I told you about. This pain experience can be regenerated quickly in the brain without even thinking about it because these get so closely wired together.

[00:14:10] So thinking about how does pain stick? So we talked about the brain can get really good at this. So there are really important neuroscience concepts. The really important neuroscience concept is salience. So if a sensation or an action is salient to an organism, it's going to stick. If it has evolutionary, if it has a role to protect the organism, it's going to stick.

[00:14:34] It's important. This is what we need to do. We need to protect ourselves. So this is a, this is the pain catastrophization loop. This has been proven over and over again in terms of how pain would become chronic.

[00:14:47] So you have an initial injury, you twist, you pick, lift up something heavy, you strain your back. It really hurts. Oh, no, I know when people strain their back, they lose their jobs. I'm going to go to the doctor and the doctor's going to tell me what's going on. Doctor told me that, oh, if I, if my back keeps on hurting, I need to come back in because that might mean I may never be able to work again. Oh no. Every time my back hurts, it's going to, it's going to keep on, means that I'm hurting myself. Okay. Maybe I should just stop to go anywhere. I'm going to skip. I'm going to not go to work today. So my back is really hurting and every time it hurts, I know that I'm damaging myself. I'm just going to stay home.

[00:15:20] The more you stay home. I'm just terrible. I can't believe that I can't even go to work. This is awful. The pain starts to get worse. I'm just so miserable. The pain starts to get worse. Oh no. The pain is worsening. This means I'm not going to be able to feed my family. What's going to happen? Start to become really sensitive.

[00:15:37] I need to pay really close attention to my back. Cause every time I know that signals come that I feel that, that sensation. I know that I'm hurting myself more. I'm going to pay really close attention to. Start to feel it more and more, and this becomes really relevant. You can see how this can lead to significant disability.

[00:15:52] On the converse, hey, I'm having some pain. Backs get better. That's okay. I hurt myself. I know the nerves is doing this. I know this doesn't mean that I'm damaged. It means that I'm not broken. My, but this pain is amazing. It just shows me that my body's doing what it needs to do to heal. I'm going to experience it. I'm going to keep on moving. I know my body knows what it's doing. We'll start to get better. So this impact is huge. Basically talking, thinking about this is not something that people do on their own. This is something that some people's brains are more wired to do than other people's brains.

[00:16:24] It doesn't mean that someone has a high pain tolerance or a low pain tolerance. It's that the idea that this particular sensation is relevant to this organism because of all the experiences that has happened in the past. So the way that you have processed pain experiences, the way you've seen your parents process pain experiences, what you expect from life, those anticipations that are just hardwired into your brain makes this loop the way it is.

[00:16:48] This is nothing that people do to themselves. This is something that happens. This is something that people are hardwired to do. This is no one's fault, but understanding this loop is kind of the help for the way out.

[00:17:02] So this leads to a quote that I absolutely love. This is from a pain scientist in University of Washington. So the Institute of Medicine was commissioned by the NIH 10 years ago to come up with a report on what is the state of pain in America? And they came up with this wonderful quote that I, I think just ties it all together.

[00:17:21] "In fact, beliefs, anticipation and expectation are better predictors of pain and disability than any physical pathology." Boom! That's it. That is exactly what makes so much sense and ties this all together for me. This is why I can look at a patient, and look at two identical x-rays, and have completely different experiences.

[00:17:42] It has nothing to do with what's going on in the body. It has everything to do with beliefs, anticipation, expectation. But what's harder to treat--an x-ray or beliefs, anticipation, expectation? What's the low hanging fruit? This physical pathology. But that has nothing to do with it. I just showed you guys, this has nothing to do with it, but this is so hard to treat.

[00:18:06] This is where this is, but this is where the money is. And this takes a lot of listening. This takes no matter what we say as healthcare providers or friends or family members, you can't change this. This is hardwired. You can wait for someone until they're ready to listen, but this is really a challenging thing to change.

[00:18:27] And a lot of listening, and a lot of patience because people don't do, people don't have these beliefs on purpose. It has to resonate with somebody.

[00:18:34] So talking about beliefs, anticipation, expectation. I really want to drive this home that this is not anybody's fault. Nobody chooses to believe and have this anticipation expectation. This is what, this is what society believes. We're part of this society, and this is what we're taught.

[00:18:50] So I wanted to talk a little bit about how pain sticks and adverse childhood experiences.

[00:18:4\54] So to talk about how these adverse childhood experiences can relate to people having more protection. Again, we talked about how the brain and the hippocampus, which is the part of the brain that stores memory, and the amygdala, that part of the brain that mediates fear in their fight or flight reaction. We talked about the thalamus, how closely they're related.

[00:19:16] This toxic stress changes the way people's brains can be wired. So this was a study that was done in 1995, that surveyed people for 10 different types of toxic stress. And they found that the more toxic stress events the people had in their lives, the more likely they were to have significant adverse health consequences, die earlier, have high blood pressure, have chronic pain.

[00:19:39] The more people experienced it, the more they were likely to have a different experience of the world because their protection system is up naturally. So these are the types of adverse childhood events. Physical abuse, neglect household dysfunction. So tying this into chronic pain.

[00:19:56] So thinking about, the CDC population is the general population. So this is the likely, this is in the general population. People normally experience forced sex, about 5% of the time, people with fibromyalgia, 20% of them have had this experience. Hit by parents. This is 10% of the general population has experienced it versus in the fibromyalgia population, 40% have.

[00:20:29] And then if you look at trying to move this thing, if you look at parents hitting each other, this is 25%. This is about similar the general population, but looking at the difference, these are the hugely impactful adverse childhood events that lead to chronic pain. Thinking about youth with chronic pain people with an ACE score of one or more, the general population is about 25% in the general. In the people, youth with chronic pain, it says the studies say 85%. I would venture to say a hundred percent in my practice, that most people with chronic pain have had significant adverse childhood events.

[00:21:01] Thinking about the life cycle of chronic pain. Again, this is part of how our brains get wired to develop chronic pain. In infancy genetics are sort of a big risk factor on people developing chronic pain. What genes that they'll up regulate or down regulate in order to create the brain that they live with. Irregular feeding and sleeping can sometimes lead to parental dysfunction. Parents’ pain exposure: children and infants look to their parents for what they should be afraid of and what they shouldn't be afraid of. So if parents pain exposure, parents are afraid of pain. The child might be afraid of pain as well. Parents, depression, and anxiety, their reaction to pain. In childhood and adolescent, the attachment to parents. So avoidant attachment styles, which we can talk about abuse, hyperactivity, which can also lead to abuse.

[00:21:33] Perfectionist tendencies are also a risk factor for pain. And mood disorders is again, parental reaction to pain. And then in adulthood, lack of social support, vivid recall of childhood trauma, occupational exposure, and development of chronic disease. So this is, these are all the, this is the recipe for the development of chronic pain.

[00:21:49] That does that mean that people, that me suffer from chronic pain? That's it that's the end of it? I'd like to say I know that it isn't actually, I'm not going to say that. I like to say, I know that it isn't the, I know that there is a way out. So I wanted to just talk about Maslow's hierarchy of needs. And I really debated whether or not to include this.

[00:22:06] Sorry. I want to get want to minimize you all. So I can't see your pictures. So Sharna, you're going to have to text me if you're pulling your hair.

[00:22:13] Sharna: Not yet. You're doing great.

[00:22:16] So this is Maslow's Hierarchy of Needs. So Maslow is an anthropologist. In 1940s. He studied some very high functioning people and tried to understand what made them self-actualized. So basically where they were not experiencing anxiety, where they were had lack of prejudice. They accepted facts. They were spontaneous. They achieved this self-actualization. He hypothesized that this pyramid underneath here is physiologic, safety, love, and belonging are all these needs that humans have. In order for them to be self-actualized.

[00:22:50] If these needs were not met, people would experience deficiency and pain. ;He hypothesized that it comes on this pyramid, that before you can experience safety, you need to have your breathing, food, water, sex sleep, homeostasis, excretion, all that, before you can move to the next level.

[00:23:09] There has been some debate as to how these levels feed on each other, but people agree that generally these are the needs of human beings. Thinking about pain as being an absence of safety, that you feel that the body's unsafe in the situation that it is in at this point. Thinking about chronic pain, is that if we are able to target the idea of breathing and you know what I was thinking about this, okay, what does that mean to breathe?

[00:23:31] I think a lot of us hold our breath when we're stressed out. So focusing on breathing is actually a little trickier than we think it is. Food. Lots of food insecurity, and also making sure that we're eating and nourishing our bodies. Water. Sleeping. These are all really important before we can ascend to safety.

[00:23:48] Sharna was talking about how the importance of family and friendship was also really important too, in order to achieve safety, but the end goal of being that we need to meet these needs. So when I talk to my residents or talk to colleagues about all right, this is really hard. How do we help people feel better?

[00:24:06] Definitely beliefs and anticipation is important, but in order to achieve safety, we can even start to address the simple basics. Are you breathing? Are you taking time to make sure that you're working on your deep diaphragmatic breathing? Because a lot of times when we're stressed out, we forget to breathe.

[00:24:23] What are you eating? How stressed out do you feel when you eat? Do you feel guilty every time you have food? So do you avoid food because you feel there's a lot of guilt around that? Are you using food as nourishment? Are you drinking enough water? You're drinking more water than other beverages?

[00:24:35] Are you sleeping okay? Are you going to the bathroom? I tell my residents. I said, make sure you're asking all your patients, if they're sleeping and pooping. Cause once they're doing that, they're good. So thinking about how this all feeds into this is the fundamental building block of safety.

[00:24:49] So why does this matter? So kind of wanted to just do this experiment with you guys. And I wanted you to think about if you believe that pain is equal to tissue injury, what is your goal of the pain experience? And you guys are welcome to, to chat and put this all in. So if you believe that pain is equals tissue injury, what's the goal in the pain experience?

[00:25:11] You guys feel free to use the chat. What do you think the goal is?

[00:25:14] Cyndee: I think with tissue injury, my goal is to make it not hurt.

[00:25:20] Yeah, right on. Yeah. Definitely get away from it. Make it not hurt because this is in the world. If you think of pain as protection, how does that change that goal in your pain experience?

[00:25:30] Cyndee: When I really hurt. I'm not thinking about protection. I'm just thinking about make it stop. How can I make it stop?

[00:25:39] Definitely. Absolutely. So thinking about how can I make it stop? Definitely it is really important. And it's even worse if we think of pain as tissue injury, that this is a danger, this is means that my body is broken. The whole goal is to make it go away.

[00:25:59] Thinking about it, maybe differently as protection is, why do I need protection at this point? Trying to explore what else may be going on?

[00:26:05] Or why do I need protection? It could be that that something's going on, but let me explore it from many different angles. Like why do I need protection at this point? Thinking about a reaction of worsening pain is, could be fear, anger, and distress. And curiosity, if it's protection and willingness to move, I don't want to move. I need to stay put

[00:26:22] There are experiments with mice. When you do when you put them in fearful situations that they just freeze. It seems like if it's a protection, it's okay to move because I, my protection system is up, but I'm not broken. Thoughts about the future, that my body's able to heal itself that, but if I'm broken, I'm stuck. And pain equals protection is maybe I can be hopeful about moving forward.

[00:26:43] So there is hope. The brain, while we talked about how easy it is for those once you've really done something over and over again, how the brain can keep on regenerating that same signal. As easy, as much as those signals are burned in, the brain is amazingly plastic, meaning that it can change shapes. Those you can change the way in which your brain is wired by paying attention to this sensation what's happening and changing the song. So what you do, you've got a song stuck in your head. Can you change the note to another? Can you change that note to a different note and constantly practicing that, which takes a lot of time. I don't know if you all had songs stuck in your head, but it takes a long time to get them out, but eventually you can.

[00:27:30] So basically trying to leave you all with these are the big things that I've learned that have really changed my life. And I just basically wanted to share with you how, why I think that why I believe all pain is pain, all pain is real, and definitely, all pain can change.

Final Transcript 091622

PSLS 1013 Candace 05122

[00:00:10] I'm an occupational therapist from Eugene. I graduated from USC in 1978 with a master's degree.

[00:00:18] Just in case you are not familiar with occupational therapy, the basic concept is that there are four occupations to our daily lives: work, play, rest, and sleep. Work includes unpaid activities that have monetary value. For example, cooking a meal is work. Play is what we do for fun. Sleep is sleep. Rest is activities that promote a sense of peace and calm. Occupational therapy patient goals relate to these four occupations. Most of my career focused on two occupations work and rest.

[00:01:00] Around 1983, Sacred Heart Medical Center was selected by the State of Oregon to serve as a regional rehabilitation program for people who had been injured on the job. It was known as the Injured Workers Program IWP for short. It was an all-day four-week outpatient multidisciplinary program. We had a psychologist, rehab medicine doctors, vocational counselors, and three types of therapists, occupational, physical, and recreational. IWP's overall goal was for our patients to have the self-management skills, strength, and endurance to return to their regular jobs. Truck driving and millwork were the most common jobs.

[00:01:49] I was ready to try something new, and I took the opportunity to work in the injured workers program. As an occupational therapist, my primary role was to collaborate with my patient to identify their really challenging job tasks. Then we would think of a way to simulate these job tasks. We'd start at an easy level and gradually increase their physical capacities. I think I visited just about every type of mill there is in Oregon so that I could more accurately simulate my patient's job tasks.

An older understanding of pain: gate theory

[00:02:27] Occupational therapists, in IWP also provided biofeedback relaxation training. Our approach to treating chronic pain was based on Melzack and Wall’s 1965 gate control theory. These two scientists connected the physiological and psychological experience of pain. They proposed that pain signals travel from the affected body part via the peripheral nerves up to the central nervous system, the brain. Melzack and Wall visualized a gate in the spinal cord. The gate could be opened and it could be closed.

[00:03:06] The gate would open to increase pain when the person overdid it physically, when they were anxious or angry or stressed out, depressed, focused on their pain or any combination of these experiences. The gate would close and decrease pain, when the person relaxed, when they had healthy habits, when they used modalities like heat and massage, when they focused on positive attitudes.

[00:03:35] IWP staff expected our patients to close the gate between their brain and spinal cord and reduce their pain by the combination of relaxation training, gradually increasing activity and exercise levels, psychological treatment, and focusing on the hope of return work. When Oxycontin was being promoted for people with chronic pain, our doctors did occasionally prescribe it for patients.

[00:04:06] The Injured Workers Program was eliminated in 2001. Luckily Sacred Hearts, director of employee health and safety had dreamed up and gotten approval for an occupational therapy position. It turned into a really fun job. In effect. I became an in-house consultant for the application of ergonomic principles to manual materials handling jobs, patient care jobs, and office jobs.

[00:04:34] I did job analyses and I assisted with return to work of injured staff. Keep in mind that I was a representative of their employer. I did not have access to medical records. I did not do formal patient evaluations. And my injured coworker was my primary source of information. What I noticed over and over again was the pain and fear were often the barriers to the injured hospital workers return to regular work.

[00:05:05] At some point in the late 2000 Teens, I stumbled onto the YouTube video Understanding Pain in Less Than Five Minutes and What To Do About it. The video seemed really hopeful. I began to watch the video with injured staff and discuss it. This was especially with people who seemed to be really limited by their pain.

[00:05:26] The video's presentation of multiple factors contributing to pain was already familiar to me. And I could easily discuss that with injured workers. But I realize now that the frame of reference behind the understanding pain video was not the old familiar gate control theory. The video's frame of reference was actually new and different.

[00:05:52] I still thought acute pain was very different from chronic pain. I didn't really grasp the news. The pain scientists had found that pain is constructed in the brain and not in the injured body part. When I think over my patient care experiences, it's clear that both my IWP patients and my injured coworkers were afraid of overdoing it. They worried about increasing their pain level. They worried about causing bodily harm.

[00:06:27] Although I hadn't yet learned to see pain as a protector. One focus of my occupational therapy practice was increasing injured workers' sense of safety and security during my injured worker program. The security and safety came from simulating key job tasks in the clinic, and gradually increasing their level of physical demand to match the workers' real life jobs.

[00:06:56] During my employee health and safety days, the doctor's return to work release served as a guide to safety and security. The work release usually specified the amount of weight and force the injured worker could lift, carry, push, or pull. It might also set specific restrictions for walking, reaching, standing, and sitting.

[00:07:21] I had weighed most pieces of equipment on the nursing units, and I measured the push pull force needed to move rolling equipment around the hospital. So I could confidently tell injured staff, which job tasks were safely within their doctor's light duty work release. For example, if a certified nursing assistant was released to 10 pounds, intermittent reach above shoulder height and no bending or twisting, I could assure that CNA that they were safe doing the following job tasks: greet and direct visitors, stock small supplies, collect meal, trays and small patient care machines, assist patients with grooming and feeding, answer call lights and prepare rooms for newly admitted patients, including moving the overbed table.

[00:08:15] Another thing I did to build up an injured worker's sense of safety and security as they performed their physically active jobs was teaching them what I call positions of strength. These are movement patterns based on biomechanical and ergonomic research. I would meet Sacred Heart injured workers at their job site, and we would practice these movement patterns.

A newer understanding of pain

[00:08:39] It's ironic that I started to learn about the newer understanding of pain. Right when my job was being eliminated. It started in March, 2019 at GOSH, the Governor's Occupational Safety and Health conference. There, I had the opportunity to hear a presentation by an OSHU psychologist, Catriona Buist? I hope I pronounced your name, right?

[00:09:04] It was called Changing the Conversation about Pain by Addressing Five Domains of Best Practice Pain Care. Then in October, 2019, at the annual conference of the Occupational Therapy Association of Oregon, I experienced a double whammy. I heard a talk by Kevin Cuccaro about the new understanding of pain and I was introduced to Sharna Prasad, the first physical therapist I ever met at an occupational therapy conference. She told me about the January 2020 second Oregon Pain Summit, and I signed up right away. Since then I have taken classes from Dr. Cuccaro and read books by Lorimar Moseley.

My pain experience

[00:09:49] Preparing for this presentation led me to remember my own worst experience with pain. It was a right frozen shoulder. My car had a stick shift. So I had to take the bus to work. I was really angry about the hassle, the pain, and the inconvenience. My physical therapist treated me with modalities and range of motion exercises. I did not do all of my theraband and range of motion, home exercises, but my pain went away and I was glad to drive my car again.

[00:10:25] Why didn't this experience all drag out? Was it because I trusted that my PT and my doctor knew what they were doing? Was it because they were sure of how long it would take me to get better, and I believed them? Was it because my PT had a very soothing manner? With my new understanding of how pain works, I'd say that it was everything put together, cognition, emotion, and sensation.

Positions of strength increase a sense of safety

[00:10:55] Now what's next for my occupational therapy career in pain science. I hope to teach positions of strength in community settings, possibly Parks and Recreation departments, senior housing, community groups, and even one to one as the opportunity arises. Positions-of-strength, aren't directly related to pain science, but concepts such as safety, protection and brain body connections can be woven into the benefits of moving through positions and strength.

[00:11:30] I'd like to show, share the positions of strength with you now in a slide show. So you wish me luck setting it up.

[00:11:39] Okay. Although positions of strength are natural movement patterns, many people don't consistently take advantage of them. And they're especially helpful if you deal with fatigue or pain on a day to day basis. And, you are likely to feel a difference when you apply the positions of strength to your activities of daily living. They are based on both biomechanical research and ergonomic research.

[00:12:16] Here's a fun experiment. Which one of these methods of picking up the cup feels more secure, more comfortable, and more safe because it's your brain's job to protect you.

[00:12:42] Once the cup was close to me, I had it in the zone. The zone is a position of strength that involves your whole body. And it's the building block for every other position of strength. Here's the zone. As you can see, uh, the zone will move with you everywhere and it doesn't matter what position you're in and you are strongest in the zone, not just your whole body, but your hands, your arms, and you get less fatigue. And the zone moves with you as you change your body position. It's quite dynamic.

[00:13:29] Forward hand and foot is a way to help you to reach directly outward without going outside the zone. If you watch, it's the left hand and the left foot working together. You can also, do this. And so if you want to, you can stand up and try it out. With your right side: forward hand and foot on the right side. With the left side: forward, hand, and foot. Or with both arms together and just stepping forward. The pattern might feel awkward and unfamiliar, but it gets to be really smooth and flowing.

[00:14:11] Oftentimes though things are not located directly in front of us. And so lead with your toe is the position of strength to use when you have to reach off to the side. So each time you can see that my toe points in the direction I'm going, that I need to work. And because my body follows, it's a way to modify your forward, hand and foot position of strength and still reach objects located in the zone.

[00:14:56] Lean on is a useful position of strength when you have to pick up objects that are down low. It might remind you of forward hand and foot because it's a similar movement pattern. For objects that maybe are all the way down to the floor, you can adapt lean on by leaning on the top counter or a table or something. And then your arm and leg away from the surface are what you use. Your leg might come up to counterbalance, and your arm of course, is picking up the object. And then as you stand up, you let the raised leg fall as you come back to standing position.

[00:15:47] Pushing and pulling. Oftentimes people will, jerk, reach out and jerk to start an object moving. And, instead, by working in the zone and using the position of strength called use your weight, you'll have more strength and you'll definitely feel more secure. Let me show you that again. What you need to notice is that it starts with step forward and a weight shift of the body for the oomph of the push or pull.

[00:16:30] We use our hands constantly. And again, bio mechanical and ergonomic research shows that it's important for them, that we work in the zone as well. So there are two, hand and arm related positions of strength: baseball bat grip, and pinch power.

[00:16:56] Baseball bat grip means that your fist isn't too tight. It's not too stretched out. You can imagine that there's a line that goes down your middle finger through the middle of your wrist and down between the two bones of your forearm. And your wrist is not cocked in any direction. And so when you're holding things, you feel really safe and secure.

[00:17:21] Sometimes things can't be gripped with with your closed hand. And so you have to do it with an open hand and just kind of compare how safe and secure you'd feel in these different movement patterns here. Using your whole hand in that baseball, that grip position should feel like you aren't gonna, spill anything in that bowl or, or anything like that, that you feel secure.

[00:17:56] Ergonomists have researched the optimal size for handles of power tools. And it's one inch to three inches across. So this is a tennis racket handle, and it's probably appropriate for somebody with a small to medium hand to feel like they really have a good grip for some strong hits in their game.

[00:18:26] Smaller hand movements are pinch power, and these muscles and joints are small. So you wanna really take advantage of whatever you can, especially with repetitive hand activities. So your activity and your pinch need to match each other. Pincer is the most fine; it's using needles and that kind of thing. Palmer is writing using pens. Key is obviously using a key. Pinch power also completely relates to baseball bat grip and the zone. And we'll, look at that in a minute. Key pinch, as I said, is the strongest way to hold things.

[00:19:16] And ergonomists recommend 12 millimeters across for precision tools like pens. So there's your 12 millimeters and it's interesting. This pen that's bigger than, a lot of pens is big enough to give you a sense of secure grip and comfortable grip as you're writing for long periods. But it's actually not quite 12 millimeters.

[00:19:47] Um, problems with fatigue, with arthritis, with weakness are really common. So I just put in this extra slide here showing that another option is adaptive equipment for challenges in activities of daily living. So the first two are key holders. This one here, you can see that perfect baseball bat grip position for this specialized knife. Pen, and pencil holders, and then jar openers. And, uh, again, these help with using more of a baseball bat type grip, so your strength is maximized as well.

[00:20:38] So, if you keep in mind that your brain is acting as a protector and helping you to identify the safest ways to perform your activities of daily living, you will be safe and smart. So just to repeat, all of the positions of strength, the zone, forward hand and foot, lead with your toe, lean on, use your weight, baseball back grip, pinch power, safe and smart.

[00:21:06] Hopefully you'll be able to use these tips to figure out the least strenuous and most safe and comfortable way to do your tasks in your activities of daily living. So your brain and your body will be in tune as you are safe and smart.

1002  Final Transcript Mo 111021 092722

[00:00:10] My name is, Maureen Forrest, better known as Mo. I'm 78 years old. And I've been in pain since I was 14 years old. I have Crohn's disease.

Childhood trauma

[00:00:24] I'm gonna talk about my father tonight. I know before I've talked about the pain from my mother, her pain, but my father was an abusive alcoholic. I watched him beat my mother. I remember him chasing her down the street with a butcher knife, trying to kill her.

[00:00:46] He would whip my three brothers and me. I remember him holding me up by one arm and whipping me with his belt. And it wasn't spankings. It was whippings. I was so scared of him, I used to tell mom that my bones shake.

[00:01:05] And, I hated the nighttime. I just hated it. When it started to get dark. I was so scared of the night. I never wanted to be out in it.

[00:01:16] It got to the point that if my dad didn't come home for dinner, we would take three different buses and go to my grandmother's house. And one of the bus stops that we had to wait at was by a tavern. And I just hated taverns. I remember sitting in the car, waiting for him to come out. And, I saw my neighbor, our neighbor, go in the tavern. And it wasn't, but a few days later she was visiting my mother, and it was lunchtime, and she was helping to make lunch and gave me a sandwich, and I refused to eat it.

[00:01:56] And it was, "Why won't you eat? Why won't you eat?" Well, I wouldn't say why wouldn't I eat. But I wouldn't eat because I saw her in a tavern, and taverns were evil, and they were bad, and they hurt you. And she touched it. I couldn't eat anything that somebody like that touched.

[00:02:14] My uncle was a Catholic priest, my mother's brother. And he asked her, "Why don't you leave?" And, she said, "Because it's a sin to get a divorce." And my uncle said, "God does not want you to live this way." And he said, "And I will help you." She became his housekeeper. So I lived in a rectory for a few years. And, life was better. It was a lot better.

[00:02:46] I was seven years old when we moved. So everything that happened before, I was pretty young. But I still felt that danger, that night could hurt you. Night was a bad time. And, um, At one time, then my dad found us, and he came. And my mom always would move way back when he was around. And I heard my mom say, if you quit drinking for a year, we can get back together.

[00:03:23] And, I would have nightmares. I'd have a nightmare that he would find us, and that he would kill us all. I remember before we left him being passed out on the kitchen floor, my mom says, “I have to give him his insulin shot, or he'll die.” And I went around into the other room, and I prayed to God that she wouldn't give him his shot. I feel kind of guilty about that now, but I know I shouldn't.

[00:03:57] But my pain and my suffering was for my fears of the nighttime. And I know that, um, chronic pain is often there's been a trauma. And my childhood trauma, that was what did it for me.

[00:04:17] I was 12 years old when he died. My mom got a phone call and she, she yelled and then cried. And my first thought was, "Daddy's coming. Daddy's gonna come and get us. Oh no." And I was scared to death. And my oldest brother said, "No, Daddy is dead." And once he died, then my dreams did stop. I quit having those dreams of him.

[00:04:48] The doctor-- and this in my twenties, and because of my constant pain... I can remember being on the living room floor and in so much pain that, I couldn't move. And my husband had to pick me up and take me to the bedroom. It hurt so much at night. And I got thinking, well, maybe it was because of dinner. I shouldn't eat dinner at night. I didn't know what it was, but my doctor sent me to a psychiatrist. and after having talking to for a while, she said to me, I think that your pain, or I think your problem with the night is, because that's when your dad would come home. And I thought, “Bingo, that's it.”

[00:05:38] But I had no instructions. I had nothing telling me how to handle it or what to do with it. So my thought of pain was you just live with it. It's something that happens. This is your fate in life. You just live with it. And there was no way out of it or nothing that you could do to get around it. Then my son had taken some, ACT classes from Lianne Dyche. And she suggested that I take them, and they really help; they help the nerves and the calming. But Lianne suggested that I go to the Lebanon Hospital with the Physical Therapy Department take the MMAPS classes: movement, mindfulness, and pain science. Well, the pain science really, really got me because I'm, um, always been interested in that type of thing.

[00:06:36] So I went. The doctor approved me to go, and I went. And then my life changed. I can't tell you how much it changed after that. I learned that chronic pain is when there's no tissue damage. I never knew that. I thought it just meant it was bad pain. So if there's no tissue damage, then, how in the heck am I to expect a doctor to fix me? You know, there's nothing that he could do for my body physically.

[00:07:10] And so I had to work on it. And I learned that I have a powerful brain and we all do. You do, too.

[00:07:23] The brain controls the pain. And, I put it not as very professional, but I start understanding what I was doing. I knew that I had so much anxiety and stress, and negative thoughts, and my emotions, and my fears. I was so afraid of the night, and I hated it if I had to be out in it. It just scared me to death. I just sure there was danger in the night. And, I learned that chronic pain comes from a trauma that you've had and, especially childhood trauma. And so that, that made sense to me. But, the important thing I learned was that I could reprogram my brain. Yeah. I call it reprogramming my brain. But you know, how did I do this?

Reprogramming my brain

[00:08:30] Well, one thing that I learned and I practiced a lot on was the, the mindfulness and, perception. I learned that if I perceive pain, I'm gonna have it, guaranteed. There are no doubts. If you think something's gonna hurt, by gum, it's gonna hurt. So I learned, with all the different tests and stuff I had, to perceive it. Just being fine. Nothing hurts.

[00:08:59] When a couple of times they put, needles into my spine and, I would visualize it beforehand, and visualization is very helpful for me too. And I would visualize the needle being just covered with Vaseline, and it just slides right on in, and there's no pain. Everything's just great. And the doctors are always amazed about how I handle it.

[00:09:24] With the night fear and my increased pain during the night, what I did was deep breathing for one thing. Dr. Cuccaro says that's the most healthy thing that we could do. And I would breathe. I'd close my eyes, and it's very relaxing. And I would breathe through my nose, belly breathe into my stomach, would expand. And then I would come back out and through my mouth and I could feel the breath coming in and out. And while I'm doing this, I was visualizing that I was very peaceful. And that I was very strong, and that I was a good person. And that the nighttime was a very peaceful time. It was a quiet time, and there was nothing out there in the dark that wasn't there during the day, the same trees, the same houses, the same roads. Everything is good, except for that, it was more peaceful at night. And I would do this maybe 10 minutes, a couple times a day, at least.

[00:10:30] And it takes a little while. But what happened was my thought in my brain, I had a strong thought that said, “Nighttime is danger. You're gonna be hurt.” And we know that pain is a protector. So it sends out the message, "Hurt. You're in danger, you better do something." And so my something it was pain and was to stay home, to stay out of it.

[00:11:01] And so by doing the mindfulness and the meditation, I was able to make the thing in my brain, like the attachment, I don't know what to call it. That was making me think that it was danger and was able to weaken that and not have that be my main thought. And I was able to make peacefulness my main thought. And it's nice outside. The darkness is a peaceful time. And I was able to change that thought. I have absolutely no fear of the night anymore. I don't cramp up at night. I don't hurt worse at night. My Crohn's... I can be off the toilet at night. Because my Crohn's is better at night.

[00:11:50] It takes a long time to do it, but it's sure worth the trouble.

[00:11:54] There's many things that can help you. What helps me may not help someone else because we're all different. But, I suggest that you work on some things, the perceiving of pain.

[00:12:12] Mind on something else

[00:12:14] I was in the Walmart store, and I was having a hard time, and my son was in the car. And I thought, "Boy, I can't do this. I'm hurting too much." And I thought, "Maureen, you know, better." And so I start noticing all the colors. So I was saying all the colors to myself, red pink, green, everything that I noticed. And I was able, because I wasn't thinking of my pain, I was able to finish my shopping and check out. You know, we've all had a bruise. We don't know where it came from because our mind was on something else.

Better life

[00:12:53] I am happy now. I feel more peaceful than I ever did before. I feel that I've, overcome my childhood and the past.

[00:13:04] At one time I was on 18 different medications, including opioids. I now have six medications. I take a lot of, but three of them are vitamin minerals, and I take turmeric and other things, plus the medications. I've had 16 surgeries. And I really feel that if I had known this, I wouldn't have had so many surgeries, especially the back surgery.

[00:13:34] But probably one of the most important things that I did is I forgave my dad. And how did I do this?

[00:13:46] Well, you know, I looked at my family. I have three brothers. Two of them are alcoholic. It was headed for three, but one decided to quit drinking. My two sons, one was alcoholic, and my brother's three children, two were alcoholic. My brother was alcoholic. My other brother had a child that was alcoholic.

[00:14:08] My family has dyslexia, bad cases, some of us and, attention deficit. And sometimes it's hard getting along in this world with that. We're smart people, but, people don't realize it. like one of my problems is the speech and pronouncing words correctly. But I got looking and I got thinking, you know, their drinking is not because their father was an alcoholic. They're drinking to self-medicate. It's the dyslexia and attention deficit and, uh, trying to get things going for themselves in this world.

[00:14:58] And, In those days, there wasn't help for that. I had one brother that after his freshman year of high school, they decided he wasn't educatable. I mean, how sad really? And there wasn't much help in my dad's age for somebody, especially for the nerve part, the part that he used to drink for, to calm himself down. My mother always said, "Love your dad. He's sick." But I never could understand how she could say that. That just seemed crazy to me that she could say something like that.

[00:15:34] But she was right. He was sick, and he was self-medicating. And so I have his picture out. I wish that I had been able to know the him part first, the part that my mother fell in love with. But, those are more the things that I think about.

[00:15:57] I'm not scared anymore. My life has really changed. My pain is so much better.

Resources

[00:16:03] I have been going through a thing with my back pain lately, but, I read a book, and it went right out of my mind. Oh, Rolly, you know the name of the book we all talked about.

[00:16:14] Rolly: Yeah, that was The Way Out.

[00:16:16] Mo: Yeah. The Way Out. And that got me going in the right direction again. And I learned some new things. And I really encourage you to study. We have a resource list. I encourage people to go on Facebook and, search, pain science. Dr. Mosley. He's great. He has some wonderful things. And there is help for you out there. Don't think there's not . It's wonderful. And, and think about a time when your pain started, and were you having trauma at that time? And if you were, you know, there's so many things that you can do. And, I just gave you a few of the things that helped me.

PSLS Sharla 1012 051222

[00:00:00] Hi, I'm really happy to be here with y'all today. I'm not a medical practitioner. I'm going to share my pain science journey. And, I'm an educator. So I'm going to talk about things that connect between what I learned, what I do in education and what I learned from Alan Gordon's book, The Way Out.

[00:00:26]  Okay. Here we go. So today my talk is going to share some of my pain journey with, back pain and neck pain interwoven with what I've learned from Gordon's book, The Way Out. It's a recently published book and of all the pain science books that I've read, because, um, I have a father who keeps lending me pain science books, this is the one that resonated with, with me the most strong and, and I think had the biggest impact of my pain science journey. So I've chosen to talk about it tonight. In my talk, neuroplasticity is going to be a key concept. I'm going to talk about it from an education point of view and from a pain self-care point of view.

[00:01:10] Um, I'm going to talk very briefly about two published scientific studies. I haven't read them, but they're referred to in the book, The Way Out, by Alan Gordon. And he has 30 pages of notes so, let me just first start by talking about myself. I'm an educator, I'm a freelance writer. I'm a wife, mother, sister, daughter.

[00:01:37] I raised four kids between Corvallis and Bangalore India, and all my life in all the experiences I've had, I've been learning. I love learning, and along the way, I believe that my brain also learned. My brain learned pain: neck pain, back pain. And, it's been part of my life for a long time. As far as I can remember, I think it started when I moved overseas. So, uh, that's part of my journey.

[00:02:14] Neuroplasticity is really important to me as an educator, I teach college success skills, and it's very important for students to understand that just because they don't know something that the student next to them knows doesn't mean they can't learn. It doesn't mean they're stupid. It just means they haven't had a chance to build those networks in their brain yet. Our brains grow and change, and understanding neuroplasticity helps students be confident to try things they don't already know how to do. I teach my students the brain is like a muscle. Neural pathways that are used--just like muscles--become stronger.

[00:02:54] And, for learners ,the bad side of that is that neural pathways that are not used become weaker. So in education, we call that the forgetting curve and we teach students why they need to review material, practice skills again and again and again, so that they keep those neural pathways strong. This is probably why, like, if you haven't used algebra since school, you probably would have trouble constructing an algebra equation today because neural pathways that aren't used become weaker with time.

[00:03:31] So when my dad lent me this book about neuroplastic pain, I was really excited to discover that he was talking about neuroplasticity. It's a new book published in 2021. And, his basic premise is that persistent pain is pain that has gotten stuck. Because your brain has learned it too well. Um, the full title, look at that title, The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain. Doesn't that just kind of sound a little bit over the top? I think, “Whoa, really? That's a tall order!” Well, this book is very convincing to me. It's chock full of anecdotes, stories, case studies, and references to scientific studies. And like I said before, there's 30 pages of notes in the back of this book. But it's an extremely readable, extremely practical book for somebody who's not medically trained to learn about how to approach pain, how to retrain the brain in chronic pain.

[00:04:51] I read this book in a time of stress, and it just seemed to me that the anxiety that I was feeling might also respond to the pain retraining that I could maybe pick up some of the things that were in the book and reduce my anxiety and be more comfortable.

[00:05:11] I wasn't even really thinking about my back pain. Although at that time, my back pain was higher than it had been before I got into that situation of anxiety. So I found some of the strategies in this book and I applied them just thinking about my anxiety and lo and behold, not only did it lower my anxiety, but it also lowered my back pain.

[00:05:35] That was a nice benefit. Okay. So one of the things that's really, um, central through this book is the Boulder Back Pain Study. This is a screenshot I grabbed off the University of Colorado Boulder website. Alan Gordon helped design and run the Boulder Back Pain Study, which I'm not really clear on when it happened, but it was published in 2021, September, 2021.

[00:06:04] So, 151 participants who all had chronic back pain that they, they rated at four or above for at least six months, you know, four on that pain of scale of zero to 10. So 151 participants of which 50 received this pain reprocessing therapy that Gordon talks about in his book. I will put the link to this study in the chat after I'm done talking, because I can't do two things at one time.

[00:06:40]  So when I read about this in the book, I read about that they did pain reprocessing therapy. They did functional MRI scans before and after the treatment. And throughout the treatment they were surveying the patients as far as their level of pain. And look at these results: 98% of the participants improved and 66% of the participants were pain-free or nearly pain free at the end of the study, which some of the designers of the study didn't believe was possible.

[00:07:13] So I was like, “Wow! those are kind of cool results.” This kind of stuff really got me interested.

[00:07:24] So Gordon also cites another study. This study was published in the journal Brain, and I gotta read this title to you because it just cracks me up. I love language, so I can't help myself, Shape Shifting Pain: Chronification of Back Pain Shifts Pain Representation from Nociceptive to Emotional Circuits. How's that for a title? Shape, Shifting Pain. I love that. So, in this study--which Gordon calls the most important recent study on pain--they studied people who had recently injured their backs over about a year, and they did brain imaging, and they measured their levels of pain. And what they discovered was for those people whose pain didn't get better, it actually shifted to another part of the brain from where it was originally when it was a pain experience because they had an injury. When it became chronic, after the injury healed, they continued to experience pain. It actually shifted. Their brain was working in a different place that just blew me away.

[00:08:34] So Gordon says that neuroplastic pain is caused by the brain misinterpreting safe signals from the body as if they were dangerous. You know, he uses lots of examples. And one of them is like, if you, if you're out hiking and you sprain your ankle, you have pain. This is good. This is protective. You do not want to keep walking and worsen your injury. The brain is doing what it's supposed to do, telling us, “Stop! Don't! Hurt! Now! Danger!” The trouble is sometimes the brain misinterprets sensations that we have in our body. Sometimes the brain becomes hyper alert to danger and, Gordon says that's neuroplastic pain, a mistake of the brain.

[00:09:21] Not that it's not real pain. It's real! The experience is certainly real, but the cause of it is different from when you sprained your ankle six months ago. Yeah.

[00:09:34] So for me, when I moved abroad, I got this back pain. And I think I might have strained my back, packing and moving things. Yeah. I might have done that. Um, but this pain came and it went and it came and it went, uh, and I'll tell you that when I moved abroad in that one month, I moved across the world with three preschoolers and my husband. My grandmother passed away. I lost a baby all in a space of one month. And then I got back pain. Oh, Hmm. And I thought it was from moving boxes and you know, all that stuff.

[00:10:24] I, through the years that I lived in, uh, in India, I continued on back pain off and on neck pain, off and on. Uh, I associated it with things like sitting in the wrong chair, standing for too long, going, for a drive on a bumpy road, using my laptop with bad posture or even playing candy crush for too long.

[00:10:52] But definitely my brain learned pain over that time. There wasn't any specific injury that caused those kinds of pains for me, but they were serious enough that. By the end of my time in India, I was wearing a neck brace when I went in the car for any distance, because I was trying to prevent the neck pain.

[00:11:15] I'll just say that too. When my daughter took up violin, I wanted to also take up the violin again. And I found that I was not able to do that without having a lot of neck pain. So I just couldn't. So I believed that my pain was caused by bad posture. I blamed chairs, beds, pillows, bumpy roads, and it's really hard to believe that pain that we have isn't caused by something that's wrong in the body. We're so attached to that idea.

[00:11:51] So Gordon and his co-author, Ziv, in their book The Way Out, they recommend that we just start to look for evidence in our own experience, that the pain that we're feeling, the chronic pain that we're feeling, the persistent pain (after we've seen a doctor and we don't have a specific diagnosis for it) probably, look for evidence that our pain experience may be neuroplastic.

[00:12:20] So I started looking for evidence. Is this neuroplastic pain? I'm going to go through some of the characteristics that Gordon lists for neuroplastic pain in his book: originated at a time of stress. Well, mine did. Common personality traits. Yep. Check all those boxes. How about delayed pain? For me, most of my pain was delayed. It wouldn't be that it hurt when I was doing the thing; I would hurt later. I'd wake up in the morning and my back would hurt. I'd wake up in the morning and my neck would hurt. And I'd say, “I sat wrong. I slept wrong. I shouldn't have tried to play the violin.” Symptoms triggered by stress. I noticed that when I went on vacation, my pain almost went away. And when I came back and sat down and started working again, my pain came back.

[00:13:18] Um, it increased in times of high anxiety and it moved around. Does your pain do that? There's some more things triggers that have nothing to do with your body, large number of symptoms for a lot of people childhood adversity is an aspect of it. I related to this one lack of physical diagnosis.

[00:13:42] I went to a physical therapist when I came back to the States and my physical therapist assured me that there was no injury, but still I had pain. So, this book, Gordon's book, The Way Out, is very deep and rich. And I'm unable to do justice to all of the content of this book, but I'm going to focus on the part that I found the most practical, which is the nine techniques that Gordon recommends for helping your brain feel safe. And I'm going to go through them all.

[00:14:21] I'm going to go through them all a few at a time. So making evidence sheets, looking for evidence that the pain may be neuroplastic and writing it down. I sat on the futon and the next day, my back hurt. So for a long time, I didn't sit on the futon. And then after I started reading Gordon's book, I sat on the futon again, and I felt no pain afterward.

[00:14:45] I wrote, that's a piece of evidence. He recommends to practice somatic tracking, not when your pain is severe, but when it's mild to moderate. Somatic tracking sounds a lot like mindfulness to me, paying attention on purpose in the present moment, nonjudgmentally. Just noticing the pain, not pushing against it, not, but just observing it in a neutral way.

[00:15:17] And sending a message of safety to your brain and he, and some people like to make jokes. Some people give their pain a silly name, or compare it to a silly animal. Lightness and jokes helps the brain feel safe and not danger. Avoidance behaviors are really useful when your pain level is high. It's fine to be comfortable. Sit in the good chair, get up and walk, take a hot shower, whatever it is that helps you feel safe and comforts you. Sending messages of safety. I think this is like super, super important. Sending yourself messages of safety. When I feel a twinge along my spine, I send myself messages of safety instead of going into like, “How long is this pain going to last? How bad is it going to get? Is it gonna impact what I can do tomorrow?” “My body is fine. My brain thinks I'm in danger, but it's just a false alarm.” Send myself some messages of safety. It's quite helpful, quite helpful.

[00:16:33] Oh, this one was a biggie: reducing over stimulation. I didn't realize the role that my cell phone was playing in my life. I really didn't. I thought it was just the kids that are on the cell phone all the time, but I'll tell you, I use my cell phone for work. I have my work email on my cell phone. I've got my Slack on my cell phone. I've got all the social media on my cell phone and you know, I have to market my freelance business. So that's work too. One of the things he talks about is, is how people be like rush, rush, rush, hurry, hurry, hurry. And these habits of urgency that we have, and these things like checking your work messages before you get out of bed in the morning.

[00:17:20] Wait a second. I don't do things like that. Do I? I noticed. I started noticing. I started paying attention, and I started putting my cell phone back in the place where it serves me instead of me serving it. Yeah, there's lots of ways to reduce over stimulation. A big one for me is not looking at the work messages until I'm in my work time. Not doing social media from morning till night. Just let it have its own space in the day. That's enough. Hiding self view in zoom. That one really helps me reduce over stimulation when I'm working from home.

[00:18:06] Another one: avoiding feeling trapped. So feeling trapped can help your brain feel like it's in danger. So planning ahead to not feel trapped can help your brain feel safe. Handling uncertainty, “Either way. I'm gonna be okay.” Catching your fears. This one's been really helpful to me, even when I was preparing this talk, I'd start to get, “What if I...? What if I...”  “Gonna be okay. I'm doing what I need to do, and I'm gonna be okay.”

[00:18:36] And last but not least, embracing positive sensations. Sometimes we focus so much on pain and we forget about feeling good. And the good feeling neural pathways get weaker. We need to strengthen them. So just take time to pay attention to the things that feel good in your life. And that will be strengthening the good feeling pathways instead of strengthening the pain pathways.

[00:19:03] So do you want to retrain your brain? I encourage you to check out this book. For me it's been a real excellent, helpful to understand how pain science works and how my body works. Thank you.

[00:00:10] Well, I'm really happy to speak tonight. I've enjoyed coming to these
meetings and getting to learn a little bit about each of you and your stories. I am
really happy to not only share my story, but also share with you some of the
thoughts I've been having related to pain and specifically my specialty, which
involves a lot of inflammation related to pain.
[00:00:45] So, as a rheumatologist, one of the main things I specialize in are
autoimmune diseases. And these are diseases where the immune system gets
really angry and revved up and starts to attack your own body. And often, it will
attack joints, but it can attack the skin and internal organs and, some of these
manifestations are annoying, and some of them are really debilitating, and often
there's a lot of pain involved.
[00:01:16] One of the things that, I have, as a rheumatologist... So, one of the
ways that we think about pain is that inflammation will activate nerve fibers and
send a signal to the brain that is painful. And my understanding of that has
changed slightly. And, I'm hoping to explain that change here over the next 30
minutes or so.
[00:01:45] So, one of the main things that I was trained on and had continued to
think about for a long time is the biomedical model of pain. And in that model,
there's a painful stimulus somewhere in the body, let's say it's a knee joint, and
that painful stimulus then sends a message up to the brain that tells the brain
that there's pain there, and the brain then acknowledges that, and then you
experience that pain.
[00:02:14] What I'm learning is that through the biopsychosocial model, which
is really quite a striking change in me. This is something that really kind of
shook me in my practice and helped me to really have to rethink how I take care
of patients. Prior to coming to Corvallis, like I moved to Corvallis five years
ago, I was previously living in New Hampshire, and I had been in New
Hampshire for eight years as a rheumatologist. And much of my time was spent
doing research. And most of the research was in the lab, and some of it was
directly with patients. And one of the projects I worked on with my mentor was
looking at osteoarthritis bone samples.
[00:03:06] So, when a patient would have a knee replacement from
osteoarthritis, we'd get a sample of that bone, and then we would freeze the
sample, and we would get proteins from the sample. And the intent was to see if

we could find a protein signature or something in the bone that had a correlation
with pain. And that's where much of the research is in rheumatology, looking at
the joint to identify what the pain, why the person has pain. And I realized that
that's only part of the story. So, when I first heard about the biopsychosocial
model of pain, it was really, given to me as a sampling by Brent Godek and
Lance McQuillan. And I heard them talking to residents, and they first talked
about the Pain Triangle, which you all know has been championed by Dr. Kevin
Cuccaro.
[00:04:07] And when I first heard about the pain triangle, I thought, "Yeah,
okay, that sounds kind of interesting." But it didn't really click. I didn't really
understand it. And then a year ago, I went to the Oregon Pain Summit in
January, and at that summit, my mind was opened. And it started largely with
the story about the construction worker who had a nail that went through his
boot, and he was in exquisite pain, so much pain that when he went to the ER,
they had to give him lots of IV morphine and some anti-anxiety medication to
help decrease the pain. And yet, when they finally got the boot off, the skin
wasn't even broken. The nail had gone between his toes.
[00:05:00] And that story was the key for me. That just triggered a change like,
"Oh, okay, I've been thinking about pain differently. I've always been thinking
about pain, in the context of some sort of inflammatory or damage situation, but
in reality, the pain is only influenced by inflammation and damage but is
interpreted by the brain in the context of that individual's current situation."
That was mind blowing to me and it was also a little bit unstead... I, I felt
unsteady. I was like, "Whoa, what's happening here?" It's almost like a
midcareer crisis almost because I felt like it completely changed my view on
how to approach patients with pain.
[00:05:56] And, I actually started asking myself the question, " Have I been
doing things wrong? Have I been a bad physician?" And, and my answer to that
is no. I've been practicing to the best of my understanding and knowledge, but I
think I have greater understanding and have more tools now to help people. So
much of the tools that I have used in the past are helpful, but I think that there
are even more tools now to really help people out. So, with that in mind, I'd like
to tell you a little bit about inflammation and pain and tell you kind of my
thoughts about this.
[00:06:35] So, first of all, what is inflammation? This is one definition: redness,
swelling, pain and/or a feeling of heat in the area of the body. And a really
important part of this definition is that inflammation is there to protect. So, it's
there to protect that tissue or that area of the body.

[00:07:04] So, most of the time, when we talk about inflammation, we talk
about it in the context of the immune system. So, this is a little picture of several
elements of the immune system. And this is not even exhaustive. There are
other elements of the immune system. But, many of these are cells. Some of
them are proteins, such as antibodies and this protein over on the left called
complement. These are elements of the immune system that start and drive
inflammation. So, depending on what type of inflammation is present, you're
going to have a mixture of some or all of these cells and proteins contributing.
The more robust or expansive that the inflammatory response is, you're
probably going to have more of these cells involved and there are some types of
inflammation that's really going to be limited just a few of the cells.
[00:08:12] But, what I'm going to tell you that's really important is that 98% of
the research around autoimmune disease and around inflammation is really
trying to dissect and understand all of the elements of the immune system, of
these cells and proteins and how they interact with each other; how they
perpetuate each other; and how they activate each other. So, that's what I have
always thought about in the context of inflammation. And, as I mentioned
earlier, I'm starting to modify that a little bit. And I'm going to show you how
I'm modifying that, as I think about inflammation.
[00:09:01] So, here are some key points when we talk about inflammation and
the importance of this. So, most of the time, inflammation occurs in the context
of some sort of infection or as a response to some sort of damaged tissue. So, if
you break a bone, some of the swelling that's accompanied with that includes
inflammation to heal the bone. If you get an infection, such as a pneumonia, you
have a great deal of swelling and cells that go to that area to help fight off the
infection. So this really is the prime reason that we get inflammation much of
the time. Now there are some cases where inflammation, which is meant to be
protective, actually becomes too abundant. And that inflammation is
overexpressed, and that leads to a harmful form of inflammation.
[00:10:12] So, in the example of COVID, when you have a viral infection such
as COVID, your immune system, you want it to act in a way that it will
recognize the virus, kill the virus, and prevent the virus from propagating
throughout your body. And for most people, that's what's happened. But for the
people who end up in the hospital because their lungs are filling up with fluid,
and most of the people who end up dying because of severe COVID, is because
they get a hyperinflammatory response. So, their immune system responds to
the COVID, but it overresponds, and it becomes So, exuberant that you get fluid
and cells all filling up your lungs and other tissues. And you get blood clots that
form, and this ends up leading to death. Of course, this also happens in

autoimmune disease. There's too much inflammation. And so we want to target
that inflammation.
[00:11:17] In the context of pain, the main model of pain in relation to
inflammation is that proteins made by the immune cells are released, and the
nerve endings are stimulated by those proteins. We often call them cytokines.
And, because those nerves are stimulated by those proteins, they send a signal
to the brain, and that is why we have pain. But, what we're learning more and
more is that, yes, the sensory nerves are stimulated by cytokines, but it also goes
the other way. Nerves can release chemicals that stimulate the immune system
and can drive inflammation. So, pain, and inflammation, and the neurofunction
can actually go both ways. So, I think that's really interesting that it's not just the
inflammation stimulating the nerves, leading to pain, but also signals from the
brain through the nerves can stimulate inflammation.
[00:12:26] Okay, so, here is an example. In the left side of this picture, you get a
splinter. And on that splinter, you have dirt, and bacteria, and maybe even a
little fungus. And so, that gets stuck under the skin, and that's not good. We
don't want that in our body, and so, our body wants to protect us. What happens
to protect that tissue? Well, one thing we do is we get pain. And we have pain so
that we can pay attention to that area. "Wow, look, I have a stick stuck in my
skin. I need to get it out," or, "I need to stop what I'm doing so that I don't get
more of these slivers in my skin." So the pain helps us to pay attention to that
area and address it. And it might mean that we pull the sliver out. It might mean
that we go soak our hand under warm water. But whatever, that's why we have
pain.
[00:13:34] But the other response that happens is inflammation. So, from this
graph, you see that the immune cells start to come out of the capillary there, the
blood vessel, and they get into the tissue so that they can fight off any bacteria
that are present. You also get leakiness of the vessels, so that there's increased
swelling. That facilitates the white blood cells getting to where they need to go.
And part of that whole process also leads to warmth and redness. Now, this is
very interesting again because predominantly the model is that you have local
immune cells who recognize that there's now a bacteria there. And in order to
get more immune cells and inflammation to the area, those local immune cells
will release the chemicals that cause the inflammatory response.
[00:14:41] However, what we also know is that the nerves in the area similarly
will release chemicals and cytokines to help increase the inflammation. So here
we have both the nervous system and the immune system working together to
protect this part of our body.

[00:15:00] I'm going to show you a study that illustrates how the nervous
system contributes to inflammation. So, this is taking healthy patients or healthy
individuals. And, what they're going to do is they're going to apply a noxious
chemical to the forearm of the skin. And, the specific chemical is called
capsaicin. And, that stimulates an inflammatory response, of the skin. And then
what we're looking at is a thermographic image. So, this is showing us how
much blood flow which is a surrogate marker of inflammation. So, they took
some of these subjects and just took them in their normal state of mind. And
these are the non-stressed individuals. And then they took individuals, and they
exposed them to what they called psychogenic stress. So, they showed them
multiple images that were disturbing and caused them to feel stress. And then
they applied the capsaicin. And what this picture shows is that the individuals
who were stressed, in other words, their nervous system was in a higher state of
alert. When they had a noxious stimulus to their skin, the inflammation was
higher.
[00:16:27] Why is this relevant? This again shows that the nerves are
contributing to the inflammation. So, this is called neurogenic inflammation.
And, of course, this picture is probably one of their best examples, and not
everyone had quite as robust response. But, when they looked at several
individuals, this same finding that having your mind in a stressed state led to an
increased state of inflammation in response to the stimulus. Okay. So, I'm
hoping that makes sense.
[00:17:00] So, we now have established that inflammation is not only driven by
the immune system but also driven by the nerves and that the purpose of
inflammation is to help protect our tissue. Sometimes that inflammation is
overexpressed. So, let's think about a situation or a disease where that
inflammatory response is overexpressed. One of my favorite illnesses is
rheumatoid arthritis. And, while I was doing research, this is the main disease
that I focused on. And, I continue to do some research in rheumatoid arthritis
here in Corvallis. This is what is often considered a quintessential autoimmune
disease, partly because it's one of the more common forms of autoimmune
arthritis. About 1% of the US population will have rheumatoid arthritis.
[00:18:03] The key difference to rheumatoid arthritis as opposed to
osteoarthritis, which is typically what you think of when the hands have
deformities in someone who's over 50, usually that's from osteoarthritis where
you get wear and tear in the cartilage and some bony overgrowth. But, with
rheumatoid arthritis, the problem in the joints is too much inflammation. So,
you can see from the diagram on the right, the kind of blown-up image that
there is a tissue in there called the synovium. And the synovium in the joint

normally is very thin, but in rheumatoid arthritis, that synovium becomes very
inflamed. So, it's filled with immune cells; it's filled with fluid; and it's got all
kinds of cytokines in there. And this leads to very swollen joints. And the
inflammation also, contributes to the pain. Now again, the inflammation
contributes. It's not the only reason people have pain. There are several other
reasons, but it is a major contributor to the pain.
[00:19:22] Now if we think about rheumatoid arthritis and why people get this
inflammation, there's a lot, this is a really complicated, and I don't want you to
get too overwhelmed by this particular figure. But, what I'm going to show you
or emphasize is that at the top panel, there are several things that are going to
increase somebody's risk. So it might be their microbiome. It might be smoking.
There's also some genetic component. And, this ultimately leads to an altered
immune response. So, one of the ways that we know that someone has
rheumatoid arthritis is by checking an autoantibody called anti-CCP antibody.
And the interesting thing is that people can develop anti-CCP antibodies years
before they ever get arthritis.
[00:20:18] So, lots and lots of effort has been put into understanding how
people develop those anti-CCP antibodies. And we have a pretty good idea
about how that works. But a real challenge is this step right here, this transition
to arthritis. So, we know how people's immune system becomes altered, but we
don't really know what step happens for the immune system to then get into the
joints and cause inflammation in the joints. So, this is a real puzzle. You'll see
that one of the speculative reasons put in this slide is neuroimmune factors, and
I think that's where there's a considerable promise that that's one of the main
reasons how the immune system starts getting into the joints. And, I'll explain
that in just a little bit.
[00:21:13] Okay, so, here's several immune cells. So, let's say that you have a
joint that somehow these immune cells get into the joint in rheumatoid arthritis.
And, what they do is they're communicating with each other. So, one of the
things that they're going to do is they're going to release a chemical called IL-6,
interleukin 6. And this is going to give a signal to the other cells to stay very
active, to keep searching in case there's an infection or something that needs to
take care of, and that is a big driver of inflammation in rheumatoid arthritis.
Another chemical or cytokine that's released is something called TNF. And this
is a major driver. So these chemicals are being released, and the cells are talking
together, and so you get this ongoing cycle of inflammation that just persists.
And the immune cells tend to feed each other and it just goes and goes and
goes. And, if we didn't do anything to intervene, then this would just continue

until the inflammation was so bad that people end up hospitalized or other
things.
[00:22:27] So, fortunately, we do understand this, and so we've been able to
develop really good medicines to try and stop this process. One of the medicines
that I frequently use is called adalimumab, also known as HUMIRA, and this is
an antibody that will block TNF. So, if I have someone with rheumatoid arthritis
who has this very active inflammatory cycle, and I can give them adalimumab,
it can block TNF. And, in the right person, it will stop that inflammatory cycle,
so that the other cytokines go down, and all of these immune cells become
quiet.
[00:23:09] Yes, that's what we want! We want the inflammation to go down. We
want the pain to go away. And, this can really help people to feel quite good.
One of the problems, though, with rheumatoid arthritis is that, if I then take
away their adalimumab, the cycle comes back. Now, if it was just the immune
cells causing that perpetual cycle, then you would expect that by stopping the
cycle and them all being quiescent, that it should stop. But that's not the case.
You stop the drug, and the cycle returns. So, here's a theory that I'm throwing
out there, and other people throwing out, is maybe there's something feeding the
cycle. Maybe the nerves are releasing chemicals into this tissue, and it's feeding
and perpetuating the cycle, So, that if you block the TNF, you can stop the
cycle. But, taking the drug away, it's going to start back up because the nerves
are still there. So, that begs the question, "What can we do to stop the nerves
from perpetuating the cycle?" And, that's still something that we have to really
explore.
[00:24:31] Okay, so I want to show you a little bit of evidence that supports this
theory that the nerves, again, signals from the brain traveling to the nerves, can
initiate or perpetuate inflammation. So, one of the studies I want to show you is
looking at the impact of adverse childhood events on childhood arthritis. So,
adverse childhood events are traumatic episodes that happen to children. They
can be things that have happened to them personally, such as physical abuse or
neglect or sexual abuse, or it can be things they've observed such as abuse to a
parent or something like that.
[00:25:19] So, what this study looked at is they took patients with arthritis who
were kids, so these are teenagers usually who had arthritis, and this is
inflammatory arthritis. And then they took healthy kids and they looked to see
how many adverse childhood events there were, and what the risk of developing
arthritis was. So, what you can see from this table is that, for the kids who had
higher numbers of ACEs, their risk of getting arthritis went up substantially. So,

for instance, in the unadjusted model, if you had more than four adverse
childhood events, then your odds of getting arthritis increased sixteenfold,
which is pretty amazing.
[00:26:10] In the adjusted model, it wasn't quite that high, but it was still quite
high. So, this is not definitive. It doesn't define that ACEs caused this, but it
suggests that there's a relationship between the brain being in a higher state of
threat or danger and that contributes to inflammation in the joints.
[00:26:35] Here's another study. This is looking at adults now in patients with
rheumatoid arthritis and the question was, "Have you had trauma? And if you
have had trauma in the past, do you have symptoms suggestive of active
PTSD?" So, the control were the group of patients who did not have trauma and
did not have PTSD symptoms. And then they wanted to see what was the
increased incidence of rheumatoid arthritis based on the prior history of trauma
and symptoms of PTSD. And, what you can see from the, probably easiest to
look at the, either the second or the third row because they're essentially the
same, is that the more number of PTSD symptoms you have, the higher
incidence of rheumatoid arthritis that you have. So, this study supports that,
again, the brain having a sense of danger or threat leads to increased risk of
rheumatoid arthritis.
[00:27:50] Okay, so, I'm going to show you another really interesting study.
And, this is something that just has always fascinated me and I've never
understood it until I started thinking about inflammation and the nervous system
in a different way. So, this is a case of a patient who developed rheumatoid
arthritis, which by the way, rheumatoid arthritis is almost always symmetric. So,
it's both hands, both feet. And, two years later, he had a stroke on his left side.
So, his left side was basically paralyzed. He no longer had nerve innervation or
stimulation from the brain to that left hand. And, this is taken some time later.
So, you what you can see in Box A is that the left hand looks quite normal, but
the right hand shows severe destructive changes. The fingers are skewed off to
the side. The bones in the hand, there's loss of joint space and there's lots of
erosions. So, this is a very aggressive arthritis.
[00:29:05] And if you look at B, this is looking at heat, which is a surrogate
marker of inflammation. You can see that their right hand has much more
inflammation than the left hand. Why is it that someone with rheumatoid
arthritis who loses innervation to one side, also loses inflammation in that side?
Well, a possible explanation, again, is that the nerves are stimulating and
perpetuating the inflammation or at least helping the immune cells to perpetuate
that inflammation. I've seen this in my own patients. I've had probably two

patients where I have seen this myself. So, this definitely is not, unique to this
case.
[00:29:52] Okay, lastly, I want to show you this really interesting study. So, this
is done out of, I think it was in Denmark or Sweden, one of those European
countries. And, what they were asking was, "Could we lower inflammation and
immune activity in patients with rheumatoid arthritis by stimulating the vagal
nerve?" Now, the vagal nerve mediates the part of our nervous system, part of
the autonomic nervous system, called the parasympathetic nervous system. So,
if you're not familiar with that, you will be aware of the concept of the fight or
flight system. So, that's the sympathetic nervous system. When we have a fight
or flight response, that increases our heart rate, it causes us to sweat, it gets our
muscles tense and ready, and it helps us to be ready for action.
[00:30:51] The opposite of that is the parasympathetic, or rest and digest. And
that is mediated by the vagal nerve. So, these doctors took patients with
rheumatoid arthritis, and most of them had refractory disease. They'd been
through four, five, six different biologic medications and still had active disease.
And they had very active disease. So, these were patients who were not just a
little bit inflamed and painful, they had very, very active disease. And what they
did is they implanted a vagal nerve stimulator in the neck. And they stimulated
that vagal nerve for only four minutes a day. And then, they did that every day
for 42 days, and then they stopped the vagal nerve stimulation.
[00:31:41] So, what you'll see in B is TNF found in the blood. So, you
remember from before that TNF is one of those proteins that drives
inflammation. And you can see that from day zero to day 42 of this vagal nerve
stimulation, the amount of TNF went down considerably. When they stopped
the vagal nerve stimulation on day 56, it went back up. If you look at C, this is
change in a disease activity measure called DAS-28-CRP. So, this is a way of
measuring active rheumatoid arthritis. The baseline DAS for most of these
people was about six. So, you can see that the amount of drop in disease activity
was approximately a third of their disease activity, which is amazing for a
nonmedication intervention. So, here again is evidence to support that the
nervous system is contributing to inflammation in rheumatoid arthritis.
[00:32:45] Okay, so this is a model that I mentioned to you before, and I'm
going to change this just a little bit and pose a new model of inflammation. So,
instead of inflammation primarily being there to fight infection, inflammation is
a result of the immune system and nervous system activating the response to a
threat to protect the tissue. This hasn't changed. There are many cases where
that inflammation is overexuberant, especially autoimmune disease. But, while

the immune system, those cells and proteins can perpetuate an inflammatory
response. Neural activity may stimulate and direct the inflammatory response.
[00:33:32] Therefore, if I can get someone with rheumatoid arthritis to control
the inflammation with the right medication, but I can also help to change the
neural stimulation by decreasing the sense of threat and the need to protect the
tissues, can I also then help them get off of that rheumatoid arthritis medication
and let them to stay in remission of their disease? I'm hoping. I think it's
interesting and intriguing. I don't know for sure, but that's kind of what I'm
thinking about now.
[00:34:12] So, finally, this is the last point I wanted to say. What I have learned
about pain with the biopsychosocial model of pain is that having a heightened
sense of threat can lead to increased pain. And similarly, that same process may
also lead to increased inflammation. Now, some people who have that increased
threat may manifest without a lot of inflammation, but if you have the right
genetics or potentially the right microbiome, then that may result in ending up
in chronic inflammation. And, therefore, treatment for rheumatoid arthritis is
not just focused on the immune cells, but also the state of the brain. And that's
what I have.

[00:00:00] Hello. I'm glad to join you guys this evening and have this opportunity to visit with you guys. I'm a physical therapist. I've been practicing for about 11 years now. And my specialty area is geriatrics. And I currently practice in-home health and reside over in the Tri-Cities area of Washington.

[00:00:22] I'm a native of Oregon. I grew up in Eastern Oregon and went to Eastern Oregon University for undergrad. But when I moved up to Washington to go to PT school, Washington caught my heart. And so I've stayed up there ever since. But I wanted to take this opportunity to share with you my story, recovering from chronic pain.

[00:00:46] Before I developed pain, life was pretty good for me. I had a position I enjoyed. I had just moved to the Tri-Cities area and got into home health. And things started to look good for our financial future. We were making progress on our financial goals. I was starting to see our student loan debt start to shrink a little bit. We even purchased our first home, and I had just celebrated my 10th wedding anniversary. I was starting to take my son up to ski slopes to learn to ski with me.

[00:01:20] I experienced an initial injury in March of 2017. I was assigned to work with a gentleman who had a lot of weakness after being ill and hospitalized for a prolonged period. And after a session, he had grown quite particularly fatigued. And when it was time to assist him back into his wheelchair, his legs gave out, and he was quite a heavy lift for me to get him safely back in his wheelchair. And when that happened, I experienced pain in my back suddenly. And at first I thought, oh, this is a minor bout of back pain. It'll resolve, you know, everybody experiences back pain now, and then. But this pain grew worse, and it traveled down into my right leg. And by the next day, I was no longer able to continue my employment duties, and I knew something was wrong. I went on medical leave and got in to see a doctor and was diagnosed with a massive L5 herniated disc.

[00:02:28] They found that it was causing some nerve impingement due to inflammation that was causing the pain in my right leg, as well as some weakness to develop. The doctor suggested that we do conservative treatment, and with some anti-inflammatories, some rest and back protection, and physical therapy, he thought that I'd recover well.

[00:02:53] At the time of the injury, I was healthy, active and I was totally confident that I was going to get better and would be able to return to work. I followed my doctor's recommendations and worked hard in physical therapy and by midsummer, after the injury, oh, approximately four and a half months, I was able to return back to work full time again. And I felt pretty good when I went back. I had little to no pain, maybe a little stiffness fatigue by the end of the day. But really I was feeling pretty good and I felt good into the fall. And through the winter, I got back into my regular activities, took my son up skiing again, went hunting that fall. And then in the winter, I even commenced a home project that we had been planning to do since we purchased our home and install a second bathroom.

[00:03:55] And so. It's been say about eight months since I had gone back to work, about a year after I had initial injured my back. That's when life changed for me. So this was a spring of 2018, and I had been working a lot of long nights on my home renovation project. It started out. Thought it'd be a simple bathroom installation. No, no home project is simple. It morphed into an endless home renovation project, and it was requiring a lot of late nights after my regular employment, trying to get this project finished. And one night after a particularly long night of work, suddenly I started to experience pain in my back, and it felt just like the pain I had a year earlier when I was injured.

[00:04:52] Well, this was quite worrisome for me. And so I immediately took it easy, wanted to let things rest. And I was worried something might be wrong. Well over the next month or two, the pain only continued to get worse. And I started to get worried. I had stopped doing all my recreational activities and stopped the home project and was doing everything I could think of to control this pain and, and get it to go away. I was trying ice and heat topicals. I did all my therapy exercises, stretching. I wore a back brace, even bought an inversion table to try. And nothing was working. If anything, the pain was getting worse.

[00:05:40] So finally, I decided to go back and try physical therapy again. Even though I'm a physical therapist, it's good to have some other eyes on you. See if I can get some other ideas of things to try. And at first the physical therapy, it started to work. I started to feel a little bit better, but soon it stopped working. And soon the pain was just getting worse.

[00:06:04] And after about six months of struggling to manage this pain, finally, I just got to be so bad that I couldn't even continue working as a physical therapist. And up to that point, I had just barely been getting through the day, meeting just the minimal demands of my employment.

[00:06:26] When the time came for me that I had to tell my employer and my wife that I just couldn't get continue working, I was filled with guilt. I was guilty that I had overworked myself to reinjuring my back. I had a lot of fear that I'd become disabled, and I'd never get better. And I worried my inability to provide for our family, what effect that would have on my marriage and our financial future. My pain had become unbearable and unrelenting.

[00:07:07] Each day that I didn't go to work, I just laid on the floor in the only position that gave me a little bit of relief, but it was only minimal. As months started progressing without any improvement. The pain just seemed to occupy my mind like a vast crater. I had no space to think or concentrate. And I began to question, would my pain ever get better?

[00:07:39] Every day was just a struggle and I couldn't even do simple tasks. And when I'd muster up enough energy to get something on the to do list that couldn't wait, it'd take days to recover. It became a struggle for me just to envision a life free of pain. And I could hardly remember what it was like to live without pain.

[00:08:03] The only thing that kept me going and not sinking into despair was the thought that when I'd be able to get to see a doctor, I'd get some help for my back and my pain. I had reapplied to open my L&I claims so I could get help. And about six months after I had to stop working. I finally got some good news that L&I had approved to open my claim, and I'd be able to go in and see a doctor. And this was quite exciting and brought quite a bit more hope after this long dark period.

[00:08:43] The physician ordered a MRI to take a look at my back again, and I was eager to get in and see the doctor and discuss the results and come up with a plan to get better and get rid of my pain. I was scheduled to go in and see the physician's assistant. And as I went in and sat down to hear the results of my MRI, she sat down and she began explaining things. And, I couldn't believe what she told me. She told me that my back was fully healed and that I should go back to work. Dumbfounded, I just could not comprehend what she was telling me. I was in more disabling pain than I had ever been in. The pain was so severe. Wasn't that evidence that something was terribly wrong with my back? Still not understanding, what she was telling me, I inquired, but what about my pain? Can't you do something for my pain? In reply, she just restated that my back was healed and that it was the doctor's recommendation that I should go back to work, and she proceeded to dismiss me.

[00:10:08] I left the doctor's office in a daze of disbelief. I just could not believe that my back could be healed and yet I had such severe pain. And I didn't understand why the doctors couldn't help me or provide any more information or answers. And worse more, I couldn't even fathom returning to work in this horrible state of pain I was in. It was all I had done for the last six months or for the previous six months when I was still working to get through a day of work and keep working. I had done all I could. And for all of that, it had just left me in a state of utter disability with horrible pain.

[00:11:01] As I sat in the parking lot with all these thoughts and questions swirling in my confused mind, I was attempting to come to grips with the realization, weighing down on me that all might be lost for help in my pain and my situation. But as I was going through this, a thought came to my mind. I recalled something my physical therapist had recommended eight months ago. He had special advanced training in pain science and had recommended I viewed some continuing education courses from the pain specialist, Adriaan Louw. At the time, I never did it, because I didn't really understand what's this pain science have to do with my situation?

[00:11:56] I had re-injured my back and once I got medical help for my back, and it's healed up, the pain will go away. So I had never bothered to watch these courses in the last six to eight months since recommendation, even though I was struggling in pain. Now with no help left, I decided that I'd watch these continuing education courses and learn something about the science of pain.

[00:12:29] I cannot even begin to describe the hope and excitement that filled me. When I started to view these courses and learn about pain science. I learned that there was a scientific explanation for my pain. I learned that I was not alone in this experience, but other people have developed chronic pain after an injury. And best of all, I learned that other people were using pain science and the practices to get better and master their pain. I learned about these practices that they were simple and effective, evidence-based ways that would help me begin to think differently about my pain and begin to engage in activity and reclaim my life.

[00:13:26] I began implementing these practices in my life. And immediately I began to experience some reduction in pain. And, I began to improve in my movement and was able to engage in activities again. I was able to start envisioning my life again, free of pain. And, even better, I had a solution of how to get there.

[00:13:52] The practices were simple, easy to understand, and rooted in an basic understanding of how pain works. Those who teach about pain science used simple stories, illustrations, and examples that anyone can understand the science. And a lot of the practices were simply learning and understanding how to think differently about pain, as well as learning how to care for myself and listen to my body differently.

[00:14:23] I want to share with you my experience as I implemented pain science to think differently and master my pain as I prepared to return to work. One of ,the things that I had to be able to do before my doctor would clear me for work was to be able to lift 75 pounds. I was strong at the time, but I had a new understanding that I needed to start out lighter and slower and allow my body to successfully experience lifting lighter weights initially and then work up to 75 pounds.

[00:15:05] I went to the gym and I decided I'd start with 40 pounds. I set up a barbell on the floor with 40 pounds, and using good body mechanics, I bent down and lifted it from the floor. And all of a sudden I experienced severe, knifelike, stabbing pain in my low back and lightning bolt of pain down my right leg. My back injury all over again.

[00:15:36] Or was it? I reminded myself that my back was healed and I was okay. My body was in an overprotect mode, and my pain was no longer an accurate indicator of harm. Once I reminded myself of that, my pain started to subside. And, even better, I didn't have an overwhelming fear and dread that I had caused horrible, irreversible bodily harm when I felt that pain, I returned to the gym every other day and continued to lift the same 40 pounds until I could do so with minimal pain and gradually built up to 75 pounds until I was ready to return to work. I initially returned to work part-time and gradually worked up to full time.

[00:16:40] And now, using pain science, I have returned to work for the last two and a half years uninterrupted full time. I've been able to resume my recreational activities, including taking my son skiing the last two winters and enjoyed a successful buck hunt last fall. And, I finished my home project, and we are now enjoying the luxury of a two bath home.

[00:17:10] I can't even put into words the awful reality of what my life would've been like had I not found pain science when I did. I am eternally grateful that I found it when I did, because it saved my life. Now in my practice, I teach anybody who's going through an injury or has experienced pain about pain science, and about the practices and how to think differently about pain. And I look for opportunities to share this information with others, and I am grateful for this opportunity to share my story with you guys.

First Pass Oct 13 2021 McQuillan

[00:00:00] Fast forward, you know, life went on, um, and I took a job in Oregon, took a job teaching residents , uh, and one day, one of my res and a resident. For those of you who don't know is that, uh, somebody who's a physician after medical school, they go into specialty training.

[00:00:26] And so I took a job teaching resident physicians. Even though I didn't have all the answers. And, um, one of the residents one day came and found me and told me about this pain lecture that they had gone to and just how amazing it was. And I, of course was curious what what's this about? And they said, well, this pain specialist in town and Kevin Cucarro, um, you know, these are some of the basics of what, what he said.

[00:00:56] And so then I started going, I would sneak in with the residents and, and it just completely blew my mind, uh, hearing how Dr. Cucarro was talking about pain. And it's not like Dr. Cucarro came across some profound new discovery. He was just sharing what the science has been telling us, but that we weren't paying attention to all along.

[00:01:28] Those of you who know Dr. Cucarro you know, how transformative his journey has been when he really started to dig into what pain actually is. And he really, um, lit the fire under me to start paying attention and, um, start reading. And, uh, so my old view of understanding pain was a pain as a, a symptom of a disease.

[00:01:59] And I gotta find the disease to be able to help the patient. And then my new understanding of pain as it began to emerge was. That pain is, uh, protection. That it's something that our body creates to protect us from potential damage. And the more I understand pain, the more brilliant I know pain is designed.

[00:02:26] You know, pain has a memory in our body. Pain has a, it, there is a memory in our brain. You know, our body learns about dangerous situations that have happened to us. And then it tries to protect us from those dangerous situations later in life. When our environment is not safe feeling, um, some of those old, some of those memories can be dusted off, uh, and we can start experiencing pain in various parts of our, of our bodies.

[00:03:02] Um, And this from a clinician's perspective is just mind blowingly different. Um, when I see my patients now, um, I still believe my job is to make sure that there's not a disease that is causing pain as a symptom. And so I do my due diligence and there's lots of good guidelines to make sure that I do a good job.

[00:03:30] Um, but then I can also, while I'm trying to understand if there's something that's causing the pain while I'm trying to understand if there's a, a secondary condition that is important to diagnose, like for example, rheumatoid arthritis, I'm also trying to understand. Why that patient, you know, may be experiencing a lot of protection and then I can start educating the patient really early on in that experience about why they may be experiencing pain in those circumstances.

[00:04:12] So lots of frustration, lots of self doubt, lots of personal, uh, distress. And, um, then Kevin Cucarro, I, I see he might or might not be on here, really changed my life. And, um, I owe him a whole lot, um, Because the amount of distress I experience now in practice is much, much better. My understanding of pain has also opened the door for me to understand my patients better in general.

[00:04:43] So it helps me understand, um, you know, pain as a biological process that exists to protect us and to keep us safe. And sometimes it's redundant and it, uh, it's too protective and there's other things in our body just like that, uh, hunger, you know, uh, hunger, we experience hunger so that we can sustain life.

[00:05:11] Um, so that ch understanding pain changes my understanding of obesity, understanding pain, changes my understanding of many of the mental health, uh, disorders that while disorders that we. Um, see the world there's, you know, just a lot of, uh, anxiety and depression. Um, and, uh, perhaps most importantly, understanding pain also led me to understand, um, the impact of adverse childhood events and how those can impact us, uh, throughout life and later in life and how important it is to understand that and to help patients understand that.

[00:05:58] Um, so it's not just about pain, it's about everything. Um, so I'm looking down at my notes now. Um,

[00:06:16] I was asked to potentially share a couple personal or patient stories that maybe help illustrate my understanding of pain and. You know, because of patient, um, privacy issues. Um, I'm gonna remove any identifying information about the patients, but I'll tell you about two patients. Um, one was a male, uh, in his late thirties.

[00:06:45] I'll call him John. His name is definitely not John. Um, he was a new patient to me, maybe three years ago. Um, he was experiencing really severe back pain when he first came and saw me when he first came and saw me, he was seeing a pain specialist and getting a whole bunch of injections, but really wasn't getting better.

[00:07:13] And so he was really frustrated with his pain. I was wondering what else could be done to fix whatever was wrong with his back. So I asked him to tell me a story. So by this time I understood how important early life events are for our pain experience. And he said that when he was a little kid, I, I don't remember the age, but my impression was, you know, eight or 10 or something like that.

[00:07:44] He fell out of a tree and he hurt his back. And he said, I fell out of a high tree and I damaged my back and my back has been damaged ever since then. And I said, oh, you know, that really sounds scary. Um, you know, tell me more when he was a teenager, he grew up in a pretty rough, uh, area and he got into some trouble with, um, a bad group of kids who, uh, one day after school circled him and, um, Started beating him up.

[00:08:24] And, um, the way John was explaining this was very uncomfortable to hear. It sounded very violent, very scary. And they, he said that one of the boys was kicking him in the back where his back had been damaged over and over and over again. Uh, John's dad, if I recall was essentially absent from his life John's mom, if I recall, uh, struggled with drugs and alcohol, I think his dad maybe was in prison or something like that.

[00:09:00] John ended up getting into drugs and alcohol himself in his teenage years and really, um, wasn't doing well in life. Ended up going to jail repeatedly. Um, And, uh, struggled with addiction issues, struggled with, um, pain issues. And then at some point in his late twenties or early thirties, he kind of grew up a little bit.

[00:09:29] He met a girl so often how it happens. Uh, they had a kid, he realized that he wanted to be a grown up for his kid. And so he got a job, got some training to become a mechanic, got into lifting weights, became, you know, really physically fit, really strong, kind of got away from his addiction issues.

[00:09:55] Eventually was really, really proud of that. And then one day, uh, he was driving along and, uh, got in a really horrific car accident, uh, and that led to a hospitalization. And that led to the back pain that then persisted from the time of his car accident. And, um, you know, so I, my old way of understanding pain, I would've looked at John and said, wow, you really must have damaged your back at 10 and may.

[00:10:33] And, uh, there's something structural that maybe a surgeon in Seattle or Los Angeles can fix. My new way of understanding pain, which is based on what the science tells us is that his body had created memories from these traumatic events earlier in life. And, um, and now this car accident caused some, uh, you know, uh, caused some of these pain, uh, issues to come on.

[00:11:08] But sort of the uncertainty of what that meant for his future. You know, he keep in mind, he had started identifying as a very physical, physical person and because of this car accident, the pain and some of the dysfunction he was experiencing, he didn't see himself as someone who could lift weights anymore.

[00:11:29] He didn't see himself as someone who could continue to be a car mechanic anymore. And he's one of my favorite patients because he was so flexible in his thinking, you know, I, I shared with him just a little bit about what I understood of his story and how I understood his story. And he said, oh yeah, that's really interesting.

[00:11:51] That that kind of makes sense. You know? And I said, do you have anyone you could talk to about some of those past traumas? And he said, yeah, yeah. I, I have a therapist. I'll, I'll go talk to my therapist. And then he disappeared for a while. Um, the next time I saw him, he was back at work and. Life was good. I mean, life wasn't perfect for him, but he's, he's back to working.

[00:12:12] He's back to, uh, spending time with his kids and doing things that he wants to do. Um, do you have enough time for one more story? Uh, yes. You're good on time. Okay. Thank you. Second story. Um, is, uh, th this is a lady. Let me think of a fake name real quick. Um, I'll call her, uh, why is it so hard to think of a lady's name?

[00:12:45] Bonnie, Bonnie. Thank you. They all, like, they all have connections and I didn't wanna make a connection there. so, Bonnie, I don't, I don't know any Bonnie's too particularly well, so, um, Bonnie also was in her thirties. Um, she I'd known Bonnie for years. I'd known her from before I understood pain science.

[00:13:10] And I actually, she was a patient of mine when I was starting to understand it. And so I got, she let me practice sharing what I knew with her in the early days. And I really appreciated that. So she would come in with neck pain and I would try to help her understand how that might relate to some of her prior traumas and prior abuses.

[00:13:31] And, oh my goodness. Did she have a lot of traumas and abuses, um, in her life? Uh, she also had struggled with alcohol, but she, um, You know, was really took to what pain actually is it totally made sense to her that it's ju it is my body trying to protect me and, you know, thank goodness for my body and, uh, and, and what it's trying to do for me.

[00:13:56] Um, so she's been doing really well, but about, uh, a year and a half ago, uh, she had an incident where she. uh, hurt her ankle. And she went to an urgent care clinic and, uh, they, the treatment that they gave her was kind of standard and kind of appropriate. They examined her, they said, yep, you hurt your ankle.

[00:14:22] And that it hurts bad enough that we'll do an x-ray to make sure nothing's broken. X-ray was negative. They said, Hey, your x-ray is negative. You know, it all looks good. Her pain persisted, that didn't really make sense to her because she had this notion that it was just an ankle sprain. So she ended up going to the emergency room a few days later, and the emergency room, they, um, you know, examined her, didn't understand why her pain was so severe.

[00:14:49] So they got a cat scan and the cat scan, uh, showed, uh, one of the tendons. Maybe there was a little bit of inflammation on the, around one of the tendons, or there was some evidence of maybe some inflammation around one of the tendons. And, uh, but they also didn't quite understand why she was experiencing that much pain.

[00:15:09] So, um, you know, I'm just putting myself in Bonnie's shoes. My ankle hurts like heck and I've had multiple doctors tell me, I don't know why it hurts like heck. Um, and it's not getting better. And sh she's having other, uh, nervous system responses to the pain. Her nervous system is so in tune to what's going on with the ankle that, uh, there's blood flow changes to that part of her body.

[00:15:39] She starts noticing that that ankle is turning, uh, colors. It's changing temperatures and she's scared cuz she doesn't know what's wrong. And uh, so. She came in. I, I did my due diligence. I actually did get an MRI, sorry, Dr. Cucarro if you're listening. Cause you know, I'm, I'm human. And I was like, I wanna make sure there's nothing horrible here.

[00:16:06] Let's do an MRI. MRI was reassuring. Um, and then I said, oh, Hey, you know, Bonnie, remember, you know, remember our conversations about what pain is. So right now, you know, you have a situation where you have a lot of uncertainty and uncertainty can be very scary and fearful. And, and do you think maybe that could be driving some of the symptoms?

[00:16:29] And she was like, absolutely. And so we sort of, I created this really brilliant in my mind kind of rehab plan for her to kind of gradually get back to activity over the next several weeks. And she got back to activity in like a week , you know, and, and, and she was fine. Um, So, um, those are two happy stories.

[00:16:56] I think I could share a lot of less happy stories because it is, it is very, very hard.

[00:17:03] On some of the things that you wanted me to address were about pain beliefs. And, um, as a clinician, I, when I think about myself, I know that I have beliefs, but I, I like to think of 'em more in terms of understandings it's how do I understand pain rather than how do I believe pain?

[00:17:28] Cuz to me, a belief can become entrenched and understanding, you know, may be more flexible. So I like to think of my understanding of pain as just an understanding based on everything I've seen and read. And, uh, and based on what, uh, patients teach me with how they respond and, and what they tell me. So, um, a brief, uh, summary, um, that, uh, I hope, um, the participants, um, got from this is, uh, you know, I, I, I'm not rehashing sort of the pain science lecture, the pain is protection, but, um, it is, you know, , so I hope that you all are hearing that, uh, pain is really just about protection and nothing more, nothing less, uh, that it's fluid, that it's fixable.

[00:18:32] You already heard from somebody earlier that they had back pain one day. They went through a program, changed their understanding. And they were better. That's amazing. And it is changeable if you, uh, are, if you understand it, um, for what it is, it's a protection, it's not a punishment. Um, I often am talking to my patients about, um, this notion of punishment and, you know, I want my patients to appreciate their pain because it's, it's part of them, you know, it's them trying to protect themselves.

[00:19:16] It's their protection system, trying to protect themselves. And I think a lot of people develop really negative relationships with their pain, which is totally understandable because it's such an unpleasant experience. but Dr. Cucarro I have to give him credit. He's he, he talks a lot about, it's not a punishment, it's a protection.

[00:19:38] And so it's changeable and it's, uh, just, it's just protection. So, uh, next steps you might consider, um, I'm not sure how many patients are on this meeting. Um, I would, uh, really encourage you to have your clinicians, any clinicians that you work with to reach out to either myself or Mid Valley Pain Science Alliance, um, about how they can become educated and.

[00:20:18] um, we put on a conference in partnership with a whole bunch of different groups. MV PSA has been involved from the beginning. We put on a yearly conference. That's really focused on clinicians. So doctors, physical therapists, therapists, occupational therapists, massage therapists, naturopaths, really anyone who sees patients who may be experiencing pain.

[00:20:45] We have a conference every year, cuz we wanna help improve their distress. When they're working with patients, we wanna help them understand what their patient experience is. And we, uh, also believe that if we can help our peers and our colleagues have a clear, more accurate understanding for what pain is, then they can, that can have a multiplier effect and, and really help their patients.

[00:21:15] Um, And I would be happy to have doctors email me and they may even say no, as a patient, I understand the doctor patient relationship. It may not always be comfortable to say, Hey doctor. So, and so why don't you go do this education , uh, that, that might be a super, might not be a super comfortable thing to say, but I think if you share with them that you, you know, that you went to this evening meeting and there's, and that you would love them to get in touch with us, then we can, you know, try to twist arms to get them engaged, to help them out and to help them be able to help you and other people, um, who may be struggling to, to, to figure out their pain, um, other next steps.

[00:22:05] So there's tons of good resources available. Um, I'll mention a few. There's a lot of really terrible resources available, um, on the internet. The internet is like the ultimate double edged sword, lots of horrible things, but some useful things. Um, one is anything by Lorimar Mosley, L O R I M E R M O S E L E Y.

[00:22:35] He's a, uh, kind of a world's pre preeminent pain scientist. And, uh, his, as far as I can tell his mission in life right now is to help people understand pain. Anything by Dr. Kevin Cucarro um, we have this local resource that, uh, is really a national treasure that, um, we're unbelievably fortunate to have him in our community.

[00:23:06] So Google Kevin Cucarro and, um, If you can sign up for some of his education that may be life changing. Um, and, uh, I think that's all the, the, the plugs I'll put in, but there's a, a bunch of other resources that can be helpful. And, uh, certain circumstances, I assume the timer was my time. No, no, you've got three more minutes.

[00:23:36] Oh, three minutes. Okay. Yep. Um, cool. Again, I, uh, really am deeply honored that you asked me to come here and talk. Oh, and one other, um, plug, uh, we have two, uh, giants in our community and I see both of their names on the screen. The other as Sharna Prasad. Um, she's a physical therapist. Who's been a very passionate about pain science and has really been the energy and force behind a lot of the initiatives that we have in our valley and the number, uh, the amount of improvement that she's bringing to our valley. Uh, our valley is just unbelievable. She created the MMAPS program that you heard, talked about, and she's always trying to find new ways to reach audiences, uh, to, to help people out.

[00:24:39] That's all I'm gonna say.

[00:24:44] Excellent. Excellent. Well, thank you, Dr. McClin for sharing your story.

[00:24:55] Thank you for the plug. Appreciate it.

[00:25:02] Okay. So now what we're gonna do is enter into the Q and a portion. Um, and so Dr. Lance, um, I've asked people, if you have any questions, we've asked you to type them in, um, to the box and I will pull that up. Do we have any questions out there? Yes. Can you see him, Dr. Lance in your chat box? I see one question.

[00:25:29] Are there more than one question? Is there more,

[00:25:32] I think I, I directed one specifically to you. Okay. I wasn't sure if it should go to everyone or just to you.

[00:25:39] Okay. So there's a question about, um, can you give us a quick nutshell of what's physically happening? When we experience pain? Like my ankle is hurting. What's happening between my brain and my ankle. And why am I experiencing pain?

[00:25:59] And the answer is really, it depends. , you know, so, uh, if I just sprained my ankle, uh, yesterday, uh, today, which I happen to do about once a month, um, there's, uh, uh, nerve, uh, signals that start sending information to my spinal cord.

[00:26:20] There's also along with those nerve signals, there's an inflammatory reaction that inflammatory reaction makes that area more sensitive. That's why after you injure something, that part of your body is more sensitive for the first couple of days, the inflammatory reaction in the spinal cord. Um, the, uh, the there's a whole bunch of, uh, other information in that same area in the spinal cord that's trying to, uh, let us know if that's, if that. Nerve information from my ankle is important or not. And then that information goes up to the brain and I'm using the word. And then, and then, and then it's really not in sequence like that. This is all kind of at the same, like it's all happening. , uh, in, in, in, in concert and in, and then in the brain, uh, the signals, uh, are go up to the brain and, and then the brain looks at, um, have I ever experienced anything like this before?

[00:27:27] Am I safe right now? Uh, so it, it accesses the memory parts of our brain. It accesses the fear and safety parts of our brain. And then it accesses the motor parts of our brain. And if there's enough evidence in our central nervous system, that there might be damage to our ankle, then we experience pain, but it's not until there's enough evidence in our brain or in our central nervous system that we experience pain.

[00:27:59] Now, after that initial injury after, so the inflammation, that's a good thing. The inflammation helps you heal. You know, it allows for more blood flow; it allows for a whole bunch of healing factors; then the ankle heals.

[00:28:11] Now let's say three months later, I'm playing soccer. And I start to twist my ankle. There's memory in the nerves at my ankle. There's memory in the nerves, in my spinal cord, and there's memory, uh, in my brain, um, in a whole bunch of networks in my brain that decide like, oh, Hey, this seems kind of familiar to something that happened before. And so again, the, if there's not a whole bunch of other stuff that my brain is distracted by, it might create pain, you know, so that I, because I had injured it before I had sprained it, it took me, you know, a month or two to heal, now, even though I didn't sprain it, it's gonna, it's gonna create pain there because it, it might think it needs to protect me there. Um, and, uh, yeah, so I think that's sort of the short and intermediate term.

[00:29:12] I think if three months later, um, or I'm six months later, a year later, I'm still experiencing pain that a lot of that is related to my brain and my environment and how much safety there is in my environment in my world. But the, the, the system is just beautifully designed to protect us from bad things that happened to us before, and to protect us from dangerous things out there in the world. Uh, and I know that pain is unpleasant, so I, I apologize for using the word brilliantly, but it is really a brilliant, amazing system designed to keep us safe.

[00:29:55] It's a little bit redundant unfortunately, so sometimes it keeps us safe when it really doesn't need to

[00:30:03] Did that answer the question? Okay. I'll take the hand as. Please. Stop, stop talking I'm teasing..

[00:30:16] That was a thank you.

[00:30:21] Now Lance, can you see the additional question? Um, that Rolly entered in?

[00:30:28] I am really sorry. I can't.

[00:30:30] No, no problem. Could you share your experience with other medical colleges and observing their willingness to change their understanding or their belief about the experience of pain?

[00:30:41] Uh, I appreciate that Rolly. That's what we're working on. Um, so Dr. Ransdell, she's an med peds doctor and, um, in the area, uh, and I have been creating education for our local residents and because we want them to go into practice with a clear and accurate understanding of pain and we've, you know, started having some and really we kind of piloting a curriculum to see if it has the outcomes that we want it to have. We're measure, we're serving the residents to see how much distress pain creates for them. And if our curriculum is successful, you know, which I hope it is, then we'll start trying to share that with other training programs. And I think that that has the potential to be shared at, at the medical school level.

[00:31:45] Now, if you have any other questions, just go ahead and type it into the chat box. I don't see any other questions out there. Um, Dr. Lance, is there anything else you wanted to add?

[00:32:13] Nope.

[00:32:14] Okie dokey. So this concludes the QA portion of Dr. McClellan's presentation. Um, if you had a question, you didn't get it typed into the chat box. Um, you can remain on zoom after the session. Formally concludes to talk with speakers and or Alliance members until 9:00 PM. Um, Dr. McLellan, thank you for being our healthcare presenter this evening.

[00:32:37] We appreciate you so much. Yes. Thank you. Thank you so much.

[00:32:41] So Tina, if you're around at the end, I'll respond to that question.

[00:32:47] you've got a few more minutes if you'd like to.

[00:32:50] Okay. Um, yeah, the COVID long haulers. Um, I I'll be honest with you. I haven't like thoroughly. Um, I haven't. Read all the scientific studies that are emerging about COVID long haulers.

[00:33:07] But I do think that, um, the, uh, I do think that it may be a reflection of some of the toxicity in our environment and by toxicity, what I mean is, um, fear and uncertainty in the world. Um, and, um, I'm worried that a lot of these sort of, kind of, um, ongoing, um, Immune system reactions are just a reflection of general feelings of lack of safety.

[00:33:47] May, you know, maybe not conscious feelings of lack of safety, but unconscious feelings of lack of safety in the world. And I think, you know, right now, um, our political environment is very charged. Our, um, you know, we live in a pandemic there's, um, there's just a lot of, um, danger in our world. So I think that those are correlated.

[00:34:14] Yeah.

[00:34:22] All right. I'm gonna mute myself. Oh, shoot. Okay. Uh, have you developed any materials to help your patients understand their pain experience? Are any of them at a place where you are willing to share, um, with others?

[00:34:36] Um, so I actually have not, um, that's a really good question. Um, and it, part of the reason I haven't is because, um, you know, I'm a super busy, uh, primary care doc, uh, with three young kids at home.

[00:34:53] Part of the reason is because pain is such a personal individual experience, you know? And so the, the Lorimer, Mosley his, uh, book Explain Pain, Supercharged, you know, one of the outcomes of his work was, uh, and one of the, one of his studies showed that if you can change, patient's mindsets about what pain is. If you can change a patient's understanding about what pain is, their pain experience really substantially improves. One of the negative consequences of his research, as far as I can tell, is that. A lot of people started trying to package that up like, oh, okay. All we have to do is teach patients about what pain is. That's all we gotta do. So here's an education session about pain, you know, and sort of a one size fits all, like here, just come to this eight or whatever. Uh, here's an education session that we created that will help you understand pain and then you'll get better. And, um, so that I think became a big thing to do.

[00:36:04] Um, after some of his research started emerging, Dr. Cucarro, if he's listening, he can correct me if I'm dead wrong, but the problem is, uh, pain is so individual and it's so patient specific and everyone's story is so unique. And in my experience, talking to patients, the education materials that I use for. It, it just varies tremendously.

[00:36:33] Even the question. Can I educate you about pain? Like, I, I, I can't, unless you're ready to be educated. So like first I have to understand, you know, how flexible is your understanding of pain, you know, and are you at a vulnerable place in life where you can maybe change your paradigm of thinking? And then I gotta understand well with you as a person and what your experience has been, whether that was, you know, lack of parents when you were, uh, you know, a toddler in the house or, uh, whether it was because you were assaulted when you were in your twenties.

[00:37:18] It, it really is different from person to person. And so I, I, I prefer that each of my. The all the education I do with my patients be really individualized. There are some tools that I go to repeatedly. I love Kevin Cucarro's Pain Triangle, cuz it's elegant and simple and you can hang a lot of things from that Pain Triangle.

[00:37:41] Uh, but other than Kevin Cucarro's Pain Triangle, uh, I really don't use, uh, consistent materials, even online materials. It, it just sort of depends on, uh, you know, where the, the patient is. Okay. And then Austin, that's a really good question though. Um, I appreciate that question. Um, cuz I think that that's a potentially dangerous thing with a notion that, oh, we just need to teach people about pain and. No, we need to help people understand pain and their experience is different than everyone else's.

[00:38:18] Are you aware of qualitative studies or just general of folks who recovered from

[00:38:22] oh, absolutely. Yeah. So check out the movie. This might, or yeah, this might hurt movie.com. I think that that's what it's called. Yeah. So just Google that movie, I think there is a rental cost, so I apologize. I don't get any, uh, financial benefit for mentioning that movie, but that's about, um, the per the author of a book called Unlearn Your Pain.

[00:38:54] I hope I'm not mixing up my authors, uh, him and some pain psychologists created a program in the Midwest and, uh, they are following some patients in that movie and those patients' experiences. So I would, I would check that. That out.

00:00:10] Good evening. It's good to see some familiar faces and some new faces. So hi everybody. Welcome. So yeah, just jump right into my pain journey, my pain story, I guess. So it started with low back pain as a teenager. Which was, it was a surprise because I was, I was very physically fit. Played soccer. Was crazy about skateboarding. Did TaeKwonDo. I was in really good shape and then threw my back out. And it was sort of a big surprise. Like how, how is that possible? Well, it turns out I was just lifting really big, heavy things at work, the wrong way. And a chiropractor helped me understand that. But he also helped me deal with my pain. He handed me some hydrocodone at the time. Actually, it was codeine at the time, and told me to learn to lift better and sent me out the door.
[00:01:05] And that sort of started my whole, it was just a recurring thing over the years of just, I would do something stupid, throw my back out, whatever. Go to the chiropractor or the doctor. Get some more pain meds and just push through. Eventually I became a carpenter and just the same routine. Did that for years. Just would work hard, and play hard, and get hurt hard. And pretty much the solution was go and get some pain meds and move on. And it was basically a few decades of doing that.
[00:01:42] The change came... well, so in 2015, I had an accident. In 2016 my leg got crushed. It broke my leg really bad. In 2016, I lost my left foot to an amputation. And it was about a year later. I was learning to walk again and ended up in physical therapy to help me with my gait and whatnot, and a lot of back pain, more associated with my gait than heavy lifting. I hadn't done any lifting in a while. And met a couple physical therapists, one in particular who's, I almost said she's not with us anymore. She's still with us. She's just moved to the other side of the country. But, she made a huge impact on my life. She shared with me the Pain Triangle, started to explain how pain works.
[00:02:32] Maybe I'll just mention that real quick. The Pain Triangle is there's three components to the Pain Triangle. Obviously tissue damage is one of those not necessarily tissue damage, but tissue damage is one of those. You've got a physical pain. Then there's a cognitive aspect, how our brain works with that. And then an emotional aspect, and how we feel about that pain or other stuff in our lives. In that pain, in and of itself, is a construct of those three things. And, ideally, if we take one or a couple of those things out of that equation, we can reduce or even take our pain away. Sandy's got some stuff at the end, I think that'll help, some resources at the end that I think will explain some of that. So for those of you that don't know about the Pain Triangle, there are some resources that you'll be able to get to at the end of this.
[00:03:28] So that's the Pain Triangle, and Veronica introduced me to that and then invited me to the MMAPS class. Quite honestly, I fell in love with the MMAPS class. I stayed for a year. It's a eight week thing, and I just kept staying. Changed my life. And so one of the first things we learned in the class was that pain is a protector. It's not a punisher. It's there for your protection. And quite honestly, that was like a paradigm shift for me because my view of pain had always been it's bad. Let's get rid of it. What do I gotta do to get rid of it? Well, I mean, for me, it was just go get some more pills, pop 'em, and move on with my day. I don't think I was alone in that. I actually knew a lot of guys that that's kind of the way, all my carpenter buddies, we got through just getting it done, you know? So that revelation that the pain is there to protect me was, I mean, that was just like, what the heck is that all about? So just really trying to wrap my brain around that, and it actually, honestly took a couple years of that in and of itself. As I've been looking at my pain over the last few years. So, that was four years ago that I started, that I took that class.
[00:04:49] Let me go on with my story a little bit. So over the last couple years, well, this last year with COVID. It kind of sucked. Maybe you all had a better experience than me, but it's kind of sucked. It's been a hard year. And so for me, it was like the first time that I really started to really look at more of some of the emotional stuff in my life. And to really kind of dissect my pain from that more emotional aspect as things have really gone kind of sideways this year.
[00:05:22] And even throughout the class, I was really dealing more with still the physical, the tissue damage kind of things. And it's in this last year, I've really been kind of reevaluating, just emotions, cuz I've actually had more back episodes in this last year than I have in years. And really as I've kind of dissected it all, I can totally see my emotions are totally affecting my back pain. There's nothing physically that's changed, you know?
[00:05:55] And I mean, cognitively, I, you know, I'm just a simple guy. Let's just leave that at that. So just really trying to understand like, as I've been dissecting, like why do I have so much more back pain this year? Well, because it's been a hard year. So it's finally helped me. I knew about the Pain Triangle, but I just couldn't put it into practice in a way that was really making sense to me until this last year of going, "Okay, I see why I've got a lot of back pain." Cuz there's no more physical tissue damage going on here. It's just stress, stress, stress. So kind of a good revelation in spite of it all.
[00:06:37] So the first two things I learned were the Pain Triangle and that pain's there to protect you. It's not there to punish you. It's there to protect you. If you have pain, it's like a smoke detector. I love that analogy there of, we don't want the fire, so, you know, if the smoke detector's going off and you hear it, you wanna be looking for what the real problem is and making sure that it's not there. I think that's a great example of what pain is. It's like, "Hey, you've got a big problem here. Let's see if we can figure it out before it really bursts into flame and burns the house down."
[00:07:14] I guess I'll just move on. The one thing that I go to all the time from the MMAPS class, and we were given so many tools, I've got a lot of tools in my toolbox, but the one I go to every single time, first thing as I start to have back pain is the Handful of Health. And Sharna'll appreciate this. She's the one that taught me this. And that is there's five things that we can do to change our health, to change our pain experience. And again, this is just one tool, but it's the one I use most every time. So that Handful of Health is there's breathing, drinking water, food, rest and exercise, and then thankfulness.
[00:07:59] And, and actually there's a kind of an in and out, yin and yang, kind of a thing with each one of these. So breathing is breathing in, breathe out. I would include perhaps even meditation into this one. Though it might be a little over here too. Just getting more oxygen into your body can change your pain experience. And it does for me. If I just slow down and breathe, it changes my pain experience
[00:08:24] Drinking, lots of water, and pee. You gotta pee. Pee it all out. That's the second thing. I'm always drinking lots more water. If my back even starts to twinge a little bit, I gotta go drink some more water, you know.
[00:08:37] Food, make sure that you're eating well. Obviously a crappy diet is not gonna do you well. So, you know, if you start, if you're having chronic pains, you know, persistent pain, look at your diet, you know, and then make sure that your BMs, that you're pooing nice and normal.
[00:08:59] Rest and exercise. Am I getting enough rest? Am I getting enough sleep? Or is it exercise? Do I need to stretch more? And exercise is a word that, that for, I think for people with persistent pain is a scary word. I think in America, when we say exercise, we immediately think you gotta go to the gym. At every turn we're being marketed that you've got to do heavy exercise. And one of the greatest things that the MMAPS class taught me is that movement doesn't have to be going to the gym. We can do movement in our chair. We did a lot of Tai Chair Chi and things like that. That movement. Another Sharna saying is "Motion Is Lotion" Just start moving. Walk around. Move your arms, whatever it takes. These things make a huge difference. Just a little bit of movement can make a huge difference in your pain experience.
[00:09:55] And then lastly is thankfulness and, and I would say toxicity for me. You know, what can I add to my life? And, what can I think of in my life that I am thankful for? And, and I've got a lot to be thankful for: family, job, friends. This last year sucked. Nonetheless, I still have so much to be thankful for. If I just stop and think about it. You guys, I've got you friends, you know. And then toxicity. There's plenty of crap in our lives. What can we do to get that stuff out of our life? It's just making healthy choices, even if that means removing certain people outta your life. Part of the stress I've had this year is because of people.
[00:10:39] So anyways, the Handful of Health, that's the one I honestly, I go to more than anything. And so those are the three tools. The Pain Triangle, pain is a protector, and then the Handful of Health. Those are the three things that I learned in the class that I'd love to impart. I mean, I'm sort of a, you know we're called "painiacs" or I'm kind of a pain evangelist. When you get me going, I will share with you and you just almost think that I'm freak. But I'm very happy to share these things with people and hopefully help them change their pain experience.
[00:11:17] The last thing I do wanna say is I still am taking pain meds. I still do take hydrocodone. It's like I go through all of these before I pull that out of my toolbox. Where I wasn't mindful about taking pain meds before, it was, it was my only tool. That's just, that was the go to. It was like I'm in pain. I go to the doctor and get some more pain pills and move on. Now it's the last thing on my list. It's like, okay, am I breathing? Am I getting food, and water, and exercise, rest? Am I getting going through all that? And I go it's three o'clock in the afternoon. I've got a few more hours of work. I'm not gonna make it without, at that point, I mindfully make that decision. I'm gonna take some pain medication. But, I rarely have to take pain medication anymore. So at least at this point in my life, it's finally a mindful thing. I've been addicted to it. So I'm not now. So that's my story.
[00:12:17] I hope it encourages somebody and thanks for listening.