This post is taken from Emma’s YouTube video, How to Treat Chronic Pain in the Brain, Body, and Nervous System. In the video, she is joined by Dr. Andrea Furlan, a chronic pain specialist.
Emma: Today I’m really excited. We have a special guest, Dr. Andrea Fulan. She is a pain expert and a physician and scientist from the University of Toronto in Canada.
And we’re gonna be talking about chronic pain today. We’re gonna talk about what it is and a lot of approaches to manage it.
So I’m just super excited to have you here today and your expertise.
Andrea: Well, thank you so much, Emma, for inviting me.
Emma: Yeah, happy to have you.
What is Chronic Pain?
Emma: So let’s just jump right in. Can you start off by explaining to us what is chronic pain and what do we know about it? What causes it? What’s going on with chronic pain?
Andrea: Yes. Chronic pain is poorly understood. It’s a subjective symptom and a lot of healthcare professionals don’t understand. So I know it’s hard I am a pain specialist for 30 years. So I study this, I do science around this. I see patients with this . And chronic pain is by definition, by the International Association for the Study of Pain, definition is it’s constant ongoing pain every day for three months or more. So that’s the definition. But of course when people come to see us, like a pain specialist, they have pain that is 10 years, five years, 15, 30 years, and then you don’t question, they have chronic pain, but it has to be constant. It has to be ongoing like every day.
Andrea: Yeah. And, you asked me about what causes chronic pain and what is it, where is the problem?
Acute Pain vs. Chronic Pain
Andrea: And it, it’s interesting because it’s not the same thing as acute pain.
Andrea: Acute pain is what we all feel we know. Like a toothache a broken bone, a bruise, that’s acute pain. I like to compare acute and chronic pain to an alarm system in the house. So. Let me see if I can explain this. We install an alarm system in our house. ’cause you want to alert if something is broken, if there’s a smoke fire, a burglar, right? Water leaks in the basement and you install those sensors on the wall, the windows, the doors. And we have those sensors for pain in our body and that is for pain.
So, pain is our alarm system. It’s the system that alerts us. Something is dangerous, something is broken. There is an injury. There is a disease.
If the pain system is working fine, it’s going to alert when there is an injury. But when the injury heals, because we all heal, we all form scars, unless they have an ongoing disease that is always traumatizing the tissue, but most injuries, they heal. Then the alarm system has to stop making that noise. And that’s what chronic pain happens because, in chronic pain, the alarm system doesn’t stop. It continues going on and on and on. And so the person, the pain is very real. It doesn’t mean that they’re imagining, the pain is super real, and sometimes the pain from chronic pain is even worse than acute pain.
That’s what the patients tell me because it’s so annoying. It’s constant.
Andrea: And because this alarm system it’s like almost living in a house where the alarm system is constantly making noise and it’s loud because chronic pain also, the volume is louder and they don’t know where is the fire. Where’s the fire? They call the ambulance, the fire truck, the police, they come and they say, “You must be going crazy because there’s nothing wrong with you.” And that’s what the doctors tell patients. They say, “You know, you don’t have anything wrong with your body. You must be imagining this pain. This must be psychological.” And, and it just makes the whole thing worse because now they’re not believed. They have to prove that they are in pain, which is subjective. They have nothing to show that they’re in pain. And what is worse is some doctors will give them medications that actually work for acute pain but don’t work for chronic pain. And they get all the side effects of medications and complications and they still have pain. So in a nutshell, that’s what the problem is.
Emma: Yeah. And so, chronic pain is real pain. It’s not just all in your head, it’s, it’s in your body. Is this right? That it’s part of your nervous system messaging, there’s something the matter, and sometimes that nervous system messaging, that alarm system gets stuck in the on position or something. It gets stuck messaging over and over and over again, and
Andrea: And the volume is high, which is worse. Yeah. We know we can measure this in laboratories, many laboratories around the world, they measure, and these people, actually feel pain higher. Can you imagine that?
Living in constant pain, but now they feel higher and higher intensity and their sleep is disrupted.
Andrea: Anxiety, depression are very common because they are always in a hypervigilant stage.
Emma: Mm-hmm. . . Yeah. So it impacts the nervous system, and I do, I do really wanna talk about that, but before we talk about that, I wanna see if my understanding is correct based on your expertise, which is that pain serves a function it’s not just a bad thing that happens to us in general, that, so if I sprained my ankle, I’m gonna feel a pain signal coming up from my ankle, and that’s gonna indicate to me to start walking differently, or not walk at all, like to limp or protect that area, or to avoid putting weight on that foot. And that’s gonna help my ankle heal.
Emma: So that would be when the pain system is working correctly.
Andrea: Correct. Yeah. You’re almost, yeah, completely correct. ’cause if you have an injury,
Andrea: An acute pain, you have to, you know, for a sprained ankle, you have to apply ice. We call this RICE, rest ice, compression elevation until it heals.
Andrea: The problem is, after the period, normal healing of the tissues again, we all heal.
Andrea: And then they continue feeling pain.
Emma: So in a healthy messaging system, if we talk about pain as a messenger, after the ankle heals, that message is gonna stop being sent.
Andrea: Yeah. So yeah, and it takes about, you know, sometimes it takes about some days the heal is the, the injuries is still healing.
Andrea: And the person already is not feeling that much pain, that acute pain. They feel some discomfort here and there. There might be some swelling.
But that pain, because the other thing that is important to learn is that our nervous system, the pain system has the ability to suppress pain.
Andrea: Yeah. So, we have these descending pathways, very powerful. We have this internal pharmacy
Andrea: In our brain that’s super powerful.
Andrea: It can release endorphins, which are a hundred times more potent than morphine. They release serotonin, which is the hormone for mood. They release cannabinoids, they release dopamine. So, the internal pharmacy is activated when we have pain and stress, right?
And so if a person has a sprained ankle or a serious injury, they may not even feel acute pain.
Andrea: You probably know some stories of people who, I just had a friend a couple of months ago. Oh my God. He came, I saw him and he had his hand wrapped. And I said, “What happened to your hand?” And he was pierced by a, he works in construction, and he was pierced by a nail. And he said, “You know, Andrea, what’s the most weird thing is that I didn’t feel any pain at all.”
said And they were trying to remove the nail, and it was traumatizing because it was oh, you know, around. And it affected his muscles in his hand and he said it didn’t hurt.
So, this is how powerful the brain is, even for acute pain, to release those powerful opioids, and endorphins that can suppress pain. And the person may not feel even acute pain.
Emma: So I have four kids. My first child, when I was in labor with her, I was quite nervous, quite scared, and I was in a ton of pain. And the people didn’t really believe me because they’re like, oh, you’re not even like that far dilated, whatever. And then I went from a four to a 10 in like a few minutes and it was in a lot of pain and the baby was ready to come out. But that experience, I had a lot of pain on that delivery and that labor.
With my fourth child, my labor went super fast and we’re driving to the hospital and I’m like, oh my gosh, this baby is coming. We’re like calling the hospital like, baby’s coming. Get ready. My God. Yeah, my water breaks in the car. We’re like turning the corner into the hospital and I’m like having the worst contraction ever. I’m like, this baby is about to pop out. And we get in and I’m in between contractions.
I get into the hospital bed real quick and the nurse checks me and she’s like, she’s crowning. And I’m like, poop and the baby comes out. And I literally felt zero. pain. Never had an experience like that in my life, but it had to have just been the endorphins just being like, we got this.
Let’s go. You know, it was mind-blowing.
Andrea: I tell a story in my book. I, in one of the pages of my book, I tell this story ’cause this is documented in the BMJ 1995 I think. So, what happened was there was this construction worker and he had a boot and he landed on a big nail. So, on the top of his boot, there was this nail coming out, right?
So, then he could see, and then he started screaming. They tried to put the nail down from his boot, and then he was screaming. So they had to bring him to emergency. And in emergency, in order to remove the boot, they had to anesthetize him ’cause they couldn’t pull the nail. So they couldn’t remove the boot because it was there.
So they had to give him opioids and midazolam. So, finally they could put the nail, remove the boot, and guess what? The nail had gone between the toes.
Emma: No, no way.
Andrea: There was not even a scratch on the skin. So, and then I talk about this in the brain in the book. I say, who can say that his pain was not real, but it was a hundred percent fabricated by the brain?
And then I talk about optical illusions, because sometimes a pain is an illusion, and an optical illusion is, you see that picture and you see the different shades.
But is your, is that a problem with your eyes? Is your eyes disease? No, there’s no problem. Your eyes are seeing, okay, but it’s the interpretation in your brain that is telling you this shade is darker, this shade is lighter. That’s what happens in the brain.
So with pain like that, man, his brain fabricated pain because it was seeing the injury and it was supposed to feel pain.
But it was interesting. There was no, no real pain.
Emma: How interesting, and that explains a lot about what chronic pain is, because chronic pain is not necessarily, it sometimes can be associated with, like you described, but it’s not necessarily an actual injury or damage happening in tissue. Pain is also part of the interpretation center of the brain, like that messaging interpretation center, and that can get stuck in a loop.
Andrea: Especially if there is that central sensitization in the spinal cord that I mentioned, that the brain is, the brain keeps receiving information, Emma, that there is something that’s an injury, but the scientists, they can look in the laboratory and there’s nothing coming. Nothing.
But the spinal cord keeps sending impulses. Our spinal cord it’s able to generate impulse, but the spinal cord is also able to block pain. The brain is able to activate glial cells that are there in the spinal cord. So when the synopsis is here and a glial cell is here, observing, This glial cell can be activated by the upper centers and block that synopsis.
So, a lot of things can happen.
Emma: That’s so interesting. And we’re in no way saying your pain isn’t real. We’re not saying your pain isn’t valid. We’re not saying you’re just making it up. We’re saying this is a different system. The interpretation system, the pain messaging system that is disordered, not the disc or the nerve or whatever injury is
Andrea: It’s going back to the alarms. When I explain to my patients the alarm system, I’m not saying that you’re not hearing this noise. It’s real.
But instead of looking, where’s the fire, we need to fix the alarm system.
How do I fix this pain system that is abnormal in my house? So if you have an alarm system, in your house that is malfunctioning, you’re not going to call the firetruck, the police, or the ambulance, you’re going to call the alarm company.
Andrea: So the alarm company in the case is you have to talk to someone who understands what chronic pain is. You have to talk to someone who is, and this could be physiotherapists, chiropractors, doctors, pain doctors. And because we know the pain system.
Retrain the Pain System
Andrea: So we know two things that work really well to retrain this pain system. One of them is exercise for the mind, and the other one is exercise for the body. Especially if they’re done together.
So, they need to understand what’s going on with the pain system and start moving. But they have to start very gradually, slow so, they don’t flare up and gradually increasing and they need to do any kind of exercise for the body works, but they need to mix a little bit.
And I have some videos in my channel that I talk about what kind of exercise is good for people with fibromyalgia, but basically we recommend them to do aerobics.
So, walking and increasing gradually the amount that they walk. Stretches because they tend to be always so tight. And strengthening exercise. We also know that strengthening, you know, some resistance exercise is important to build up muscles, but they have to go very gradually.
Emma: Interesting. that’s really interesting to me. And as you talk about, the nervous system and the pain messaging response, it really reminds me a lot of how anxiety works in the body too.
So, anxiety is also another type of alarm system, like those emotional alarms that set off the warning for danger outside.
And anxiety and fear is a healthy, natural, normal emotion. We’re supposed to have it, like, I want my child to feel some bit of anxiety before they cross the road so that it makes them think, oh, I should look both ways.
And when people develop anxiety disorders, their ability to determine what is a real threat and what is not a real threat gets disordered. So, everything feels like a threat. And so they avoid more things, which then their brain turns up the volume on anxiety because their brain is like, oh, I escaped that presentation. I avoided that relationship. So, now I feel better.
So I’m gonna make my human do that again. ’cause that’s why I survived avoidance.
Andrea: The same thing. The same thing with pain.
So the same thing happens with pain and we even have a name for this. It’s called the fear avoidance behaviors that they have a fear of movement.
So, we have basically people with pain, they fear the things that cause pain and they avoid them. And one of them is movement because if they put a body position in certain positions and they feel that pain, their brain will receive the message, this is dangerous. So, avoid doing that
And when they avoid, they don’t feel pain. So, they reinforce that message, oh, okay, I’m fine. So, I should not be, and then they come with a list of things that they don’t do anymore. Those are the things that I can’t sit in that chair.
I can’t carry those bags in the grocery shop. I can’t drive more than 34 minutes because if I drive more than 34, my pain starts.
So, they have all of that, those lists of things that are just conditioned behaviors,
And these are synopses that your brain made.
We need undo those synopses. And the way we show them that this is possible is by exposing them to those activities. Okay. So the physiotherapist will take you to do that activity and when you feel that pain, we don’t want you to suffer pain. The same thing. You don’t want a person to have a panic attack, but we want them to, when they are feeling that pain, now they start doing the mental exercise.
What are the messages that you’re sending to your brain? Send messages of safety.
You are safe. You are not broken. Your back has healed. You had a disc herniation 10 years ago that is gone. Disc herniations, they don’t last 10 years. Your body actually reabsorbed the disc herniation. It’s not there anymore. Oh. But I have the MRI. We don’t treat the MRI. We treat the person and you are not broken.
One of the problems that I have, Emma, is that in chronic pain, they are very fixated with the images that they see.
Emma: Oh, interesting.
Andrea: Very. I don’t think you have the same thing ’cause you don’t have a image of the anxiety in the brain what’s happening.
But in chronic pain, they come and they show me, but doctor, look at my x-rays, look at my MRIs have. And then they show me all the problems that they have and then I say, “Okay, let’s put this aside. Okay, let’s put those papers aside. I’ll look at them after. Let me talk to you first and let me examine you.”
So, when I am examining them, I say, actually, you are not broken. Actually you are. You can move, you are able to move.
Your body’s really strong. So those papers are just like gray hairs that we have. We all have gray hairs as we grow older. And actually there’s a lot of research showing that if you, MRI people who are just walking on the streets today, you were going to find a lot of disc herniations, disc protrusions, disc bulges.
Oh my God. And the older the person gets, the more common other things, but they’re not having pain. So, usually there’s no correlation with chronic pain acutely, acute pain, of course, if you’re having like a, pain shooting in your leg that just started, you do an MRI and you show a disc herniation.
Yes, that shooting pain coming to your leg is probably a disc herniation,
But chronically very poor correlation.
Emma: That is so interesting to me because what you’re saying is, part of chronic pain is learned conditioning. Right? So, if we look at these old studies of Pavlov’s dogs, Pavlov was a scientist and he trained these dogs to start salivating to a bell by pairing that bell with food and then eventually remove the food. And they’re still salivating when there’s no food there, right? That’s a nervous system and autonomic nervous system response to a stimuli that’s not usually paired.
Like usually bells don’t make people salivate or dogs salivate, right? So that’s paired conditioning or learned conditioning. And what you’re saying is that in some ways the medical model, where people are shown an image that says you are broken, you have something really messed up with you, creates this paired association with helplessness like learned helplessness.
And people believe the reason I’m feeling pain, the reason I can’t move is because look, I have this proof that something is wrong with me that is why I’m feeling pain. And you’re saying, well, acute pain, yes, but chronic pain in general, the pain, the pain system, tell me if I’m wrong on this, the pain system actually can reregulate even if there is an old injury, and to stop sending that message so much.
And the pain system will adapt and turn down the volume on those pain signals, even if there is an old injury there. But there are things we do psychologically or behaviorally that maintain that volume on that pain to be louder.
Andrea: You’re totally right. You got it. And the research is fascinating because we know all of this now. I graduated from medical school 30 years ago, and what I used to say to patients at that time is completely different from what we say now because in the last 30 years, a lot of advances in the pain science area has been because we have now ways to study the pain system.
We did not have a way before with function MRI, with imagings of this areas of the brain that activate with pain. So, we can now see what’s going on inside of the brain. When you provoke pain, when you alleviate pain, when the person says that they are in pain, when they say they’re not in pain, and you modify this in the laboratory and you see what’s going on.
So it’s fascinating.
Emma: So I wanna put out a guess here, and you tell me how close I am. I do not know what the research says on what’s going on in the brain when there’s chronic pain, but my guess, I’m gonna throw out a guess here, that it’s the HPA axis. So the, like the hypothalamus-pituitary-adrenal glands and like the amygdala lights up with like a danger response.
That’s my guess. That’s what nervous system activation is.
Andrea: The danger center of the brain and pain is a danger, but it’s not only the HPA axis,
Andrea: You know, the other one that is very much involved, it’s super interesting. I could be talking about this for hours.
Emma: I like this stuff too. But yeah. Gimme the short version.
Andrea: So, the other one that is involved is the insula.
Emma: Oh yeah. I’ve just been started to learn about the insula. Tell me more.
Andrea: The insula, which is part of the limbic system. For those of you who don’t know, limbic system is part of our emotional system. There in the middle of the brain. And the insula has a posterior and an anterior portion. And they have different functions.
I’m not a specialist in insula, but what I know is that when a person doesn’t have chronic pain and you provoke pain, like in a laboratory, they’re going to activate mostly one portion of the insula. think it’s the anterior one.
And so, and that has a function about, you know, giving the emotion what is, what the interpretation, because the brain will interpret this sensation.
That’s what the brain does. The brain will receive these sensations coming from the body. Oh, let me tell you about the sensitization. I also have to explain to you what sensitization is. Don’t let me forget that.
And the brain will receive this information from the periphery, and then the insula will interpret, of course, the prefrontal cortex, the other areas of the brain. And then the brain will decide, what do I do with this information? Do I send the firetruck because there’s a real injury, or should I count down because I know nothing is dangerous?
I know I’m looking at my foot. I see it’s not broken. So this pain will go away in a few minutes. I know it will, I had experience that it will, and so I know.
Now in people with chronic pain, when they go to these laboratories and they’re studying the insula, it activates the posterior insula.
Which has a completely different function. It is more like, the catastrophization, it’s more like the interception.
It’s more like pessimism. They tend to see the worst. So, there are now some therapies. They’re talking about insula retraining, and training these people to shift to see pain differently so then they can activate the other area of the insula.
Emma: That is so interesting to me because a training I just attended on treating anxiety. The trainer was talking about how for some people’s anxiety, it’s very much about the insulate approach. So, part of what the insula does, from what I understand is it scans the body for signals. And so, people with anxiety have a higher sensitivity in their insula are more sensitive to their signals in their body of anxiety. And then they’re gonna have a stronger fear reaction to those signals.
So, if you think about someone who starts to have like big physical sensations like fight, flight, freeze response, their heart might start beating faster, their breathing is going faster. And then they look at that, they interoception, they scan their body for those signals, they notice those signals like, “I’m breathing too fast!” “Oh my gosh, this is awful! What if I have a panic attack?”
And then they spiral into having much worse symptoms of anxiety and then sometimes do have panic attacks or they’re like, “Oh my gosh! I can’t allow my body to feel this way. I must avoid leaving the house so that I don’t feel this way.” And that insula, that body scanning is much louder in some people, it’s anxiety sensitivity index like is much higher for some of those people.
Andrea: Yeah, exactly. The insula will do the same thing for the person in pain because they will receive those messages, those interception messages, and they will, because pain always activate the stress response. They’re connected.
And so if they’re in pain, pain is a stressor and pain will activate the adrenaline, the cortisol, so they will have the rush and they will feel their heart racing, their stomach upset.
And that will just spiral. It’s almost like a panic attack.
But I wanted to tell you about sensitization because a lot of people don’t know that. In the spinal cord, right where the neurons, so if you remember a little bit of anatomy, so those sensors in the body, sensors coming about pain, sensors about you know, the tendons, the skin. In the skin we have a lot of sensors, lots very specialized for pain.
And so, they’re bringing messages of pain and they enter in the spinal cord. In the spinal cord, they make a synopsis there that goes to the thalamus, and then the thalamus distributes to the all areas of the brain that should be informed, right?
So in the spinal cord, we always thought that that’s just a relay of information. It’s just a synopsis. You know, one neuron talking to another one and sending the information up. No. The spinal cord, that area where that synopsis connection happens, does a lot of things. To the point that that synopsis can be modulated. So, it’s almost like a mini brain that happens there.
We have the, we have cells, glial cells that control the synopsis so they can shut it down, they can activate, they can make it go faster. They can make it go slower, this connection.
And one of the things that happens in this synopsis is sensitization.
We call the central sensitization that this synopsis can, in the absence of peripheral sensations coming, it can activate itself. Let’s say that the person had chronic pain or they had pain, pain, pain, acute pain for a couple of weeks or months and they were stressed. So, there was this sensation coming in the spinal cord that modifies that spinal cord synopsis, and now you don’t need this impulses coming anymore from the periphery, but the synopsis keeps sending information.
It’s called central sensitization, and we know that if you give opioids to that person, opioid will make that central sensitization worse.
Andrea: Yes. And so that’s why some people when they take opioids, you notice that the pain starts spreading, more constant pain and they are still taking opioids, even large doses, and they’re still in pain. And you ask them to paint. We ask them to paint in a pain diagram. Can you paint in this diagram where I do a feel pain and they feel pain in areas that are spreading to their body.
And they have sensitization like sensitivity in the skin. And actually the treatment is if we can help them to lower the dose of opioids, you can see the pain sometimes getting better. Sometimes the pain doesn’t get better, but they feel more alert, they feel more awake, they feel better overall because they’re not having the side effects.
Treatments for Chronic Pain
Emma: Okay. Should we jump into talking about a few more treatments for chronic pain? Like what some of the options are? You’ve already mentioned exercise as being helpful, especially if it’s gradual and gentle and slowly building up. Right?
What else can people do for chronic pain?
Andrea: So in terms of exercise, we always recommend water-based. If they can do water-based exercise, that be even better because then they will be doing all those forms of exercise. The water also helps them to relax. The heat, if the water is hot, they can also relax the muscles. Yeah, so exercise is one of the mainstream that we have to regulate the pain system.
The other ones are mind body exercises, so we do have mindfulness, meditation, vagus nerve exercises, all of those are very valuable, but I would recommend them also to do this. And there is new evidence that you do this in the context of a pain neuroscience education.
It’s called PNE, Pain Neuroscience Education.
So if you explain to the person why they’re doing this to retrain their pain system, they’re more motivated, they will be more engaged with those exercises. They will see the benefits that they’re more tolerant to pain instead of just doing the exercise for the sake of doing it.
So. you do those meditations. Also, journaling is great because when they journal their emotions, what they’re feeling, they might see that they are catastrophizing. They might see that they are having an overactive reaction to something that is minor.
You need to show to them that MRI, those x-rays are not so bad. They’re normal for the age. They are part of being human.
You know, I tell my patients I’ve never seen my whole life, never. Someone especially above 40 or 50 years of age who has a normal MRI.
So, it doesn’t exist. So, learning all of this and doing those exercises, relaxation and connecting the mind and body is so important.
Emma: So, I’m fascinated by this idea of the Pain Neuroscience Education because basically that’s the foundation of hopefulness. So if you look at positive psychology, Martin Seligman identified this idea of learned helplessness, which is this idea like, oh, this is permanent, this is chronic pain, this is never going to go away.
Or like people say, oh, I have this, you know, disc problem and that’s why I’m in pain. And that is the learned helplessness side of it. And when you do that education, what you’re basically doing is saying, Hey, let’s be a little bit more flexible in our thinking. Let’s be open to this idea.
Like, what if chronic pain could change. Like, what if it’s not as rigid as you think? And when it comes to mental health, I’m doing this all the time because people say, well, I have depression. So I’ll be like, oh, let me teach you a skill that’s helpful with depression. And someone will say, that’s cool Emma, but I have clinical depression, so you know, all I can really do is cope.
And this idea that’s out there is because we’ve educated people so much about like the reality that depression is a disorder. It’s not just in your head, it’s not a weakness. But people have taken that one step further to saying, well, depression is permanent. This is a characteristic of me. This is something that will never go away.
And that’s not how mental health diagnoses work. Mental health diagnoses are a description of the symptoms that you have. And we describe these symptoms in a cluster so that we can all talk about the same thing. And we can educate people and researchers can do research and we can study medications that work, but it’s not like when you get a diagnosis of depression or an anxiety disorder that that’s saying like, this is something you have and you are, and you always will have, and saying, this is what you’re experiencing right now.
It’s real, it’s legitimate. The chronic pain they’re experiencing is real. Like it’s not just in their head,
Emma: But the learned helplessness aspect of this is this is permanent, you know, or it’s rigid thinking that says, oh, my only treatment options are like surgery, medication, medical treatment. With chronic pain maybe, or with mental health, my only treatment options are medication and just coping. And it’s like, well, there’s actually a lot more like, let’s just be flexible in our thinking about this. Right?
Andrea: Yeah. So, in chronic pain is the same thing. In chronic pain, they also come to me and they say, well, but I have this as a chronic disease. It’s arthritis or it’s you know, neuropathic pain and I’ll have this for the rest of my life. I just learned how to live with this. It might be true, Emma, that because there are three types of pain, nociceptive chronic pain. Let’s say that they have an ongoing injury that is always, you know, damaging their body. There are some diseases that are really nasty, like rheumatoid arthritis if it’s not controlled, it’s always destroying the joints. They need to take anti-inflammatories or the biologics. But if they can’t, then they’re going to suffer always some type of acute pain. Neuropathic pain is the second type of chronic pain that they have a nerve injury. And that nerve injury may be always triggering some impulses to the brain.
So, they have that constant impulse. And the third type is nociplastic pain, which is the name for this pain that we just described. That is the malfunctioning of the pain system. So, sometimes they have mix, they have a chronic neuropathic pain, but they also have some component of chronic nociplastic pain. So I tell them, for the neuropathic pain, you’re going to have this forever. Like let’s say it’s a diabetic neuropathy, that the diabetes damage your nerves. You have these burning sensations in your feet or your hands. This is not going to go away. And medications for neuropathic pain, they’re good, but they don’t resolve a hundred percent. So maybe the person would need to cope with that pain.
But in addition to that neuropathic pain, they have that nociplastic component. Like, they have the fear of the pain, the paralyzing, the catastrophizing, the anxiety related, that pain, the movement the fear of movement, the depression, the anxiety, the panic attacks every time that they have a flare.
So, for that one, there’s a lot that they can do. And the best results that I had in those 30 years of experience with my patients are the people who actually, they learn how to do self-management.
They learn lifestyle modifications. They learn about their condition, and then they change the way that they see pain, the way that they communicate pain with others, because chronic pain is very lonely.
They suffer alone. People don’t believe in them. Some physicians will not even believe in them and say, oh, I don’t know what’s going wrong with you. I operated your knee. So, some surgeons will tell them, I operated your knee. Look at your X-ray. It’s perfect. I did a good job. I don’t know why you keep having pain.
And so they feel abandoned and then they can’t communicate well even with their families. At work, it’s a nightmare because they need accommodations. They’re stressed. Their managers don’t know what’s going on.
Why do you ask accommodations? You look so normal.
Emma: Yeah. That could be very isolating and, and make people feel maybe more shame or more stress, which is gonna accentuate that nervous system reaction. Right?
Emma: Yeah. And you mentioned lifestyle changes and, and I know there’s a couple of those like sleep and nutrition. Can those be helpful with chronic pain?
Andrea: Yeah. So I just wrote a book, 8 Steps to Conquer Chronic Pain, and the eight steps are basically lifestyle modifications. I talk about the first step is retraining your pain system. So, learning about this, what’s going on. The second one is, how you handle your emotions, because emotions can really activate everything. And then I talk about sleep, nutrition.
I talk about exercises because a lot of people don’t, they don’t even know that they’re malnourished. Malnourished doesn’t mean that you are, you know, [inaudible] underweight. A normal weight person and even overweight person can be malnourished.
Because they lack the essential ingredients. They’re not eating well. And for chronic pain, we need our omega threes. We need our vitamin B12. We need vitamin D, we need, you know, the magnesium. Those are things that if you don’t ingest in your diet, the amino acids that will make your serotonin, your dopamine, if you don’t ingest them, your body doesn’t have where to take them from because omega threes are essential fatty acids. And if you don’t ingest them, the body’s not going to make it. And I’m not a big fan of supplements. I don’t like supplements. I think a healthy diet is all you need.
Emma: Yeah. But I would agree with that and I think there’s, there’s some real problems with the supplement industry and the way people use supplements. So, it’s definitely ideal that people can get the right foods from their diet. I mean, right now, for example, magnesium’s very popular, but yeah, you can eat like a quarter cup of pumpkin seeds, more nuts and leafy greens in your diet, and that can, can really help.
Okay. Well that’s, that makes that those all sound really helpful and I’m excited about your book. I wanna give more people more resources to send them to,
That’s awesome. So let’s talk about medication for a minute. Can you tell us like, what people should consider when they’re thinking about medication for chronic pain?
Andrea: Yeah, so the five Ms that I tell people are mind, body, movement, manual therapies, modalities, like things, heat and cold and tense machine, and then medications. I always mention medications the last because I say if you do all this for you may not need medication,
But some people need, especially if they have chronic pain from a nociceptive origin, like I mentioned, rheumatoid arthritis.
If they have rheumatoid arthritis, probably they would need medications to handle the inflammation. If they have neuropathic chronic pain, they probably need some anticonvulsants antidepressants. That’s the way we know how to calm down the nerves and the nerves that are firing from, you know, the diabetes or the alcoholic neuropathy.
Neuropathic pain are things like pain caused by the damage to the nerve system, alcohol, diabetes cause a lot of damage to the peripheral nerves, but stroke, multiple sclerosis, spinal cord injury that cause damage to the central nerve system. Now if they don’t have a nociceptive pain or neuropathic pain for neuroplastic pain, we don’t have a lot of medications actually that retrain the pain system.
We do use medications in that situation if they have a comorbidity, like if they’re too depressed, we use them antidepressants. If they are too anxious and can’t sleep, we use some sleeping medications and opioids we try to avoid for nociplastic pain, but we might use for people with nociceptive and neuropathic pain in low doses, more like an emergency situation for a short period of time if they have like a setback or if they have a flare, then okay, you’re going to use this for a couple of days. But we try to avoid chronic use
Emma: Yeah, that makes sense. Makes a lot of sense
Andrea: and anti-inflammatories and acetaminophen, we tend to keep those for more, more for the acute pain,
So if a person has an acute injury like a toothache, then those medications are really helpful because they will reduce the inflammation. But for chronic pain, there is no chronic inflammation that will get better with anti-inflammatory.
So that’s why people with chronic pain, they say, they tell me I take so many Advils and it doesn’t do anything to me. I said, because you don’t have the inflammation, the inflammatory response right now.
Emma: Yeah. Interesting, interesting, interesting. Okay, well that’s just really fascinating.
Where to Send Patients for Help with the Mental Side of Pain?
Andrea: So I’d like to ask you, because my audience is also going to see this video, and I talk a lot about, you know, the emotions, how they affect the pain system, how they affect pain. So, I’d love to hear from you. Now it’s my time to interview you a little bit.
So if a person has anxiety and we all, you know, we all have our stressors in life and we overreact, what is that you would recommend for someone who is in, let’s say they have chronic pain and they also have anxiety, what would be something that they can do for themselves, like at home? Some breathing, exercise, short meditation, and where should, where can they go? I find that it’s so hard for them to access care because it’s expensive.
Emma: really expensive.
Andrea: It is hard to find. Then I never know if I’m going to send my patients to a psychotherapist and they understand chronic pain. Because if they don’t understand, maybe they will tell my patients, oh, all you can do is cope with chronic pain.
But actually, if they don’t understand the Pain Neuroscience Education, if they don’t understand this concept nociplastic pain, they may not be helping the patient fully.
I would like to send my patients to some psychotherapists that understand the pain neuroscience, that understand what pain does to the pain system. All these modifications that it costs so they can help the person to revert.
So what would be your advice to my audience?
Emma: Yeah, so it’s a good question and in full disclosure, I’m not a chronic pain specialist. But I have been learning quite a bit about it and I can suggest a few approaches that do have some research backing to them. But, okay, here’s the first thing. The type of therapist you see does matter.
So if you go to a therapist or a psychologist who specializes in CBT, they are mostly just gonna work on your thoughts, and that can be an effective treatment for chronic pain, like, the types of thoughts that we think that accentuate pain or like increase that pain spiral or continue to send, reinforce that message to the nervous system that I am in danger are thoughts like catastrophizing or black and white thinking.
So catastrophizing is like, oh my gosh, this is awful. I’m never gonna be able to do anything. This pain is never going away. If I feel a little bit of pain, it means that I’m gonna feel more forever. And so that kind of thinking can be challenged and adapted to be more healthy thinking. You can consider that, you know, you can consider different approaches thinking and I’ve got a lot of videos on things like that on my YouTube channel.
I have an entire course called How to Process Emotions. It kind of walks people through both the mind and body of like understanding emotions and how you think. So, that’s what a CBT therapist would do. And I would say on average that’s what many therapists practice. I use more Acceptance and Commitment Therapy and I use a trauma-informed, body-based somatic approach as well.
So in Acceptance and Commitment Therapy, one of the big approaches I would work with people on is willingness. So, willingness is the opposite of struggle. So when we scan our body or we scan our emotions or we scan our thoughts and we see something there that we don’t like, it’s uncomfortable. So pain for example, is uncomfortable and is anxiety.
Anxiety is uncomfortable, sadness is uncomfortable. Guilt is uncomfortable. I don’t say that these are negative emotions or negative sensations. I say these are uncomfortable. Our tendency with these uncomfortable emotions is to try to suppress them, to distract ourselves, to avoid them.
Like you said, people often stop moving or to you know, catastrophize in our heads about them or to label them and judge them, this is bad, this is awful, this is terrible. And all of those responses, instead of decreasing the pain, they actually accentuate it. Or instead of decreasing anxiety, they just inch it up a little bit and they create a cycle where that goes up and up and up.
So with Acceptance and Commitment Therapy, the critical skill is willingness. And if you google my channel, if you search, you know, Therapy in a Nutshell, willingness, I’ve got about eight videos on this, and the main idea is when you notice that sensation, you use a non-judgmental attitude. So, you can describe it.
Ooh, this feels stabbing. Ooh, this feels tight. Ooh, my stomach feels upset. And you use describing language instead of judging language. So it’s very different to say, oh, this is uncomfortable. This feels tingly. This feels burny than it is to say this is awful. Right? So, you create some space with your language and then you say, I can be really curious about this.
I can allow this sensation to be here, and I can also scan my body for other sensations. So, like if I’m having a lot of pain in one area, or if I’m having a lot of anxiety, or I’m noticing my stomach upset, I can scan that anxiety, I can scan that pain and be like, okay, I’m gonna notice that I’m gonna make space.
I’m gonna allow that to be there. I’m gonna remind myself that I can handle this. I can allow myself to feel these feelings. And I’ve got some exercises on that. One of them from Steven Hayes’s book, Willingly out of Breath, where you literally practice holding your breath until it’s uncomfortable then creating space to notice that discomfort and just practicing like distress tolerance basically.
So that’s willingness. I could talk about willingness all day. I’ve got about 10 videos on it, but you create emotional space and all that does, let’s say your pain is at a five when you come in, or your anxiety’s at a five when you come in, instead of saying, oh my gosh, this is awful. I can’t handle this, which takes the pain up just a little bit.
You say, okay, I’m gonna make space for this. And sometimes that keeps your pain or your anxiety right at the same level, and sometimes it takes it down. But what it doesn’t do is accentuate that cycle. And so, you can kind of interrupt that cycle of like being anxious about anxiety, being afraid of fear, feeling ashamed about being ashamed, right?
And you just take that pain level or that anxiety level down a notch.
Those are the skills from Acceptance and Commitment Therapy that I think are really valid. And then I could talk more about like some somatic treatments for nervous system stuff, if you’re interested.
Andrea: Somatic tracking.
Emma: Yeah. So, like, like trauma therapy takes there’s a lot of approaches to trauma therapy too, and some people do a cognitive behavioral approach to trauma therapy and some people use, you know, Acceptance Commitment Therapy. But my favorite approach is really nervous system informed.
There are trauma practitioners out there. You could look for them by searching for someone who does somatic therapy and they teach people how to reregulate the nervous system. And so, someone might practice, you know, or learn about polyvagal approach and using the vagus nerve to regulate the nervous system. And the first part of that is kind of awareness.
Like let’s be more awareness about our nervous system states. There’s the activated state, the sympathetic state there, or well above that is the calm relaxed parasympathetic state where you’re relaxed and gentle and socially engaged. You feel safe and secure. And then when you’re in fight or flight mode, that’s the sympathetic activated state where you’re more tense, tight. The inflammation response happens there,
And then the lowest level of the polyvagal state is the shutdown response. The collapse response, where kind of you turn, you go back to a parasympathetic response, but it’s not a healthy one. It’s more of like a closing up, locking down, giving up, feeling hopeless, and not a lot of healing happens there.
So, the first step with, you know, somatic treatment really is gaining a little bit more awareness. What state am I in? And with chronic anxiety, with chronic pain, my assumption is that a lot of people get stuck in that second state, that sympathetic arousal. And so, when you become more aware of that sympathetic arousal, you’re constantly vigilant, you’re constantly tight, you’re constantly tense, you’re constantly jumpy, you’re constantly anxious or in pain.
Then when you’re aware of that state, you can use body-based treatments to relax your nervous system and to remind your nervous system that you are safe right now, to go back up into that safe, social, relaxed state. So if you want, I can show you one of those or I can just direct your audience to my channel.
Andrea: Amazing. Yeah, I think we can recommend. Can you do a demonstration now?
Emma: Yeah, a lot of these just take a moment. So, I’ll show two. I mean, obviously most people know about diaphragmatic breathing. So, I’m not even gonna describe that one because it’s really powerful, really effective, and go watch any video on it and learn how to move your belly when you breathe.
But one that I will show that’s kind of my new favorite is and Peter Levine teaches this. He’s a somatic practitioner, and he calls it like a big foghorn. Like if you hear a boat in a harbor and it makes this sound, this is the sound we’re gonna have you make.
So you breathe in gently, and then as you breathe out, you go, Ooh, you make like a voo sound long and slow.
And as you do that, a couple things are happening. You’re breathing with your belly, you’re lengthening your outbreath, which also triggers that slowing of the heart rate. And the slowing of the breathing sends a message to your nervous system to calm down.
And when you vibrate your vocal cords like that, when you hum, it stimulates the vagus nerve, which sends vestiges in both directions.
It sends it from the body to the brain and the brain to the body about whether to be activated. It stimulates that vagus nerve to trigger the vagal break or the parasympathetic response to soothe your nervous system. So that’s one of my new favorites is the voo breath.
Andrea: I think my family is going to hear that noise a lot now in the house. Thank you so much, Emma, for teaching those strategies. I think people need to learn those things that they can do for themselves. And then they see the results ’cause what happens is once they see those small changes and they perceive, you know, their heart is slowing down, they’re less stressed, and therefore the pain is less intense,
That’s how they learn. The same thing they learned that walking a little bit is safe.
And then they say, you know, I started walking 10 minutes. Now I’m walking 15 minutes, and then I’ll increase to 20 minutes because I feel safe. And that’s what we want them, because we don’t want them to be paralyzed by the fear of pain.
Emma: Right? Yep. Because that just takes that pain up a notch, and then the nervous system just gets more and more activated. Right?
That’s so cool. And I really do love your hopeful approach, your hope-based approach. Not hopeful, like, oh, we could just try. No, but you really believe and you understand that when we learn these skills and strategies, you can really decrease your chronic pain, right?
Andrea: yes. Yeah, they can. They feel less pain. They feel they have more days without pain.
This works great for migraines. This works great for irritable bowel syndrome, people who have abdominal pains, chronic pelvic pain. There is also temporomandibular joint pain.
Of course fibromyalgia, complex regional pain syndrome, CRPS, phantom pain. Because phantom pain is another type of nociplastic pain. You feel pain in an area of the body that doesn’t exist anymore,
So, they can retrain their pain system to normalize again. It works great for chronic low back pain, chronic neck pain, and chronic pain affects one in five adults, so it’s lot of people.
It’s super interesting. The brain can change, it’s neuroplasticity and it can change for good or for worse.
Emma: That’s right. And if we learn the skills to adapt to, to maximize on neuroplasticity, we can actually rewire a lot of things like anxiety and chronic pain, right?
Andrea: Yeah. So the person can relearn. and there’s no age, Emma, where there’s a limit. So, some people say, oh, I’m too old to relearn and learn something. I had people 90 years old that they were able to change their thinking, exercise, include some movement in their life, recreation.
They were less lonely, they were more social. And they tell me, I still have some pain, but it doesn’t bother me anymore. I know to handle. It doesn’t control my life anymore. They’re so happy they come to me and they say, I just came here to say goodbye, Dr. Furlan. We don’t need you anymore.
Emma: That’s the best. I love it. That’s awesome. I believe in it too. I’m sure of it because I’ve seen it too. So, that’s great. Love the work you’re doing. Where can we find you?
Andrea: Yeah, so my channel, Dr. Andrea Furlan that’s the easiest way to find me on YouTube. And my book is Eight Steps to Conquer Chronic Pain, A Doctor’s Guide to Lifelong Relief. And so, people can find me any bookstore where books are sold.
Emma: Sounds amazing. Okay. Thank you so much. Really appreciate your time. Good talking with you.
Andrea: The same here. I love talking to you.
Click below to check out Emma’s course, How to Process Your Emotions.