Wellness Coaching for Chronic Pain: Part 1 - The Science

Ani
Hi, and welcome to the Somatic Coaching Academy podcast. Good morning, Brian. 

Brian
Good morning, Ani. How are you today? I'm doing great. How are you?

Ani
I'm really good. I'm excited for today's podcast. What are we talking about?

Brian
Well, this podcast is part one of a two-part series that people have been asking us to do and that we've been promising to do for a while. So I'm really excited. Now we're actually doing it. What are we doing? So we're doing wellness coaching for chronic pain. This episode is great for, well, obviously, health and wellness coaches, but also rehabilitative therapists, mental health professionals, coaches, anybody who's coaching with people. Oftentimes, people's bodies have experiences that they would call painful for a prolonged period of time. This podcast episode is for you. This is episode one, The Science. Then next week, we have Wellness Coaching for Chronic Pain episode, part two, if you will, part two, which is the Practices.

Ani
Great. And it sounds like it's also going to be good for anybody who's ever experienced pain. Absolutely. I don't know if any of our listeners can relate to that, but probably everybody.

Brian
Yeah, most definitely. So this topic is really near and dear to my heart and my body also and my life experience. Spent a lot of time in my life not only studying these things and working professionally with people experiencing chronic pain, but also my own life experience.

Ani
I know you love the science anyway, but did you really dive into the science of chronic pain when you were treating patients with chronic pain, or was it really more of a fascination once you started to have pain stuff? Or maybe it was... 

Brian
Well, it's a little bit of both. But at 14 years old, I had my first back pain episode. I was lifting weights, and I was really, really pushing myself hard. Around that same time, I had lost my grandmother. My paternal grandmother died of cancer right around that same time in my life. Those two events of her dying and also me really overdoing it physically were definitely combined with one another. Now, I didn't realize that at the time. Sure. That was actually a coping mechanism I was using to deal with the massive pain of losing her. She was so important to me in my life. I had that back pain upset at 14. Then I actually developed chronic back pain after that. It's really young. Yeah, very young. It's really young. Yeah. From the ages of 14 to 41, so about 27 years, I experienced episodic episodes of chronic pain flare-ups. I would go between them for periods of time where I'd feel okay, maybe even good. Then also periods of time where I was just not feeling great, but not totally laid out either. But basically, the way that it worked is between the ages of 14 and 41, once, twice, maybe even three or four times a year, I would end up with something that would happen, and I would just be completely laid out.

Brian
So much spasm in my back I couldn't get up. Awful pain. I'd be on the couch. I need help getting out and off the toilet. I need help in and out of the shower or tub. I couldn't reach down and tie my shoe, those kinds of things. Anybody who has experienced chronic back pain knows what I'm talking about. You're literally debilitated and crawling around on all fours, that stuff. That was my life for 27 years, through college, through my young adult life. Even though I was an active person, I did a lot of things in the outdoors. I still have these episodes of really horrible back pain.

Ani
Do you think that influenced your decision to want to be a physical therapist?

Brian
Absolutely, I think, very early on. I was always interested in the body. I was always interested in physical health and wellness and sports and all that stuff. And I also had that combination of, wow, and I also sometimes don't feel really great in my own body, and I can't actually do things and that stuff. And so I would say subconsciously, it wasn't conscious awareness, but I think in some ways it was like, oh, and maybe I can figure out how to help myself.

Ani
Yeah. I mean, I know you were interested in the body and medicine kinds of things since you were very, very young. So I can imagine that influenced your decision.

Brian
Yeah, for sure. So when we start this conversation, so for me, I had those early experiences of this really horrible pain that lasted a long time episodically. I went into PT school, started to learn a little about it. But even in PT school, you don't learn much about it. You learn about the nervous system. And I think about my very first job out of school was actually at Buffalo General Hospital. And my first job in my first job was in the outpatient clinic. Actually, I take that back. That was my second rotation within the hospital. I first worked on the inpatient orthopedic floor with a lot of hip and back surgeries or knee surgeries and that stuff. And then my second rotation was outpatient therapy. And I can still remember, had a lot of people coming into an inner city hospital with back pain. And of course, what we learned in college about how to treat back pain was to get the body stronger, strengthen the body, strengthen the legs, strengthen the core. By the way, the core strength exercise we learned at the time weren't really core strengthening exercises. And I can remember clearly a couple of patients, very clearly, that were in terrible pain during their therapy because I was taught to push them.

Brian
And now, it's like, I wish I could find them and send them a letter or say something, Oh, my God, I'm so sorry. I didn't know better. That's what they taught us. And by the way, that wasn't working for me either. But I just thought there was something wrong with me that the strengthening exercises weren't working on me because I was still having back pain. Sure. It makes sense. So I thought, Well, this is what they're telling me to do, so let's go ahead and do this. And now we know so much more. We know so much more about pain itself, and that's what I want to dig into in this episode.

Ani
Was that the impetus for you trying to find out more about pain science when you realized that what you were doing with the patients wasn't really working? What was the impetus?

Brian
I wish I would say yes, but it took me a long time after that. Oh, really? Yeah, it still took me a while. I went on to work at Craig Hospital, which I've talked a lot about in our podcast, which was an amazing experience. But even then, still didn't really understand a lot about what causes pain. Because what we were taught, what I was taught in school, and what a lot of people are taught in school, is that if you have pain, it's because there's something wrong in your body. It's a disc problem, or a facet problem, or a torn muscle, or whatever it is, fill in the blank. I'm not saying there's not truth to that because sure, if you fall down, bang your knee, you get a bruise on your knee, that's probably the source of whatever sensation is that you're calling pain. I mean, that would make sense. But what happens after the wound heals, what happens after the bruise goes away on the knee, or what happens after the muscles mend themselves, if you're still having pain after that, then is it still associated with the body reason for the pain? And since that's what we thought it was, we started to go, maybe the tissues aren't healing.

Brian
Maybe something else is going on. Maybe we need to chase this around. Maybe there's something going on with the nerves. Maybe there's something else. And I spent a lot of time chasing pain around people's bodies, and chasing pain around my own body, by the way, too, with little, very little effect of actually being helpful. Right.

Ani
I think It's interesting that you were also having the experience as the practitioner, because when I was treating patients with pain back in the system, I didn't have pain symptoms. I don't think I really was able to have the same inquiry and understand the experience as you did. I don't think I questioned it quite as much. Part of the reason I'm saying that is because we've talked to so many practitioners that when we introduced the new science of pain, I mean, these are seasoned practitioners most of the time, too. They're thinking like, Why didn't I hear this? Why didn't I learn this in school? Why am I just hearing this now? This makes perfect sense, of course. Then it actually works when you do it with the clients. But I think for myself as a practitioner, I think that's one of the reasons I didn't question quite as much what was going on, because I was not having the same experience. I went to my job, I did my job, I did the things I learned in school, and I liked that application of it, but I don't know that I was really questioning the way that you were.

Brian
Yeah. And part of that, too, I always had this, I guess, I would say imposter feeling, too, because people are coming to me to help them with their pain, and I'm like, I can't even help myself. So I'm not sure why I'm telling you what to do. So there was always this level of discordance within myself that I needed to resolve. And I think that was also part of the reason why I kept being motivated to learn more, because I felt like I was out of integrity a lot of times. I was doing the best. I was doing what I was taught to do, the best thing I knew to do, but it wasn't even working for me.

Ani
I know you have a lot of science to bring to us, but I'm curious that moment when you finally figured it out that you were like, Oh, there's something different that I'm doing that now I can bring forward. Do you remember?

Brian
Yeah, I will. Actually, I'll tell you that part of that story as we go through the science, actually, because I've got a couple of interesting touch points as we go through the science. Great. So one of the things that really helped to flip our research, flip the research, flip the understanding, flip the mindset around what pain actually is. It was actually a phenomenon called phantom limb pain, which if you're not familiar with phantom limb pain, it's when someone has an injury to a foot or a hand, and the injury is so bad that the hand or the foot can't be salvaged, and then the hand or the foot is amputated, and the person who has the amputation still feels the pain in the hand and the foot that's not there anymore. So it's not that they feel the pain at the end of the appendage where the amputation happened. They actually feel the pain where it was, out in space.

Ani
I remember I only treated one person in my clinical career who had phantom limb, and I still remember exactly where I was and them, because it was one of the most fascinating moments of my clinical career to see that actually happening. I read about it, I learned about it, but to see it was wild.

Brian
As someone can describe all the things going on, what is going on out in space. And unfortunately, the very first people who experience phantom limb pain, a lot of veterans coming back from wars and that stuff. And they're explaining this phenomenon of phantom limb pain. Of course, at that time, the science was, wait, you can't have pain unless there's an injury in the body. So unfortunately, people- So now what? So these people were put on psychotic medications, were drugged, were medicated because they thought it was some type of psycho-somatic thing that was happening, and that was a mental disorder. It was a mental disorder, yeah. I just go back and I think how sad that is because now we know exactly why people experience phantom limb pain. When I bring up this idea of phantom limb pain, when I teach and travel, one of the things I let people know is I say, Listen, there's four types of sensors in the body. We talk about the body being sensory in and motor out. Sensory information comes into the spinal cord, into the brain, and then the brain and the spinal cord can create a motor response to the sensory input.

Brian
There's always this sensory motor loop going on all the time. There's sensory information coming into the nervous system, and there's four types of sensors. There's mechanical sensors, mechanical, temperature, chemical, and nociceptive. Mechanical signals bring in light touch, heavy touch, those kinds of things. Temperature brings in hot/cold, chemical brings in acid base, and nociception brings in...

Ani
I don't know. I can't see it. You got to tell me.

Brian
Well, what I was taught- You get it? Yeah, I can't see it. Nosy? Nosy, yeah. Okay, you got me.

Ani
That's why I was over here. You're smiling.

Brian
You're waiting for that? Okay, so I can't see them either. What we were taught in school is that the nociceptors were pain receptors. But now we know that's actually not true.

Ani
Yeah, I was taught that, too.

Brian
Because if that's true, then how do you explain phantom limb pain? How can you explain people experiencing pain if there's no receptors at all anymore in the region while they're experiencing the pain. We know nociceptors are actually what we call danger receptors, tissue. The brain needs a way to determine whether or not there's going to be damage to tissues. That's what the nociceptors bring in. They can bring in all kinds of different stimuli, and oftentimes it's noxious stimuli, but that's different than pain. There are no pain sensors in the body. That's the very first thing when we talk about new pain science that we really have to embrace and really realize and understand that there are no pain sensors in the body.

Ani
When we talk about this every time, it reminds me of how long it takes for academia to catch up with new science. Because we've been teaching this for, what, 15 years or something? You probably learned about it even longer than that. But it takes a really long time for academia and the things that we teach all the professionals in college to catch up with new science. And I think it's important that we remember that whatever practitioner we are, it's not that when we hear this stuff, it's wacky or woo or whatever. It just takes a really long time to catch up.

Brian
To catch up, exactly. So when we know there are no pain sensors in the body, when I say that to people, people are like, Well, then what's pain? How do you explain that? What's pain, actually? We'll look at this, go a little bit further with the story. The sensors do bring information into the nervous system, remember. You're going to have sensory information coming in the nervous system. Now, the very first place that the sensory information, in other words, if I'm touching my finger, if I'm squeezing my finger or something like that. That information is traveling up my arm and then into my spinal cord. The very first place that it synapses is in the spinal cord. At the spinal cord, there's something called the dorsal root ganglion. We say it's the most distal part the brain or the most distal part of the central nervous system. It's really where the peripheral nervous system, the central nervous system meets. There's a gap right there, what we call a synapse. At that synapse, there are sensors actually at the synapse themselves. At that synapse, the sensors can be what we call upregulated or become more sensitive. If you have a constant stimulation coming into the system, we also have to remember that the brain has no direct experience with the outside world.

Brian
Exactly. We talk about it as being the CEO locked in a high tower of an organization. With no windows. With no windows. It literally has no direct experience with the world. Everything that comes into the processing parts of the brain comes through at least one synapse, one connection. At those synapses are where information can be modified or changed as it comes in. It's almost like- And summarized. And summarized. It's almost like if you were the CEO of an organization, and the only way you can get information is through your administrative assistant, and only the administrative assistant can walk through your door. Everybody else in the company, when they want to talk to the CEO, they have to talk to the administrative assistant, and then the admin assistant brings it into the brain, into the CEO. Then the CEO is making all their decisions based on that information.

Ani
And by the way, there could be assistant upon assistant upon assistant bringing all the information to the next person, to the next person, to the next person.

Brian
Correct. Yeah, exactly. And what if that admin assistant is having a bad day? Are they going to deliver the information clearly and accurately? Probably not. And then the CEO is going to get inaccurate information and then make decisions based on inaccurate information rather than real information.

Ani
And what if they've heard this story every day all the time?

Brian
And they're in it again. All right, do it again.

Ani
So the story that took an hour to tell the first time they went into the office. Now it's like five minutes or five seconds.

Brian
That's the bottom line. Exactly. If we come back to this pathway, if I'm squeezing my finger and I've got information coming up, if my finger is being being squeezed for longer than customary, longer than it would normally be squeezed, then my brain's like, What's going on out there? I'm getting sensory information coming in that I'm not used to getting. If it's a little longer or a little more intense than it's customary, the brain will go, I need more information about that. I need more information. How does the brain get more information? A couple of ways. Number one, it actually upregulates the sensitivity in the system. Now, it makes it more sensitive. Yeah, it makes it more sensitive. I'm squeezing, let's say, with 2 pounds of pressure on my finger, and I'm doing it for longer than it's customary, my brain's like, What's going on out there? It upregulates the system to make it feel more sensitive. Now, that 2 pound squeeze feels like a 10 pound squeeze in my brain. The squeezing hasn't changed, but the sensitivity to it has changed. That's one way. The other thing the brain can do is actually lay down more sensors in the area.

Brian
When I'm squeezing under my finger, actually, let's say there's 100 mechanical sensors sensors in that area, they can spread to 150 or 200 sensors in just an hour or so. Wow, that quick. Yeah, that quick. You can actually change the number of sensors in that area, which again makes it more sensitive. You're also upregulating the sensory flow of information if it happens, again, longer than it's customary. When that comes in that dorsal ganglion, every time you have a sensory information come in, you have what we call a reflex loop goes back out again. It's called the monosynaptic loop. Imagine when you go to the doctor and hit your knee with a hammer and your knee kicks, that's a monosynaptic reflex. That's happening all the time in the spinal cord. So sensory information in creates a motor out. And that motor reflex can be up to 20 times greater than the sensory input. So what does that look like? Well, it looks like if you're walking past a hot stove, if you've ever done this before, and you put your hand on a hot stove, most likely you don't put your finger on the hot stove and go, Oh, hot stove.

Brian
Maybe I should lift my finger off. No, what do we do? We're like, we jump across the room. We get a massive motor output for a small sensory input. It's way out of proportion. But we're designed that way to get away from danger. When you have that sensory input come in, you get a motor output out, and so you get muscle contraction. If you're squeezing that hand for just a little longer, over time, what happens is you start to get tight. Your arms get tight, your shoulder gets tight, your neck gets tight, you're trying to get away from the thing. All that tension is that constant motor output again. Now, that motor output gives you another sensory input, which now has more tension associated with it, probably different temperature changes, different S-base changes. Now, you've got what we call a loop going in of sensory and motor out, sensory and motor out, noxious coming in, more motor output out, more noxious in, and that's called wind up. It winds up the peripheral to central nervous system and you get changes at the spinal cord itself that make the whole system more sensitive. This hasn't even gotten to the brain yet, by the way.

Brian
This is just happening in the body itself. How are we doing? Making sense on this journey? Yeah. Okay, so now the information goes up into the brain. The very first place that the synapses on the brain is in a place called the thalamus. Now, I know you love to talk about the thalamus.

Ani
Oh, well, the thalamus is fascinating. Go on.

Brian
It comes to the thalamus, and the thalamus has a couple of best friends. The amygdala and the hippocampus are like the best friends of the thalamus in there. This is what we call the subconscious hub of the brain, where the thalamus is the part of the brain where brain waves are propagated from. It has a lot to do with our state of consciousness and also the way that we move through the world in terms of what we believe about the world. Do we believe the world's a safe place? Do we believe it's a threatening place? Do we believe we're safe? Do we believe we're not safe? Do we believe we're good people? Do we believe we're not good? Kind of thing. That's happening from the thalamus all the time.

Ani
Before the information even gets to the brain, it's going through this place where it's being where our beliefs are. It's being filtered. Exactly. Through our beliefs.

Brian
Yeah, filter through our beliefs. Before it even gets to the brain. Exactly. Before it gets to the neocortex. Technically, that is part of the brain, but the neocortex. It's also being filtered through the hippocampus, which has to do with our memories. It's being filtered through the amygdala, which is the hub of the limbic system. This is all the limbic system. The limbic system deals with our emotions. You can think about this information that's coming up from the body is being filtered through our beliefs, our memories, and our emotions before it even lands on the neocortex, which is where our primary sensory and motor strips are.

Ani
This is one of the reasons I think it's so unfair that in a general way, we tell people that they should just think differently about stuff. Because let's face it, sometimes it works. But most of the time, it's really, really hard. Because of what you're describing right now. It's really unfair of us to judge ourselves if we've ever tried to change anything just by thinking about it.

Brian
Yeah, exactly. It's very disempowering and unfair. Because there are things going on biologically that are intertwined because we're never just a thought being, we're never just a physical being. It's all the things. We're always wound together. This information is coming up and finally landing in the parts of our brain where we determine what the sensations mean. Because the meaning making is at the end of that chain. Because what we determine, our motor output is going to be a lot of times based on what we make the meaning of it to be.

Ani
If you think about it, we really passed it through the filters that are going to basically tell us what it means in any way.

Brian
Exactly. It's really like on our neocortex, we're actually deciding what to do about what we've already determined it means.

Ani
It's more like the CEO in the brain in the cortex is getting this plan. It's not like they're going, Let's do this and let's do that. They're going, "Okay, stamp it."

Brian
Yeah, right? Well, yeah, that's very true. They're just stamping it. Yeah, it's a good point. When we think about what is pain, so we got to come back to this idea of what is pain, because when we talk to people, and I do this talk, and I remember very clearly, very vividly, several years ago, I was doing this talk, and there was someone in the back row of the room I was in doing it. She said, Brian, hang on a second. I had such bad back pain last year, and you can't tell me that didn't hurt. I said, I'm not telling you it didn't hurt. I'm sure you were experiencing something in your body. No doubt about that.

Ani
There's this conversation that... I've seen it happen all the time, too, where people feel like they're making... You're saying that they're making it up. Yeah.

Brian
You're not making it up. I know you're experiencing something. Here's what we call the new pain equation or new pain recipe. What is pain actually? Pain is output, not input. It's another thing you want to remember. There's no pain sensors in the body, and pain is output, not input. Why would the brain output pain? Well, here's the new formula. When the sensations you're experiencing in your body, plus the emotions about that sensation, plus your beliefs about that sensation, plus your memories of that sensation, if all of those add up to equal threat, then your brain will create an output of pain. If they're not threatening, if the sensations are not threatening, then they're just sensations. If they're threatening, then we have pain. But here's the crazy thing. As soon as we determine it's a threat, our brain and our nervous system will do a whole bunch of different things than if we decided it was not threatening. That's literally like a... Which stamp are you putting on the plan, like you said?  If you're putting the red stamp on that plan, the threat stamp on it, then you send that off to Defcon 2.

Brian
But if you put the green stamp on it, it goes off to some other department that actually goes, Oh, this is fine, and it calms things down. If there's threat, you get more ramp up. If it's green, you're actually not a problem with it. That moment of determination of whether or not it's threatening is critical right there. When I was having this conversation with this woman in the back row, She said, You can't tell me I wasn't having a pain. I'm not. I'm sure you were experiencing a lot of discomfort in your back. I said, And there must have been some threat associated with it. Otherwise, you wouldn't have been calling it pain. I could tell you that story at some point, too. I walked her through that process very quickly, but I want to make sure we keep plugging along here. Because when we look at the science of pain, and we look at chronic pain, especially, when we look at the difference between acute pain and chronic pain. Acute pain is pain that's lasted less than three weeks, three to four weeks, often associated with post-surgery stuff. There's a cut, there's a gash, there's maybe an acute ligament injury or something like that.

Brian
And so acute pain occurred for the amount of time while the tissue is healing. I was going to say tissue damage, primarily, right? Yeah, exactly. Yeah, and remodeling and that stuff. Now, if the pain sensations, the sensations we call pain, are existing longer than the time it takes for tissue healing, that becomes chronic pain. We do know that when we do fMRIs, well, I don't mean I don't do these, when the researchers do fMRIs of people in acute pain compared to chronic pain. Even in the same people who transition from acute pain to chronic pain, people who experience acute pain, there's a lot more activity in the brain in the motor sensory strip, in the neocortex, like the highest parts of our brain. And in people with chronic pain, there's a lot more... Actually, there's very little activity in the neocortex, and there's more activity in the limbic system, in the thalamus, in the amygdala, in the hippocampus, in a place called the nucleus accumbens, which has a lot to do with dopamine and motivation. So chronic pain actually lights up the limbic system. Now, we did a podcast several weeks ago or months ago, I don't know how long ago, where we actually posited the idea is chronic pain an emotion?

Ani
Right. Yeah. Which is fascinating if it's living in the limbic system I mean, maybe.

Brian
Yeah, we are maybe. But there's definitely some overlap there because that's where you see a lot of that correlation going on. We know that once we've gone to a chronic pain situation, that this is what we call a biopsychosocial phenomenon. Chronic pain is a biopsychosocial. It means there's a biological element to it for sure. There's something going on biologically. Now, that might not necessarily be that there's tissue not healing anymore. It could be that there's a wind up in the dorsal ganglion and the dorsal horn. It could be that there are changes going on in the brain itself. Those things are true, too. It could be that there are adaptive patterns going on in the body that continue to misfire nervous system. So there's definitely a biological component. We wanted to say that for sure. This isn't all living in people's heads. There's something going on biologically. Yes, that's true. But we also know for sure that there's stuff going on psychologically also. The primary psychological thing that's going on is either is this person filtering life as being safe or are they filtering life as being threatening? Because, again, either one will trip that signal either way.

Brian
When you're feeling safe in your body, how do you feel in your body? Relaxed, open. When you're feeling threatened, how do you feel in your body? Tight, hypervigilant, constricted. You can imagine that that would also... Well, just because you're feeling that tells us that it's interacting with your nervous system and actually your body. There's the biological, psychological, and a sociological. We also know that people experience chronic pain. There's something going on in their environment and in their social, a relational experience also. It's always those things.

Ani
Yeah, so that's really fascinating, right? The body and then the mind and relationships.

Brian
Yeah. Biopsychosocial model. When you're doing wellness coaching, working with people with chronic pain, you're experiencing chronic pain, realize it's never just the biological piece. Never, ever, ever, ever, ever, Let's transcend that. If you're spending a lot of time chasing around the biological issue that's going on in the person's body, you're never going to find it because it's never only that. It's always all of it. It's more complicated than that. While it's more complicated, more fascinating than that, it actually doesn't mean it's more complicated to help. Right, 100%.

Ani
I think that's part of the really interesting thing I've been thinking about recently with the science. I've been listening to a lot of science recently, and I'm like, Wow, this is so complicated, meaning there's just so many different pieces. Helping it doesn't have to be complicated.

Brian
Exactly, yeah.

Ani
Helping it can be really simple.

Brian
When I hear the science, and the science is really fascinating and complicated, it actually oftentimes reminds me how simple it is.

Ani
I think that's the paradox, right?

Brian
Yeah, it's crazy. Let's dig into this emotional piece for a second. I just want to share a couple of studies with how, in a very practical way, do we understand that emotions impact pain? Well, there was this was an interesting study that was done where they were working with people with chronic back pain. These people had chronic back pain diagnosis, and they had them do all their battery of tests, like their Oswestry test and their pain indices test and those kinds of things. Then the study was like this. Each person in the study had to go into a room and do a computer task. The computer task was timed. They had to sit at a computer and then try to get something done. They had a clock ticking, and they had to really focus, really pay attention to do the time task.

Ani
Foreshadowing, are they going to frustrate the people? Well, yeah. Because that sounds like a recipe.

Brian
Yeah. This is the part of the- Technology. Well, this is the part of the study. The person in the study is in the room doing this computer task, and there's one other person in the room who's actually a part of the research team, and it's their job to distract the person who's doing the computer thing. Okay, so that's...

Ani
That's realistic.

Brian
Now, before they break this group up into two groups- I bet a lot of people have this study going on in their house. Well, listen, yeah, right? This is it. All the time. This is it, right? So this is it. Exactly. So they break them up into two groups. Now, the first group is told, You can't say anything to the other person in the room. Basically, just shut up and do your work. Focus on the task. Ignore the other person. Focus on the task, ignore the other person. The second group is told, You can do or say whatever you want. At the end of the study, it turns out that the first group, not surprisingly, has statistically higher pain and disability ratings after the experience than the second group does. You've already foreshadowed it. What's the difference between these groups? Do whatever they want.

Ani
They can interact with the issue and release, I think, some of the emotional stuff going on. Because what's going to happen if you can't express, you just got to stuff it.

Brian
Yeah. The first group is suppressing an emotion. When I teach, I share this study a lot when I travel and I ask people, I say, So has anybody ever been doing a computer task where you have to get done a certain amount of time and somebody won't leave you alone?

Ani
It's literally the best study I've ever heard, the most realistic.

Brian
Realistic, right? I'm like, Yeah. They're like, How many of you have kids? It's like, where the kids are like, they need your attention. They're like, Just go away. I got to get. But how many of of us say, go away? How many of us say, leave me alone? How many of us close the door? Not many of us because we've been socially conditioned, whatever, fill in the blank, the story after that. But I think it's fascinating that emotional suppression does have... It's always linked with chronic pain episodes. And technology. So you asked me the question earlier, when did it start to click for me? So when my son was young, God, he was probably only four or five years old or something like that. In the area where we live, a friend of ours at the time had a ski hill, and he had teenagers, were his age kids. It was a ski hill. He inherited this property from his family. He was an engineer, so he rigged up a Ford motor, and he put a tow rope on it and built a tow rope so that he can hang out of the rope and get dragged up to the top of this hill and then ski down, drag up.

Brian
We brought all our kids there, and his teenagers would go and they do flips and tricks. All the young kids loved going there and watching the teenagers do these things. I loved watching. It was really cool. We used to go on weekends and to this little ski hill, and and ski and stuff. Next to that ski hill, there's another little hill that our friend wanted to open up and develop and be like, Oh, let's make another run over here for the kids. One summer, we did a work party and went over with chainsaws to clear the property. There were two work groups. One was the work group with chainsaws, and the other work group was clearing a barn at the bottom of the run that had collapsed, and there was just barn debris everywhere, and we had to get it cleaned up. I went over there to do the work party. Everyone else my age had a chainsaw, and they were up on the hill chainsawing and dropping big trees. I was paired up with all the teenagers that were in charge of clearing the debris around the barn. First of all, I was a little put off by that.

Brian
I was like, I want to be up the hill with the big boys using chainsaws, but I didn't bring my chainsaw, so I'm going to basically just tear a barn down. At a certain point of the day, the teenagers, they're just laying around doing nothing, farting around, doing teenage stuff. I'm the only one pulling boards off this barn. I got so frustrated. I got so frustrated. In my head, I'm like, Why am I the only one doing all the effing work? As I think that, I grab this piece of roof on this barn, and I feel, ping- In your back. In my back. I know what comes next. I know in 10 minutes, I'm not going to be able to move. Like, literally, I'm going to be out of it in 10 minutes. I'm like, Oh, man. I'm like a 40-minute drive from home. I'm not going to make it home, actually, like this. I just slink- Talk about threat. I slink off. I slink off. Plus, I don't want anybody to see me, and I'm embarrassed, and all the other guys got their chainsaws and all this stuff. But I slink off to a quiet spot in the woods, and I just lay down.

Brian
As I lay down there, this occurs to me. I'm like, Oh, my God. Every time I've had a chronic back pain episode, every single time is because I've been frustrated. It dawned on me in that moment. Wow. Dawned me in that moment. That was the frustration that was actually an initiating trigger for every one of my episodes. I just laid down on the ground and I did some deep breathing, and I did some movement practices that I've been working on for a little while. I was basically doing some supine somatic practices. As I breathe, I did some body scanning, and I did some gentle movement. I coordinated breath and movement. I did all the somatic practices. Now, this is actually what we call the First Day For Back program, actually came from this experience. I was able to get up off the ground which was unheard of. Which previously was unheard of and was able to get in my truck and drive home. Oh, my gosh. Then when I got home, I got on the couch, and then I was in bed for four days. But that was progress for me. That was huge. That was huge That's what I wanted.

Brian
That was progress.

Ani
That was an amazing insight.

Brian
Because I realized that it was frustration.

Ani
Yeah, you recognize the pattern.

Brian
Yeah, exactly. For me, it was a very core, Oh, my God. Every time I have that, my back goes out like that. It's frustration is one of the elements in it. That got me really curious about, what if I just address that single element, which is harder than I thought it was going to be because frustration is tied in this deeper, deeper patterns, deeper beliefs. But I had a thread I could start pulling on.

Ani
Yeah. Wow, that's really fascinating.

Brian
Yeah. That was the first moment that that started clicking for me. We know that emotional suppression for everybody I've ever worked with with chronic back pain or chronic pain, emotional suppression is always present 100% of the time.

Ani
Yeah. Say it again.

Brian
Oh, yeah. You say it again, right?

Ani
Emotional suppression is part of it 100% of the time.

Brian
100% of the time, all the time. Repressing, suppressing emotions.

Ani
Yeah, we've seen that over and over and over again. One of the reasons why we say on our websites and stuff that we can help people to learn the strategies that have miracle-like results is it does feel like a miracle when the emotions can finally come out and be expressed such that they don't have to continue to produce pain.

Brian
Yeah, exactly. Wow. Exactly. It's so cool. So let's just segue into the social piece for just some time, because we've talked about the biological piece. We've talked a little bit about the biopsycho piece. Let's talk about the social piece. So chronic pain, again, there's always some type of link with a social or a social relational aspect of it. So there's been research to show that when people are in the presence of their loved ones, that they statistically rate their pain as being higher.

Ani
I'm sorry.

Brian
Well, so why are you laughing? What's going up for you there?

Ani
I predicted you were going to say, lower in your head. When we see our loved ones, our pain starts to dissipate. But the reality of the fact that it makes it higher is, first of all, funny. But then the next thing is it doesn't have something to do with the vulnerability around that, the threat, potentially, of what that could be or mean. I mean, it's deep.

Brian
Well, so it could be, or it could be there's some type of secondary gain in there. In other words, if you and I were at a doctor's appointment for me for my back pain, and the doctor says, Brian, what's your pain rating? If you weren't there, I would say a five. Sure. But when you are there, I see a seven. Yeah. Why? What does that mean? Why would you do that, Brian? Why would I do that? Well, I mean, from a secondary game perspective, it would be to get more sympathy, to gain something. We can say we don't know what the person's gaining, but for statistically, this isn't just one person, this is everybody. Everyone will statistically rate their pain, or a statistical number of people, let's not say everyone, a statistical number of people will rate their pain higher. When we do that, because the only reason we do anything is because we're thinking about gaining something.

Ani
I'm just thinking about the level of self-awareness required in the person who we're going to be having this conversation with. Listeners, congratulations. Have a very high level of self-awareness to even be able to sit here and listen to this. Because literally, right? People who have a difficult time developing self-awareness or tons of defensiveness or stuff going on, they can't even be a part of that conversation.

Brian
Yeah, for sure. Wow. There is one more... This isn't specifically with pain, but there's one of my favorite books is called The Sickening Mind. I don't remember the author's name. But the author goes back through history and he looks at disease trends, ulcers or heart disease, different cancers. It goes all the way back into the 1800s and looks at trends of diseases. Back pain is one of these trends. It turns out that it's interesting that when these trends are going on, more people all of a sudden get these problems. When there's another trend, those problems go down. There's always something. But what he likens it to in the research is to show that the power of social acceptability is such that the body will generate physiological experiences, even if they're that we call disease or illness, because they're socially acceptable, because they're a part of the trend. Everyone else is doing it. Everyone else has this problem. So you got an ulcer? I have ulcers, too. You have a back... Oh, I have a back problem, too. Oh, I have a knee problem, too. So our drive for social safety, social acceptance as humans, is so powerful that it actually changes our physiology, even if it creates disease.

Ani
We saw trends like this in our clinical practice. The vast majority of people that would come in with back pain were men, family men, usually, too. The vast majority of people who would come in with headaches or shoulder neck pain were women. This is just an example. Because it was like all the ladies had the neck pain. It's really fascinating. I've seen this in a few instances. It's very cool.

Brian
As I started learning more about these things, these all informed how I was going to go about with my own self, how I coached myself, how I worked with myself, all those kinds of things went along with that. I do, before we close out this episode, I'm so heartened by this because the medical industry is moving in the right direction on this. There's a new definition. That's so great. The core international association, the International Association for the Study of Pain, there's a new definition that they've come up with for pain. Now states that pain is an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage. They're no longer saying that pain is because of tissue damage.

Ani
Yeah, wow.

Brian
They're saying that- Do you know when that came out? Within the last few years, just a couple of years, an unpleasant sensory, and they're actually even saying it's an emotional experience, not a physical experience, an unpleasant emotional experience associated with or resembling that associated with actual or potential tissue damage. I really am so heartened to start to hear new definitions come out that are looking much more broadly at the chronic pain experience. Because then it allows us to authorize and gives us permission to start utilizing strategies that are not solely biologically focused, which is what got us in a lot of problem with all the OxyContin and the opioid epidemic was because we are going after it from a purely physical lens. But also there's people who are wanting to make a lot of money off of people suffering. There was a part of that, too.

Ani
Sure. Boy, that's really great. Yeah.

Brian
That's our science episode. Next week, when we get together and do wellness coaching for chronic pain, the practices, you're going to hear a little the rest of my story, and you're going to hear about the day that Ani walked out on me.

Ani
Oh, no. We don't have to do that, do we?

Brian
It's a part of the story.

Ani
I'm glad I have a week to prepare for this. It's a really good story, though.

Brian
Yeah.

Ani
Yeah. Okay. Well, I hope you enjoyed this one, and I'm sure you're going to catch the next. We'll see you next time.

Brian
Thanks a lot.

Ani
Bye-bye.