Today we have pain psychologist Dr. Rachel Zoffness on the show to teach us about pain & injury. Rachel teaches pain education to medical residents, serves on the pain education faculty at Dartmouth and is the co-president of the American Association of Pain Psychology. She is also the author of The Pain Management Workbook, an integrative, evidence-based treatment protocol for adults living with chronic pain. In part 1 of this 2-parter, we dive into the science of pain both acute & chronic. We break down real-world examples of how a biopsychosocial brain interprets pain and what turns up & dampens pain signals. Check out Rachel's personal website here You can also buy the Pain Management Workbook here Please also follow Rachel on Twitter & Instagram (Apple users: Click 'Episode Website' for links to..) Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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On today's episode, Understanding Pain and Injury with Rachel Zofniss. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a fighter. former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. We're going to talk all about pain today. We have Dr. Rachel Zofnes on the podcast today, and I have a bit of a bio here, so let me read it out. So Dr. Rachel Zofnes is a pain psychologist and an assistant clinical professor at the UCFS School of Medicine, where she teaches pain education to medical students. She completed a visiting professorship at Stanford University. She is also co-president of the American Association of Pain Psychology and serves on the board of the Society of Pediatric Pain Medicine. Already extremely impressive, all the accomplishments and achievements. She is the author of the Pain Management Workbook, which I have beside me right now and I have read through, which is, so her book is an integrative evidence-based treatment protocol for adults living with chronic pain. She also has authored the Chronic Pain and Illness Workbook for Teens. She also writes the Psychology Today column, which she calls Pain Explained. I could go on and on, but she's accomplished a lot and she loves what she does. Um, I originally had her on to, well, I asked some questions to the patrons about pain science and then we had to reschedule. So this is a long time in the making. So apologies for those patrons who submitted their questions in a Still waiting for this episode to come out. It is out now. But I read her book. Her book arrived after we rescheduled her interview. And I loved it, loved the book. So reached back out and said, after part one, can we do a part two talking about more practical strategies and coping strategies for people with pain and just goes through the workbook that is her book, her pain management workbook. And she agreed. And so we'll do this interview now. We'll dive into all things pain and get a deeper understanding around pain, what happens when you are injured and trying to overcome a certain injury. And then we'll finish up part two later on with some more practical takeaways. And so hopefully this is a very complete two-part interview. I'll include the link to her book on Amazon as well as all of her other social media accounts on the show notes as always. And I hope you enjoy, so let's bring her on. Rachel, thanks for joining me on the Run Smarter podcast. How are you today? I'm great. I'm excited to be here. Fantastic. Can you pretty much just give us like an intro where you are, where you're from and how your career has evolved to where it is today? Already, that would take an entire hour. I'll give you three minutes. So I am a pain psychologist, which is a thing that no one really has ever heard of. I am a native New Yorker. I grew up in New York. I now live in California. I'm an assistant clinical professor at UCSF where I teach pain education for medical residents. I also am pain education faculty at Dartmouth where I similarly teach physicians and multidisciplinary healthcare providers about pain. I have a private practice and I am a passionate pain education disseminator. I feel like everybody deserves to understand their pain. And so few of us have ever been taught about pain. So I spend a lot of time writing articles. I have a psychology today column called pain explained where I write about how pain works and what to do about it. And I write books about pain education, like the pain management workbook. And gosh, what else do I do? And how did I get here is a much longer story. Most psychologists are not trained in pain. I'm sure we'll end up talking about about that. But I was a kid who had chronic pain and I've had chronic pain as an adult as well. And I always professionally wanted to live at the intersection of medicine and neuroscience and psychology. And I studied pain as an undergraduate at Brown. So this long and winding road landed me exactly where I feel like I'm meant to be. Wow. What a mission. What a passion. I think I've had a lot of pain. episodes on my podcast in the past and I've actually appeared as a guest on other podcasts talking about pain because it's something that really fascinates me as well and something that I just, I find it tricky that people don't know a lot about it and something a lot of us experience very frequently. So if someone is coming to you, I know this is probably like a very blank, blunt question that you're probably used to answering, but if someone isn't really familiar with the description of pain or like what the purpose is or what the types of pain are, how do you best like to explain what exactly pain is? ask hard and good questions. How do I like to explain what pain is? That's taken me a while to craft and people who are pain nerds, like if anyone is listening to this podcast and is down the rabbit hole with pain, you'll know that there are lots of definitions of pain and there's like not really great agreement. But I'll give you my favorite. Pain is the body's warning system and it evolved to protect you. But like every system in the human body, the pain system can and does fail. Pain is not a biomedical process and we've all sort of been brainwashed to believe that it is. And by that, I mean, it's very easy to believe that pain is this biomedical thing that's constructed by the body. Like if your knee hurts, easy to believe that pain lives exclusively in your back. and is a message that something is wrong with your knee, that your knee is damaged, but that's not actually accurate. What we actually know from neuroscience and research is that pain is actually constructed by the brain, not by the body. And one of the reasons we know that is because of something called phantom limb pain. And phantom limb pain is when an accident survivor or a trauma victim loses a limb and they continue to have terrible pain in the missing body part. So... you literally have no leg, but you have terrible pain in the place where the leg used to be. So if pain lived exclusively in the body, like in your knee or in your back, then no leg should mean no pain. And the fact that isn't true, the fact that you can have terrible pain in your leg and no leg tells us that pain is actually constructed elsewhere and that elsewhere is the brain. So pain is this... ubiquitous human phenomenon. Everyone has it except for a tiny, tiny percentage of people who are born without the ability to feel pain. And I used to think that sounded so wonderful to not feel pain, but those people don't live very long. Right? You've broken a leg and you continue to run on your leg. You're gonna really damage your body. So pain, especially acute pain is considered this very important, helpful. a warning system, a danger detection system, and it tells you something's wrong, you need to change your behavior. But what we've learned, what science has taught us is that chronic pain is actually a completely different animal. And with chronic pain, what we know is that the brain can become sensitive to pain over time. So small inputs from the body, small sensations can actually lead to big output. So you're... your brain is responding in a very sensitive way to non-dangerous inputs from the body. So what pain is, as you can tell by my description, pain is complicated, it's ubiquitous, it's normal, it's helpful, it's evolutionary, and also treating it is sometimes really tricky. Yeah, and you answered my next question perfectly. I was going to ask like, why is it important to understand chronic pain? But I love that definition. It's like the body's warning system to protect you. And it is a warning system, but sometimes that warning system can be tricked. Sometimes that warning system can have a few, like, you know, it could have missed messages or misinterpret certain messages. And like you said, if it is the brain that's producing this pain and it's not the body, that's why things like phantom limb make total sense. And it's why. that it can be misinterpreted because the brain is the one that's trying to receive all these messages and trying to interpret all these messages and the relevance or the importance of certain messages just might get miscommunicated, which is why you do sometimes experience pain when there is no real threat. The body thinks there's a threat, but the messages get a little bit mixed up, which is something that we need to really understand in order for us to deep dive, take a deep dive into the rest of today's content. So it's a really nice way of summing things up. That's exactly right. And I also need to be careful. Like I strive very hard as a pain psychologist to minimize the divide between physical and emotional and brain and body. And so at the end of the day, of course the body is important when we're talking about the production and the reduction of pain. And it's always this, you know, intercommunication between brain and body, body and brain back and forth all the time. It's like this beautiful dance, you know, and like you said, sometimes signals get confused or the messages are misinterpreted, but you know, it's always brain and body working in concert with contributions from the context and environment around you. And I also wanna also say, I'm sure we'll get to this too, that I was saying before that pain is not a purely biomedical thing. And- to sort of expand on that, pain is actually a biopsychosocial phenomenon, which is a word I try and work into every conversation about pain because pain is so poorly understood. And the word biopsychosocial sounds intimidating, but actually what it means is that there's three major factors that create the pain that we feel. And the biological factors are the ones we know the most about and hear the most about, right? Like tissue damage. system dysfunction and inflammation, but there's also a psychological domain of pain and there's a sociological domain of pain. And those three together actually produce the pain we feel. It's not just the biological. It's sort of that sweet spot in the middle where those three domains overlap. And I think the psychosocial domain of pain ends up getting ignored or passed over or stigmatized so much that we just really, we rarely talk about it and we rarely treat it. And if you think about it as a Venn diagram with the biological at the top and the psychological and the sociological at the bottom, two thirds of pain is not actually biology. Two thirds of pain is actually psychosocial. So if we're not talking about psychological and cognitive and emotional factors or sociological and social factors, we're missing two thirds of the pain problem. So people living with chronic pain are not going to heal if we're exclusively treating and talking about. biological or the biomedical bubble. So I just wanted to insert that in there. Yeah. And this will tie in really well with my next question. Um, because I do have a lot of runners who have chronic pain or a lot of chronic pain sufferers reach out to me and say, Hey, I've got plantar fasciitis or I have proximal hamstring tendinopathy. I've had this for years and years and years. And I can't help but notice a connection with those who have chronic pain. And they also say that they have had a history of things like, um, depression, anxiety, like a lot of, um, mental health issues. And there seems to be a link. It seems that those who, um, do have that history of mental health seem to be more likely to develop chronic pain. And it's just a connection that I've seen, but does that make sense within this biopsychosocial model? things to say about that. So the first thing I want to say is people living with chronic pain are often stigmatized. Like there's this real A lot of physicians don't wanna work with people living with chronic pain. And I think part of that is that the presentation is often really complex. So just to say upfront, chronic pain definitely has a relationship with depression and anxiety. And I'm hopefully gonna make that super clear so that we all understand why. But just to say upfront, when you are living with pain for many years, pain steals a lot of things from you. It can steal your ability to work, your ability to run, your ability to play and hang out with your kids. It steals away your hobbies. It can steal away your sex life. It can steal away your salary. I mean, pain really does a number on people's lives. So when people come to my office and they say, I've had pain for 10 years and I'm depressed, my response is, yeah, duh. Like, yeah, of course you are. Like pain has taken so much of your life and your pleasure and your identity away. I'm more worried about people who come into my office and tell me their mood is great. They're really happy. They've had terrible chronic pain and it's interfered with their functioning in their life and their ability to experience pleasure, but like everything's okay. That's much more worrisome to me. So yes, we know that there is a relationship between chronic pain and anxiety and depression. And of course it's also normative for anxiety also. When you're in pain every day, you're worried about your body. You're wondering if your pain is ever gonna go away. You're wondering if you're ever gonna be able to run again and have a normal life again. So yes, it's normal to experience low mood and some anxiety with chronic pain. So that's part one. Part two, I would like to give you a little bit of nerdy pain science, if that's okay, to explain the relationship better. I think it will help. Okay, so I should say I am a... real nerd, like capital N nerd. And I just think pain science is so fascinating. And one of the things I've really dug into is pain neuroscience. And pain neuroscience helps me understand how pain works more explicitly. And it helps me understand this relationship between thoughts and emotions and pain. So I just wanna, the way I wanna say it is I hopefully gonna tie together this relationship. So, so. We have established that pain is this thing that's constructed at least in part by the brain and that the brain uses all available information from your environment and from your body to determine whether or not to make pain and how much. So that's thing one. Thing two is I wanna give you a metaphor. If you imagine that you have a pain dial, like a volume knob on your car stereo that lives in your central nervous system in your brain and your spinal cord, and you... Imagine that there are things that can turn pain volume up and there are things that can lower pain volume or turn pain volume down. There's three things in particular that raise or amplify pain volume. And this is for all humans. This is just how the human brain works. One thing that raises pain volume is high stress and high anxiety, raises pain volume. So something like a pandemic is going to change your brain to amplify pain. And that's the result of your limbic system, which is your brain's emotion center. And we know in stressful circumstances and environments, and when we have anxiety, what that does is the limbic system then sends a message to your pain dial, turning up pain volume. So pain feels worse when we're stressed and anxious. And the second thing that raises pain volume is negative emotions. So negative emotions like, depression or sadness or anger or frustration or rage, that whole host of negative emotions. We know also limbic system raises or amplifies pain volume when mood is low and emotions are negative. And thing three is attention. So when we are home and stuck inside and we can't go out and we can't hang out with friends and we can't engage in pleasurable activities and we're focused on our pain. our brain amplifies pain volume. So pain feels worse when we focus on it. The reason this is good news also is that the opposite is also true. So when stress and anxiety are low and our bodies are relaxed and our thoughts are calm, the brain lowers pain volume. So pain feels less bad when we are relaxed and calm. Pain also feels less bad when our mood is high and our emotions are positive. So we're happy, we're engaged in pleasurable activities, we're doing fun things. Our emotions are... joy and happiness and gratitude, we know that the brain will lower pain volume. And the third thing is attention. So when we're distracted, if you're really absorbed in some activity and you briefly forget about your pain, that isn't actually magic, that's your pain dial. So all of this to say, research tells us that when we are depressed and when we are anxious, our limbic system quite literally raises pain volume. So pain is amplified and pain feels worse. when emotions are negative. I know that was a long answer to your short question. Well, it just makes me think of not even just a chronic pain example, but just those who are injured like, or just runners who are injured, these volume dials to control your volume, say anxiety, like people, runners, when they get injured, it's associated with a lot of anxiety for some people. Like if someone is injured or if someone is rehabbing their injury and then all of a sudden they get a flare up that can produce a lot of anxiety in itself. And when runners are injured, when you talk about negative emotions, a lot of people attach themselves to a lot of negative emotions like, Oh, my body's letting me down, I'm letting my friends and family down training for this race. Um, I'm letting my run club down and a lot of this negative emotions and self talk, uh, sort of accumulates. But then that third one, when you talk about tension, It's again, not being social, it's having to stay inside. It's not doing the things that you love. It's sometimes running is a real positive mental release and meditative for a lot of people. And then as soon as they're injured and they're unable to run, you're taking that away and it builds up this tension. And so this is actually turning up the dials, which makes pain or the pain experience more painful. And it's, it sort of. Accumulates on both the ones who are suffering from acute injury, but also those who are in that chronic realm as well, which it makes sense why it's so hard for the population. So the ones who have been, or have had depression and anxiety in the past, why it's so hard for them to overcome this pain, because they're so used, they're like so attached to negative thought. It's like their emotional home. It's where they'll go to straight away as soon as they do experience pain or do experience some sort of tension or taking, like I say, taking your freedom away and just focusing a lot on that negative dwelling and negative visualizations, all that sort of thing. Catastrophizing is a very common pattern within this population. Would you agree with that? I'm sitting here nodding my head at everything you're saying. I think you're saying it beautifully. I think for runners, there's a lot tied up in running. It is a coping mechanism for a lot of us. And I should say, like, and I mentioned this to you earlier, I've never considered myself a runner because I don't compete. I've never run a marathon. I'm not fast. I'm very slow. I stopped to smell flowers and chase butterflies. But I've been running multiple times a week for the last. years and running is one of my major coping strategies. And the times when I've been injured in the last decade, my mood totally crashes and my stress totally goes up because I'm losing an outlet. You eat up a lot of adrenaline and thank God for that when you're running. And I think for people who are even much more serious about running than me, it's also part of your identity. So, when you're part of a run club or you're a marathoner and suddenly you can't run anymore. part of your identity is taken away from you too. So you have coping taken away from you. You know, you're not using up or burning off all that adrenaline and all the stress hormones. And on top of that, now there's this like identity thing. And like you said, there's a social or sociological aspect to pain too. And when you're worried about letting people down, of course your stress is gonna be worse. And all that stress and anxiety and the mood crashing and everything, not having coping strategies, all of that contributes to pain amplification. That's exactly how that works. It's like a perfect storm. Part of me just wants to say, well, like this is the why and how do we get to what we should do about it? But I think we'll cover a lot of that in part two when we get you back on. I guess when it comes to someone's actual experience, if a runner is listening to this right now and they are injured, a lot of them will be thinking, okay, how much do I... How much is relevant? How much is my body saying my knee is sore? I shouldn't run on it. And how much is it? Okay, maybe I'm just too stressed. Maybe I'm just too wound up. Maybe I'm just focusing on negative thoughts. Maybe it's all okay. Should I really be interpreting these pain signals as danger or should I just kind of like not hold it as much relevance and just try and get on with life? How much, like what can be there? their practical takeaways, what can be their level of relevance? If I tried to be everybody's doctor, I would a fail and B get sued. So I have to be very careful when I answer your question, but I don't want you to get sued. Yeah, right. So what I will say is this, what I will say is this, um, if you have an acute injury and acute is three months or less, the thing that we usually coach people to do is rest and repair, right? Your body needs to rest and repair. If there's damage to the body, like if you've torn something, like I recently twisted an ankle, like yes, you're not supposed to run on a twisted ankle. You're supposed to rest and let your body repair. So, you know, my ankle was swollen and it was bruised and you could see there's something going on. Yes, you rest, you repair. You're not supposed to completely immobilize. You're supposed to move a little bit or whatever, you know. But when your pain has been going on, for many, many months, or if you've had pain for years, you can bet that there is no longer soft tissue damage. Soft tissue damage repairs. It does not take three years for soft tissue to repair. That's not how the human body works. So when pain has become chronic, what we usually say is that there's another process at work and that process is called sensitization. I mean, there's lots of ways that pain becomes chronic. but the peripheral nervous system can become hypersensitive and the central nervous system, the brain and spinal cord can become hypersensitive. So the way I like to teach this concept or explain this concept is by asking people to think of any skill that they were bad at, they practiced it and they got good at it over time. So do you have a thing? Do you have a skill? I'm gonna quiz you. Do I have a skill? Um, yes, you were bad at it. You practiced it. You got good at it over time. I'm quite good at Rubik's cubes. Oh my God. Good to know. Okay. So the way I'm going to say this back to you is the pathways in the brain are like the muscles in the body. The more you use them, the bigger and stronger they get. So if you said to me, Rachel, I want really big biceps, I would say Brody. That's great. Go to the gym. lift weights and your biceps will get bigger and stronger with time. And it's the same with the human brain. So the more you practice the Rubik's Cube, the bigger and stronger the Rubik's Cube pathway in your brain gets. Because the Rubik's Cube is very much about your brain and the Rubik's Cube pathway gets bigger and stronger the more you flex it, the more you use it. Guess what happens in the human brain the longer we have pain. the longer we inadvertently accidentally practice pain, the bigger and stronger the pain pathway gets in the brain. The bigger and stronger the pain pathway gets in the brain, the more sensitive we say that the brain is to pain. And by that, I mean, took me a long time to figure out how to explain this. But when the brain is sensitive to pain, what does that mean? It means that small, non-dangerous inputs from the body result in an amplified pain response from the brain. So for example, if we say a dog is sensitive to smell, that means that a dog will come into this room and sniff around and pick up on sense that you or I will not even detect because our noses are not as sensitive, right? So small sense to a dog's nose seem very big and it's the same to the brain when we have chronic pain. So... Small sensory signals from the body are amplified and to us they're perceived as really big. So people living with chronic pain, this is often the process that's at work. So it's just sort of like, I try and always say that it's individual, right? It's like, different people come into my office and there are different things happening with their bodies and different processes at work. But in general, it is safe to say that people living with chronic pain, their brain has undergone a change. That's what neuroscience tells us. And there's some sensitization process at work. And so the treatment for that is actually the opposite of what you think. You think you're supposed to stay home and rest for three years, but that's actually not at all what you're supposed to do. You're supposed to move your body and walk and create a pacing plan and get outside and resume activity. So yes, I don't know if I answered your question. I went down a rabbit hole with that one. I love these rabbit holes as well. It makes me think of... the explained pain book when they're saying, if you have a sore knee and the brain says, we have a sore knee, we shouldn't move it, we shouldn't run on it, we shouldn't do anything to produce pain. Over time, the book like illustrates what a better way for the brain just to be as efficient as possible as to just associate movement of the knee with pain and just like make that connection, make that like neural tag. But then when the knee is better. When the knee has totally healed biologically, there's nothing physically structurally going on that tag is still there. And sometimes when people develop chronic pain, that tag, all it takes is you to move that knee. All it takes is for you to think about moving that knee. All it takes is for you to look at other people moving and using their knees for that tag, just to spark, just that tag, just to go off and say, what are you doing? We know that that's bad for your knee. And As a result, because the brain is quite smart, we'll start producing pain, even though there is no dangerous signals. It's just that tag that's there, that's quite hard to overcome unless you know these sort of processes. that we make is the difference between hurt and harm. And the two are different, but we conflate them. We assume that they're the same thing. And that's actually adaptive for us as humans, right? Because hurt or pain often means harm or danger, but not always. But if you, you know, over time, if evolution trains us to respond to some hurt or pain by stopping movement, stopping what we're doing, you know, resting that is adaptive evolutionarily, right? Like if you break your leg and you're resting, that's gonna save your body, right? But what we know about pain is that hurt and harm are not actually the same. So you can be in pain and not actually be in danger. And there's all these examples of this, you know, where you have pain, but there's not actually a dangerous injury or you have no pain and there is a dangerous injury. So we try and uncouple hurt from harm. They're not always the same thing. Hmm. And it's almost like what the brain gives relevance to. Like I had this example, my girlfriend has a sore shoulder and she woke up in the middle of the night sleeping on that shoulder and she woke up in tremendous pain. And then that was in the middle of the night when she was dazed and she woke up throughout that day and didn't experience shoulder pain the entire time because she forgot that happened that night. And it wasn't until when she got home from work and settled down and she thought, actually, I remember last night I woke up just briefly and my shoulder was in extreme pain because I slept on it. And it wasn't until she remembered that, that the brain was like, Oh yeah. And then she started feeling shoulder pain. She hadn't had shoulder pain the entire day until she remembered that she had a shoulder pain that night. And so you can always, usually when I talk about this in person to people, they can usually come up with a couple of weird examples where it like now that we know that all pains from the brain, they kind of make sense. Do you have any, any sort of little anecdotes or little things that have happened to you in the past that might, um, make sense or something similar to those lines? Oh yeah, totally. I mean, I always, I think about like the times where people are playing soccer games and it's not until the game is over that they notice they're bleeding or they've broken a bone, you know, and it doesn't hurt until later. or if you've ever taken a shower and you notice you've blackened. without the hurt. You have, you know, there's broken blood vessels. There's something wrong with the body, but you haven't even noticed it. And there's also these examples in the clinical literature that I love to talk about. I even named them the tale of two nails. It's like these two examples from the nerdy neuroscience and pain science scientific medical journals that report on these two construction workers. And one jumped off a plank straight onto a nail. and the nail went through his boot clear through to the other side and he was in such terrible pain. He was rushed to the emergency room. They sedated him with opioids. And when they removed his boot, they discovered that the nail had passed between the space between his toes. No way. Yeah, there was no tissue damage. There was no entry wound. There was no blood, nothing. But his brain, which we know is your danger detector, believed he was in danger. So it made pain to protect him. You know, and he, I mean, he wasn't faking it. His pain was real. And there's this alternate example of this, another construction worker who was using a nail gun and the nail gun accidentally discharged and ricocheted backwards and clocked him in the jaw. But he saw this nail shoot across the room and bury in a wall across from him. And he had some like, you know, jaw pain and he had a headache, but he went on with work and life for six days. And then finally went to the dentist for his toothache and the- The dentist took a scan of his jaw and of his head and discovered that there was a four-inch nail embedded in his face, protruding into his cerebral cortex. Oh my God. Yes. And I have like pictures of this. I love these two stories. They're so illustrative, but he had very little pain. He saw the nail, or I should say, his brain used all available information, but because he had seen this nail shoot across the room and bury in the wall, his brain decided that it didn't need to make pain. He wasn't in danger. And so he had very little pain and thank goodness he went and got a scan. It wasn't that there was no pain, but it was very little. So I just think these examples are great to illustrate that the amount of pain you have does not indicate the amount of danger the body is in. And also you can have pain without tissue damage and you can have tissue damage without pain. Like the two are not the same, but we often are tricked into thinking that they are the same. This episode is sponsored by the Run Smarter Online course. Runners are very self-motivated and always challenging themselves to higher feats. So one of the three online courses to choose from is dedicated entirely to boosting running performance. Unlike the other two courses that focus on preventing and overcoming injury, this course has modules on breathing, strength conditioning, mental resilience, foot function, and so much more. It's tough teaching and learning these concepts through a purely audio format. So combining the podcast with these video courses is a great way to enhance your learning. And once you sign up through my website, you'll have access to the course videos both on the Run Smarter website and through the Run Smarter app. And to say thanks for being a podcast listener, enter the coupon code podcast at checkout and get a three-day free trial. This unlocks all the content within the running performance course and unlocks my other two courses, all to do with injury prevention and overcoming specific running injuries. You won't even be automatically charged at the end of this three day trial. So head to the online course hyperlink in the show notes to begin. Yeah. I think that ties in really well or segues really well into talking about pain sensitivity in general. So we know that, uh, thoughts, we know that social and like social context does have relevance to pain sensitivity. Is there anything else that we haven't discussed today that might contribute? to or dampen pain signals? There's a lot. So when we talk about the fact that pain is biopsychosocial, what that means is that there's all of these contributing factors to the pain experience in all three of those domains. So there's biological contributors, there's also psychological contributors. We talked about emotions. We could talk about thoughts for another hour and a half. So when we think negative or catastrophic thoughts, which you brought up before, research says that also amplifies the pain you feel. And then also in that psychological bubble, there's coping behaviors or so how you're behaving or coping as a result of your pain. So we know that inactivity and social isolation and all of those things are gonna amplify pain volume, but doing the opposite is gonna reduce the pain volume. So making sure that you're being social and seeing friends and going outside and going out into nature and getting sunlight and. moving your body, engaging in pleasurable activities, going to the lake, going and writing. I mean, there's like a million coping strategies that can actually change your body's experience of pain, but we just don't really talk about it that way or think about it that way. Yeah, so I mean, there's a million things that can change the pain experience, but I think the challenge is reframing pain from this like biomedical model where really the only power you have is to take a pill or like get a procedure done and go for surgery to this like more biopsychosocial frame where you're changing your own pain volume by, you know, zooming in on all three of these domains of pain and trying to figure out, and I do that with all of my patients. We draw this picture of all three domains and then we figure out what are things that we need to change in each one. And I think there's so much power in that. There's so much power in realizing that you have more agency and control over your body than you thought. you did. Yeah. The other like aspect I want to talk about was like foods, diets, sleep, those sort of impacts on pain sensitivity. But from what we've discussed now, it seems like, okay, if you eat junk food, it might increase the sensitivity of pain, but that just might be because you're associating like if you eat junk food, you feel bad about yourself, you know, your thoughts and like social constructs. It's like, maybe that's what's contributing to the pain sensitivity itself and similar to sleep. Like if you have a poor night's sleep or if you go a week of having poor night's sleep, maybe you're a bit more irritable, maybe a bit more anxious, maybe you're a bit more wound up. So perhaps that's where the biopsychosocial construct comes into it rather than it actually being the foods and actually being the sleep that's turning up pain sensitivity. Is there anything to comment on that? I would say that nutrition and sleep live in the bio bubble. Like they live in the biological domain of pain. And there's a ton of literature on the way that sleep impacts the pain you feel. So yeah, I would say that, yes, sleep definitely impacts pain and nutrition definitely impacts pain. You know, they say you are what you eat. Yeah. So like, you know, if your body's going to repair, especially from an acute injury, you have to feed it right. So I would say there's definitely, there are definitely contributors of sleep and nutrition in the bio domain of pain. And when I think about treating pain, I'm always looking at all the factors. So one of the things that I'm always doing is offering people help with sleep hygiene. So I have this like handout, this really nerdy like sleep hygiene tip sheet to help people get back on track with their sleep. And And I do also talk to patients about nutrition. You know, you're right. Like junk food, of course, is not gonna help anybody. And I think especially as you were saying before, when people get depressed or anxious, people sometimes rely on food to self-soothe. So it becomes this sort of self-defeating cycle of, you know, I can't run because I have this ongoing injury or have this ongoing chronic pain. And so I'm feeling really depressed and miserable and I'm on my couch indefinitely for all these months. And so I'm like eating ice cream and potato chips to self-soothe. And ultimately like that's actually detrimental to my body and detrimental to my pain. Yeah. Good to know being, being mindful of time. I want to get to some of these patron questions and then, um, see how we go for time at the end. So, um, Karen asks, or has this question after she's had chronic pain for, or had chronic pain for 23 years, had surgery is now pain free. However, remains of the body, the sorry, however, there remains this pain body and still hinders her. She wants to challenge herself in pushing her endurance boundaries, but she has fear of getting injured. The fear of injury and the fear of pain is holding her back. Any ideas around this? What can you say for, for Corinne? fear of pain is real and it's normal and it's adaptive. If we didn't fear pain, we wouldn't learn not to put our hand on a hot stove. So totally makes sense, totally normal, especially when you've had the trauma of having pain for 23 years of having an interfere with your life. So what I would say about that is, so the kind of treatment that I do with my patients is called cognitive behavioral therapy. And there aren't that many pain psychologists out there. And there's not, the treatment often isn't affordable because insurance companies don't reimburse very well, which is actually why I wrote the pain management workbook because I wanted to give resources that were affordable and accessible. But what we do in cognitive behavioral therapy and all of this stuff is in the pain management workbook is we go after the thoughts that feed fear of pain. Fear of pain again is totally normal, but it also can really... torpedo you when you're trying to get back to your life. So thoughts like I can't run because that thing is gonna happen again. You can go after that using cognitive strategies of cognitive behavioral therapy. So I like to call the voice that generates those thoughts pain voice. I find it really helpful to externalize that voice and help myself remember that, you know, it sounds like me but really it's just my pain voice and it wants me to stay home and stay inside and be miserable and depressed, right? And pain voice sounds different for everybody. For some people, it's the voice that says, don't run, that bad thing is gonna happen again. You're gonna get injured all over again. It's gonna be terrible. And the way to go after that is to recognize her, notice her when she happens in your head and write her down, write down everything she says. You know, I'm broken, I'll never get better. I can't run if I do that bad thing will happen again. You know, all the things you write down. And then you go after her, you challenge those thoughts. And we have a lot of thought-challenging strategies in cognitive behavioral therapy, probably too complex to go into right now, but suffice it to say that anxious thoughts post injury, post-surgery, post-chronic pain are normal and natural, and there are absolutely ways to go after those with cognitive strategies. And we'll definitely do a deeper dive in part two when we talk about more practical things that you can do. Sam, she asks, someone once advised me when I feel pain during a run to focus on the spot and breathe into it to make it quiet and down. And she said it works 99% of the time, but she's not too sure why. We know that when the body is relaxed and when the brain is calm, we're thinking calm thoughts, we know that that's going to turn down the pain dial. The role of the limbic system, that's exactly what it does. So when we breathe into a part of the body, what we're doing is we're slowing down, we're regulating our oxygen intake, we're changing our blood flow, and we're releasing muscle tension. So all of those things are absolutely. going to change the pain you feel. And I love that it works for her 99% of the time. That's awesome. I mean, I wish it were that successful for everybody. I think you're also, so the things that you mentioned is also addressing the biological side, but it's might also be addressing the psychological side. If you're breathing into it, you're a bit more calm. And if it worked really well for you in the past, there's that belief there that it is effective and therefore will be effective. You know, the way I always try and talk about it is, you know, the brain and body are connected a hundred percent of the time, a hundred percent of the time. So your psychology is always affecting your biology and your biology is always affecting your psychology. There's never a time where, you know, your emotions aren't biological. If you think about what emotions are, they're hormones and neurochemicals. So, you know, yes, absolutely. Brain and body are always connected. When you're breathing into something, you're affecting your physiology, your biology. your brain, your body, all of it together. Great. And lastly, for these patron questions, thanks to all the patrons for submitting these questions. Lucy asks, does PMS affect pain perception? The honest answer to that question is I am not sure. If I had to hedge a guess, I would say lots of things happen to women's bodies when they're pre-menstrual and there's hormonal changes and there's brain changes. So it would not surprise me one bit. Um, if certain people became more sensitive to sensory messages from the body, but I don't, I don't actually know the science of that. Okay. Yep. Thanks to everyone for submitting those questions. Um, before we wrap up, I do have a question and you kind of alluded to this when we had a chat prior to this interview, uh, when you're trying to educate. Chronic pain sufferers about pain science and it's stemming from. other factors that aren't just biological. Um, how often are you getting pushbacks? How often are you getting some sort of, Oh, you're saying it's all in my head. And why is it so hard for certain people to accept this by a psychosocial model? I, I feel like I, I'm always, um, dealing with that because I think. But as a pain psychologist, you're always sort of, I feel sort of like a used car salesman sometimes, like I'm selling this thing that I know is wonderful and helpful, but people don't know that pain psychology is a thing. So yes, people are often thinking that I'm saying, oh, it's all in your head or you're crazy, but that's never what we're saying. So the way I like to talk about it is, Pain is always biopsychosocial. It's always a brain and body issue. And it doesn't, while it doesn't live in your head, it is constructed by your brain. So if we actually want to treat your pain, we can't just be treating your body. We have to be treating your brain as well. And I also find that it's helpful to talk about pain psychologists like myself as pain coaches that sometimes takes the stigma out of it for some people because it's easy to believe if you're a referred to a psychologist that your physician is saying that they think you're crazy or it's all in their head. But listen, if we know that pain is this brain-based experience, it makes no sense to endlessly go to physician after physician seeking medications and procedures. It's not gonna work. And research says that it doesn't work for chronic pain. So yeah, I think we do have to sort of address that stigma and talk about it and find ways to help people feel comfortable seeking out. cognitive behavioral therapy or biofeedback or, you know, all of these other non-pharmacological approaches to chronic pain, because that is ultimately the most effective treatment. Yeah. And it might just take several different examples or explaining pain science for, to really land with someone because I've had several runners come to me with chronic pain. I show them these pain science resources. I show them the pain science. episodes that I've done in the past and they come back to me and say, yeah, but that's not really me. That's, um, like I, I'm not depressed. It's not in my head. Like when I squat, my knee hurts. And when I always squat, my knee hurts. It's been going on for, you know, five years, but that squat will hurt. And so it must be something in my knee. And I think it's, I don't know, is it a defense mechanism? Is it, I don't, I'm not entirely sure, but I think if someone were to reframe it in a particular way, or just make it land in a different way to know that it might be biological, the longer it goes on for, the less relevance that biological section kind of has. Like you said, if you've had it for three weeks compared to three years, but to just know that even if it is biological, the psychosocial component of it is so relevant and so important in all aspects of pain. I get that all the time too. People will say to me, no, but my pain is organic. No, but my pain is from this injury. And I just think the most important piece of this is to constantly reiterate that all pain all the time is biopsychosocial. There is no such thing. Like we talked about the tail of two nails, like the nail through the boot, but not the foot, and then the nail to the face. There is no such thing that, there is literally no such thing as pain that's purely biomedical. There's just no such thing. whether your pain is organic or it's from an injury or it's from a surgery or you've had it for 20 years or two days, all pain all the time is biopsychosocial. All of it, all of it. But people don't know that. And there is this stigma, like this sense of like, no, but my pain is real. My pain is organic. So I just think pain education is so important. And that's actually why I love nerding out about it because people don't know that. Yeah. And I like to share my pain experiences and my injuries with podcast listeners. And doesn't matter how long I've had the injury for, whether it's a week, a couple of days, a couple of, a couple of weeks, a couple of months, me understanding pain. Like it helps in all contexts. It helps in every single pain, every single injury that I've had, no matter how long I've had it for, just understanding it and getting to grips with how I'm actually experiencing, how it's being interpreted is such a success in my mind for my recovery, just having understanding, having answers in like. knowing why these certain things are happening really, really helps my recovery. And I can just imagine those who are worried, those who are uncertain, those that were confused about pain signals can just spark a lot of worry and it just manifests itself, which hinders recovery. And so no matter how long you've had your injury for, I do highly recommend that you grasp this concept as much as you can, maybe get additional resources. Maybe. listen to the same episode a couple of times over until it finally lands, because it doesn't matter what injury you have or what pain you're experiencing. Understanding the pain helps provide you with a lot of answers, a lot of clarity, and can help calm down the mind and help your true recovery, help you help recover faster. Would you agree with that? Agree 100%. Fantastic. Rachel, I think we, as we're wrapping up now, I do want to advise the listeners about a few of your resources, um, in particular your book, because I do have your workbook. I've read through it. I absolutely love it. And that's why I've reached back out to you and say, let's do a part two where we actually talk about all of these components within the book. Because before we started recording, I was saying that I was flicking through every page, like nodding and being like, yes, this makes so much sense. This is so true. It lands really well for me every single page, every single paragraph. And so, If people want to learn more about you, more about the book, more about, um, like your website, where can they go? I Brody, I really appreciate that feedback. Um, it means a lot coming from someone like you. So thank you. Uh, the pain management workbook is on Amazon. Um, again, I'm like a staunch supporter of affordable accessible care. And I think our healthcare system is so broken. So it's like 20 bucks on Amazon, the pain management workbook. I do have a really nerdy website. People are wanting to learn more about pain science. I have a resources page with a ton of stuff on there, websites and podcasts and books and all the things. And that's just my last name at softness.com. And I joined social media during the pandemic. I've never really been a social media person, but I was so sad about missing opportunities to go to conferences and do things like this and meet colleagues that I... jumped on social media. So I'm on Twitter, I'm at Dr. Zofniss, D-R-Z-O-F-F-N-E-S-S, welcome to be my Twitter friend. I also am on Instagram, at the real docs off. And I do a lot of work in the pain science space, trying to spread the word about how pain works and what people can do about it. So yeah, I hope to hear from people. Fantastic, I'll keep all those links in the show notes. I'll... keep like an Amazon link to the book as well. It's amazing, like 20 bucks is unreal. I know like the explain pain book, I don't know why the people have reached out to me and said like, is there any other resources to recommend? Because the explain pain book is like $123. And I looked on, I didn't realize it was that expensive when I bought it, but it's, yeah, it's really getting up there in price. And so compared to $20, I think is, yeah, it's a no brainer. I agree that the resources out there are expensive and sometimes inaccessible and especially pain psychology resources, there just aren't that many of them. Yeah. Rachel, thanks once again for coming on. I had a blast. I always love talking about pain science and I can tell obviously you're very extremely passionate about this and educating it and you do so in a very clear manner. So it's pretty obvious that you've been doing it for quite a long time and you're very passionate about it. Thanks for sharing all of your knowledge and I look forward to part two. Also be sure to check out the show notes for links to the podcast Facebook group and links to learn more about becoming a podcast patron who contribute $5 Aussie per month to get inner circle VIP access including an invitation into the exclusive Patreon Facebook group and a complete back catalogue. Patreon only podcast episodes, which you can access within the app. Also on the app you can even find a link that takes you to my online physio clinic, where I assess and treat runners from all over the world, so I can be on standby if you ever need one-on-one physiotherapy assistance. Once again, thank you for listening and becoming a Run Smarter Scholar, and remember, knowledge is power.