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We continue our journey! If you haven't listened to part 1 of my chat with Dr. Rachel Zoffness please do so. Today, we dive into practical steps and strategies people can do when they are suffering from pain. Rachel first talks about the concept of 'Cognitive behavioural therapy' and what you think, affects how we feel emotionally, affects how we feel physically, which affects how you behave. Next, Rachel discusses some pain-control strategies and relaxation strategies such as mindfulness, body scanning and breathing exercises and explains why this helps reduce pain. We finish off with the 6 lifestyle tips for better health and reduced pain all from her book the 'pain management workbook'. 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.
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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In today's episode, part two of our talk about pain and injury with Rachel Zofnus. 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 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. Welcome back, welcome to part two of our talk with Dr. Rachel Zofnus and we are talking about all things pain science and injury, understanding pain. Please listen to part one if you haven't already, it's not going to make a whole lot of sense if you just dive into part two, but today we kind of cover more practical strategies and practical examples straight from her book. And so we dive into a couple of things. We dive into cognitive behavioral therapy. couple of pain control strategies, relaxation strategies, talk about negative self-talk and some lifestyle tips to help you manage your pain. It's really enlightening. It's packed full of content and you're going to love it. I did have a bad microphone day. I just got off the call with Rachel this morning and my microphone's been quite dodgy at the moment. It's very fiddly, very touchy and so I'll need to fix that. But I tried my best to do some audio editing. So hopefully It's seamless for you. Hopefully there's not a lot of disruption or it's too annoying. So I've done my best. I'm not much of a techie when it comes to audio software. So when things do go wrong, I'm not too sure how to fix it in the moment and then try my best to rescue it later on in the audio editing process. I hope you love this one. Rachel's so easy to listen to and it's awesome to listen to someone who's so passionate about her field and helping people. So she's doing brilliant things in the world. Let's get it underway. Rachel, welcome back to, I guess, part two of the podcast. How's your day been going? Complicated as always, but rewarding and awesome. And I'm glad we have a part two. It just means we have so much cool stuff to talk about. Yeah. I'm glad that like, as soon as I dove into your book and dove into ideas to talk about, I think it almost needed to be a two-parter because it's such a, it's a new concept for a lot of people, but trying to understand it first and then. work out some ways we can use it once the understanding is there is, it's a very good way of like just absorbing knowledge and just learning something new. And so last time we mainly just recapped on pain as a biopsychosocial experience. So it's not just about pain as I guess the body producing signals. It's also how your brain processes it psychologically. the social circumstances that surround that pain and what meaning you give to that pain can actually be a totally different experience. We also touched on how important the brain is and when pain, it's essentially the brain is trying to protect you, that's its overall job, and it's trying to say there is pain or say there is danger, that sometimes those messages can be a little bit mixed or maybe misinterpreted by the brain. the idea about some practical applications if someone does have chronic pain or debilitating pain, we can dive into a few things today to help them. Yes, and just to zoom out and give a little more context, which I'm sure you're going to do also just so I'm like, I'm a pain expert, a pain psychologist, which no one has ever heard of before. And I teach pain education at UCSF and at Dartmouth. And the book that which was written with the goal of disseminating pain education because, you know, Brody and I are both of the mind that everyone deserves to understand their pain and runners and athletes in particular are very familiar with the experience of pain. And it would be just so helpful to talk about not only how pain works in the brain and body, but also techniques for managing pain. So, as you mentioned, part one was talking about how pain works and the neuroscience and science of pain. And then today we're diving into specific techniques that are in the pain management workbook. Did I say that? Okay. Yeah. And in fact, like with the notes I have in front of me, it's actually kind of breaking it down into chapters. I have like chapter two, this is what we discussed chapter three, chapter four, and like everything throughout your book. And I wanted to try and find a way to structure this episode in a way that's like easy to listen to, easy to absorb, but just like every chapter I went through, I'm like, yes, we need to talk about this. Yes, we need to talk about this. And instead of turning into a. part three, I tried my best to just kind of break it all down into the very, very key points that really resonate with part one. But yeah, exactly. I think we'll obviously leave links to the book as well. I have the book in front of me as well. But let's dive in. So chapter two, you talk about this concept called cognitive behavioral therapy. And maybe if you can just describe in your best terms what that actually is and how that is beneficial for someone who is in pain. Yeah, I think I would be remiss if I didn't say at the very beginning of this, there is a lot of stigma around therapy for pain. In fact, there's a lot of stigma around anything that isn't medication or a procedure like a surgery for pain, which sucks because if we're actually gonna effectively and accurately gonna... talk about and treat pain, we have to conceptualize pain as a biopsychosocial problem. And I use this word last time, and literally all that means is there are of course, biological and biomedical components to pain. But there are also psychosocial components to pain. So our social relationships matter, our environment and the context matters. Our our thoughts about our pain and our body actually impact the pain we feel, and our emotional health affects our physical health because the brain, not surprising to anyone, is connected to the body 100% of the time. So when we talk about treating pain, there's this treatment that's considered evidence-based, it's rooted in science and research, and it's called cognitive behavioral therapy. And that's what I do with my patients. And from an outsider perspective, it's honestly as if I'm performing some sort of miracle and I am not a miracle worker, but I see patients of all ages with all sorts of pain who get up out of bed and get back to life and get back to sports and get back to activity after months and years in bed. So I can say that it works and research supports that it works too. And what it is this treatment that goes after this biopsychosocial, all the biopsychosocial. of pain. So it targets the biological processes, but it also targets the psychosocial processes that are contributing to pain. Cognitive, we go after cognitive components of pain. And by that I mean, what are the things we're thinking that are contributing to pain amplification? And also, what are our attentional processes doing to our pain? That's cognitive also. When I say cognitive, I mean of the brain, things that are happening in your head. So For example, a lot of us when we have pain, and this applies to me as well, we spend a lot of time reducing and restricting activity over long periods of time. And we spend a lot of time in bed or at home and thinking about our pain or ruminating about our pain. And what science and research shows is that focusing attention on pain actually amplifies the pain you feel. So the more we think about our pain, the more we focus on our pain, the worse we're gonna feel. But the opposite is also true. We know that distraction strategies can reduce pain, minimize pain, and we also know that changing thoughts around pain, especially catastrophic and very scary thoughts about pain, which amplify it, can be targeted and that when we change thoughts about pain, we can reduce the pain we feel also. So we do a lot of cognitive stuff in CBT. We also go after a lot of behavioral processes and I wanna make sure not to use language that's confusing. By behavior, I literally mean what we're doing to manage our pain, there's lots of things that we do and stop doing when we have pain. So what's typical, especially when people are living with some chronic pain condition, which happens a lot to runners, is that they reduce activity and they rest. So they stop seeing friends, they stop going outside, they stop running, obviously, they stop a lot of activity and exercise, they stop hobbies, a lot of things change when we have pain. But what research shows is that over time, our reduction in activity also will amplify pain. So while that strategy is great for a short-term acute injury, like a broken bone or a muscle tear or whatever, it actually is really bad for a chronic pain condition. So behavioral strategies are, what can we do to change the way you're managing pain and what can we do better? So there's a lot of behavioral strategies that can change the pain we feel. Improving and going back to activity and life is one of those strategies. So we put together pacing plans for pain. So literally pacing for anyone who's run a marathon, you know, that you can't go outside and run 26 miles tomorrow. You would die. Actually, you guys would probably be fine. I would die. I would not be okay. You have to pace. You have to put together a plan, you know, with running short distances and all the things you need to do to get your body and brain in shape and ready. run a marathon. And the same is true with pain. If you think of healing from chronic pain as a marathon, you have to do little bits at a time to get your brain and body ready for this race. So we put together pacing plans. We also use a lot of relaxation strategies, and we use things like mindfulness and meditation, which can sound horrifying to some people, but I suspect we'll probably talk about why that actually affects the brain and affects the body. And we also target a lot of lifestyle strategies and CBT as well. Lifestyle medicine is very important when it comes to pain. So people living with chronic pain will tell you that some of the things that fall off course when you're living with chronic pain include sleep. And there's a ton of literature that shows that messed up sleep can trigger... longer and worse pain episodes, and then worse pain makes sleep worse, and that becomes a self-fulfilling prophecy. And of course, nutrition affects the pain we feel, and social engagement affects the pain we feel. So we target all the pieces of this puzzle when we do CBT. Yeah, so it seems like CBT encompasses a lot of different strategies and a lot of different processes in order to hit a lot of the targets that we need to focus on, like that biopsycho and social components. Um, so just to reiterate, we learned last time that thoughts actually affect or amplify or dampen pain signals. And so negative emotions can amplify your experience of pain. And what the CBT tries to do is change, I guess, your relationship or change, or identify how you're thinking. There was a really nice, in the book, there was a really nice like four step kind of flow chart, which said like what we think affects. how we feel emotionally, which makes a whole lot of sense. If we're always thinking of pain and the things we can't do and dwelling on a lot of things that will affect us emotionally. And what affects us emotionally affects how we feel physically. And that, I guess that's the relationship between our thoughts and pain and how we feel physically affects how we act or how we behave. And like you said, that behavior might be stay at home. That behavior might be. stay on the couch and eat junk food and watch TV all day because I'm in pain. Or if we switch that and change the way you're thinking or change the way you're being affected, maybe getting up and being active every day is something that would be quite positive and actually change that relationship and change that catastrophizing or dwelling kind of habits that a lot of people that are in chronic pain might be in. Is there any other, I guess I was on a call with one of my patients yesterday and he has been having a lot of chronic pain and been doing really well over the last like three or four weeks. And he said, one of the best things that I've done is walking every day and just getting out and just being active. He thought that was one of the real key parts of his turning point. Um, if some, if someone wants to try and change the reaction, change their behavior. Um, yes, getting out and walking is a good step, but is there any other advice you might have for someone to make a small step towards this positive behavior? Yeah, definitely. First of all, I love the example. Second of all, you described that CBT flow chart perfectly. I couldn't have done it better myself. And that actually is the crux of CBT. We learn in CBT that thoughts affect emotions, affect the body, of course, necessarily affect behavior. 100% of the time. And it's always this like multi directional thing, right? Like, thoughts can affect directly the body and the body can directly affect your emotions and your emotions can directly affect your behavior. So all the things are just interconnected all the time. And for, for folks who are interested, I do think the visual is really helpful. And we can't do that on a podcast. But, but when you see it, it's just so intuitive, and it makes so much sense, but we just don't talk about it that way. So I just wanted to thank you for that summary. I thought it was perfect. You're welcome. Yeah, and yes, I do think actually walking is a great way to start the pacing part of a pain management program because it's so accessible and so easy and you can just roll out of bed and put on a pair of sneakers and go outside into the sunlight. And even if you can only walk for 60 seconds, that's pacing, that's starting somewhere. And the doing something plan is always better than the doing nothing plan, always. And the tip that I usually give my patients is, it's really helpful to think about some valued activities. And what I mean by that is activities you love and miss and wanna get back to. So it might be ice skating and it might be fudge making. It doesn't actually matter what it is, but if you can identify some valued activities, then we can put together pacing plan for that specific unique activity. So, you know, a pacing plan for fudge making might literally be, you know, get off the couch and find grandma's fudge recipe in the kitchen and write down all the ingredients that might be step one of our pacing plan, you know, and step five of that plan might be get in the car and drive to the grocery store and spend 20 minutes in the store walking around picking up groceries because that's very hard for some people living with pain, right? So it just it depends on your goal and it depends on where you're at. but we create unique pacing plans for every person depending on their particular valued activity. Yeah, and it's good to know that pacing plan doesn't have to necessarily always be physical. Like if someone does have pain, say, if I walk for a few minutes or if I get out of the house for a few minutes, it will spark up my pain. It can be something that's social. It can be something that's addressing that biopsychosocial, that social part. Um, having friends over or like engaging in other people doing things that make you happy, that isn't necessarily something that's physically challenging. Um, it can just be socially engaging and help you that way. Exactly right. And I suspect for this crowd, since, you know, runners are listening. The goal, nine times out of 10, is gonna be get back to running. But sometimes the best way to get back to running is sort of like circuitous. It's not necessarily this direct beeline where you're walking and then you're jogging and then you're running. That would be really nice. But sometimes it's, like you said, it's increasing various activities in various domains of your life, like just getting out and being with friends or going to the grocery store or whatever, whatever the valued activity is, and it doesn't necessarily have to be running to jogging. Sorry, walking to jogging to running. Yeah. Cause we're almost identifying this. Okay. How we think affects us emotionally affects us physically affects how we act. We're almost identifying that, that flow, that structure and kind of hacking it and like reverse engineering it to help benefit you rather than it being this downward spiral that you might be unconscious of. So it's bringing it to the conscious awareness and then using ways we can hack that process to, um, benefit you, help you on the improve is there. What one step you talked about in the book as well is identifying pain triggers and listening to it, it might sound like, um, it might sound like it's easy to identify pain triggers, but when you delve into it a little bit more and think that maybe there's some emotional triggers rather than just physical, it might be a little bit more nuanced, might be a little bit more detailed than people might expect. Um, what kind of pain triggers might people look out for? if they do have chronic pain. There are so many different kinds of triggers. I always, I try and always keep my framework for pain and everything to do with it biopsychosocial because I do think what happens a lot of times with pain in medicine is that we are looking exclusively at biological or biomedical triggers. So, but they are, they do exist across the board. So, triggers can be all different kinds. So I can think of... you know, sometimes people will say, when I sit in one position the entire day, my back feels really terrible. I mean, or whatever, whatever part of the body hurts, my leg feels really terrible. And we know that happens for lots of reasons, right? Like muscle stiffness and soreness, we know that motion is lotion and that when you're sitting, you know, everything gets creakier, everything hurts more. So one could just be an example of a trigger, it could just be sitting all day. Another trigger that people talk about a lot, and maybe it's just because I'm a pain psychologist, so they tell me these things, is family conflict. That's a huge trigger for pain. So it could be like relationship issues with a partner. It could be, you know, in fighting in the family. It could be, you know, there's a whole host of things. And also in that psychosocial domain, trauma is a huge trigger for pain as well. So there could be emotional abuse or physical abuse, and we know that trauma doesn't just live in the head, it also comes out in the body. If I may, there's a great book called The Body Keeps the Score by Bessel van der Kolk. The Body Keeps the Score. And it talks a lot about how trauma lives in the body and various ways that trauma shows up. So yeah, like you said, triggers for pain can be across the biopsychosocial spectrum. You're the second one this week to advise that I get that book. So I think wow. Yeah. Okay. It makes me think there's a lot of times when someone has. chronic pain and, or someone has plantar fasciitis for several years or proximal hamstring tendinopathy for several years, I often get them to do a pain diary, especially if they're not sure what's triggering their pain and they're fluctuating in their pain constantly, but they're not too sure what it is like. I have them do like a diary, sometimes like a daily diary or maybe a little bit more detailed, but some clients actually say to me, I've identified my trigger. It's when I have a load. a low mood day, like, or when I'm giving myself like a pity party, or I'm like really down about something, that's when my pain comes up. And it's really surprising for me to, for them to have that revelation themselves. But for now understanding what we know about pain, it makes a whole lot of sense. Totally. And, you know, I think we talked about this in the last episode, just that there's this pain dial that lives in your central nervous system. And if you imagine it's like the volume knob on your car stereo, there are a lot of things that can turn pain volume up and also turn pain volume down. And negative emotions, absolutely, neuroscience shows, amplify pain volume. So when you're having a really crappy day and mood is low and you're depressed, or you're frustrated and angry, or you're stressed and anxious, the brain, your limbic system, which is your brain's emotion center, is actually gonna amplify pain volume. So whatever pain you had before, when you're having a crap day and your mood is low and your emotions are negative, pain is going to feel worse. And that's a great example of an emotional trigger for pain. And, you know, as we were saying, triggers can be social, they can be environmental, they can be emotional, they can be biological, they can be familial. But yeah, you gave a great example of an emotional trigger for a pain flare. Chapter three talks about paying control strategies. And there was kind of, okay, number one is set some goals. And you kind of mentioned valued activities is a really nice outcome or a really nice idea to set a goal for that. And number two was pacing strategies, which you mentioned just making really gradual steps. In the way of pacing strategies, could you maybe provide or what components are. in a successful pacing strategy or some where, or some ways someone might go wrong with those sort of strategies. When you say what you mean by go wrong. So is there, um, maybe errors or mistakes that someone might make to think they are doing a pacing strategy when in fact it's, um, maybe yeah, detrimental. Yes. I understand what you're asking. Okay. Yeah. So what I see a lot with people who come to me with chronic pain is, um, They do this thing where they rest for long periods of time and pain subsides, feels less bad. And then they go and do all the things. So on any given day, when pain is less bad, they'll go grocery shopping and go for a run and see their friends and get all the work they're behind on done, they'll catch up. They'll just try and pack everything into a quote unquote good day. And then what happens nine times out of 10 is that you crash. It's too much for your body to handle. It's too much for your brain and you feel so bad and your pain is so bad after that, that you're in bed or at home for days or weeks at a time. And then, you know, you rest for long enough. Then you have another good day, a low pain day, and then the same thing happens. You do all the things. So I see a lot of people who are sort of doing this boom bust cycle where they rest for a long period of time, they do all the things and then they crash and resume. And that actually is detrimental, like the boom bust cycle over time is going to lead to decreased functioning, and it's not going to help pain. So a pacing program is actually quite the opposite, with the same intent. The intent is to get you back to all of the things, but we're doing it incrementally and in small bits. So again, if the valued activities are, you know, ice skating, fudge making and running, we're going to figure out what kind of plan we need to get you back. doing those things, but a little bit at a time. So week one might be, you know, going for a 10 minute walk. And that's what we're doing. Like eventually we're gonna get you back running and marathoning, but for this week, what we're doing is 10 minutes. And the problem of course, for all of us is, we are all impatient. Like we all want a magic bullet. We all want a magic pill. And I include myself in this too. Who doesn't? You know, pain sucks. You want it to go away right away. But the secret is... There is no magic bullet. There is no magic pill. It doesn't exist. It does not exist. So, you know, this is the best we've got. This is the best science tells us we can do, which is pacing. And that's, you know, again, gradually getting the brain and body ready to resume that activity, but we have to go slow. So week one, we might do 10 minutes of walking every day, taking breaks as needed to like, you know, make friends with dogs that cross our path and drink water and stretch. And week two, maybe we can add five to 10 minutes. So maybe week two, we're doing 15 to 20 minutes of walking. And week three, maybe we're adding in 30 seconds of jogging. It just, it depends on the person. But what science tells us is that over time, this actually increases your ability to function and decreases pain. Yeah, and the book has a nice graph around instead of experiencing that boom bust like you were describing. Yes, there are slight fluctuations in pain like you might have a bit more pain one day, a bit less pain one day, but it's very like they're bumps rather than boom busts. But then over time, if you take a step back and look week by week, that strategy you're actually heading up and to the right, which is fantastic, but there are little bumps along the way rather than it just being this wild fluctuation of symptoms. And when it comes to people's behavior that I've seen, there would be a couple of... people that sit in one camp of they have pain, they try and rest and the pain doesn't go away. So then there's like, I'll just put up with it anyway. And then they work through pain and push themselves and just decide, like you said, get everything done. Even though they're in a lot of pain because they're fed up with it. And so they decide to push through it. But then there's the people in another camp who as soon as they start feeling good, they get overly optimistic and they're like, oh, maybe I can get back to running or maybe I can do this. Like I'm feeling great now. And they have this real urge to really go for it. And that can lead to that bust as well. And so really try and recognize these strategies and recognize that the goal is to make sure it's slow. Make sure you have patience, make sure that it is a part of your plan. So in all of those examples that I was describing, that's ill advisors going against the plan. Whereas if you have something written down and you're following the steps to the letter, it leads to. more success, it leaves you a bit more accountable and a bit more, um, keeping things manageable. If it's written down, you know what to follow. Exactly. Right. I think we delve into a couple of different relaxation strategies. Like you mentioned, the mindfulness or the meditation, or I think the book talks about the body scan as well. Um, we don't necessarily dive into all of them, but maybe just one kind of example and why it is important for someone in pain to practice these strategies. Um, so full disclosure, I also have had chronic pain in my life. And I remember when I first learned about this stuff, I absolutely thought it was hogwash. Like I just, I thought it was like, you know, um, God, what's that word for medicine that isn't really medicine. And it's like fake and funny. I can't, the word is escape. Yeah. That's a good one. I just thought it was like, woo. Um, but, but the more I've delved into pain science and the more I understand the neuroscience of pain, the more I am able to appreciate the power of these strategies for changing pain. So just to say the science gives me meaning and structure when I prescribe these techniques for managing pain. So the science is this, when you have pain, pain is one of the biggest stressors there is for human beings, like being in pain all day every day for months on end is hugely and terribly stressful. So What we know is that what stress does to the human body is it triggers the fight or flight response. You know, it ups the adrenaline in your bloodstream and it triggers tense and tight muscles and it triggers all these negative catastrophic thoughts and, you know, negative emotions. And together that creates a recipe for high pain. That's exactly what causes the maintenance and amplification. pain. So what that tells us is that in order to reduce pain, we have to really be mindful of the opposite and practice the opposite. Like if you have a stressor all day every day, your body is going to be in a state of stress unless you do something to change it. So one of the things we can do to change it is implementing relaxation strategies to turn off the sympathetic nervous system arousal that's maintaining and amplifying pain. So where we start with these relaxation strategies is often really basic stuff that we know immediately and directly changes physiology. And what I mean by that it immediately changes your sympathetic nervous system arousal level, and it turns on your parasympathetic nervous system which can dampen the pain messaging that's going from brain to body and body to brain. So we start off and with belly breathing or diaphragmatic breathing, which is a strategy that's ubiquitous throughout relaxation strategies and mindfulness meditation and all these things that we often recommend for pain. And belly breathing quite literally or diaphragmatic breathing is using the muscle called your diaphragm in your torso, just below your rib cage. And when you breathe in, the way I like to describe it is imagining that you're filling your belly with air as if it's a balloon. And you can even put your hands on your belly and. feel your belly expanding with air. And most of us, when we're in a state of stress, which is like most of us most of the time, especially during a pandemic, or especially when we have pain, we're chest breathing or we're shallow breathing. And that keeps the sympathetic nervous system in a state of activation. So when we breathe low and slow into our bellies and we allow our breathing to become slow and we pay more attention to our breath, what that does again is it lowers that. pain volume or that pain dial that lives in your central nervous system and it turns down pain volume. So pain feels less bad. But as you mentioned, there's a bunch of relaxation strategies and mindfulness practices that research shows can help dampen pain. And if someone was to practice this belly breathing, they're breathing slow. Um, they're perhaps sitting or lying down hands on belly and just registering, or like feeling it through their hands. How often? how many breaths, is there a certain cycle that we follow? Hmm, good question. I wanna say upfront by the way, that I am not pretending that this is a magic cure for pain. Like nobody in their right mind would say, oh, by the way, relaxing is gonna get rid of your chronic pain. Like that's not at all what I'm saying. I mean, there's this like multifaceted biopsychosocial approach that we're recommending for treating chronic pain. And it's not like one single thing is gonna be the cure. I also like to listen to guided audio when I do it because what I find is my brain bounces around, like all of us, like I have a lot of things on my mind, a lot of things that I'm doing. So in a moment of silence, in a moment of quiet, you know, my brain is thinking about a lot of things. And so my stress level sometimes goes up in moments of quiet. And I find that I really have to focus and sometimes that's hard. So listening to guided audio can sometimes be a useful tool when we're doing these relaxation and mindfulness practices. And you can see those, you know, a lot of people have heard of these apps like Calm and Headspace. There's an app called Stop, Breathe, Think that I happen to like. And there's also Guided Audio that comes with the workbook too, which has all the like mindfulness and relaxation practices for pain. I do recommend lying down. I even recommend covering yourself with a blanket. The more soothed you can be, the better off it's going to be. Wow. And I think if... What if the listeners are really loyal and they've listened to a lot of episodes of this podcast, this will actually start tying in with a few other episodes that we have had on. So it doesn't sound like it's all magic because of those other episodes. Like for example, we had a massage therapist on to talk about, yeah, massage doesn't really release muscles. It doesn't really do much physically to the muscle, but what, where the benefits do come in is relaxation is paying attention to a certain area is like. Just doing something in your day that's proactive for whatever pain or whatever tightness that you do have and mentally it really helps. And that's why you get off the massage table and you have less pain. You feel like jumping around. You've, you've actually had a very positive outcome and neurologically. And, um, yeah, just when it comes to the brain, when it comes to the central nervous system, the sympathetic parasympathetic I've had, um, someone on to talk about fight or flight or talk about um, sympathetic and parasympathetic when it comes to recovery. And we want to switch the brain and we switched the body into that parasympathetic phase in order to start absorbing that stress or start really getting into that recovery mode and constantly being in that sympathetic go state, the body just breaks down. And so I hope a lot of these lessons are sort of tying in together. And in fact, we actually learned that breathing out triggers that parasympathetic nervous system to activate. So if you're really breathing slowly, and especially during that out phase, it actually activates that parasympathetic phase. And so hopefully this is tying into the science on other episodes that we've heard and isn't just something brand new that people are finding really foreign. Um, so yeah, hopefully it's all tying in. Wonderfully helpful. And, and not for nothing to circle back around when you are paying attention, when you're being mindful, when you're practicing these. relaxation strategies like the body scan and all of these other things, you also are relaxing your muscles. So like, again, it's back to that thing where the brain and body are connected 100% of the time. So when you're turning off the sympathetic nervous system, you're simultaneously relaxing your muscles, you're lowering the pain dial in your central nervous system. It's like all the things altogether at one time. Yeah, and it's similar in the opposite when someone does have pain, they constantly think you have pain, they constantly. They're constantly worried about a certain movement. They're clenching their jaw. They're tightening their fists. They're constantly thinking about that. That is winding up the nervous system. It's winding up the muscles. It's winding up your thoughts and emotions. And so that mindfulness and breathing, body scan, all that sort of stuff does the absolute opposite. So yeah. Exactly. Very real science and highly recommend. And the belly breathing is something so easy that you can do. Something so easy that you can start with. And if you do find benefit from it, maybe just do it more and maybe just that five minutes of belly breathing is just like this entry level just to give it a go. This episode is sponsored by the Run Smarter Online Course. Injury prevention has been hands down the most popular topic on this podcast. So one of the three online courses to choose from is dedicated entirely to injury prevention. Videos that dive deep into tendinopathy prevention, running analysis, shoe insights and 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 injury prevention course. and unlocks the other two courses, all to do with overcoming injury and boosting running performance. 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. Chapter five talks about, this is one I really want to talk about negative self-talk and what you call the pain voice versus the voice of wellness. I do know a lot of people that kind of dwell on not necessarily be conscious of how they're thinking, but they do have this very active negative self-talk. Can we maybe delve into that a little bit? Yeah, I love talking about this. It's one of the most untalked about things in pain medicine is what happens, you know, cognitively when you're experiencing terrible pain. So there's a technique that we use in pain psychology, and it's called externalizing. And the voice in your head. It's just easy to believe the thoughts you think, and it's easy to believe that those are true. And I have a neighbor who has a bumper sticker, and the bumper sticker says, don't believe everything you think. And I just think that's so wise and so powerful because we fall into this trap all the time, and your brain, unfortunately, gives you false messages all the time. And one way of targeting that when you have chronic pain is to externalize that voice take that voice and make her separate from you, external to you. So what I usually ask my clients to do is to imagine what their pain voice looks like and give it a name. We can call it Bob, doesn't matter. And what does Bob look like and what is he wearing? And sometimes it's helpful to think of Bob as evil looking. And sometimes it's helpful to think of Bob as a very kind, friendly grandpa who's just trying to help you and keep you safe because ultimately your pain voice isn't trying to hurt you, it's trying to protect you, it's just doing a bad job and doing it in the wrong way. But, yeah, but pain voice is that voice in your head that says, nothing has worked, therefore nothing will ever work. I'm broken, I'll never get better. I'll never run again. you know, people are so disappointed in me, I'm letting everyone down. It's just, you know, we can all recite those negative, crappy, awful things that we hear in our head when we're injured or in pain. So one technique is writing them all down and assigning them to Bob and just recognizing that those, it sounds like you, but it's not you. It's just pain voice that lives in your head and it's trying to keep you stuck at home and inside because it thinks that that's the thing that's gonna help you the most. But of course, science tells us, especially for chronic pain, that is not true. It's patently untrue and it's the opposite of what we need to do. So going after pain voice or Bob requires this three-step process. And in pain psychology, we call the three-step process the catch it, check it, change it process. Catch it, check it, change it. So it's three Cs. Catch it just means notice that it's happening. What does pain voice sound like? And I have people write down. what their pain voice sounds like. There's a lot of overlap, but it's unique to everyone. You know, some people's pain voice says things like you're a loser, you know, just unique to everyone. Change it, catch it, check it, change it, change it, catch it, check it, sorry, check it. Check it means, I had to catch my own order of things. Check it means check to see if it's actually true. It might be true, you know, that you're broken and you'll never get better. But we always wanna test these thoughts to find out if they're facts or if they're just anxious thoughts, right? So the thought, I'm broken, I'll never get better. Is that a fact? Is that factually absolutely, certainly without question, absolutely true? No, it's not at all. But if you say it enough to yourself, you surely are going to believe it. So it's really important to check the thoughts and test them. And there's a list of questions that we ask our pain voice thoughts that are also in the book. We can't go through them all, but is this a fact? Is one of them? What evidence do I have that this thought might not be true is another one. And then step three is change it. So once you hear the thought, and you've checked it and you know it's a big fat lie. How do you change it? How do you talk? to it because we always want to talk back to Bob otherwise Bob is in charge of our brain he's driving the bus and he's amplifying pain and that's I just always circle back around to that if we're talking about pain voice the reason we're talking about it is because negative thoughts amplify pain that's what neuroscience tells us so if we just let Bob drive the bus pain is going to continue to stay bad so step three is changing Bob and talking back to Bob and saying things like, yeah, actually that's total BS. And it's not true at all that I'm broken. I have pain and I've had pain for nine months or whatever, but there's all these strategies I haven't tried yet and I'm going to try them or whatever it is you need to say to Bob to shut him up. And there's lots of things that we can come up with to make him quiet down and to sort of lower pain volume. So that's one of those cognitive strategies we use in CBT that has been found to be so helpful for pain. If I could just... rephrase it or take it in another direction. Cause I see a lot of people coming to me with a couple of like pain questions and injury questions. And they, they say a couple of things. One, they said, I've tried everything. Nothing works. They, they say, Oh, I've been to all these doctors, all these health professionals that are know what's wrong. They can't fix me. Um, they say that I've had all their scans. They show nothing, but when they constantly repeat this, they, and they constantly say this to themselves, they're kind of almost building up an identity around themselves. They kind of, I am the person that can't be fixed. I'm the person who has seen everyone and they can't fix me. And when you're talking about this pain voice, that is just the pain voice talking. And some people shift into that identity to think that's who they are. Whereas what you're talking about is if you. externalize it, it is now a separate entity. Like that, that voice is someone different. You are not that person. That's right. Because I think wrapping yourself in an identity, I'm a person who has pain. I have chronic pain is really disempowering. Can get you really stuck once you believe it. And once you think you are that person, it can be so difficult to become unstuck. And using this strategy can turn this disempowering, really difficult. place to get out of and just, it just turns into something that's a little bit more proactive and a little bit more disengaged from that identity. Have you seen that same pattern? Yes, totally correct. So two things to say, the hardest people for me to treat are the people who are fused with their pain identity. Pain has become their life, it has become their meaning, it has become, you know, it's everything. They live in like all day every day is like about. pain. So and by the way, just to validate, yes, like when you have pain, of course you think about a lot that's inevitable. So no one's saying don't think about your pain, like you're going to think about your pain. And if you try and push it away, that's going to be worse for you. It's like saying don't think about a pink elephant and don't think about a pink trunk. Like, that's the first thing your brain does. You can't not think about it. So we're not saying that it's more noticing the voice. noticing that it's real, noticing that it's bringing you down and making you feel terrible, and it's stopping you from engaging in all those behaviors. And that goes back to that CBT cycle where thoughts affect not only how you feel emotionally, but affect how you act. If you're thinking, I'm broken, I'll never get better, there's no point in getting up. You're not going to get up, right? So that affects behavior. But the other thing I want to say about that is, when patients say to me, I'm broken, I'll never get better, the scans are showing nothing, Like what they're actually communicating to us as healthcare providers is how helpless and hopeless they feel. And I do think it's so important to validate that and name it like, yeah, totally. You're feeling like unseen or dismissed or hopeless or helpless. And your future is feeling really dark. And that makes total sense because when we're living with chronic pain, normally and naturally, mood crashes. That is what happens when we're living with pain day in and day out. So when you're feeling discouraged and sad, you know, that doesn't mean you're mentally ill. That's absolutely normal. And I just find it so helpful when healthcare providers say, I hear you, I am in this hole with you, you are not alone. Of course you feel sad. Of course you feel stressed, anxious about your body, you know, especially when your identity is as a runner and this thing has been taken away from you. Of course you're, of course you feel this way. That is normal. And I'm with you and you're not alone and we're going to figure this out. I just, I think validating is so helpful in situations like that. I think the pain voice itself, have you seen often that the pain voice comes on more at the end of the day because when people like less distracted or people like less active, um, because a lot of times I have people come to me and say, Oh, my pain, like I'm fine during the day, but it's like, as soon as my day finishes, as soon as I lay down, as soon as I like, I'm not distracted. That's when, well, first of all, pain's amplified and I start to dwell on a lot. Is, do you find that as a very common pattern? Yeah, I think it varies from person to person. So, um, not surprisingly when I, I work with also kids and teens, in addition to adults and when I work with kids, interestingly enough, the beginning of the day, right before school. is often the worst for them. And that's not surprising because stress and anxiety spike before school for a lot of these kids. And so that amplifies pain voice and that amplifies pain. But yes, for a lot of people that I work with in bed at night when there's no distractions and your brain is swirling and ruminating, often is when pain voice is the loudest. And one of the reasons for that is cause you're tuned in. Like over the course of your day, you're. doing so many things, you're on Zoom, you're talking to friends, you're whatever, whatever it is you're doing, you're reading, you're typing emails, and then at night, everything is quiet and you're listening for the first time to the thoughts in your head. And so if that's true for people, that night is the time when you hear a pain voice, that is a phenomenal opportunity to get up out of bed and go to your desk and write down what pain voice sounds like. If you can tune in, catching her is the first step to changing her. So... It's not necessarily a bad thing that people are hearing pain voice at night. It just means that's a great time to tune in. And then what we would do the next day during the daytime, the daylight hours is go through this activity. We call it detective questions in the book where we're asking questions like, is this a fact? What evidence do I have? This might not be true. And then we write down the answers to that. And then when we hear pain voice that night, you're gonna practice talking back. So you're gonna hear it, you're just gonna make sure that you're tuning in and listening, and then you're gonna practice talking back. So sometimes it's just a good opportunity for mental exercise. Perfect. I want to finish today's episode with at the end of the book, you have a couple of lifestyle tips. There's six tips or six points here and maybe just like a brief brush over of exactly what you mean with each point. So number one, you have the brain loves balance. Why is that so important? The brain loves balance. And by the way, thanks for reading. I can't remember the six points that I put in there. So the brain loves balance. So there's this word in science that I happen to love and the word is homeostasis. And homeostasis literally means balance. All the things in your body are balanced and your body is striving for that all the time, right? That's what hunger is. Hunger is your body's message that homeostasis or balance has been disrupted. You need to feed your system. When you get cold, that signal from your brain to your body, that's what that is. Your homeostasis is disrupted, you're no longer the temperature, the balanced temperature that your body likes to be. So your brain is giving you this message that you're off balance. And pain is often also a signal from your brain that homeostasis is disrupted. So brains with chronic pain do really well with balance. So we want to make sure that all the time we're keeping all of these lifestyle factors balanced. Like we're getting sunlight. We're going outside, we're, you know, being social and being with friends. We're getting sufficient sleep. Our nutrition is balanced. So there's all these components of balance that it's important to think about when we're trying to treat pain. A lot of these points we've already discussed, but the second one was sleep better to feel better. And we all know the importance of sleep. I've had tons of episodes around sleep for recovery. And if someone wants tips on say sleep hygiene. strategies. There's an episode with Dr. Amy Bender that they can listen to. And anything you want to touch on, anything when it comes to sleep and pain? I know we've already talked about it a bit on this episode. Yeah, just that it's like this normal thing that gets disrupted with chronic pain and that if that's happening, that's something that we expect. And there are very concrete strategies we can use to get back on track again. And I would say one of the most important strategies is getting out of bed and not laying there for many hours when you're not sleeping, because we all fall into that trap where you're not sleeping and you're stressed and miserable and pissed off because you're not falling asleep and you just lay in bed and you're getting more and more stressed out and angry about not sleeping. And what happens over time is that your brain starts associating the bed with bad things, with not sleeping. And what we want your brain to do is associate your bed with being unconscious and drooling and passed out. So the best thing to do, believe it or not, when you're not sleeping, is get out of bed after around 20 minutes or so and go do something relaxing, you know, like listen to a mindfulness meditation or even color in a coloring book. I know that sounds ridiculous, but that's very relaxing even for adults or, you know, read a trashy magazine, something not too stimulating and then get back into bed. So there's a bunch of sleep hygiene tips in the book also. It's funny, my girlfriend showed me yesterday a coloring book that she got for her grandma. And it's like literally a really extensive coloring book that's... really finely detailed and she finds a therapeutic that she can just like color in like a peacock. That's like the two page big peacock with a lot of fine details that you can just do that. And so that might be a nice strategy as well. Exactly right. The other points were okay. Point three was exercise in the brain. I think we've covered that quite extensively. The fourth one was sunlight and nature as medicine. Anything you want to touch on with that? Yeah, I always want to talk about that too, because who talks about that when they talk about pain? Like nobody ever, right? So what's really interesting is the way pain works in the brain is there's a number of neurotransmitter systems that also get disrupted. Again, I should have mentioned I'm a nerd and I just, I love the science of pain because it helps me understand the body so much better. And one of the systems that gets disrupted with pain is your serotonin system. So we know that when you have chronic pain, which again is one of the biggest stressors on the human body, mood crashes and emotions become negative. And when that happens, of course, that's linked to our serotonin system. So most people have heard of serotonin in the context of, you know, if anyone's ever been on an antidepressant, the most popular medications and antidepressants target your serotonin system. So people think of serotonin as sort of like their happy hormone. And I use that word very casually because it's a neurotransmitter. It is not a hormone, serotonin. But What those medications do is they raise the level of serotonin in your brain. Guess what also raises serotonin in your brain? Naturally, being outside, sunlight. When you get sunlight in your pupils, and I just mean casually, not by staring at the sun. You do not need to stare at the sun. But when sunlight goes into your eyeballs, your eyeballs are part of your brain, and sunlight stimulates the production of serotonin, which raises your mood and lowers your pain dial. And yes, I'm oversimplifying it, but the details are not important. Also nature, being in nature, science shows raises levels of serotonin and dopamine, which raise mood, make you feel more pleasure and reward. And that also in turns lowers pain volume. It makes you feel more relaxed. Awesome. And I guess the fifth and sixth point were nutrition and health. So I think we actually talked a lot about nutrition on part one and how that can actually be help or be detrimental for pain volumes and changing that pain dial as well. But when it comes to social medicine, anything that we need to add anything that's really important to mention? Yeah, I do want to say something about social medicine, because that was the most confusing thing to me when I started doing work in pain. Why is there this social component to pain that makes absolutely no sense? So here's what science tells us. You know, the worst punishment you can give a human being? Isolation. Yeah, that's right. The worst punishment you can give a human being is not Thanksgiving traffic and it isn't even going to prison. If you mess up in prison, you are put in solitary confinement. What does it say about human beings that the worst thing you can do to us is isolate us from other people? In the presence of others, the human brain produces all of these chemicals that make us feel good physically and emotionally. Your brain produces oxytocin, and higher levels of dopamine and serotonin, and also this amazing magical chemical called endorphins. Endorphins are your body's endogenous, naturally occurring opioids. They decrease the pain you feel. In fact, all of the neurochemicals I just mentioned are implicated in pain reduction. Those are produced by your brain in the presence of other people. It is not random that I recommend. social interaction as part of a pain management plan. In the absence of others, research tells us, those chemicals all crash. Serotonin and dopamine and oxytocin and endorphins, your brain's natural painkillers, all crash. So it is actually... an important part of a pain management plan to stay social, to be connected. People always tell me that the best part when they're in the hospital after a surgery, the best day that they have is the day that the people, their friends, their loved ones are able to visit them. That's the best day. That's the day they feel the best physically and emotionally that is not random. So social medicine is an important part of pain science. Rachel, you've knocked this out of the park, both part one and part two. It's been... a very enlightening session and I know people have learnt a lot. The pain management workbook is available. Um, I had the link on part one. I'll keep it into part two. People might think like we've covered so much today. That's pretty much covering the book, but we've only just scratched the surface on what the book actually covers. There was so much, so many things I wanted to talk about, but had to keep it to the hour. And It's an actual workbook. Like it's actually, you've got templates, you've got forms so that you can actually fill in yourself and, um, it's, it helps the process. So I highly recommend it. I'm going to be recommending it to a lot of people that do have a lot of pain and need to spend more time understanding pain. And so, um, anything else you want to touch on the book, what it includes, or have I done a pretty good job of selling it? I mean, what I want to say is thank you. Like, it means a lot coming from you. You're like a pain expert. And. you know, coming from you that feedback means a lot. So I really appreciate it. And the book was a passion project like authors don't make any money like this is not What this is about. I think healthcare should be affordable and accessible to everybody. And we all know that the healthcare system is deeply and horribly broken. And things like cognitive behavioral therapy are not affordable and accessible to most people living with pain and I just think that's unacceptable. So I actually wrote the book just to make this sort of stuff like pain education and all these techniques. accessible to people living with pain. So it's like 20 bucks on Amazon. So I guess that's the thing I want to say the most is that, you know, our healthcare system is broken, but there still are resources out there. And you know, if this is something that people are wanting to dive into more, you can find a therapist trained in CBT and ask them to go through the book with you. Great. And I'll keep all of your other social media, um, plugs in there as well from season, uh, from the part one. So I had your, um, Twitter and Instagram as well that I'll, including there. I was just checking part one to see if I had that included. Rachel, thank you so, so much for coming on. It's obviously a deep passion of yours and no surprise when you said that you're a bit of a body nerd and a pain nerd, because it shows, it shows the passion and the amount of detail that you have and the amount of care and like empathy that comes through your voice when you're talking about this sort of stuff. It seems like this is right up your alley and you're doing great things in the world. So thank you for all you do. And thanks for coming on. Thanks for having me, Brody. 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 of 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.