Your body is more like an ecosystem. Mhmm. It's not a broken down car. You buy it once, it depreciates over time, and we break down. Right? Right? It's always working to repair. It's a wear and repair process going on, not a wear and tear.
If you've ever dealt with chronic pain, you know it's not just about what's going on in your body because it affects your whole life. And sometimes, even if you've had test after test, you're still left without the real answer of what's going on or any relief from the pain. In today's episode, I am talking with Emily Warren. She is a doctor of physical therapy and owner of Mindful Movement Physical Therapy here in Holiday, Utah. Her clinic specializes in spine care, pelvic health, but also chronic pain, and they take a really wonderful whole person approach to healing. Emily is here with us today, and she is going to share her approach to healing and help us break down the different types of pain. Pain from injury, pain from inflammation, pain that comes from having a sensitive or overwhelmed nervous system, which a lot of us don't know about. We talk about how emotions and stress and past experiences, even our daily habits can all play a role in what we're feeling and most importantly, what we can do about it. So if you've ever been told that your pain is just in your head or you were told that there's nothing wrong with you, you're just having pain, then please listen to this and share it with someone who you know is having chronic pain because it is super helpful. I'm so excited for you to listen.
So if we get a client who just really feels like they have no power in anything, they can't do anything about their pain, probably because they've been seeing so many people. Yeah. Research has shown they do not need passive treatments. The thing that actually can help is them feeling successful in their body.
Emily, thanks for coming today. I think this is such an important conversation that we're gonna have today about pain. So thank you for coming and sharing your wisdom and your expertise.
Thank you for having me. I'm really excited to be here and hope this will be helpful for a lot of people or insightful at least.
Sure. Of course. Now as a physical therapist, you deal with pain. Right? Usually, people are coming to you because of pain, maybe occasionally because something else is happening. But by and large, most people are coming to you because they're hurting. How did you tell us just briefly, how did you get into physical therapy, and then how especially have you become so passionate about helping people with their pain?
I've been a PT for thirteen years. And before that, I had a background in psychology. So I've always been interested in the human experience of pain, and it just started in, inpatient, more like rehab, working with spinal cord injury, brain injury, stroke. Neuro was my first love as a physical therapist, and I saw, I mean, every person I treated was in a good amount of pain. And I really grew to appreciate the brain as the powerhouse for movement and also pain. And then in my transition out of neuro rehab, I transitioned more into orthopedics.
And it's similar problems. Right? We're working with people in pain, and I won't even say a lot of pain or a little pain. People are in pain, right, and have pain and movement problems. And I just became more convinced.
Like, I need to get better at helping the person in pain rather than just I say just, but it's important, like strengthening muscles. And so over the process of being a PT for thirteen years, I've just become an avid learner. Like, I need to get better Yeah. Because chronic, pain is a huge problem, and I wanna help people. And so that's been a bit of my process as a PT.
I am now in orthopedics. I specialize in the spine and pelvic health and, see a lot of joint pain. Back pain is probably the biggest, back pain, hip pain, neck pain, osteoporosis related injuries like a fracture, and then the pain resulting from that. So that's a bit of a picture of where I've come from and my background. Always been interested in pain and how I can help people.
So glad, yeah, that you do what you do. I think in medicine, it's really easy for us when we deal with the same thing over and over to kind of just put a label on it and say, like, you've got back pain, you've got hip pain, you've got whatever. But from the patient experience, it has such huge effects on their lives. Even just mild chronic pain Mhmm. Can really start to make you feel a little crazy sometimes because you just can't keep having that.
So people with chronic headaches or chronic neck pain where it's just constantly nagging, it doesn't have to be totally debilitating pain Mhmm. To be quite limiting or to have an effect on your life. So I love that you take it so seriously. I see a lot of patients who I recommend go to physical therapy or have come to me after physical therapy. And one of the complaints that they often get is like, yeah.
I didn't really do anything. Right? Like, I went to physical therapy. They gave me some exercises. Nothing really helped.
And I do think part of that is because people don't always do their exercises. Right? As a patient, I know that's true. But I also think that a big part of that is because oftentimes, the person treating their pain doesn't see pain with the big picture that it is. Right?
They're just looking at you have some pain in your knee. I also noticed that when I do an assessment, you're weak over here. Therefore, be strong over there, and then your pain will go away. And it's it's really so much more complicated than that. So we're gonna really take a more comprehensive look at pain today so that people can see opportunities to get rid of pain, which is really we care about function and we care about the experience.
Yeah. So let's start with the very absolute basics. Just can you just define what pain is? Yeah. So pain, the official definition is it's an unpleasant sensory and emotional experience with or without tissue damage.
K. And so just breaking that down a little bit more, it's sensory and emotional. Sensory is just physical. Right? It doesn't say or emotional.
So it's just both. Yeah. K. And then with that statement, I I sometimes explain to my patients, it's like your brain is in a tiny black box, and that black box is your skull. And this is a an a metaphor by Lisa Feldman Barrett.
I love how she explains it. Your brain works out of prediction to keep you alive and safe. Mhmm. And so your brain is getting all this data from your internal environment and from your external environment. It's in a black box.
It doesn't know that this is a psychological interact you know, it doesn't make a difference between the physiological data from your body and then your interactions with your people and your environment and your food, all of the things. It's just making data. It's taking in data and it's making an output of pain. Yeah. And so that's why I like to break down.
This is I can't separate the two. Like, I'm very interested in a person in pain. What's the context around their pain? Because it matters. And then to break down the other part of, like, it can be related with tissue damage or tissue injury, and you can have pain without tissue damage or injury.
I just wanna highlight that because I think we forget about that. Totally. Right? Even practitioners like we do. Right?
Right. As a PT, coming out of PT school, I didn't even no one told me that. Yeah. I'm just thinking, oh, what's the structure problem? Let's fix the structure.
Yeah. But pain is just a bigger experience. You can have pain. You can have tissue damage. You can have tissue damage.
No pain. Mhmm. Plenty of us are walking around with degenerative changes in our spine, degenerative changes in our knee, disc bulges, even herniations. And 20 and 30 year olds, they've done studies and, images of people, and they're not symptomatic. Mhmm.
And so that's when we have to start to separate the two and say, hey, there's something bigger going on here. Your body is more like an ecosystem. Mhmm. It's not a broken down car. You buy it once, it depreciates over time, and we break down.
Right? Right. Your body's an ecosystem. It's always working to repair. It's a wear and repair process going on, not a wear and tear.
Mhmm. And I think the language we use in medicine needs to change Mhmm. With people with pain. Right? And I tend to take a more optimistic approach on that.
So that's a lot right there. Yeah. And I I wanna reiterate a couple of those things because I do think it's super important. Number one, if there's tissue injury or tissue damage. Right?
You sprained your ankle. You broke a bone. You tore a ligament. You dislocated something. That's a legitimate pain response.
Right? And there's the physical we'll get into this in a minute, but there's the physical nerves that say, ouch. You know? Like, that tore. Ouch.
Your brain says, I I can feel that that caused me pain. But at the same time, your body is taking in the rest of it. The brain takes in the rest of the circumstances around it Mhmm. And also kind of says file save. Right?
Yep. Absolutely. It says, I'm gonna remember that. I'm gonna remember this whole context. So if it was a onetime injury or if it was a traumatic injury that was associated with other horrendous emotional impact Mhmm.
Or if it's over and over and over, then you still have that nerve sending the signal saying, ouch. Mhmm. But then you have the emotional part of the brain saying, I remember what happened here and and saying file save file save override. Right? Like, it's just I'm gonna protect you.
I'm gonna protect you. Taking in that data. And one of the things that is so important in this is when people have, especially chronic pain so we'll break it down a little bit more for acute pain and chronic pain. But especially when someone has chronic pain, it's really easy for us because we're as as patients, we're used to the conventional medical paradigm, which is you have a problem. Let's keep imaging until we find the tissue damage.
And that seems like a really good idea. Right? So we have chronic pain, and we're like, let's look again. Let's get a different MRI. Let's try this.
Let's try this. And I think that's good. It's definitely good to understand. But just because there is tissue damage around the area that you're having pain does not mean that the tissue damage is responsible for the pain. Absolutely.
And that seems very counterintuitive to people. I know. But it can lead to ongoing pain because you keep managing this tissue damage that is not the source of the pain. Or even worse, you end up with surgeries and interventions that can make things worse. And the idea that, like, what you mentioned of people having degenerative disc disease, walking around perfectly fine is so important for people to know.
Because the fact is, if we image you enough, we will find evidence of wear and tear on your body. It's going fishing. Right. Yeah. Keep looking.
You'll find something. But then you feel obligated to fix it, which could make things worse. Yeah. So I guess I didn't really need to reiterate that, but I just think it's so important to really understand this idea of different types of pain. And, also, just because you find tissue damage doesn't necessarily mean that's what that's your answer.
Right. Right. It's a part of the story. Right? Like, so if you think of pain as like a cup that overflows.
The overflowing is the pain. Okay? And, there's different things that fill up that cup that make the pain overflow. And one of those is structure. So it's important to me.
I wanna I do wanna know what's on someone's image if they bring to me an X-ray or image. A lot of times, I like to see after I evaluate them Yeah. So I can have an unbiased approach there. Anyway, structure, genetics, sleep, worry. These things fill the cup, and there's been research around it.
We're learning more. And then it's and then the cup overflows for whatever reason. Okay? And so structure is a part of that, and it's important. And we can get that structure if we create the optimal environment for health healing.
We can get it to calm down. But we can there's so many opportunities to help people, worry, stress, Jeanette, like the, inflammation. Right? And we deal with, like, perimenopause, all of that. The inflamed hormones are huge.
So there's so many ways to go at it, and I I just want a structure and image is one thing, but we can work on either building the cup, like, getting a bigger cup, getting more resilient too, through the movement and our choices. We can also work on the other stuff to decrease the sensitivity of someone and their pain experience. And so I think people just need to know that. Right? Structure and tissue matter for sure.
I love the way that you're describing that. I wanna make sure that that we're understanding you correctly. So are you saying that if someone is experiencing a lot of stress in their life or, you know, has other aspects of their life that are not necessarily related to the injury, that that can actually change their perception of the pain they're going through? We have data on that. Is that what you're saying?
Yes. Yeah. Yeah. It can increase their sensitivity to pain. Mhmm.
Because remember the black box analogy. Your brain doesn't know we make the the distinction between emotional and physical. Right? It's getting in this data and it's making a physiological response in your body. Yeah.
And so stress matters. And so if someone comes in to work with me and they say I've had this pain for two years, I had an image, I had disc bulge, disc herniation at that time, and I'm still in pain. And I wanna know more. Right? And it may not have been an injury that brought it on.
It just came on. I'm like, tell me the context of what was going on in your life at that time. Not because I'm, like, going to say you're stressed. You need to calm down. Right?
It's more of, like, this is the ecosystem we are dealing with. Your body is an ecosystem, and I wanna understand this ecosystem and the state the status it's in or was in. At that time, your pain started and helping them make sense of their pain experience because a lot of people are confused and scared. Mhmm. And a part of our job as practitioners when we have that element is, like, decreasing the threat value in their pain.
If we kind of had an idea, like, if I don't know what's going on, I'm going to refer out. But if I have a pretty good idea, part of my responsibility as a PT is helping them, like, to decrease the threat value, not to say you're out of alignment. Your spine you the jelly donut, you know Discs. The discs bulged and it's splattered. I don't know.
There's so many fear mongering things that I'm just like, no. I want I want to learn more, and, I think it's a lot of it's about the language we use with people in pain. Yeah. Because if you blame it only on tissue damage and we're not very good at fixing that tissue damage, then you're kind of of a creek. Right?
And that's pretty hopeless. Like, that's that's and that's not the reality of it. So many people can feel better. We're gonna go into the detail of perception of pain, and you mentioned sensitivity in this threat value. I wanted to dive into that a little more.
But before we do that, help us just be really clear on this and understand what is the difference between changing our perception of pain versus saying it's all in your head or saying you're a hypochondriac or saying, like, you're just overreacting. There's you don't actually have an injury. There's not real pain there. Like, chill out. Right?
Because Mhmm. There's a little bit of nuance there, and I think a lot of patients have experienced the latter where they go to seek help and they're told, like, no. There's nothing wrong with you. And the patient's left saying, but I still am experiencing pain. So what are they supposed to do with that?
But think like, well, I guess I'm crazy or they're missing something, so I need to get more imaging or I need to do more fancy stuff. Like, how how is the idea of perception of pain different than making pain up? Good question. Well, just talking hormonally. Right?
I think hormonally, our perception of pain with the drop of estrogen, I think there's been some studies, and I'm learning more in this, is how our perception of pain increases. So usually, I go back to the basics on that. Like, I do think it's it's not, helpful for practitioners. If we really don't know what's going on with a person, could we just be honest and not say, well, it's because you're stressed out. Right.
We could say, you know what? This is, I'm I'm not finding anything structurally. What does this mean? What do you think about it? Mhmm.
Like, ask them. Right? And listen better. Yeah. And then say, like, where give them options.
Like, what are some things we could do here? Or maybe let's have a conversation around, the pain system a bit. Yeah. Keep it simple for people. People are overwhelmed anyway.
Right? And so there's an element where I believe every person that comes in and they are in pain. Right. I but I'm not going to only pin structure Yes. On their pain.
And I think that's where we get into trouble. Right? We're trying to pin structure because it's less well, not because it's less work for us. We're just good at that. We just like black and white answers.
Yeah. And people are not black and white. Right. So I don't know if that directly answered your question. I think that's the point.
I I mean, that is the point that I think is important to recognize is that we as practitioners should believe that people are in pain whether we know the etiology or not. Oh, yeah. And that's really the first step. And I think when you say, you know, this idea of stress worsening the perception of pain, I 1000% agree with that. Our perception and stress is so key to the way that our body processes everything.
Mhmm. But just because we say the perception of stress can worsen your pain experience does not mean we're saying you're stressed, and therefore, the pain is your fault, and you should chill out, and it's all made up. And if you just weren't so anxious, you wouldn't be having pain. Yeah. Like, those are two very different things.
Mhmm. I don't want to tell someone that they're making something up or that they should just chill out. But at the same time, if there are ways that we can help them, then we need to, with sensitivity, say, let's look for the tissue damage. And if we don't find it, I have other Other options. Options for you.
We have other ways and understandings to help. Yep. Hey. It's Mallory. Can you do us a big favor?
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When we think about, different types of pain, we've kind of danced around this a little bit. Mhmm. Help us understand what are these different pathways of pain because most of us just know, like, that hurt. Yeah. Therefore, pain.
So help us understand the different ways that the body experiences pain. Yeah. So I like to keep it simple for myself too, so I kinda simplify it. So we have pain, and there's different types. And I'm looking at for this as a physical therapist.
Right? So we have nociceptive pain and neuropathic pain and then nociplastic pain. Okay. I will simplify that. So nociceptive pain is like tissue issues, joints, muscles, tendons.
There's sensory endings in our body that pick up data from that, and that data is chemical. It's pressure, mechanical load, and temperature. Mhmm. And then those those sensors are sent to our body. Brain makes the output of pain.
Right? So if there's danger going on in our body, our body can pick it up and then send it to our brain, and our brain makes that judgment. So that's nociceptive pain. Joints, we can just say nociceptive pain behaves more consistent under load and predictable. Mechanical load makes it worse in some ways.
Sitting makes it worse. Standing makes it worse. Walking brings leg pain. You know, there's all these little things we can put together. It's usually in one spot.
Like, it doesn't really spread widespread pain. Mhmm. K? And it usually responds to cold or it doesn't respond to heat as much. So this is more when we're talking about, like, tissue issues.
I hope it's better. What we think of most of us are thinking of as classic pain. Right? I touched the burner, and I I drew my hand back because my skin hurt. Or I tweaked my knee, and now my knee is aching and sore.
Even I I think you'd put in that category like gas pain. Right? If you get dilation of the intestine, that doesn't have nerves like touch nerves. Mhmm. If you touch your intestine, you don't feel anything, but it has you mentioned pressure receptors or stress or, stretch receptors where if you get distention in the bowel, you'll get pain even though you're not touching that spot.
Absolutely. That's what we're thinking of with most of us think of as classic Yes. Pain. Yep. And that's where, we kind of get stuck, in health care.
We're looking for nociceptive pain all day long. This nociceptive pain doesn't tend to wander. Right? Right. So you're not getting pain in this joint and then pain in my shoulder and then pain in my Exactly.
Side. It's it's every time you do something, you get the pain, the same stem every time you have the same stimulus, you get the same outcome. It's pretty predictable Yeah. For the most part. Maybe a little Sure.
You know, gray here and there, but it's predictable. And then, there's neuro neuropathic, and that's where the neural tissues are irritated. Mhmm. And there's chronic irritate not chronic, but there's irritation of the neural tissue. So it usually behaves in a path down a nerve root or a nerve pathway.
Mhmm. And those behave a little differently. They're they're really tough to manage. They can be tough to manage. And so there's neuropathic, and then there's also nociplastic pain.
And nociplastic pain is more like central pain mechanisms. We can just say that. Like, your brain and spinal cord have become hypersensitive. Mhmm. K?
We've gotten really good with pain at this point. Usually, the pain can be more widespread, multi joint. It can it's typically they like heat. It's just these are just little hints. Right?
And then they don't respond as predictably under load. You know, it could be like, oh, I woke up today and I feel awful and it's everywhere. And then tomorrow, I'm I'm better and it's gone and then it'll come back. You know? So there's just these little hints of Mhmm.
More nociplastic or central pain mechanisms kicking the pain system up. And is there a difference in character of the pain? So sharper stabbing or burning or zinging or anything like that? So neuropathic will be a bit more like sharp and electric type sensations. They come, they go.
And they're really it's a little more abrasive. I don't know what else to do. But, honestly, with nociplastic, as I've worked with more people in pain, it's kinda can be any of it from my personal experience, but I don't I would have to check research. Some women I've worked with have diffuse numbness and tingling down their arms. Mhmm.
And they're told to go to a hand surgeon or something for carpal tunnel. I'm like, hang on. Let's let's screen the spine. We screen the spine. Nothing changes.
Let's work on and this I give them my hypothesis and, you know, and then they're and I have them put together their story and it's more like, okay. Let's work on the pain system through movement. Mhmm. Anyway, so it's a little more variable. I would say it can kinda be weird.
So, yeah, I I I totally agree with you. Tell us then about if you have tissue injury, is there any sort of predictable timeline that you're like, okay. I know I had an injury. Mhmm. I did I waited my time or I recovered or I did whatever surgery.
Or is there a time that you're thinking, like, that pain should have gone away by now if it was just tissue damage? Yeah. So, great question. So tissue healing times in general, and I'm just gonna keep this simple for the most part. This is, like, what we learn in school, and we're just tissues heal in twelve weeks for the most part.
K? We can just assume with a normal functioning ecosystem, that's a caveat. Right? Tissues will heal within 12. Bone, muscle, tendons Mhmm.
Ligaments, they will generally heal within 12. Now significant disc herniations that are very irritable, can take a little bit longer. Six months, some of the research is kind of back and forth. So tissues heal within that time frame. And then if it's lasting longer than about twelve weeks, I'm already thinking, okay.
This might be a pain system problem. Time is a really big factor for me when I'm screening someone from for tissue injury. Mhmm. And, like, if someone had an injury, it happened two weeks ago, they rolled their ankle, there was swelling, all of that. We are still in this repair process, and Yeah.
That guides my treatment. If this happened two years ago, I am less I am less apt to say this is tissue damage every time you have pain. Right? I'm not I'm not tissue damage. Right.
Right. Right. I'm I'm not thinking in my head as a PT is they are damaging something when they have pain. Mhmm. It's a little it's farther apart.
Yeah. But if the time is less than 12, it's probably closer together. If you have pain and you just, rolled your ankle, I'd say let's let pain be the guide in your decisions Yeah. How you load your leg. If pain is two years well, it started two years ago, we are into pain system problems.
I would say let's not use pain as our only guide here because that's where we get stuck. Pain doesn't necessarily, at that point, mean that there's structural damage. Mhmm. It means that your pain system is on and firing and you've gotten really good at picking up pain. Mhmm.
And you're just and that's just happened over time. And so what can we do? There's different approaches. So one I really like is where are your goals and your values in life? Let's orient maybe our decisions more towards your goals and values knowing that we are not doing damage to that structure.
We are moving in a way that's like, okay. I wanna move more. I wanna be more healthy. I know I have pain, but I'm not gonna wait for that pain to be zero to move. I see.
So that's just how I coach people. And I do work within, like, irritability. I'm not asking them to blow through pain and ignore it, but I'm like, let's let's choose a range, like tendons. I'm like, three or less. You know?
If it's tendon sensitivity that's last lasted for a long time, I coach them on, like, acceptable pain, yellow light pain. Let's poke into it. Let's back off a bit. And then red light pain. So I I want people to know what pain we think is okay to work through, based on my best knowledge and, learning there and also their story and then what they can tolerate and then, move forward through there.
So if they're having you know, if you feel like they're in the acute phase of injury, they've Mhmm. They've just had knee surgery and you're working with them on, you know, rehabbing their knee, that's going to be one thing. I mean, that's a totally different approach. If it's more chronic pain now where it's going on and on and on, then the idea that being just persistent tissue damage that you need to address the tissue damage becomes less likely. And instead, we're looking more for recovering the the pain system, the brain and connection, the memory of the pain, the the experience of the pain.
We're working more on that and also getting function back at that point. Mhmm. Yeah. So even at that point, the tissues can still be irritated. Mhmm.
Right? There can be chronic irritation. So if pain's lasting longer than three months, some of the I categorize this in my brain because I need to simplify it. But I'm thinking, okay. This structure can be chronically irritated because of loading habits, right, or other things, hormones.
Mhmm. Right? There's other things medically going on, and I use referrals for that. But chronic irritation under load, that's fine. So we can modify that.
Mhmm. We can work with that. We can find pain free movement or pain minimal movement to get people moving and stronger and build self efficacy. Chronic inflammation is one. So if the system the ecosystem is chronically inflamed, then it's gonna be hard to get out of that.
And I think that's a big one here. Right? We have a lot of metabolic disease, all of, a a lot of things going on in peri postmenopause. So I'm screening for hormones. How are people sleeping?
Sleeping is correlated with neuroinflammation. And then also nervous system sensitivity. Mhmm. And it can be a combo of anything, any of these two. It's not just like I have one of those things.
The system's so complex. So these are ways that we could have persistent pain after tissue damage should be resolved. Right? Mhmm. You mentioned these different things.
So go back through those, and let's dive into them a little bit more. I think one of the frustrations that I see my patients have and and even as a practitioner is saying, well, where do we start? Oh, yeah. Totally. Do you start with the evaluation of the tissue?
Do you start with inflammation as a system? You know, are we looking just to decrease inflammation overall? I have a lot of patients who come in with chronic headaches, but there are more tension headaches. They're at base of the head Yeah. Where it connects to the spine.
And we're thinking, gosh. Could that be musculoskeletal, or is it more hormones? Is it more and I think some of that comes with good questioning where we're saying I tell patients, you have to be your own best detective because I can only put a puzzle together with the pieces that that you're giving me. Yeah. So if you tell me that you are getting this pain wherever it is at the end of your menstrual cycle, that's helpful for me because instantly, I'm thinking there's a hormonal modulation of this.
Right? It's not just tissue injury if it changes with your menstrual cycle. So I guess I'm going off on a little bit of a tangent. That's a really great question. But I think it's really confusing of how do we start to unravel this ball of yarn of, like, gosh, it could be so many different things.
Maybe walk us through when you get someone we'll stay with chronic pain because I think that's more of the issue that we're discussing. When you get someone who has a chronic pain issue, how do you even begin to know have we fully evaluated the tissues enough? And then when do we say, like, this is just more of a systemic hormones, sleep, stress sort of thing versus you're in that, that chronic sensitivity, that nervous system sensitivity. So maybe walk us through how you would approach, helping a patient. So I've had a lot of mentorship through Carolyn Van Dyken.
I just wanna I'm like, I can't talk about the stuff I've learned without crediting the people I've learned it from. And she has really helped me hone in on this. So as a PT, this is what I do. Let me pause right there. Is that a typical PT or you specialize in pain?
She does or even when someone goes to a pet physical therapist, is this the experience they can expect where they need to find a physical therapist that specializes in pain? I would say you might have to shop around a little bit. Yeah. Yeah. It depends on the setting.
I treat one to one. Yeah. So I have this privilege where I can do this. So I look for whenever someone comes in, I I assess tissues, of course, first. So I I also do these questionnaires, and this is where what I've learned.
And they're validated through research to help me see what's going on with psychosocial factors that could be driving the ecosystem of pain. But first and foremost, as a therapist and a mechanical therapist, I am looking at the tissues. Right? And I'm screening no matter what their pain if they've been in pain ten years or two days, I'm looking at mechanically what's going on with structure and sensitivity there. That's my first priority because that's what I do through movement and all of that.
So I screen that first, and I'm at the beginning, I'm having a conversation about the ecosystem. I'm not pulling this out after, and I've had to learn this, after I mechanically screen. And then I can't really find anything. And then I'm like, okay. Let's talk about stress.
You know? Yeah. I'm I'm having this conversation at the get go. I screen mechanically. I'm looking for joints joints, backs, hips.
Do they like certain directions and certain loads? Do they hate certain directions and loads? Let's work with that to decrease the sensitivity of that joint, whether or not it's labral tear, whether or not it's whatever. Let's decrease the sensitivity of that through movement and load. If I really can't find anything, I I look at, okay, let's have a conversation around what's and this is happening the whole time.
What increases your sensitivity and your pain? Tell me more about the behavior. And then we talk about, what increase I'm listening to them. I will say that first. It's like, what's going on with their system so I can better understand.
And then we have a conversation around, okay, here's these questionnaires you filled out. And this is what I'm seeing. You're hitting the cutoff way beyond the cutoff of central sensitization or your nervous system's hyper, hyper alert. What's going on? Does this feel real to you?
And or, stress, anxiety, depression, I'm screening for that so I can refer out if they might need a little more support. Insomnia, all of those scores. I'm not trying to overwhelm them, and I really keep it pretty simple, but I'm like, I'm curious here because I am thinking maybe this is priming the pump for your pain system. Can you tell me more about that? Does this feel real to you?
Yeah. Right? Because it doesn't matter if it's real to me. It's like, does this feel real to you? And then then we get buy in.
It's like, okay. I can see the connection of why my migraines flare when my mother-in-law comes over. You know? Like, there's just weird stuff the body does. Yeah.
And so it gives them more power over it. And then that's what I do. I think that is what you're asking. I start there with the tissues. I'm having a conversation at the beginning about the system.
I'm listening to them. I'm wanting to know where do they wanna start. So I let them choose, and I do not give them 10 exercises. Yeah. After the first session, I'm giving them one max of two things.
Yeah. And we just chip away at that sucker. If it's like if this is chronic persistent pain, it's gonna take a while. Yeah. It's not I mean, some people have been some are faster.
Right? We don't really know. But, I think if people feel heard and they understand Yeah. What's going on, they're they're buying and they'll make choices and decisions that are best for them. And I want them to lead that.
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This is you touched on so many important things that I wanted to emphasize. I think number one, this is why it's the insurance system sometimes doesn't work very well because the insurance system drives on time efficiency, and this is not efficient work. Mm-mm. This is not a ten minute visit, a fifteen minute visit, even a twenty or a one time thirty minute visit because you as a practitioner have this this is how I visualize it as a practitioner myself is in my brain when you're talking, I have, like, bubbles or thoughts that are coming up, and I'm thinking, could it be one of these 10 things? And as you're talking, I'm crossing off nope.
Nope. Nope. Maybe. Maybe. Maybe.
And that takes time. It takes effort for you as a practitioner to let your brain kind of sift through the information, to gather the data, to sit and pause and think and let it sit in and say, that's interesting. That's a little different than what I would expect. And then you ask more follow-up questions. This work cannot be done in fifteen minutes.
No way. It can't be done right. You know, if you have an acute injury and you go to your doctor and you say, like, I fell off a curb, and now when I do this, my ankle hurts. Like, great. Get an x-ray and move on with your life.
Right? Yeah. But these chronic pain issues, they take time. Mhmm. And our medical system, sadly, is not very well built for time.
There are some areas that it's getting better. There's a field called physical medicine and rehabilitation or PM and r. You say PM and r? But Yeah. An and, not an n.
And they do a really good job at taking time and slowing down and kind of pulling these pieces together. But I just wanted to emphasize that first off of what you're describing your brain is doing as a practitioner and taking the time to listen and to validate and say, do you know what? I believe you. Yeah. I just don't know what the answer is yet, but I fully believe that this is your experience.
And that is it does take some searching to find a practitioner who's going to use that model. So if you're frustrated by the medical system and you feel like no one's listening, yeah. Yeah. That's the thing and find someone who will listen. The other thing that I think you said was so I mean, everything you said was so important.
But in screening for anxiety and depression, I just wanna take it back then because I think so many women especially are gaslit to say, like, I went to the doctor because I was having this symptom and they sent me home with an anxiety medication. And that's not what you're saying. I think when we say we're screening for depression and anxiety, it's because if your brain is in I call it brain inflammation, depression and anxiety. Mhmm. If it's in a state where it's not firing the right ways, where you're chronically down or you're chronically anxious Yeah.
That's going to change your experience with the pain. And if we ignore that, we're not gonna get the results that we want with your pain. Right. So when we're screening for anxiety and depression, it's not so much so we can say, check. I found my answer.
I dismissed you. Oh, yeah. Right? Like, go get your antidepressant and don't come back because we found the reason for your pain. It's your depression.
Right? Right. That's not at all what you or I are are going to do for patients. But treating depression and addressing the fact that you are in a depressed state or a chronically anxious state is part of the healing journey to help that perception. Anything you wanna add on that?
I come at it like it it's helpful for me to screen for it so I know, maybe at what level there's different cutoffs for, like, maybe getting some clinical help. Yeah. But I know that anxiety and low mood have been correlated with this insensitized nervous system. Yeah. So it's nervous system dysregulation.
There's a physiological effect on the body. And so I'm I instead of just seeing it on the list of the comorbidities they have, okay, we need to breathe. You know, let's just let's just calm down the stress. Right? I'm thinking, okay, this is priming the pump of your pain system.
There's multiple way movement strategies. I'm all about movement for anxiety and also depression. Yeah. So if someone's clinically depressed or, say, moderately depressed, research has shown cardiovascular exercise, five days a week at a zone two, like 60% of their max heart rate, can have huge effects on depression. So I'm always promoting, like, okay, how can we use movement to help this?
Right? And so I think that was a answer to your question. Yes. I'm not like, oh, this is the cause of your symptoms. I'm like, this is priming the pump probably in the ecosystem of the pain, you know.
What do you think about that and see if that makes sense to them? And also acknowledging that chronic pain can cause depression and anxiety because not feeling good is hard. Yeah. It wears on you physically and emotionally. Chicken or the egg.
Right? Exactly. Exactly. Yeah. I wanna go back a little bit because I think it's super interesting physiology and really helpful for people to understand this idea of sensitivity.
So tell us about that physiology that that happens where you say, actually, there's some people that actually you just touch gently, and it is their body tells them that was really painful. Mhmm. And in conventional medicine, often we say, like, man, you just chill out. Like Yeah. You are just overreacting.
But there's actually physiology that goes along with that hypersensitivity. Will you explain that? Yeah. So what I use that sign. It's called, hyperalgesia or allodynia.
Right? Like, to like, nonthreatening touch becomes threatening. Yes. And so I I screen for that. I ask questions into that just to get a gauge of, like, okay.
I think we're dealing with more of a, central pain mechanistic kind of system here. And, as far as the physiology behind it, I can't remember all of the stuff because it's so freaking complex. But I will just say when the brain and spinal cord becomes so good at picking up pain, things that are supposed to be non painful become painful. Yeah. And so your system's just so wired and so become so good at trying to protect yourself.
And so that nonthreatening touch can become painful. And that's why pelvic pain, there's a huge amount of I don't know what the right word is it. Like, there's a lot of nociplastic pain and pelvic pain. Yes. Right?
Trauma in there, like and I don't do internal work. My PTA does, but I can screen for it, and I know, okay. The tissues are probably very sensitive just through hearing them, talk about it. Right. Heart touch is very sensitive.
So there's multiple ways we can go about to decrease tissue sensitivity. You know, in a physical exam, I can do, like, more sharp, dull Mhmm. Like, those kind of tests to see what's more sensitive and work with that. And they call it, like, peripheral sensitization where the periphery, the tissues are sensitive. And then there's more of the central pain Yep.
Mechanisms. So there's a little bit of both. I'm still learning in that department because it's so complex, but I just see when someone when nonthreatening touch becomes threatening, there's a nociplastic component. Yep. How can we work with this?
And and, there's different strategies there. Did that answer your question? Yeah. It did. Yeah.
I I think it's so interesting. We see this sometimes after c sections where someone will get, like, we call it trigger point pain or trigger points where you get this really acute pain that doesn't make any sense. Like, it's it's way stronger pain than it should be. We see a lot of it in pelvic pain and in vaginal pain, pain during sex where it's like, this is out of proportion. And I call it mom voice pain.
So I call the nerves, you know, you have some when if you're a mom, you know, when your kids are like, hey, mom. Mom. Mom. Mom. Mom.
And the more they bug you, then the higher reaction I'm gonna give. Right? Like, the more they do it, the more I'm like, what? Yeah. And that's kind of what happens with nerves.
If you sit and bug a nerve over and over, for example, if you get a tiny nerve stuck in your c section scar Mhmm. We can't see it. Right? So we can't avoid them. Yeah.
If you get a nerve kinda trapped in scar tissue there, then it's like every time you move a little bit, it's rubbing on that nerve. And it's it's like that kid going mom mom mom mom mom mom. And eventually, the brain is like, what? And then the brain will overreact every single time we get that movement after that. Yeah.
And so that's that that peripheral sensitization. So that central sensitization is more of that overreaction of the nervous system. You mentioned threat. Right? Yeah.
So our body, it's looking for threats nonstop to keep us safe. Right? That's not malfunction. That's appropriate function. Mhmm.
But if we've had experiences that rev that cycle up, then pain will be perceived more intensely for us because our brain is on high alert. So it's gonna be like, oh my gosh. What was that? Oh, what was that? What was that?
Yeah. And you might be doing something silly or or totally ridiculous, but the brain is like, ouch. Oh oh, okay. Just kidding. Like, that didn't hurt.
Right? Talk about that for a second? Yeah. So, I I screen for this as well, but it's it's sounding a lot like, worst case scenario thinking or pain we call it pain catastrophization, which I hate that term, but it's it's this experience with pain that is totally normal in the short term. Yes.
I I messed up my knee a few weeks ago on the trail, and I go into about seventy two hours of thinking I will never run again. Right. And I'm a PT, and I'm like limping. I'm it's an acute inflammatory phase and I am bummed. And my husband's like, can you just pull out of it?
And then that settles and it yeah. I start to move better and I'm no longer thinking worst case scenario. Yeah. When someone has high worst case scenario thinking, that can actually prime the pump in our pain, and that's a risk factor for being in pain one year out. Yeah.
One year out, moderate to severe disability. And I think that's a part of that. It's like hypervigilance, right, and rumination around a pain. It's almost like this is pain, my hand is pain, and it's fused to the front of your face. Yes.
You can't see anything else. You can't see anything else and that is what's dominating everything. And that makes that pain system on high alert, keeps it going. And so how can we, educating people about pain is helpful to diffuse, but also mindfulness and and, noticing and getting practice with mindfulness practices to, detach from that, see it for what it is. But we also don't have to attach all the meaning behind it.
Yeah. Right? Of like, I am never gonna get better. I'm gonna this is gonna spiral. All like, what we believe becomes true or, like, what's repeated in our head becomes true to us versus just the truth.
Right? Like you said earlier, the brain doesn't know the difference between a thought and a real happening. If you are perceiving life as super dangerous, then your brain's like, got it. Hypervigilance. I will be on the lookout for anything.
Yep. I think it's so important for people to understand in this situation, this doesn't mean you're making it up. It doesn't mean that you're a hypochondriac. It doesn't mean that it's not real pain. Mhmm.
This is legitimate pain. It is legitimately your brain telling you that hurts. You couldn't, like, intentionally ignore that if you wanted to. Right. But what we don't do is treat it with ice or treat it with, you know, pain medications Yeah.
Because it's not the same pain pathway. Yeah. It's actually your brain upregulated and saying, gosh. You know, think about this, especially in situations of abuse, heaven forbid, or Yeah. Trauma where people get in a car accident and then they get chronic pain afterwards.
We have to understand what else the body is doing, and you're saying ecosystem. Right? What else is the body doing to store this memory of pain so that I can avoid it in the future? Yeah. Well, that's great and all, but, like, you're not helping me anymore.
If we don't recognize that's a thing, then we can't treat it. We can't address it. Right. Right. But if we recognize that the brain actually has a role in this, then we have to address the brain.
We can't just keep doing MRIs and steroid injections. I mean, those are great, and we should do them when we need to do them. But if someone's having chronic pain, we want to use more tools. Right. And part of those are understanding, like you said, are do you have depression going on that's changing the way your brain is perceiving stress?
Yeah. Yeah. Do you have anxiety that's keeping you on red alert and having more threat sensations? Right? Like, oh, that one felt dangerous to me even though it was just a little tap.
Yeah. I never said this is in your head. Oh, no. Right. The brain is always a part of it.
Yeah. I mean, it is in your head, but It is. But it is. In your brain. Yeah.
It's like real. Yeah. Or it's like not compartmentalized. Yeah. It's all one.
And this is where it does get really powerful. And if you skip all of this explanation that we've just had and you just say, if a patient comes in in chronic pain and you're like, have you tried meditating? It's not gonna hit the same. Right? Like, you're like, dude, I just told you that I, like, I can't get out of bed Yeah.
Because my back locks up or I, you know, I can't function anymore because of my neck pain, and you're like, I really think meditating on it would help. Like, you're missing a whole bunch of the Yeah. The points in between. But if we understand, like, how pain actually works and understand how the brain plays a role in this, then suddenly, it's like, oh, so maybe I should spend some time in stillness connecting with my body and saying, like, you're sending me messages. I see you, body.
Yeah. I see what you're telling me. I'm just gonna sit with that. I'm not gonna panic about that. Like, I can live with that pain a little bit.
Mhmm. Could we go into real quick some movement options for people with Yeah. I wanted to say so, like, what what can we do then? So perfect. I'm all in the I want to get people moving and living their best healthiest active lives and even people with central pain mechanisms.
I mean, a lot of us are walking around with that. Right? It's not just this special population. It's just like all of us pretty much. But there's movement options for everyone.
So let's just say I have someone who has a lot of stress in their life, a lot of stress, emotional load. Research has shown that there's effectiveness of yoga. Mhmm. I prescribe tai chi and chi gong Mhmm. For patients because it's new and novel for the brain.
So usually, central pain mechanisms like novelty. Mhmm. We need newness. We need to rewire. Neuropathic pain, it needs unloading time Mhmm.
For nerves. And then nociceptive, that's the joint. They like movement. We just gotta be a little tricky there. So with with the central pain, movement for stress would be yoga, tai chi, chi gong, anything that helps to evoke the relaxation response, but it also gets all the joints moving Yeah.
And all the neural pathways moving. So it's a great practice for people with, high stress. You know, if if they have a lot of pain catastrophizing or just, like, worst case scenario, hypervigilance, I go into mindfulness, also learning more about pain. This is interesting too. They've linked low self efficacy.
So if we get a client who just really feels like they have no power in anything, they can't do anything about their pain probably because they've been seeing so many people. Yeah. Research has shown they do not need passive treatments. The thing that actually can help is them feeling successful in their body. Mhmm.
And so that's when I step away, and I'm like, this is more about you than me. I'm not going to just massage or dry needle the whole time. Yeah. Let's give you some success. And so, stepping away from passive treatments have been shown through research.
Also, I just if there's depression, anxiety, or even the then that's priming the pump. Mhmm. Like, let's talk about what are some movement. What can we go for walks? Can we get that heart rate up a little bit, get it activated?
Mhmm. And then some breath work after. So there's so many options for people. I know that's very, broad. It depends on the resistance training.
It's been shown to be very effective with or help with depression, anxiety too. So I'm all in that category as well. So there's options, but at the same time, it doesn't have to be overwhelming. We can focus on one thing. I am not telling I'm not saying you need to do all of this.
Mhmm. Let's just focus on one, make that change, and over time, we can maybe add something else. You know, it does not need to be you need to bat a thousand Right. From the get go to get that pain down. I think when we get in that tug of war of pain, like, I'm going to make this go away, it gets worse.
Yes. It's so interesting listening to you because what you do is very it's a different field than what I'm in, although there is some crossover with chronic pelvic pain and and different things, and I am often the first stop, you know, when people say, like, well, I have this joint pain. I'll say, well, go see a physical therapist. I don't I don't know joints. Like, I don't I don't know mechanics.
I can't help you there. But hearing how you approach it is actually so similar to how we have to approach our patients with things like chronic fatigue or chronic inflammation or various things like this where we have to start so slowly. We have to pull way back and say stop running, stop doing Orangetheory, stop, you know, exerting all the time, like, pull way back. But we don't stay there, and I think that's where people make a mistake in physical pain as well as fatigue and healing is that they pull back and they say, I guess this is where I have to live because I had to come all the way back and do nothing in order to function from a pain or from a fatigue perspective. And I say no.
Yeah. You have to pull back enough to touch bottom, and then you move forward again slowly. So for chronic fatigue, we often do things like two minutes of walking, and then the next day is three minutes of walking. And then the next day is four minutes. Oh, four was too much.
Okay. So three minutes for three days and then four again. It's it's a matter of recognizing your limitations, but programming the body. One last thing I'll say about that. The way that I've explained it to patients when we're just talking about, you know, the body is all interconnected, but so much of it is so much of the way the body functions is based on programming.
Yeah. So it's very much like a machine, like a computer. And you push all the buttons and you put in all the data and you put in all the the the programming, and then the computer goes ding and out pops the outcome. Right? And if we want a different outcome, it's tempting to be like, I'm the machine's broken.
It's broken. I can't fix it. Someone figure out where it's broken so you can repair it. Yes. And that is that self efficacy that you're talking about.
We have incredible, I think, untapped powers to heal our bodies. Yeah. But we have to understand that before we can do that, and we have to understand that so much of the reasoning for why the body functions the way that it is is the programming that's going into it. So in order to change the outcome, we have to change the programming. Yeah.
And we have to do that slowly. You can't come in with a sledgehammer and break it up. You have to come in and tweak each knob and each dial and say, okay. How is my sleep? I'm I'm gonna try to go to bed ten minutes earlier.
How is my movement? You know what? I think I'm gonna try that two minute walk. Mhmm. How is my brain?
Maybe I'll just try to, like, sit and take a ten second breath. Like, it doesn't have to be major. We just have to start Consistent. Yep. Consistently telling the machine, our bodies, what we expect of it.
I expect to be able to move pain free. Yeah. We have to keep telling our bodies that. Or I expect to be able to move with minimal pain. Yeah.
And and putting these pieces together to program the body to get what we want, there's it's so cool. Like It is. It's so cool to go through that process with someone and see that it works. Mhmm. But it's slow, and it can be difficult, and it's tedious and requires a lot out of us as as patients.
But I think that it's so empowering Yeah. To do that when you're not looking for the magic person who's going to heal you, the magic test, the magic imaging study, the magic pill that's going to be the thing that finally heals you. You are the thing Yeah. That's going to heal you with the team. You know?
A team that can help with medications and can help decrease inflammation and help tell you how to do this. You don't have to do this on your own. But, anyway, that was a really long winded explanation, but it just strikes me that there's so much crossover between the way the body heals. It's the same if it's tissues versus cells versus Yeah. Hormones versus anything that we're dealing with.
Yes. Yes. Yes. As hard as physios or physical therapists sometimes or it's hard for me because people come to me with an expectation that I'm gonna fix them and you too. Right?
Yep. And sometimes I am magical because it's mechanical pain. And I'm like, I know how to do this. Yep. Right?
And then it's like, okay. This is a pain system problem, and I have to have that language around, you know what? I'm not your fixer. Yeah. I am here for you, and we are going to facilitate this healing process.
And let's just come up with where you want to start. So Yeah. I think that's been humbling for me because I started out as, like, I'm the fixer. And now I'm like, well, nope. You know, like, some within reason.
Right? I can really help people, but it's less about me fixing. Yeah. And it's more of, like, this team approach, to helping people with persistent pain. Yeah.
So Yeah. And it's one of the reasons conventional medicine is what it is is in my conventional medical background, like, those are it's super satisfying as a doctor to have someone be like, I'm I'm having heavy periods and it's ruining my life and I take out their uterus and they think I'm a magician. Right? Like, hey. Period's gone.
Mhmm. But to actually heal the body to really allow it to be its fullest, healthiest self, it just it's it's not really part of the conventional model very much. Right. But, man, it's so good. It's a good thing, and it's a good thing you're doing.
So I'm glad you're doing it. We are out of time. Is there anything you wanna wrap up or emphasize for women dealing with chronic pain that we haven't touched on? I think we touched on a lot. Yeah.
I would just say if you're in pain sometimes it's good for people to take a vacation from trying to fix it. Yes. So if you need to take a break, that's okay. But seeking help that you feel like you are heard and that you can get on board with and there's things you can do. Pain doesn't mean tissue damage.
It's it's a huge experience, and we need to work on the ecosystem where I'm not just giving you breathing just to breathe and calm down. It's like, no. Actually, we wanna change the physiology happening. And so being open to other strategies is is amazing. If if people are open to trying new things, which a lot of people are Mhmm.
Then I I firmly believe people can get out of pain. It'll it'll pop up here and there. Right? And, there'll be some flare ups, but we can manage that if people know what's going on with their body and feel empowered to make some changes. Yeah.
So, yeah, I think that's mainly what I wanna leave with. Well, thank you so much for sharing your expertise. I'm so grateful you're doing what you're doing. People deserve to have the care that you're offering. So tell us where they can find you.
Sadly, it's just in the Salt Lake area that you're practicing right now, but tell us tell us how they can find you. Yeah. So I, own mindful movement physical therapy, and I have another PTA I work with. We do spine and pelvic health. We do, in person and also virtual coaching.
So I do have clients and coaching clients in other states, that I work with. Oh, awesome. I'm just helping people understand their bodies better and get moving more and to feel good for the long haul. So that's what I love to do. And, yeah, I'm in holiday just down the street.
Yeah. Yeah. So thank you so much for what you do. I think it's huge and more people need more comprehensive care. Yeah.
Right? One to one care that spends time listening to people in pain because it's hard. Yeah. But doable. Doable.
Yeah. Well, thanks so much, Emily. Thank you for having me. Thank you so much for tuning in to today's episode. A huge thank you to our guest for sharing their insights and time with us.
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