If you are in a situation where you go to the doctor and they can't find what's wrong with you and you are still experiencing something negative or painful, your body's gonna be like we need to send out more signals. We need more information, and so it will start to make that sensitivity rise in your body.
Welcome back, my friend. If you have been struggling with chronic pain, this is the episode for you. We've talked about chronic pain in the past, so that's a great place to start, and we're going to continue to build on that in understanding what it is that causes these pains to become chronic and very difficult to treat. Today, we're diving into the fascinating and very hopeful side of chronic pain, because yes, there is hope with Dr Sarah McNurlin. She is an amazing physical therapist here in Salt Lake City. She is the founder of pinion physical therapy, and is a specialist in nervous system informed care, specifically trained in advanced pain therapy techniques that really help our patients completely get rid of their pain, which is worth a pause in and of itself. Sarah helps everyone from elite mountain athletes to weekend warriors to anyone dealing with chronic pain to find their way out of pain that has become their default system and their default experience. We will explore why chronic pain doesn't always mean there is ongoing tissue damage or that there is even something quote, unquote, wrong with the tissue. We are also going to explore what is actually happening in the brain and spinal cord when pain becomes chronic, and most importantly, how specialized physical therapy can help calm those signals, restore the safety cues to the body and get you moving again and back to normal, whether you're living with persistent pain, yourself supporting a loved one, curious about the mind body connection, whether your pain is related to an injury or a surgery, whether it's fibromyalgia or plantar fasciitis or chronic pelvic pain. Today's conversation is going to be super helpful for you. It's full of science, but lots of practical tools and lots of encouragement. So I hope you will listen along with us. We hope you'll enjoy this episode and find it helpful. Please let us know if you find it helpful so we can offer more like this. If you want to hear something else from us, let us know we're always open to hear from you. The purpose of this podcast is to be helpful to you, so please let us know what you want to hear next and share with a friend. Let us keep developing this great content that can be helpful for you. And let's get started.
One of the mechanisms that happens in chronic pain is we will actually cluster those closer together in an area so that we get more information. Therefore we are more sensitive to the sensory inputs around us.
Sarah, I'm so glad you're here today. We are talking today about chronic pain, which affects a huge number of people, especially women. So I don't want to waste any time. I want to dive straight in. Tell us a little bit about your history as a physical therapist and how you came to specialize in chronic pain especially.
Yeah, good question. Thanks for having me. I'm very excited to talk about this. I feel like everyone needs to know about pain. Yeah. So I have been an orthopedic physical therapist for over 10 years, and as I was treating back pain and spine pain, I started to realize that I didn't have the tools I needed to help a certain population, which was this chronic pain group, and so I took it on as my mission to do all these continuing education classes and figure out mentors and start to learn so that I could help this population. From a personal standpoint, I actually have multiple family members who have suffered with chronic pain there most of my life, and actually lost a family member to complications with some chronic pain stuff. And so sorry. I really like being able to help people understand this and hopefully give people hope and better outcomes because it's touched my life very personally as well.
Thank you for sharing that. Pain is something that we shouldn't underestimate, right? It's living with day in, day out, pain, even if it's not every day, if it's waxing and waning, but having that chronic presence of pain in your life, will you give us a little bit just summarize that for us, a little bit of an idea of what it's like for a patient living with chronic pain. It can be fairly all consuming, where my patients in particular are kind of like always on the brink of just surviving and day in day out, it takes up so much mental bandwidth and so much hope and joy out of people's lives, and so trying to figure out ways that we can reclaim some of that is really important for the population I treat.
And it doesn't have to be like terrible limiting pain to have a pretty significant impact on your life, right? I'm pregnant right now in my third trimester, and you get these just nagging discomforts that every time you bend over, you get a little stitch in your SI joint, you know, and and that's nothing like someone living with chronic pain, but it gives me a little bit of a window of like every day having that just annoyance, even if it's just a slight annoyance, it wears on you. You get emotionally tired, you get irritated. I feel like you live kind of revved up and just just like a shorter fuse. Is that something that you're seeing like, how is chronic pain affecting these people's lives outside of the actual pain? I think it's really hard to show up authentically and to like, be a parent or be in your job and be present when you always have this kind of nagging thing. And the unfortunate part of chronic pain is when you do have this constant nagging symptom, your nervous system is on edge all the time, which impacts everything, but it also feeds back into this feedback loop of chronic pain. So chronic pain stress creates this scenario in an environment where you're actually probably going to have more symptoms, and so it can be a really, really frustrating experience.
Yes, and I want to really dive into that, what you're just talking about with the nervous system before we go there. I think that if you are someone living with chronic pain, as a patient, as a person, who is it? Who do people go to? I think there's a wide array. And I think many people will start with their primary care doctor, and maybe they see an orthopedic specialist, if it feels like bones and muscles. Maybe they see a neurologist. If it feels like nerves, maybe they see a rheumatologist, if it feels like joints, where else do people go to get support for pain? Kind of, without going into too much detail, where do they go?
Yeah, and a lot of times, chronic pain does end up being a multidisciplinary thing, where people are often having to see a couple different providers to get the care that they need. PTS are a really great place for a lot of chronic pain, especially if you see a PT who's versed in it, because we just have the advantage of time with our clients, which a lot of health practitioners don't, and so you can really establish a relationship. Have time to listen to people's stories, get enough data and really start to tackle the different ways that pain influence things in the body system. There are also, like pain psychologists who they focus on some of the mental aspects of that and some of the like neurologic rewiring,
a lot of times a like, if you have spine pain, a spine specialist or whatever, like joint specific, definitely, having someone with a medical background on board can be really helpful. And then a movement provider that you trust can also be really helpful. So I know a lot of my clients really like things like Pilates or yoga instructors that they trust,
basically people who are going to see them and be able to work with them and make modifications, make them feel safe and make them seem feel heard and seen. Yeah. Okay, now, help us understand what your role? You've kind of just said it already, but, but maybe going to a little more detail of what is your role? What are we talking about, specifically today when it comes to treating someone with chronic pain? Good question. So when I look at pain as a physical therapist, I sort of see three different places that we can input or make change. And so part of my goal, if I see someone is to figure out, like which of these is going to make the biggest impact? Do we need to tackle all of them? Do we need to tackle one of them? How do we kind of do that? But essentially, pain has like an input, right? Like a sensory input. We can change pressure or strength or load through your body, and that can influence the pain you experience. We can also change the way that your nerves or your body translate that information, or whether they pass that information on, and how they pass that information on into your brain, and then we can change the way that your like overall nervous system is receiving that information. And so for me, there's kind of three places we can test that, in the clinic. If we do a full evaluation, and we look and we watch you move. We talk to you. We we have these tests and objective tools that can help us decide which of these components is probably paying a bigger role in your symptom presentation, and then which ones we want to choose to tackle, and which ones maybe we see if we can wait on not all of these things are really easy to tackle. And so sometimes it's like, let's start with low hanging fruit and do some of these things and just get you moving. And sometimes, like, no, let's, let's go for the heavy hitter. You've had this for a long time and you're ready. Okay, so I want to go back through all of that in a little more detail. But the next question would be, who this topic that we're talking about today?
Who is this for? Who is this really going to resonate the most with, I think, anybody who actually has chronic pain. So when, when we look at chronic pain, it's really anything outside of what we would consider a normal healing tissue window, which is about 12 weeks. So if you've had pain for more than three months, you likely fall into this chronic pain category. The other group that I think would definitely benefit from this is even if you don't have chronic pain, but you have episodic pain where your neck flares up every you know, you move on, yeah, and you get the like, crook in your neck, or you, quote, unquote, throw your back out. This can be really helpful in helping people understand why those patterns exist and how we can navigate them. Okay? Now I think when a lot of people think about a physical therapist and dealing with pain, they're thinking about you'll have better words for this, but I'll use the words quote, real pain or not real pain, right? Like you have a tendon issue, you have a muscle issue, you have a nerve issue. And where some people get the biggest frustration is they go to one doctor and they say, well, it's not this, and they go somewhere else, well, it's not this, and they end up with this vague sort of sense of pain. And I think when they go to physical therapy very frequently, it's not helpful. You know, they'll give them a set of exercises, and it didn't work, and so they'll be back to ground zero. Kind of lost. Help us understand is this what you're talking about with chronic pain, only people who have a true, identifiable source for pain, or we have this whole other group of people, like with fibromyalgia or autoimmune disease, that have joint pain that's migrating around their body. You know, sometimes it's my left knee, sometimes it's my right hip. You have people who have just higher sensitivity, like they just seem to get these aches and pains from random things all the time that last for weeks and then they'll go away. So when we think about a physical therapist who specializes in pain, is it only that type of pain with musculoskeletal injury, or are you also able to help people with that more vague, unidentifiable type of pain? Yeah, good question. So we can help both. And a lot of time there is both happening. I think it's we would like everything to fit in these, like, neat boxes where it's like, this is musculoskeletal pain and this is nervous system related pain. And a lot of times there's contribution from a bunch of different things that are creating the pain experience or the pain sensation. And so the a lot of times, making sure that we are dealing with some of the quote, like more physically based things can be a good way to make the nervous system happy, which can then impact some of the other components of the pain system. It might be good for me to just like, kind of explain what exactly pain kind of is and how that pain system works. Yeah. So when it comes to pain, we can have it's basically an unpleasant sensory or emotional experience with or without tissue damage, and when I'm in the clinic, I really like to use analogies to describe this. The pain system is pretty complicated. There's a whole bunch of things that go into it, but I think people understand it best with some simple analogies. So one example I use often is this idea of you walking down the street. So our body has sensory receptors all over it, and it is constantly taking in information. That information goes from those sensory receptors through a peripheral nerve to our spinal cord, from our spinal cord to our brain, and then our brain listens to that information and decides something about it. Yeah, a lot of the sensory stuff that we are experiencing day in and day out, our brain doesn't actually care about, like, the way that our clothes feel on our body. We are getting pressure signals from our pants right now, but neither of us are probably thinking about our pants, because to our brain, that's like, not important. We know we have pants on now, if I showed up to this interview and didn't have pants on, my brain would be acutely aware of what I was feeling right that would give me a different sensation and maybe trigger an uncomfortable emotional or physical response.
So if we're walking across the street, our foot is getting all this information up into our brain about the pressure, the speed, the cadence, all of these things, and then say we step on a nail that will be a sudden change and a big depolarization or big pressure, message, yeah, to our brain, and our brain then goes, that was different, yeah. What do we think about that? And a lot of times in that scenario, our brain will give us a painful sensation so that we can make decisions accordingly. So the goal behind pain is it's protective. It's going to keep us out of trouble, and so we have to have a negative experience so we can change something in order to keep us safe, so that nail, that signal goes still up the same pathway in our brain, our brains flags it as being different than the handful of other.
Steps we just took, and then we have this cascade of response where we look down, we see the nail, we take the nail out, maybe we go to the doctor, we get a tetanus shot, stitches, whatever that pain will slowly start to calm down as we understand the situation and we feel like the threat is gone. And that's a very complex thing that our brain is taking in all these emotional and physical and environmental cues to decide whether or not we're safe. Yeah. So we actually have built in pain mitigators into our body so our and in the same way that we can kind of send signals up, we can actually dampen the signals that are coming. And so one of the things that can happen is if we understand the situation, if we're having a normal course of healing, and if all that stuff feels kind of status quo, we send out natural opioids into our body, and norepinephrine and serotonin, all these things that dampen that signal, yeah, so that we stop experiencing pain. So that's kind of a that's what should happen, yeah? A normal response, but there are a lot of times where that response is either not proportional to what we're experiencing physically, or we start to have maladaptive behaviors because of the frequency we're getting that information or the environmental context or cues around that. Yeah, yeah. I think that makes so much sense, and it's so important. One of the things you mentioned before we recorded is the pain is a protective mechanism, not always a sign of damage. And I think that is at the root of a lot of frustration when people are trying to figure out chronic pain and what you've just described, because you start having pain. So you go to the doctor, and you say, Doctor, what's wrong with me? And they do an MRI, or they do a physical exam, they do different things, and if they find something wrong, maybe then they recommend physical therapy or surgery or, you know, injections or other things. But very frequently, if they don't find anything wrong, then they say, nothing's wrong, and the patient is still left, saying it still hurts. And I think what our brains want to do then is find what's wrong, find the thing that's broken, find the thing that's damaged. And so just you summarizing that to say it's a protective mechanism always and sometimes, damage can help the whole way that we're trying to evaluate. Why am I feeling this pain, because if we only look for damage, we're going to miss other causes. But if we can look for what is our body trying to protect us against, then we start, really starting to uncover some pathways. So maybe that's the next best step to go to you
mentioned. Maybe this was before as well. There's a difference between chronic pain and acute pain. Acute Pain would be kind of the normal pain response that you would expect, and when it goes longer than that, then we're in chronic pain. Did I say that? Right? Yeah. So with chronic pain, if it's a tissue damage, we'll leave that for a second and maybe come back to it. But if there's no tissue damage, and you as the practitioner are starting to have the idea that this is not tissue damage, this is a protective mechanism. What next? What do you do next? Yeah, so even in that case, we still have to sort through some information, right? So when it comes to tissue damage, we will have a natural healing cycle. So say you, say you cut your finger, right? And we know that that is probably going to heal within three months. Most of the time it's going to heal significantly faster, but three months is like our long window, right? So that tissue scars up, and then immediately that tissue is not actually ready to tolerate a ton of load. We have to kind of gradually reintroduce it to movement and and get that part of our body ready to tolerate load. So there are times where people have pain that is mechanical or has to do with tissues, and there's not actually tissue damage anymore. Nothing is still healing, but it's not ready for the load that we're asking it to do. Okay? And so in that case, we need to put someone on like a gradual loading program. Tendons often have this where people injure a tendon, they have like a tendonitis, tendonosis, and they they rest, and they do all the things to let that thing heal, and then they go back to running, and they still have their pain. And a lot of times, it's not that that tendon is still damaged, it's that that tendon is now not ready to do the load that you want it to do. Yeah, and so we need to put someone on like a graded loading program, so that can still be a situation where people have the pain experience or they're signaling, but the signal isn't that tissue is being harmed or damaged. It's like, Hey, this is different than we want it to be. We're different than we expected.
Outside of that we then also have these
expectations right where, if you are in a situation where you go to the doctor and they can't find what's wrong with you, and you are still experiencing something negative or painful, your body's gonna be like, we need to send out more signals. We need more information, yeah, and so it will start to make that sensitive.
The rise in your body so we have at the at our receptors, right? We talked about this before, one of the mechanisms that happens in chronic pain is we will actually cluster those closer together in an area so that we get more information. Yeah, therefore we are more sensitive to the sensory inputs around us. And then at our spinal cord, we can up or down regulate that signaling based off of whether or not we want more information. And so in chronic pain, a lot of times, we are getting more signaling going through in a bigger, faster way than we would normally, day to day. Yeah, and then same thing with our brain, where, like, we're not getting the information we need. Your brain's gonna be like, cool. We're gonna send it to more parts of our brain. We're going to ask our emotions about this. We're going to ask our memories about this. We're going to and it takes this really clean, crisp, clear track that we thought when we have acute pain, or kind of this sudden onset of pain, and it just makes it widespread and kind of diffuse, where it's just searching for answers any way it can. And in doing so it makes stuff really sensitive, yeah, so then all of a sudden, these, these cues that would normally not alarm our brain, are starting to get picked up in ways that they have never and so that's where we start to have these, these symptoms really painful and real, right? These are, these are never made up. These are always real, true, painful, negative experiences about information that is maybe not indicative of tissue harm or tissue damage. Have
you ever tried red light therapy at uplift for her, we are big fans, and we and I use it ourselves regularly. Red light therapy helps support energy healing, reduce inflammation and improve skin health, and there's more and more data to support that. One of my favorite at home options is the loom box, a powerful, clinical grade device that combines red light with near infrared light, so you're getting both surface level and deeper tissue support. It's easy to use and makes consistent red light therapy actually doable. One of the things that I love about the loom box is how easy it is and how compact it is, so you can grab it out really quickly, use it while you're in bed getting ready to go to sleep, and then put it away and not have to unpack a big, complicated device. I use it most nights as I'm going to bed, mostly just for relaxation. I find I feel very calm and wake up with good energy. So it is one of my favorite wellness add ons. If you're thinking about adding it to your wellness routine, we have a link in the show notes that will save you $250
off of a loom box. You can also find it on our favorite products page at uplift for her.com now back to the show. I always think of this with my kids, because I have a young one who has a very loud voice, and as kids do very frequently, an overreactive, overreactive response. So very frequently in our house, you will hear some child starting to wail like they are dying. And usually they're not actually dying, right? They're not actually queuing that something horrendous has happened, but they only have one response. So whether they stub their toe, or, you know, the top fell off of their marker, or, you know, their sister hit them, it's all the same response. And that's, I think, what you're talking about when you're talking about up regulating, is sometimes that that input is just yelling at our brains, and it doesn't need to yell at our brains. The stimulus could be tiny, it could be major, but the brain thinks you're dying either way, right? The brain perceives it, and I think that's really important to recognize, because oftentimes even doctors and even practitioners will feel like we're making it up, right? Like you're overreacting, you're not in that much pain, but the perception of pain is not your making it up. It is literally the nerve signals yelling and so that it's important to recognize that it's not fake, but it's also not necessarily representing accurate reality, but that's not in your control, so it's not that you're making it up, but it still could be an overreaction of your body. Yeah. I think one, one example that's sort of useful to help people understand that is this idea of like your pain actually being like an alarm system. Like, imagine alarm system in your house, yeah, right, where, if you have an alarm system and you somehow have someone break in and your alarm system doesn't catch that. Yeah, you're going to go back to that alarm system. I need more sensors. I need window sensors. I need glass breaking sensors. I need, I need to make this so sensitive, because it obviously didn't catch the threat. Yes, right? And then all of a sudden, that alarm system is going off every time a branch hits your window, every time the wind, you know, blows something into your house, every time your kid screams, yeah, you have this over sensitive thing where it's not actually capturing threat anymore, even though it is very much going off, yeah, and that's where.
Sure like this, your nervous system can really dictate how your body feels safe or not safe, and its perception of safety and threat. Will you take that one step further and explain that idea of the nervous system? Because we've talked about nerves, peripheral nerves, meaning the nerves that feel stuff, right? You can have more receptors. You can have more alarm systems, you know, in the nerves. But how does the nervous system? Because when we think about the nervous system, we think more about our perception, right? So we're talking more. I call it cave woman brain. It's like that really primitive brain who's starting to give some cues. Will you explain? Maybe the difference and, or the interplay between we were talking about a second ago, peripheral nerves, meaning I feel sharp, I feel sensation, versus the nervous system, which is not that type of sensory input. Yeah. So we basically have, like a conscious set of nervous system and an unconscious so we have in one one side, we have our sensory coming in, and then our motor like the nerves that tell our muscles to fire, that's pretty much conscious to some degree, yeah. And then and what we think of as quote, unquote real, we can tangibly appreciate that. All of us know what that's like. You stub your pinky toe on the dang corner of the bed, and you know what that feels like yes, and then we have kind of this unconscious part of our brain, this, like sympathetic, parasympathetic part of our a lot of our autonomic nervous system really plays a role here. And I think the best way to help people understand that is a lot of your audience's moms, if you had a bad night
of sleep, the yelling that your son has or your child is just that much more grading, right? It's just that much more threatening to like your ability to focus and to understand poor sleep, a heightened nervous system, a fearful nervous system, is going to register sensory input differently. And it's in part of that is if we are our if we have all these like little fires that we're trying to deal with, our body is so worried about our protection that it's like, what if we miss the big fire? Yeah, what if we miss it? And so in that case, what it does is it makes sure you also don't miss the big fire by making everything so sensitive. Words like, I know you're not focusing very well. I know you don't have enough sleep. I know that you're stressed, and so I don't want you to miss anything. So I'm going to give you a ton of information, and we're going to be really sensitive to it that way we don't miss any threats, because your body is not acting and behaving in a normal way. Yeah, I want to spend some time talking about what to do about it. But before we go there, there is still this other category of pain, which is autoimmune, or what the medical world does not really understand very well, fibromyalgia, or, you know, these things that we can't do an MRI and see, oh, there's tissue damage there, although sometimes there is but, but when we have this waxing and waning pain, or less consistent pain, right? How does that fit into this conversation? We can look at that as sort of like, more of like a centrally driven thing, where a lot of times, in those cases, people are having hypersensitivity, because an autoimmune stuff, like your body's kind of already attacking itself, like you're kind of already under threat all the time. We we can talk about the reasons why, or, you know, kind of trying to find the root cause. But from a pain standpoint, sometimes it's just trying to make someone's capacity bigger to handle, like threat or response to that. And so
you had a podcast with Emily, and she talked about this cup, right? This idea of like, if your cup is so full, anything that comes in it will overflow. As soon as it overflows, you have pain. We can put less things in the cup, right, remove some of the stressors, or we can make your body's ability to handle that, yes, more you have more capacity to handle what is already there. Yeah. And so a lot of times with the autoimmune stuff, it is doing the things that give you more capacity, that take off the systemic load. So really honing in on sleep and diet and nutrition, as someone who's had autoimmune stuff and bad flares. In the past, I can attest that, yeah, my symptoms of neck pain and those things, they get worse when I overall am in a like, more inflammatory, if you will, stay in my body. And so when I start to feel this, come on. The first thing I do is sleep. I really prioritize sleep above all else, and just try and get my body to believe that there are less fires happening. Yeah, down regulating. Yeah. Okay, great. Well, where do you think is the next step that we talk about here? I do like I said I want to talk about, like, what do we do? Is there anything.
Else do you think we're missing from understanding the ideas of chronic pain? Obviously, we could go on and on. I really, I think it's also important to recognize that our brain has pain mitigating capabilities. The term we often use is what's called Wet brain where, and that's to, essentially, we flush out the signaling that's happening. I like this example of
you're walking across to your living room and you step on a Lego that Lego hurts so bad, yeah? So bad for like two seconds, right? And you probably have a little bit of, like, tissue damage, tissue damage, yeah, of some sort, yeah, minimal, but to some degree, yeah. But your brain immediately gets rid of that signal within like, a second or two, because one it's like, yeah, I've stepped on 1000 Legos, yeah? Because this is what my living room always looks like, the environment, the cues, the context, all of that makes sense. It doesn't feel threatening, yeah, your body can recognize it. So we have this, this thing that happens in our brain where it, like, washes that signal away, so we stop experiencing the painful stimulus, yeah, and but on the flip side, say, the last time you stepped on LEGO, you then tripped and, like, broke your leg or something, and that was a super traumatic experience, then you might actually have a maladaptive response to that where, like, you step on that Lego, and your pain is through the roof and persistent because your brain associates the Lego as being threatening for something bigger. Yeah, and so that's where the environmental context really plays acute. But our brain is really good at turning down pain, if it has the opportunity to,
if it understands that, if it can, if it can feel safe, it will let that signaling go, yeah, which is cool, yeah. I think of this, especially as a gynecologist, we deal a lot with pelvic pain around endometriosis and interstitial cystitis, or painful bladder syndrome, or, you know, chronic vaginismus, various things like this. They feel very unsafe, right? And they tend to keep coming. You know, every time you're intimate, or every time you have different things like this, it's going to come back again and again and again. Or every time you have a period, it comes back again and again, and every time it comes back, then it shows you that, see, I knew it, I wasn't safe, because there's that pain again. So when we're talking about safety then, and maybe this goes into like, what do we do about it? How do we give the body safety cues when you're in pain, right? Someone who has endometriosis and painful periods is going to listen and be like, Yeah, cool. But like, I'm not doing this on purpose, like, I'm not having a period and feeling freaked out, per se, right? So what do I do about this painful period? Obviously, I can go to my gynecologist and get get physical treatment, whether that's hormonal treatment or surgery or whatever. But from your perspective, what are some things that we can do for these chronic pain syndromes to send the body messages of safety once it's safe, right now, if you have a torn ligament, then, like, everything in your body is going to be like, not safe, and that's appropriate, yeah, and we often can't turn down some of those signals if we actually have a lot of active tissue damage. Yes, the,
I think a couple of things in the pelvic world especially, are being able to
feel what it feels like to be safe, and so finding yourself in situations where you can really understand what your body like feels like when it's calm, and what your pelvic floor feels like when you are calm and when you feel fully protected, and then making sure you find those environments during flares and remind your Nervous System about those but there are things like diaphragmatic breathing and all of the kind of like mindfulness meditation stuff that actually can do a lot for improving your brain sensation of safety, taking someone out of fight or flight and putting them into parasympathetic however they do that is really effective at making the nervous system feel like it doesn't have to pay attention to every single little detail. Yeah, I love that. I think of that in a couple ways. One, we talked about like my noisy kid, right? Who's Who's having the same level of reaction no matter what the stimulus is. And we can train the body. It sounds like what you're saying. We can do better at training the body to have the appropriate sensory response, right? So if you have, if your uterus is cramping, you're not going to, like do a bunch of meditation and not feel that, but can you perceive it more in proportion to what's happening? Now, endometriosis is not the best example, because you can't sometimes it does really, really hurt, yeah, but, but in general, any type of pain response, when you mentioned earlier, if we're in fight or flight, we're going to perceive it more intensely. And if we're not in fight or flight, we might perceive it less intensely. So always taking that time. I love what you said about.
About kind of memorizing how that feels to not be in pain, which might be hard for some people, because if it's really chronic. But this is something actually that comes up with our mental health therapists, is if our brains are used to being in a certain anxiety mode or depressed mode or whatever mode, one of the tools that we use is choosing a memory that that is not that mode, choosing a memory that is joyful or peaceful or calm. And then we close our eyes and we go to that memory, and we try to live that memory right now, because our brain is not actually very good at knowing whether it's past, present or future. Like, if you're thinking about it, then it's there with you. Like, it's like, oh, that's where we are now. So that's interesting to hear that come up with, like, a mental health therapy tool as well as a physical pain tool. Is saying, Can I memorize what that feels like to to move without pain or to rest without pain, and can I close my eyes and try to, like, recreate that in my body a little bit? I love that. Yeah, I the thing that just popped into my brain about that is this idea of also changing the way you talk about it. Yeah, I have people who come in and they're like, they use these terms, like, My bones are grinding and like that. It's just so, so descriptive, which is helpful for me to understand where they're coming from and and I understand that. But if, if what we're trying to the fact, yeah, if what we're trying to do is make your nervous system feel safe. If you describe things as stabbing, and this is my my muscles are ripping apart and all that stuff, your nervous system is gonna be like, wait, what? Yeah, it's, it's like this idea of a little kid running across the playground and falling Yeah? And if that mom yeah is like, oh my god, oh my god, yeah, yeah, that little kid is gonna be like, Wait, what am I okay? I must be hurt. Yeah, I must be hurt, yeah? Versus like, if that mom can, like, come at that eight and then calm and thoughtful and a little bit more like objective in her words, like, how, you fell down? What's going on? Can I help you?
That really does change the perception of safety and threat, and so sometimes I'll give people an exercise where it's like your goal for the next week is to not ignore but not use the word pain. You can use any other descriptor you want talk to your body. Talk reference it like it's a little kid, and you don't want to scare it. Talk to it like it's your grandkid, Yeah, or like your little baby, yeah? Where those words that the way that you are depicting these sensations, does impact your nervous system's perception of threat, yeah, in a real way. Yeah, this, it's this is really getting to the meat of, like, how we can actually heal. And I do think, as patients, sometimes we don't want to hear this, because it does feel like we're saying this is in your head. So you use your head to get better. And I we talked about that earlier, but I want to go back. This does not mean it's in your head, but you do have more power over it than than you realize. The more that we're just going and looking for damage, looking for damage, looking for the next shot, the next pill, the next magical thing, the more you're getting rid of your own power to heal your body. And your body's listening to you. It's listening to you and your brain and your messaging more than it will ever listen to a pill or a shot or other things. So we really do get the, I think we get the best results when we include your mind and your perception and your words and your you know vibe, even in this healing process. It also reminds me when my kids fall and they start to howl, right? And sometimes they'll come in from outside and they're crying and and you don't know if something terrible has happened, like, did they lose a finger or or not, you know? And so one of the things I'll always say is I'll get down on their level, and I'll look at them and say, Are you hurt or are you scared? And they say, I was scared. Okay, okay, now we can calm it down. And I almost feel like that's the conversation we need to have as we start to have an experience is to say, Is this more pain, or is it more fear of pain? I think of this especially with people with painful sex, and it's one thing that we have to keep asking, especially because we'll be doing treatments along the way, and the pain sensation, the actual nerves will start to fire a little bit less, but any firing will trigger their perception of pain. And so by asking, like, what is it actually that you're feeling? We do this sometimes with pelvic exams, where I'll say, like, I'm going to put my hand right here. I'm not going to move. You're safe. I'm not going to move. I'm not going to do anything that you don't expect. What is the sensation you're feeling right now. Because at first they'll flinch right like, Oh, I'm afraid of that. I'm that's gonna hurt, but if you actually ask them, they say, actually, okay, that feels pressure, that feels a little stretchy. That's not what I was expecting. It's not what I like, but it's not pain, and I'm not in danger. And sometimes by continue.
Continuing to retrain in that way of I'm safe. It's not pain, and if it is pain, it's not a scary pain, like it's a dual I can live with that. Then they put their brains back in charge, and then, as they continue to have that experience again and again, then it starts to down regulate the system, because the system is now responding and saying, See, yeah, now I'm good.
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So I don't have to spend time looking at the labels and trying to find the ingredients that trying to remember what I was supposed to avoid. They just do that all for me. So I know anything that I buy from them is already screened and is something that I can trust. So use code uplift for her for 10% off at just ingredients.us. Now, back to the show. Will you extrapolate on that? Because I know you see this more. Yeah. So that kind of reminds me of like someone is like a C section after a scar. Sometimes people are so sensitive to touch there the nerves are higher, yep. And so one of the treatments for that is to do like, graded exposure and more, like, we'll say, like, okay, take a cotton ball and rub that against it. Rub it on your arm and tell your brain this is what a cotton ball should feel like, yeah. And then put it on your scar and help your brain collect these data points around what is normal sensory and what it could feel like, maybe what it should and isn't that just so cool, like the body is really quite fascinating that you can even do that? Yeah. So when the when someone comes into me with chronic pain, and we've kind of dealt with some of the quote, unquote mechanical and the we have them on a graded exercise program, and we're getting them moving again, one of the things that we can actually test for is this idea of, are you having sensitivity in your peripheral nervous system versus your central nervous system? And we actually have tests that we can do with with standardized data to see, like, how sensitive is your current nerve nervous system, like, how, like a touch test, or there's what kind of yeah, there's a couple. The first one that I'll typically do is what's called laterality. Have you ever heard of that? So laterality testing, the test itself is, I do it on an app. There's a free app that you can do, but you basically look at a picture of, typically, it's an extremity, and you have them decide if that is a right or left of that extremity, as fast and as accurate as you can. And a lot of these apps will have like, a picture of a hand, and it's in different orientations. That ability for your brain to determine right versus left helps us understand if you have what's called smudging. Have you heard of that? No. So this is all new, loving it. So our brain has a map, like a real estate map of in our hand represents a certain area, our foot represents a certain area of our map, and that map is basically the same for all people. And so if you move your hand in your brain, that area on an MRI would like light up if we've had pain for a long time or the sensitivity, one of the things that can actually happen is our brain loses track of where it thinks it is in space, and it starts to quote, unquote, smudge that area in our brain. And so that can lead to actually, pain, sensory stuff going into other parts of our body, outside of where we maybe initially had tissue damage. So if your brain can't recognize right versus left, it doesn't really know where it is in space. And so it's not getting accurate information. And so we can teach it to get accurate information, which then helps collect all these data points that tells us that we're safe, right? If we can't sense where we are, we have no idea if we're safe or not. So laterality testing is one of the main ones, and to fix that, we give people exercises where they go through this like trying to figure out and clean up this system. The other big one that I'll use in the clinic is what's called two point discrimination. So that's the ability to determine one point versus two if it touches you simultaneously. And then there's thresholds for how close or how far those two points need to be away in order for you to feel them. So we have norms on our body where in our hand, we can discriminate two points that are very, very close together, because we have a lot of sensory there. Our hands are very smart from a sensory standpoint, on our back, that is like, significantly different. We're talking like a couple inches versus a couple millimeters. So we have norms of these areas, and we can test people in areas where they've had pain.
Pain and see if they fall within the norm. A lot of times, my chronic pain, people have significantly worse understanding of this two point discrimination. They do very poorly on this test again, because our brain along the way has lost track of sensory information in an accurate way. Yeah, it's too busy trying to collect all the data that it doesn't process that well, and it starts to create this smudging sensation. So we can then train people again. We can do exercises and things that are fairly cognitively based. They're all sort of brain exercises, but they help improve your body's ability to map those out. And so that's laterality. And then we do graded motor imagery, where it's like, we kind of talked about this, where it's like, you imagine a sensation. You you imagine what your limb is doing that is normal, or what your back is doing that is normal. And you keep giving it that over and over and over again. And then you make it more and more complex. And that makes the brain super happy, for reasons we've kind of already discussed. And then the last tool that's so valuable, especially if people have like limb pain, would be mirror therapy. Again, mirror therapy, yeah, where we put a mirror, and we have people look at the reflection of, quote, unquote, the good side, and we have them do all these things. And that tricks our brain into seeing, realizing and sensing what normal is. It's the same concepts as the the cotton balls on this, the C section, all kind of works. The same pain system. We just have lots of different tools for different areas. And so the whole goal of this is to retrain your brain how to collect data accurately, so that it can perceive threat accurately. It's really so fascinating. I'm thinking of it from a patient perspective, and I think one of the responses would be that that it feels too easy, that feels too simple. Can you give us some examples, either specific patients or just generally? How much better are people getting with this when, especially if it's something that that they've struck out everywhere else. I think of patients with plantar fasciitis, or sometimes with SI joint stuff, or sometimes with pelvic stuff, where it's like, Listen, I've done all the things I was supposed to do, and now I just hurt. How much better can you actually help people to feel? Yeah, you can kind of resolve symptoms with these exercises. The cool thing about these tests is because we have norms, and we've had and we can collect baselines, we can actually see improvement Exactly. It's more objective, yeah. And so it is a, it's a, I love it as a PT, because it's a great way for me to get buy in, and it's really validating for people, yeah, where we do these tests and I tell them what normal is, I'm like, this is where you are. And people are like, Yeah, that makes sense. And sometimes that can be so helpful, because they've had a lot of practitioners tell them that nothing is wrong, yeah. And so it's nice to have an ability to point out the system that maybe is the most impacting of their symptoms, yeah, and then we can watch those values improve, even if there is tissue damage, like you think of with plantar fasciitis or some of the feet disorders especially, are really difficult, and they can do an MRI and show that it's all inflamed and angry. And even then, just by working through the cognitive central nervous system processing perception of pain, you can get resolution of that inflammation. Yep, amazing. Yeah. The brain is very, very plastic and very adaptable, both good and bad, like we see this on both ends of the spectrum, where we can really easily spiral into this kind of like chronic pain world. If we're not getting answers we're not getting if stuff is is kind of moving in that direction, but we can also very quickly and pretty simply unspiral something. Yeah, I tell people, we just need to know where to look, and then we need to pick an intervention that feels sustainable, doable, effective for you. The cool thing with chronic pain is there's often a lot of places that we can try and target and things to do and trying to figure out, like, what's going to be good for you in your particular case, like, is this something that is actually doable? Or do you have the time to do these exercises? Is this something that you buy in on? If we're not getting those things, we got to find something else. And usually there's a couple different ways to try and intervene here. But once you stop that snowball, you can kind of UN snowball relatively quickly, because your brain starts to learn that it's safe and that these things start to make sense again, and it likes that. So as you're talking about this, I am I'm pretty blown away this. This is really fascinating information. And I would assume that this is not the typical toolkit of a physical therapist. Is that? Is it pretty specialized? Or how much does your average physical therapist? I know all of them understand pain, but in terms of understanding some of these cognitive tools and other tools, how easy is this to find for people who are like, I actually do want to find someone who can help me with this. Yeah, unfortunately, we we didn't get a ton of this in school. A lot of the science is relatively new. We've really made a lot of gains in the pain.
Science World in the last couple years. Yeah, so I didn't actually learn anything about campaign, to be perfectly honest, in PT school. Now I graduated over a decade ago, so I know that they're starting to teach this in classes, but I had to take a bunch of continuing education and a lot of kind of separate mentoring in order to achieve that. So if you're looking for someone in your area who does that, checking out their website and kind of seeing and then, like asking, like, do you have you taken any extra education in these things? A lot of times
they will have, like, books and things, like, I have, I have all the pain books and the kind of the tools to do these testings. You can ask if someone knows what laterality is. If they don't, they probably don't have a lot of skill set in teaching or in kind of treating some of these more chronic pain situations. I think it's just helpful to know I think anytime we're looking for a medical practitioner, the more specialized we get. You kind of want to know what you're looking for, and so it's helpful to know that that's not the norm. Because I think so many people have gone to physical therapy, and they sort of check that box as like, Oh, I already tried physical therapy, but what you're talking about is really a huge adjunct to traditional physical therapy. Now, when you're helping your clients, you'll still help them in those ways of like, Let's do these strengthening exercises or your weaknesses on this side, and that's about as much as I know, but you know, helping them through more traditional physical therapy. But this is going to be something that's additional, that that if you've seen a physical therapist and didn't get these results, don't check off all physical therapy. Yeah, yeah, yeah. And it's interesting, I having worked with chronic pain for a while now, it still blows my mind. How, how little pain education anybody is getting in any part of the medical system, right? Even I will still use a lot of these concepts for my post op patients, where there's a lot of pain catastrophizing that can happen after a surgery, especially if you've had, like, a repair, where it's like, you start to have symptoms that are different or unexpected, and the first thing is like, oh my gosh, did I retire my ACL is my is my rotator cuff repair still good? And so there, there's a lot of value, and even people who don't have chronic pain, to at least understand the like basics of how the pain system works, yeah, and what things influence it, so that you can set yourself up, so that maybe you don't fall into that chronic pain trap, where, if you can kind of calm down those fears and and have a little bit cleaner idea of what is and isn't affecting the pain system. You can eliminate some of those things that might make that system over sensitive. It's really interesting. It makes me wonder, and maybe you know the answer this about pre procedural sort of consultations, you know, before you have a baby, or before you have a hysterectomy, or before you have an ACL repair, how that could change the experience, if you can, kind of, and I, as a surgeon, would try to prepare people as well and as accurately as possible. So some of that means, like, this is going to be uncomfortable for you. This is not going to be uncomfortable. Most people have this experience. And I do think the more that we can say this is the norm, that is helpful, because if we don't as surgeons, you know, if we don't prepare people, I think it's all very scary, you know, especially depending on who you talk to, because you can talk to five people, and I don't know why humans tend to do this, but they want to share their horror stories more than anything. And so if you're going in for a procedure and you talk to someone who's had that procedure very often they will be like, Oh my gosh, this was the worst, and here's the worst, and here's why. And then we're going in expecting, like, when's it going to start? When's it going to start, when's the worst part going to happen? And so do you ever do any pre procedural counseling? Do people come for that? If I have someone who I know is going to surgery, I'll absolutely do that. I wish there was more of that happening in our medical system. I just time, right? Yeah, it is. It's just time. But I think really helping people understand what is potentially the normal spectrum of symptom sensations, kind of what we would expect, and then when we should be concerned with outliers. Yeah, is can be really valuable, yeah. But yeah, everyone always has that uncle or someone who you know had a terrible whatever, and they're especially birth stories. People are terrible. I don't want to wear your story possible. Yeah, thank you. But I so and being mindful of that, right? If you understand that, how your emotions and how your perception of threat impact that then keeping yourself out of situations where people are going to tell you horror stories before procedures is a really great idea, right? Yeah, as someone who's had a baby, that was one of the main things. My doula said it was like, just don't let anyone tell you about their birth stories, because no one is going to tell you the like, good everyone wants to share their.
And it's like, just go in with open mind, and not all this fear based kind of mongering. Well, what are we missing here in this conversation? I feel like you've talked about so many great things. Maybe. Are there some things people could DIY? Are there some things people can do at home as they're dealing with chronic pain? I really think about, especially my patients with autoimmunity and with these, these kind of they've struck out, you know, like, I don't know that someone's going, they're still hoping that someone's going to do the MRI, that's going to see the thing that's wrong, and then be the pill or the shot or, yeah, right. But so often it's not, it's, it's, it's different than that. So are there any other things people can do on their own to kind of jump start this, or is it really a matter of finding the practitioner who can help them, especially when we're talking about fear, because part of the whole fear is, is there something wrong? Is there something that's going to get worse or going to limit my mobility? You know, Will I ever be able to run again? Will I ever be able and so having someone who can really weigh in and be like, Yes, I do think you'll be able to do that, but it's going to be a long road, or it's going to be a short road there. Yeah, yeah. I don't think you can underestimate that. Yeah. I do think, especially as you get back into activity after a big episode of something kind of more stressful or traumatic, I see this in spine pain a lot, where a lot of times people have, like, disc herniations, and they feel like that happened because they were, like, squatting or lifting inappropriately. But they'd like to do those things. They want to get back into those and there's so much fear about getting back into those activities where they go into overprotection mode, and in some way, shape or form, that actually is like a sort of a self fulfilling prophecy for a flare up. Yeah, I had a guy in here, and he had a he had a disc herniation. He responded really well to treatment. It was he had pretty significant symptoms to begin with, and I ended up seeing him a year later because he was still having pain with squatting. And so I took a look at his squat, and I was like, what happens if you just, like, unclench your glutes and breathe and kind of relax into that. And he had no idea that he was, like, holding on for a dear life, kind of protecting, because in his brain, the squat was what caused his pain, the pain and so he was in this, like, super clenched, really protected thing, and that was actually what was then causing the mechanical pain, because the spine couldn't move the way that it was supposed to. So if you're in a place where you want to get back into something and you don't know how to do it, or you don't feel safe, like, also find someone to help you do that. Yeah, a good trainer or a PT, but then just someone who can watch and behave, this looks okay. This is normal, yeah, yeah, yeah. But I think that, like where anybody can start is just trying to find one way to regulate that nervous system, yes, right, yeah. Can you optimize your sleep? Can you optimize your hydration? We like hydrated tissues. They function better. Can you take something off your plate. Can you deal with a stressful situation slightly differently? A lot of those subtle nervous system changes start to have really big impacts day over day. If you are in the chronic pain world, especially if you're in your like autoimmune
Yeah, flare, yeah. So just and again. It doesn't have to be you don't have to do all of these all at once. Literally, one thing, stick to it, and then start to collect data points about that. Where it's like, oh yeah, I slept a little bit better. How do I feel today? I feel a little bit better giving yourself the check in, where then you start to give data points about health and safety and resiliency, and you start to train that nervous system like, Yeah, I'm actually safe. I'm safe here, yeah. And this idea of like, Is it fear, or is it actually something that we need to be concerned with? I love that the last question, one of the last questions I have, is, you mentioned earlier. You know people who sleep weird and wake up with a crick in their neck, or people who throw their back out. Those people may not see a physical therapist because they know if they wait three or four days that it'll go away, but it's still happening over and over. Is there anything you can tell those people about things that they could do to watch for or to help it resolve more quickly, or anything? There a lot of times those actually do have fairly what we call mechanical patterns, where they seemingly come out of nowhere, but a lot of times, there's some early warning signs and symptoms, and we can kind of do in a clinic, like a range of motion screen and help people understand what are their potential triggers. So it's a lot of times like in the most simple way, if you do some kind of daily mobility routine, and you just take stock of how that feels every day and start to notice if something starts to feel stuck a little off. Usually, that's going to be a precursor to you waking up with a stiff neck or kind of, quote, unquote, throwing your back out. There's a lot of times these.
Settle early warning signs if you have a mobility routine or a daily routine where you just take stock of how you are feeling, it can just be as simple as that. And then if you if you feel like stuff is a little stiff, then do your usual things that make that part of your body feel better when you have that. One of the things that I love about doing this podcast is I get to hear recurring themes from different experts, from from all different parts of our health and wellness. And one of the things that that makes me think of that you're talking about is in chronic illness, one of the biggest problems we see is a disassociation from the body, like I learned to ignore my body's cues. We think of this with eating disorders, or we think of it with being overweight or with chronic fatigue, that we we skip our body's first warning cues or our first messaging, and we just get used to ignoring that. And so it's interesting hearing you say that about mobility is so many of us just we're just powering through all the time. We're just sort of waking up, getting it done and going back to bed, but how much better off we would be just to get to know ourselves, our mind, our body, our soul, our mobility, our range of motion. You know, I should know everything there is to know about my body, so that then I can say, like, this one's weird, and maybe it will resolve just by you seeing that and letting go, but then you can go to an expert and say, This side's weird, you know, and be able to have that identity, I think that a lot of people get gaslit when they go to doctors feeling very knowledgeable, right? Yeah, they'll go to the doctor and say, this is, this is where, yeah. And a lot of doctors, I think, will poo, poo that, and be like, come on. Like, I know what I'm doing. You don't need to tell me my job, but I actually love it. From patients, the more you can give me about what you know about yourself, I'll take it like that's hugely beneficial for me to not have to start from scratch and ask you 80 questions. Like, if you can come and tell me I love it. So getting to know our bodies and reconnecting to our bodies helpful in everything, but especially in this pain process. Yeah, for sure, I I always assume that patients are their expert, right? Yeah. And my goal is to listen to the context cues that they're giving Yeah, and help them kind of piece together maybe some of their blind spots. Yeah, exactly the stuff that they bring to the table. Totally. What would be your final words? What have we not said? Or what do you want to reemphasize or summarize? I think just that there is hope. Yeah, I it's chronic pain. Can we've talked about at the beginning, can be so devastating in so many ways, and so impactful in so many ways. But I have a skewed vision of this, because I treat it and I see it, I see people get better, but there is hope. You can live without pain every day. We can take the edge off. We can slowly move to stuff that is pain free. We can kind of retrain those systems. And our bodies are extremely adaptable. And so just in the same way that they can be sometimes maladaptive, they are also so capable of being adaptive in really positive, beneficial ways. And so I think just like, if you're stuck in this cycle, don't give up hope yet.
Yeah, just don't give up hope.
Well, thank you for sharing that. I think
pain can be really devastating, even if it's quote, not that bad, you know, and and I'm so glad that people like you are doing what you're doing to spread hope, to spread hope, to help people find results so that they don't have to live in chronic pain. Because no one, no one does well with that. No one deserves that. And I think it is so hopeful to know that even if there is something truly wrong, right, like well, no one's going to be able to help me, because I've got this thing that's wrong, but that that doesn't have to be the end of the story, that, yes, maybe there is something that's not working how it should in your body, and maybe you can't fix that, but you can sure change the experience around that. Yeah, for sure. And we don't need to know all the answers to make changes in symptoms. Yeah, exactly. Well, gosh, this has been so good. I hope that those who are dealing with pain will listen and find the hope that you're sharing and the benefits that you're sharing. Where can people find you and work with you? Yeah, so I have a clinic in Salt Lake City. It's called Pinyon physical therapy.
You can find me there on Instagram. I have a personal account and a business account. Dr Sarah mcnerle on DPT and Pinyon physical therapy, and I'll put those in the show notes, yeah, yeah. And I share all kinds of fun stuff on there that is helpful, hopefully, for sure. Well, thank you, Sarah for coming on. It's been such a joy. Yeah, thank you for having me. I really appreciate it. Thank you so much for tuning in to today's episode. A huge thank you to our guests for sharing their insights and time with us. We are grateful for the incredible support from our sponsors and to all of you listening. We couldn't do this without you. If you enjoyed this episode, please consider subscribing on your favorite platform. You can find us on our website, uplift for her.com, YouTube, Apple, podcast, Spotify.
By or wherever you love to listen. And if you found value here today, please share this episode with someone who would benefit from it. Leave us a comment or give us a review. It really helps us reach more listeners like you. Thank you for being part of our community. Stay tuned for our next episode. Lastly, this information is for educational purposes only and not intended to be medical advice. You.
