Sensory Approach to Manual Therapy
Sensory Approach to Manual Therapy
Touch as Therapy: Exploring Pain Management Techniques
Can touch actually alleviate pain? Discover the groundbreaking insights from Pavel Goldstein, head of the Integrative Pain Laboratory at the University of Haifa's School of Public Health, as he unpacks the profound power of touch in pain management. Inspired by his personal experience during his wife's labor, Goldstein's research reveals how empathetic touch from partners can provide significant pain relief. Join us as we explore his compelling study with romantic couples, where simply holding hands demonstrated remarkable analgesic effects.
Touch is more than just a physical sensation; it's a powerful tool for communication. In this episode, we delve into a fascinating study on empathetic touch and its neurophysiological impacts. Learn why the initial research focused on female subjects in pain and their male partners, and how empathetic touch enhances brain synchronization and physiological harmony. We also touch on the broader implications for therapeutic practices, shining a light on how intentional touch can bridge emotional and physical gaps.
Finally, we navigate the complexities of chronic pain and its distinction from acute pain. Chronic pain, often misunderstood, requires innovative approaches like Pain Reprocessing Therapy (PRT) and rethinking the role of placebos in pain management. Hear compelling case studies that illustrate pain as an alarm system that sometimes misfires, and the evolutionary perspectives that frame pain as vital for survival. Pavel Goldstein's insights offer a fresh and hopeful perspective on understanding and managing pain, encouraging listeners to be attentive to their bodies and the messages pain conveys.
For more information on Pavel Goldstein and his work visit: iPainLab and to share your stories please go to PainStory.Science
Hello everybody and welcome to another podcast of the Sensory Approach to Manual Therapy. Today my guest is Pavel Goldstein, who is the head of the Integrative Pain Laboratory, also known as iPainLab. He is also at the School of Public Health at the University of Haifa and he's going to be my guest today talking essentially about touch pain chronic pain, acute pain and where we're moving forward with our ability to properly and easily understand pain and get a better client story of pain, so that we have less of a subjective and more of an objective understanding of where we're moving forward with pain. So welcome.
Speaker 2:Thanks, thanks, troy, thanks for having me here and, yeah, I'm very excited.
Speaker 1:Yeah.
Speaker 1:So the first thing that got me interested in contacting you was an article that I'd read in a massage therapy magazine called Can a Loving Touch Reduce Pain therapy magazine called, uh, can a loving touch reduce pain?
Speaker 1:And, as a manual therapist and as most of my followers or listeners, uh, and even a lot of my clients who listen to my podcast we're all interested in manual therapy and touch therapy because that's our primary mode of treatment, and so an article as as wonderful, as kind of loving touch reduced pain for me, obviously I gravitated towards it and I loved the read and I found the story very compelling. And I found the story also not necessarily that bizarre. It was wonderful and it was unique because it was yours and your partners, but it wasn't necessarily something that clients haven't told me about or that other massage therapists or physios haven't expressed a similar reaction. So I just wanted to get, if you want to tell everybody a little bit about that story, and then what made you inspired to essentially further go down the rabbit hole of the research behind it beyond just, oh, I had a great experience. And then, moving on to something else in life, yeah, thanks.
Speaker 2:So at some point in my life my wife was pregnant. So at some point of my life my wife was pregnant and basically, when you know the time was, we got to eight months she started the delivery process.
Speaker 2:So we got to the hospital and we got to the delivery room and you know I had my ba in psychology. So you know, I felt like you know I have tools really to help my wife, you know, to manage all this pain right and the stress and apparently, you know, being psychology is not enough to manage it right. So you know, I really tried different tools and I I don't remember, you know, right now I don't remember what it was exactly but at some point he said to me like shut up and just hold my hand.
Speaker 1:I was going to say interesting moment to try to be a psychologist to your partner, which normally doesn't work to start with, let alone throwing in labor.
Speaker 2:Yeah, yeah, exactly yeah.
Speaker 1:So yeah, so I did it.
Speaker 2:I did it, I hold her hand and when we talk later you know after all this chaotic process. So she said me that basically holding the hand was very therapeutic for her and she didn't feel much pain when I was holding her hand and I was amazed, like you know, I was.
Speaker 2:You know using a lot of touch in generally, so I wasn't like much surprised, but still, like you know, in this very stressful situation, when I didn't have anything like to suggest her, the touch was something that kind of saved me, and maybe in our relationship, I don't know. So, yeah, so I, at the same time, I was in search of my topic for my PhD, so I decided to take this idea and to construct a scientific study based on this concept. So that's what I did. I designed the study, of course, with my supervisor, my collaborators. My supervisor was Professor Simon Shama-Itzuri from University of Haifa. So we designed this study, we invited romantic couples and we provided a pain stimuli to the woman, to the female partners and the man was in different condition.
Speaker 2:He could, in one condition, hold her hand or be just present there or be outside or, in the enforced condition, also had a stranger who was holding the hand. So I think it's also very important because, you know, touch is very uh. What is important in touch is also a context intimacy and contextualization around the touch yeah, yeah, exactly, yeah, exactly.
Speaker 2:So we ran this study and we found that romantic touch reduced the pain of our female participants. But I think more interesting was we found a very interesting correlation. Basically, the effect of analgesia was much harder for couples who was more empathetic, with more empathetic partners specifically so couples who was more as a partner was more empathetic. The effect of touch was stronger.
Speaker 1:Yeah, okay so, and so this is, you know this result? Yeah, this is really interesting because, as manual therapists, we are taught in school to really remove the romance aspect from touch, because it's supposed to be therapy Right, and it's this. There's a lot of qualities in manual therapy that are unknown. There's a lot of stuff that we still don't fully have answers for about why it works, and this is really what this podcast is about is about trying to understand a lot of the unknowns, and one of them is often context.
Speaker 1:You know, you're sitting in a room for most massage therapy.
Speaker 1:Most clients who get massage therapy not all of them, but most are fully undressed or in their underwear, they're laying in their sheets and they're being touched by another person.
Speaker 1:And outside of your romantic partner and possibly your doctor, there are very few humans who touch almost the entire body when you're either fully undressed or undressed, and there's often this miscommunication or a lack of understanding with new massage clients who create sometimes an unhealthy connection with their therapists where they feel closer than they really are.
Speaker 1:Where they feel closer than they really are, often it leads to them divulging secrets and stories in their life that they wouldn't normally divulge to a massage therapist who is not a psychologist and not trained to do any of that kind of stuff. But there's this sense of intimacy that often is apparent in massage therapy and it's interesting because you're saying that that romantic touch seems and that empathetic touch seem to have a more positive effect on pain reduction, and yet it's something in massage therapy and physical therapy and all these other versions that we specifically try to remove from our environments and it just it leads to a tricky scenario ethical scenario in my mind of well, if it helps my clients get more pain-free, but also I'm trying to avoid the romance. That's a tricky line to walk now, in the future. So that's an interesting point to have to bring up.
Speaker 2:Yeah, yeah, so I can clarify it. So I'm not sure that this is a completely romantic component, because empathy is a very general term, like it's your ability to take shoes of someone else, right? So it's basically your ability to understand what happens to the other, right? And that's what actually what we found. Like the people who have this ability right to get to understand better, understand what's going on the other side, they success better to you, know better to help their partners to reduce the pain, right. So you know, if we take it like more generally, we know from previous studies that touch, social touch, can communicate different emotions, stress, right. So in this context, we can think about touch as a communication tool, right? So you can communicate your empathy. You can communicate your empathy with a partner, but you also can communicate your empathy to a client, right?
Speaker 2:So if you have, this like empathetic skill, right, so you not necessarily need this romantic component, right? So, specifically in a couple, use romantic component, because this is like what connect you, right the empathy pre-exists? Yeah, exactly, but if you're professional, you know how to create this. Let's maybe also call it the Alliance, right? So yeah, psychology school, it walk in the line. So you also create here lines with your client. Yeah, in massage, we in.
Speaker 2:Yes, I call it walk-in alliance, so you also create here lines with your client yeah, in massage, we in massage, we call it empathetic touch exactly yeah, but you know, I sorry, but I want to bring this example from psychotherapy because actually, you know, in psychotherapy is a term, we call it common factors. So common factor is basically something that the effects have a therapeutic effect but not directly related to your psychotherapy tools. Right? So, and what we understand from the studies, there is no like good or bad therapeutic instruments, but what actually is really effective is this alliance. If you know how to create alliance with your client, you have, you are efficient therapist, psychotherapist.
Speaker 1:So that actually ties into my last podcast I just did with a lady named Dr Luana Paloca. I'm not sure if you're familiar with who she is, so I just did a podcast with her. I just published it the other day and one of the things, yeah, on placebos and I just taught a class on placebos at a convention and one of the things we talked about in that podcast was conditioning and expectation. And I think condition and expectation, particularly the expectation, really lead to that alliance.
Speaker 1:If my clients come in and they say they're experiencing certain symptoms, certain discomforts, and I'm able to tell them that, based on my experience, based on their pathology, based on the return to average, the return to means of their injury, that they should expect these results in this many days, this many weeks, this many months, the recovery period, the prognosis, and it's met, then all of a sudden they feel trust and that they go okay, this person is someone who understands my symptoms, they understand my experience, they understand my story and they also have a good handle of how I'm going to progress. And it creates that sense of trust and alliance and I think that's often one of those unsaid components behind any version of therapy, be it psychotherapy, be it getting your nails done, getting a pedicure, being a facials, being getting a massage, manual therapy, even a doctor, client relation, patient relationship, where that level of alliance, that level of trust, the greater the trust we see with some research, the greater the trust, the greater the outcomes. The less the trust, the worse the outcomes. Same treatments, same medications, and so to me that's always one of those interesting components.
Speaker 1:And it brings me to a question on the study you did here. You had said you primarily you only had female subjects who were the ones having pain subjected. Was there a reason that you chose not to have men on the receiving end of the pain and women being the empathetic touch? Was it just as a control, reduce variables? And is there potentially a future study where we'll have men receiving the pain and getting empathetic touch from a female partner?
Speaker 2:Yeah, yeah, yeah, thanks for this question. So we tried different settings, research settings in different directions. You?
Speaker 2:know, originally wanted to run it in both directions but this was just like so complicated in terms of time we couldn't really arrange it. So that's why we decided to take one direction and, you know, I basically just since I was inspired by this delivery room situation, right, so I just, you know, use it for my research study and yeah, that's how we got specifically to these settings, but definitely it's really interesting also to run a reverse direction and to see how it works in reverse, yeah, in opposite direction.
Speaker 1:It would be interesting to.
Speaker 1:I wonder, because as a male therapist I receive both female and male clients, but a lot of female therapists who I speak with and I visit primarily receive male clients, and a lot of and to me that's always an interesting thing is that male clients traditionally want to see a female therapist. Female clients don't care who they see. And when you talk about that empathetic touch and the pain, it's interesting to see if that empathetic touch is naturally conditioned to be a motherly touch, a female expression of touch, and less that male conditioned I'm a tough man, blah, blah, blah kind of experience. So that empathetic touch is harder to get from a man. And that's an interesting. It's just an interesting cultural component because different cultures view that differently and I wonder if that would ever play in. I wonder if the research ever could get to a point where we would actually be able to see oh, you know, females tend to have a more empathetic touch, or at least they've been culturally conditioned to believe so kind of concept yeah, you know I think it's very complicated question.
Speaker 2:You know, causality is always, I think, the most complicated part here, right? So we can see some correlations between different processes, but to understand the causality is very, very complicated, right? So I guess we can today really to answer it. You know, we can just kind of Too many variables.
Speaker 2:Different areas, right, and they try to explain it from cultural perspective, from neuroscience perspectives, but yeah, so I guess we could also have both right. So we have some, you know, genetic background and some also our environment that also shape our behavior and it's really also very important in our development and in our society. So yeah, maybe at some point, we understand better all these processes and the composition of these processes.
Speaker 2:Because I think you know what was really new in our research is actually some mechanistic understanding of how this empathetic touch works in neurophysiological mechanisms.
Speaker 2:So basically, you know, in our first study, as we said, we just, you know, measured levels of pain and empathy. But in our second experiment we did very similar setup, but this time we also measured electrophysiological signals from the brain of both participants and also physiological measurements such as heart rate variability and respiration rate. And the goal of this experiment was to understand mechanisms that underline these effects and what we found that basically, when in a condition where comes just pain without the touch, we found decrease in level of synchronization between the brains. So, like you know, we have some level of synchronization in different social situations. Right, and what we found that pain decreases synchronization between the brains of two participants if they're not touching, if they're not touching exactly but not touching if they're not touching exactly. But when it comes a touch together with the pain we see increase. Really, you know, it's like boosting the synchronization. So like touch is really trying to compensate and to increase the synchronization between the brains. And also the same findings we found for harder variability and respiration rates.
Speaker 1:So when you say synchronization in the brain, like you just said, heart rate and breathing, those are more body related. But in the brain are we thinking more that stress levels are equalized? Do we see cortisol levels equalized? Do we see wavelengths change? What are the synchronization statistics that you're looking for, when we see with touch versus without touch?
Speaker 2:Yeah, so you know in this study we didn't have measurements of cortisol, like different hormones.
Speaker 2:it's really interesting to see how really the processes we found correlate also with hormonal changes. But basically we found that the synchrony, you know, like the way how we kind of communicate with each other on the brain level, so we kind of try to simulate the processes. Basically this mechanism may underline this therapeutic effect of touch. So basically the pain itself is a stressor, it's a huge stressor and it just basically disconnects, creates some disconnection between the partners and when they have touch as a tool, they recreate this communication and even make it stronger. Like you know, you have different level of stress and you have also the tool how to recreate this communication and use this tool and for more empathetic people it works better. You know we replicated this, funding this communication and use this tool and for more empathetic people it works better.
Speaker 1:you'll replicate this funding so more empathetic people also have higher level of synchronization in touch and pain that synchronization that you're describing was that and the communication component to it. Was that primarily only through touch, or were they also allowed communicating verbally with each other?
Speaker 2:no, no, it's just tactile communication. We didn't use any verbal communication that's really interesting.
Speaker 1:So the pain that that leads me to a whole other podcast, that I'll have to find specialists and maybe you can help me find people who know about this stuff.
Speaker 1:But just about the idea of touch as a communication tool, because that leads to the idea of can touch be a communication tool, which I mean it's not a leap in logic too hard for us to say yes, but it's a leap in research to say we know it is, but to touch, you know it's not a you know. As somebody who primarily touches people all day long, it's not hard for me to sit there and say, well, of course, touch tool, I can give a loving touch, I can give an aggressive touch, but at the same time it's a different thing to say well, touch communicates clearly, and so that that's a very interesting beginning step to the idea that communication is primary is the touch behaves as a communication tool no, no, definitely you know like, but if you seem just uh about in terms of development, our development, you know, when we have preterm babies, what's the most effective tool to manage uh preterm skin to?
Speaker 1:skin. Yeah, basically, you know like we don't have.
Speaker 1:You know, today we live in this so complicated technological world, but no one invented a better tool than skin to skin so that actually leads me to another question, and this is deviating a little bit from some of the stuff that we talked about, but it's a very good question. Can touch communicate clearly that you know, like if I say I'm happy, I'm communicating very clearly an emotion sensation, all these things and contextualization around it. Touch in some examples, like when I touch my daughter, I have a six-year-old and a 10-year-old. When I give them a caress and a loving touch when I'm putting them to bed, it's quite clear the touch is calm, loving, and I can do more aggressive touch.
Speaker 1:But in our general everyday life, you know, you're on the Metro, you're on the bus, you go get a cup of coffee, you touch someone's hand. Are we shutting communication down in that touch or are we just not perceiving the communication it's? I don't know if it's there's space for it in this podcast, but it leads me down a rabbit hole of thought process around the effectiveness of touch as a communication tool. Because in an intentional environment like a massage clinic, I can see how touch has very clear communication. But in a non-intentional environment, just in our daily lives, it leads me to a whole slew of questions on the effectiveness of touch as a communication tool. Yeah, but you know.
Speaker 2:I think we can think about this like you know, touch as intelligence, like you know, sensory intelligence right so you have a tool, but you need to learn how to use this tool, right so you know, I guess maybe many people just not aware of existing this tool and they may be not using it correctly or in the full, like 100 percent. Right, but when you get to massage therapy, like you, when you become a professional, you increase this intelligence. Right, so you can use this tool more efficiently.
Speaker 1:That's I like, that I'm going to have to think about that and try to put together an article. You increase this intelligence, right, so you can use this tool more efficiently. I like that. I'm going to have to think about that and try to put together an article format or something for a magazine, because I really like that. That's a good idea. So then, from this, did that bring you down the idea of going down towards chronic pain, or had you already had an interest in chronic pain, and what brought you from the acute more to where you are now, which you know by the end of the podcast, my listeners will know why I'm so interested in what you're doing and why I want to promote it, because I think it's really interesting some of the stuff that you guys are doing.
Speaker 2:Yeah, so basically, you know, uh, completing this study, I uh, basically I was relocated to us to boulder, colorado, and I started my postdoc there and basically I found it was 2016. I think it was like a peak of opioid crisis in the US, right. So, like everyone was talking about it and it was really crazy Like, and of course, I was exposed to all these processes related and I kind of say to myself, hey, it's pretty cool. I am dealing with social neuroscience. It's pretty cool and you know, it's kind of uh you know, it's very uh interesting to communicate it to some media.
Speaker 1:But uh, you know like there are so many people around me that suffering from chronic pain and all the support crisis. So I felt like bad with myself that you know I'm doing all this nice stuff and so much suffering around me and that's actually how I uh got to the field of chronic pain so and by chance, it was in colorado, where I mean, I happened to live there for a long time and the va there and the end shoot center and tor wagner, you know, like they happen to be pain.
Speaker 2:it happens to be by chance, a a very, very, very specialized area of the us, yeah, yeah you know, like I really am so happy that I was like part of this process or established in this process. So, like you know, at some point when I was a postdoc, in the lab we had two therapists who came, so one of them was Dr Howard Schubiner and Alan Gordon, another therapist. They came and they said you know, we have a therapeutic approach for chronic pain, but you know, we are therapists, we are biased, so we don't know if it's really work, so we just imagine it. So let's run a study and see how basically efficient is our approach.
Speaker 2:And that's how I started all this story establishing therapies like PRT and other therapeutic approaches. So Dr Yoni Ashar then he was just a PhD student in the lab he took on himself to run this study and it was really amazing. It was really amazing study, like you know. Just think about it. Like I was so amazed. Uh, they got around 200k, uh dollars, uh, you know to to basically fund this study during using just crowdfunding. Crowdfunding, like they just asked money for research. They like they get gave away, like maybe some meditation or something like that. But you know, it's not the usual model like of like, like you know, mostly for crowdfunding, you kind of you need to deliver a product, you know a device or something right, and people like I think it just emphasized how big was the problem of the COVID crisis and what was going on with chronic pain treatment. So people was ready to give money right away to establish some new therapeutic approaches.
Speaker 1:So, with that in mind, with these new therapeutic approaches and you had already mentioned the PRT, which is something that I wanted to talk to you about is that where you were first exposed to? And, for those who don't know what PRT is, it's pain reprocessing theory, and I'm going to let Pavel talk about it a little bit more, because I think he has a lot more experience with it than I do. But is that where you were first exposed to it?
Speaker 1:Yeah, experience with it than I do, but is that where you were first exposed to it.
Speaker 2:Yeah, yeah, so that was PRT. Yeah, there is another approach.
Speaker 1:EAT, but yeah, it mostly was, I think, PRT right, and do you want to talk a little?
Speaker 2:bit about it. How do you communicate what chronic pain is right, Because it's different from acute pain.
Speaker 1:Yeah, so feel free. So this would be a great time before we get into pain processing theory, um, reprocessing theory, if you want to talk to us and just highlight some of the differences between what happens with acute pain, where we see act, we see actual tissue damage, the the threat perception is real, the the stimulus level is high, versus chronic pain, which I mean even now, chronic pain theory. There's, there's still a very big amount of our understanding around chronic. We know a lot about chronic pain and we know just enough about it to be dangerous, in that we have theories around chronic pain and they're good.
Speaker 1:But you actually, I mean even today, I was reading an article this morning before talking to you about how chronic pain can it be conditioned? And it's a really interesting question because a lot of people will say yes, it can be conditioned, and a lot of other people who are just as intelligent will say no, it can't be conditioned. And I think it depends a lot on our understanding of what condition theory is around pain and things like that, and so our understanding of chronic pain, even though we understand the mechanisms in the brain, the actual reason it exists, the multidimensional components that create pain perception and threat perception and the smoke detector theory and all these concepts around. Pain is still so hard to say. From client A to client B is replicated in the same way, so do you want to talk to us just a little bit of the mechanisms that separate our movement from sub three month pain to past three month pain?
Speaker 2:definitely, definitely. But since you started with conditioning, I want to give you an example. We just recorded a podcast with one of our past patients who recovered completely sorry, recovered from chronic pain and I want to give this example. So he had migraine. Migraine as it was started exactly at 16, like 4 am, 4 am, every day, pain, 10 of 10, like very strong pain, you know, like people who didn't experience it. You can imagine it, like you know how, you know how strong is it. So she had super conditioned pain, like it was started every day. Who didn't experience it? You can imagine it, like you know how, you know how strong is that.
Speaker 2:So she had super conditioned pain like it was started every day, uh 4 am, 4 pm, sorry, uh. So we got her to our therapy. You know, today we have therapeutic, our own therapeutic approach, and we have a system how we help people with chronic pain. So, uh, I, maybe I will, you know, maybe I will skip this whole process, but today she's completely out of pain, completely like zero. He doesn't have any migraine episodes.
Speaker 1:He also was on drugs.
Speaker 2:He got to drugs. He was spending around $2,000 a month for the drugs. So you know, he was like really addicted, and she stopped completely the drugs and today she's free of pain. Right, so it's just one of our recovered patients. So I think it's important to talk about examples, but, yeah, about chronic pain. So first of all, you know, I want to argue that pain is really good for us and for our survival right. So when we have tissue damage, it's really safe for us.
Speaker 2:You, know there is a rare genetic condition when people don't feel pain, and we know that most of them survive till their surgeries. So pain is really important for us, you know, like maybe both of us survived till this podcast because of pain.
Speaker 1:I actually teach a class around a concept called the evolution of pain and how a lot of it's based off of David Brown's studies from the University of Cambridge and talks about how pain is an essential component to the evolution of the human species and that without it it we would not be alive today, based on infection rates, disease rates, bone densities, muscle strengths and things like that and how pain has this. Really, even though it is an unpleasant experience, it is by far one of the most essential experiences to survival. The species definitely.
Speaker 2:You know I wanted to take it later but maybe I will mention it. You know we can look at pain as a teacher, right? So because of pain you really you can develop yourself like you know it's really kind of, you know, push you. It's push you really to make some changes, some development. You know, not everyone's success to make it right.
Speaker 1:But this is exactly about evolution right evolution.
Speaker 2:So you know we have this diversity, yeah so, but you know, when we?
Speaker 2:okay, we talked about pain as really a process that really protect us from a danger, right, so it's kind of alarm system. You can think about it as alarm system and alarm system can stuck, it can stuck, okay, and you know, from this perspective you can think about chronic pain is really like some uh, uh, you know uh, damage to this system. This is like one perspective. We can also think of the, you know, reframe it a bit differently so we can frame it, you know, a motor beauty way, like you know, and I have two interpretations, like one of them is like, for if I want to shock people, I say like it's, you know it, basically it's a damage of the system, but in more therapeutic processes.
Speaker 2:I uh reframe it a bit differently, and I say so pain is a message right that your brain tried to send you and specifically in the cases of most of the cases of chronic pain, you misinterpret this message because you think you have a physical damage. But it can be something different. So you can imagine it as a dog like you know you have a dog sitting in your head right and you know the dog basically may try to protect you from zeves right or some other. You know potential damage you from Ziv's right or some other. You know potential damage, right, and then basically have his noise right, but another like. But you can hear your dog also because he's scared, right, he depressed right, he have like I don't know, he want to eat, to drink, and you know you can think about many reasons, right.
Speaker 1:You actually make me think about something that we just talked about with touch as a communication tool. So pain and touch are processed in the brain, so similarly, you know, they get to the brain on very similar pathways. There's the whole pain gate cycle concepts that people are going to be familiar with, and so earlier we talked about how touch is this potentially a communication tool? It was a theory and I don't want people to think that we're talking fact, we're talking theory. We're in the philosophical nature of touch and pain here, but we thought you'd mentioned that maybe touch is this idea of, it's a communication tool that people are just not masteries of, and people who go to school on touch become better educated on how to communicate with that tool, touch. So I wonder if pain is perhaps the same thing.
Speaker 1:Pain is just another version of communication, and when we have the alarm going on, we have, you know, I think Dr Mosley or Lorimer Mosley talks about, is the smoke detector theory.
Speaker 1:You talked about the dog, the alarm going off.
Speaker 1:There's all these different descriptive texts around pain being stuck in a positive feedback loop. We can talk about the HPA axis, all these things like that, but are all of them just potentially the pain trying to be a communication tool and us as humans experiencing it going. I'm not smart enough to understand that communication tool because I haven't taken the time to study it. Similar to if we start speaking in Hebrew I know very little Hebrew, you happen to know a lot so there's going to be a lack of communication because it's a communication tool I don't understand. And so if I mean I think that's kind of the foundation of the pain, neuroeducation science, which is the more you understand the science of pain, the less likely you are to continue in your pain loop. So I'm just wondering, based on what you said about touch, because they process in the brain so much, it almost seems like it's a similar component that just because we don't understand it, we see it as a danger and as a threat. But it's just another version of communication definitely, definitely.
Speaker 2:So you know like uh but the complication here.
Speaker 2:It's maybe a really very complicated message that, like you know, in some cases it really can communicate some real danger in your body. For example, you have a pain in your stomach. What's the indication of this? It may be appendicitis, or it may be some other reasons, like maybe you are scared about tomorrow's lecture, that you need to run in front of thousands of people, right, so the same pain can be an indicator of completely different processes. I think this is the main complication here, right, and I can say, like you know, yeah, you can say hey, you're a pain researcher so just can you classify for me, like, which pain means what?
Speaker 2:And I can't say like explicitly, you know I can't answer you right Because it's really complicated and too many factors and depends on many contexts. So we should be very careful when we try to interpret this message. So in some cases it's really, you know, the brain tries to say hey, be careful, you know there is a danger, immediate danger, and some other cases it's really trying to communicate something different. But I think here another point where we're stuck. So in cases of cancer we really will try to rely on experts in this field because we're we are not familiar with cancer, right, in terms of pain, if we try to talk about pain it is different, right?
Speaker 2:So from childhood we get this understanding and knowledge of what pain is right. We fell down, we get this, you know scratches and we have pain. We completely understand the connection, right. We completely understand the biomedical connection of pain, right, biomedical model of pain. And then later, when we develop chronic pain, we try to use the same model for interpretations, right, and that's where we fail. We fail there. So because we try to interpret completely different processes with kind of simplistic model of biomedical pain yeah, and my, my listeners and people have taken into my classes and stuff like that.
Speaker 1:They're well aware that we know there's a lot of research out there showing that the level of tissue damage doesn't correlate to the pain symptoms. Uh, out, when we're in chronic pain, in acute pain, that's a different story. That's. I fell, I scratched my knee. It's acute, three later. If my knee still hurts, we're moving away from the acute phase and we know that tissue damage, herniated discs are reabsorbed and we know broken bones heal and yet pain persists for an extended period of time.
Speaker 1:But I want to go back to something you had said earlier that I thought was really interesting and it made me think of a concept I imagine you're familiar with, the concept of allostasis. Yeah, of course. So when you talked about the idea of, let's say, I have a pain in my gut and it's appendicitis versus a lecture and I'm causing pain, my theory that I have in my understanding of pain and my question to you would be my stress around doing a lecture, which the more clearly I could sit down and logic my way through my fear of lecturing in front of a lot of people. Do I know my material or my slides in the right order, all that kind of stuff. I, the more I logically sit down and don't let that fear become uncontrollable, I can say, okay, this is an anxiety, this is stress, it's helpful, it's going to make me do a better job in my study.
Speaker 1:Versus I have a pain in my appendicitis. I don't know what this is. One is an unknown one if I, if I focus on it, becomes a known quantity. But the more people just say, oh, this lecture is super scary, and they don't think about it because they're fearful of it. Or this exam is scary, or this job interview is scary, whatever it is, if that anxiety and stress level becomes significantly high enough to surpass their allostasis, their ability to handle stressors, prior to essentially going into a fight, flight freeze state, if that kicks off, would that be enough to instigate a pain response as a defense mechanism to say change behavior, do something different. In which case it's not the same as saying anxiety causes pain, but it is enough to say there is a connection somewhere between your ability to handle stressors, allostasis and your ability to create discomfort in the body yeah, first of all, I think you know, if you talk about mechanisms, we know that both pain, emotions and stress can be communicated to our.
Speaker 2:Wait, I forgot the name. Uh, get to our gut, to our gut, right, yeah, our gut, we can integrate it to our gut through vagus right yeah through the vagus nerve.
Speaker 2:So, basically, we know that our gut is kind of a small brain. We found neurons there, right. So you know like this communication happens in both directions, right, and so all these messages can be communicated. And you know, like, when you really prepare yourself to a lecture, so I think it's like a natural process, like you know. Like you know, you have this around system in your brain, right, that basically uh want to keep you safe, he want really good for you, he want to keep you safe, but the definition of of safe it's kind of very subjective in this case, right so how it can pertain like this system really not really care about your wellbeing.
Speaker 2:let's say, okay, it's really care about your Survival like it's evolutionary process right. So it's a really evolutionary system. It's really not care you happy, you unhappy, you need're unhappy, like you know. You need to make your kids, you need to, you know, give your child, you need to help them to grow up right and you're done, basically, that's why, after 40, years old basically, if you don't do effort by yourself, basically you know you can die.
Speaker 1:Yeah so, essentially, pain is there to say survive at all costs, propagate at all costs, and that's the limit of what I care about. I don't care if you survive, happy or sad, as long as you survive. I don't care if you're a good or a bad parent, as long as you appropriate. And so that's really where pain kicks in, as this mechanism.
Speaker 2:Yeah, definitely, definitely.
Speaker 1:So we need really to understand better.
Speaker 2:If we understand the language that our brain tries to communicate with us, we can really, you know, then we can increase our well-being, can understand, even understand better, all these messages. And I think, exactly here pain come as a teacher, because, uh, because of these processes, you know, like, all this, uh reprocessing that you should do really to be aware of everything that happens here, in your case, your specific case, you really have this, your personal growth, right, it happens, you have your personal growth really to become more aware to your body, to your communication, brain-gut communication or some other processes in your body, right, because we know that chronic pain is not the only way how our brain communicate with us, right, so it can be really reflected through completely different processes. You know, you know, like, uh, all the other conditions that related to our diets, right, how we eat, so all so, all of this, it's basically different ways how brain try to communicate with us.
Speaker 1:Yeah, fantastic. So once you got into the mechanisms of chronic pain, you started understanding it more. I want to be conscious of our time constraints here. It's already you know we're already 45 minutes in and I know it might be about an hour to an hour and 30, I'd said. But I want to make sure we get through all this stuff and I especially want to make sure we get to some of the stuff you're doing at the eye pain laboratory, because the you know I've put up my story and I think it's really interesting for people to see what you're doing, because I think it's an interesting thing. So do you want to transition into a little bit talk about what you're doing with the idea of pain detection and the goal behind creating this objective measurement tool and how you're going about doing it, since it's a voluntary process for people?
Speaker 2:Yeah, sure. So my lab called Integrativeative Pain Laboratory and basically it's in fact that pain is a really complex signal. We can't just try to look at the pain from a very specific angle, right, we'll miss a lot. So in our lab we are trying really to look at the pain from completely different angles. So we research biochemical, neurophysiological processes, but also we use digital tools trying to capture subjective experiences in different ways. So one of our projects is called Pain Story, so you can find it on painstoryscience.
Speaker 1:And I'll have all those links in the podcast so people can go to the website and link it, because I think it's I love what you're doing, so I'm a big fan of it.
Speaker 2:Thanks, thanks, troy. So basically this idea came from you know my observation, like you know, when you come to a doctor right and you have pain, the doctor have very specific model right of his understanding of pain and he mostly filtered out all of you, most of your story right, all emotional process that you want to share and what happens to you, and you know he needs very specific points that he needs for his biomedical diagnosis, right and I think the most so I think the most famous story of that is a client who comes in with a broken leg and it takes them 20 minutes to get to the point of I broke my leg and the pain hurts here, and the doctor is sitting there impatiently and the client's like well, last week I was moving a guy's couch.
Speaker 1:Well, it actually wasn't his couch, it's because we had to borrow a truck and I had to go get a different truck. And all of that story around the truck and the couch is the story that this person, individual, annotates towards their pain. But the doctor's just like no, you fell, you hurt your leg, that's all I need. When in reality the story around it actually contributes to their discomfort. And it's like you're saying the story matters definitely, definitely so basically what we want to do in this project?
Speaker 2:we want to capture the whole story, the whole story of the pain, and so we developed this digital platform, the platform where people can share the stories of pain. So we have some kind of questions that help them to create this story. So we record the stories and some other subjective measures and we really want to understand better. We want to develop better also models of understanding the chronic pain, because, you know, mostly we as researchers.
Speaker 2:We read the literature and we, from this understanding, we create, we run new research, right, but we have much. We don't have much exposure to real patients and here I think you know we have this really moment where we can really learn from the main expert of chronic pain, right, people who live with this pain. So we want to have this first hand expertise of these people.
Speaker 1:So actually I was one of them.
Speaker 2:So you know, I can also say us so yeah, so we have this project and we want to use later machine learning algorithms to create some classification to better understand all this complicated experience, because, you know, another issue that comes here is diversity, right? So it's a huge diversity of stories, of experiences, of factors that affect pain. For example, you know, right now in this project, what we see, really one of the very interesting factors is actually interpretation of patients what caused their pain. So just knowing how they interpret what caused that pain, you can predict very interesting outcomes, like levels of pain and also their openness to go to psychotherapy for pain.
Speaker 1:There are two studies that makes me think of. One was a study that was done on women going through labor in the Inuit culture in Canada, where they often don't have hospitals accessible Often it's midwifery delivery. It's not always a doctor and medication is not always available and so they were studying pain levels in active labor for women of the Inuit culture versus westernized culture visualized or viewed as a painful experience. It's viewed as this spiritual experience of growth and development and giving to the community and bringing somebody into the community, and oftentimes they don't describe labor as a painful experience, even if they have episiotomies and shearing and things like that. They don't describe it as painful. They describe it as a joyous, wonderful moment.
Speaker 1:And in Westernized culture, where we see it on TV, we see it in shows, we see it on, you know, we're culturalized to believe that labor is supposed to be really intense and painful and the screaming and all that kind of stuff, and that in those experiences a similar style of labor, even without tearing, is perceived as a painful experience. And there's a lot of components to that. So it's not as simple as saying that. It's just their vision of it, because there's less medication in the North and things like that because of resources.
Speaker 1:But that was one thing and the other oh, I'm blanking on the other one. That's too bad. Oh no, the other one was I believe her name is Dr Schlemmer or Sherman, I can't remember from the University of the Palo Alto Center in Nevada, and she talked about how they did a study over a year with 40 subjects and based specifically on their attitude towards pain and their outlook. They were able to predict with an 85% accuracy whether or not somebody would develop chronic pain, and I found that incredibly amazing that simply their attitude and their views on pain were enough to actually predict whether or not they would have pain.
Speaker 2:Definitely. So, you know, like I want to remind you, you started to talk about expectations, you remember it, and I want to talk, you know, to take it in very close term terminology, so we call it predictive coding. Yeah, so right.
Speaker 2:So our brain, you know, is definitely manage every process in our body, but one of the important processes and also evolution, important processes that manages actually predicting the future right, and it's about safety, it's about our safety. Want to know if there is a danger coming soon right, and it's about safety, it's about our safety. We want to know if there is a danger coming soon right, so we're always trying to predict what's going on right and what will come next, right, and basically here, based on this process, we build our expectations. Know we have definitely many good rights that come in with our current values, but we also kind of created this. You know sensitivity maybe we'll call it right sensitivity to pain and you this idea that we need to avoid pain right, and try also to develop some technological tools to avoid pain, right.
Speaker 1:So it's definitely, you know it's complicated, it's really complicated.
Speaker 1:The predictive thing is interesting because when we look at it long term, with predictability around pain, you know we can look at an axon and simply look at. You know how neurotransmitters fire across the synaptic cleft when we predict behavior, we can actually start replicating that synaptic activation just by predicting behavior, without the actual behavior being replicated, which is an interesting component. And then you translate that to discomfort and I use an example of an individual who I know in my life who had frozen shoulder but we went to a festival and they were pain-free majority of the day. But we went to a festival and they were worried about other humans hitting them by accident, so they put a sling on and then every time a human got close they would hyper react, they were overvigilant and they would get scared and they would tense up and they kept replicating pain because they were predicting something that never occurred and in the process of predicting it they created a muscle contracture or spasm that was high enough in threshold to replicate discomfort.
Speaker 1:And to me it was always interesting that predictability around pain. But we don't see it as clearly in the opposite, if I predict something that is pain-free, we don't see pain-free experiences as clearly. And I guess my question is is that because of our mastery of the communication tool that we talked about with pain, or is it because that's not how the brain behaves With prediction? It creates threat for survivability, but if we predict something that is a feel-good response that has nothing to do with survivability, the brain kind of says I don't care about that. So it doesn't actually affect our painful experience in a positive manner.
Speaker 2:Yeah, as I said, you know this evolutionary part of the brains are not care about your well being, and basically the second one, right so? Basically this is not so evolutionally important you know, like to really important to predict pain-free moments and safety, right. This is what you do with, maybe, your prefrontal cortex, and you really try to control through prefrontal cortex, all these automatic processes that happens inside your brain, right, and trying really to alert you, right.
Speaker 2:And so I think this is exactly the dynamic, like how you become, how you develop this control over this automatic system that try really to alarm you in the cases where you don't need it.
Speaker 1:So then, so I guess my last question, before I let you go here, would be based on what we're talking around pain. I'm coming more and I know research is slowly beginning to back this up, but it's still a really tough subject to breach, not only with scientists, but even with doctors and let alone with clients and I'm not allowed talking about medicine with clients so I don't, because I'm a massage therapist. But it's this question around analgesics Tylenol, ibuprofen, acetaminophen, painkillers when the pain is non-threatening. So let's say, you have a mild headache versus a debilitating migraine. Should we be trying to numb that discomfort or should we be allowing that discomfort to be a signal in the brain that says pay attention, change your environment, change your circumstances? Or should it be numb it?
Speaker 1:And we see this in athletes a lot, right Like right now. I'm a big hockey fan and it's the NHL playoffs. Right now there's a really high probability and the Euro Cup's about to go on and there's going to be a lot of players who are injured and they get given cortisol, and they get, or and they get given all these medications to play through their pain, and yet the pain is kind of this big signal saying stop playing, you're potentially damaging your body. So, even though the science may say the pain is a good thing for you and you should be paying attention to it, we should be using it from an evolutionary standpoint. When it comes to living with the discomfort, is it simply I prioritize play over my pain? Therefore, I want to play and I don't care? Or should we be re-evaluating our priorities based around our understanding of pain?
Speaker 2:yeah, so you know, as you know, like everything in our life, you need a balance, right? So most of the processes is that we are really researching and generally exist in our life. They have u shape, right, they have u shape because you have like you know a point where you're like optimizing point right. So like you want to increase something, increase, increase, increase. You have optimizing point and then you have decreased or maybe asymptote diminishing returns, things like that, yeah.
Speaker 2:So I think it's exactly the same here. Like you know, I also want to connect it as pain as a teacher, right? So definitely at some point we want to use pain as a teacher and you know we can. We want to develop our threshold, pain threshold, but we need to listen to our body. So you know, like, specifically when we talk about professional sport, I guess in of the cases you kind of extend this and you're not really in a good place. So when you really use some analgesic to play, I am not sure this is a good way to listen to your body.
Speaker 2:If you have really like pain, like small pain, like three, four, it's manageable and tolerable, so you definitely can use it as a teacher. Okay, yeah, I understand right. So you know, your body tried to communicate me something, but you know I'm okay right now you know three, four it's not so high, right.
Speaker 2:So I can maybe a bit continue and I will see what happens to me, right, but when, generally when you use uh analgesic, you basically uh, you, you reduce this communication with your body. This is exactly like you know example, like in the delivery process, when women they get epidural, right. So what happens? Like, right, on one hand, you don't feel pain, but you also lose control with the birth process, and we know that in many cases it ends up with a surgery, right, because you lose this control.
Speaker 1:So I think it's the same here.
Speaker 2:We want to you know, at some extreme cases, when you have a really strong pain let's say seven and above you definitely you should use an analgesic right Because you know you don't want to suffer. That's okay.
Speaker 2:Right To use it locally for acute pain, but definitely this is not a treatment for chronic pain. And not to use it locally for acute pain, but definitely this is not a treatment for chronic pain. And not to use it in chronically like consistently, permanently, right. So this is, I think, where we fail in general, our understanding, like we, I think in general like a lack of understanding, we try to treat chronic conditions as acute conditions because you know many doctors they think that the patient want to reduce his pain here and now. But there is a study that was just published. When you ask patients, they much more worry about your future, future pain and what will happen than your pain right now. If the patient will know that his pain will end three months from now, it will be completely different case.
Speaker 1:Yeah, there was another study that was done around the effectiveness of, or the pain modulation intensity that was necessary to perceive positive outcomes. And essentially a client was asked you know, based on our treatment today, if you walk away with 50% pain or what would your ideal pain-free experience be? Before you walk away saying I paid money and I was okay with the service, and most begin the conversation by saying I want to be 50% pain-free. And so the clinician says well, so if you walk out and you're only 40% pain-free, was today a failure? And most clients say, no, that would be amazing, but I would like more. And eventually they all come down to this number of saying if I only had a 10% change in my pain today, I would still see the treatment as a success.
Speaker 1:And it goes all the way down to just 10%, which, on the vast scale, 1 to 10,. I went from a 10 to a 9. I went from a 7 to a 6. That's not a lot and honestly, most good therapists do get better results than that. But it's amazing to see that that's how minimal of a result it takes for a client to say it was a positive experience and that they want to keep going down that process of recovery. That's fantastic, Definitely Also a related point.
Speaker 2:if you talk, you know there is two studies from Australia. One of them showed that opioids they're actually effective just as placebo right in managing chronic pain. That was one study. And then they, you know I was very surprised to see that they also run a study with acute pain and they showed that opioids is effective as placebo also for acute pain.
Speaker 1:The placebo stuff. I mean, I just like I was telling you earlier, I just studied, I just did a podcast with Luana Paloka and I did two others and I'm going down a bit of a rabbit hole with the placebo stuff. I think it has its limitations, but I think we also haven't experienced, we haven't delved into enough of its capabilities and it's a tough subject because it's one of those things in research, reducing placebos is a positive, but in the clinic I don't care if a placebo is present or not. You got better. That was the most important detail. But I also think some people get too excited about placebos, thinking that it can be the end-all, be-all and there's an ethical dilemma there. But that's another conversation.
Speaker 1:Well, I really want to thank you for today. Is there anything you'd like to say? To wrap up, or to at least some? You know how for people to put their stories on the. I mean, I'm going to have the links to your website If people are interested in putting up their personalized chronic stories. And I want to comment as well for people who are interested in putting up their stories with some of the integrative pain laboratory studies stories that there's. There's a lot of resources out there, showing that belonging to a community on its own who self identify with a similar discomfort can actually reduce your symptoms of discomfort. So for people who are living in chronic pain, just belonging to a community of other individuals who live with chronic pain, no treatment, no other intervention can actually help reduce symptoms of discomfort because they feel like they have a safety net to fall back onto. So if people are suffering from chronic pain, you know, putting their stories into this similar, this iPainLab story platform could be a really interesting way to help clients and patients with their discomfort as well.
Speaker 2:Definitely, no, definitely. Social communication and connection is super important to feel that you're not alone. But you know, I want to comment on this if you have one minute.
Speaker 1:I have all the time you want. I want to respect your time. I don't have clients for under six hours.
Speaker 2:Yeah, yeah, so you, you know, like, I see many communities, like you know, in facebook, uh, chronic pain communities and actually I become sometimes scary because if it's communities that not managed by professionals, sometimes it gets to really bad points, like when people, uh, you know, catastrophize stuff and then just support each other in this catastrophization and it just comes to like not a really good point in terms of, uh, you know, therapeutic effects. So, you know, I, I basically I think you know you definitely need community, but you need this manageable community when you have people who know, like you know, who can lead you right it becomes like a like an echo chamber almost, where people they just focus on how bad life is, with no potential outcome.
Speaker 1:That's a positive change.
Speaker 2:Yeah, exactly yeah.
Speaker 1:Yeah, that's a really good point, and on my website I actually have a lot of resources like paying the IASP. I have some stuff from Paying Canada, paying BC, all these communities, and they're all managed, which is really great. But that's a component that I never thought about either, because in my mind it was always just, oh, the community matters. But it's true that if they just get stuck in the fear, avoidance or the pain catastrophizing, it's very easy to just further go down that same pathway, and because all it does is creates that predictability of more discomfort and not necessarily of safety or recovery, that's great. Well, thank you so much. Is there anything you want to tell the listeners before we go?
Speaker 2:So yeah be, sensitive and careful with your pain, listen to it Really, try to understand what message is. So, as we say, you know, in in some cases it will really try to communicate with you immediate danger to your body, but in other cases, especially if it's chronic pain that you already know, it may communicate something different and basically I think there's a way to deal with it, to understand these messages and it may be really a journey. It may may be a journey, it may be not like something that you can really figure out in one day, but I think it's really interesting journey that and in this journey you can really grow up and you can develop yourself, and not just in terms of pain, like really to to heal from pain, but you can get out a different person and you know, get different skills that will help you in even other aspects of your life fantastic.
Speaker 1:Thank you so much, pavel. I appreciate your time, I appreciate your knowledge and I hope that this podcast brings some people to to submit their stories and that I'm excited to see some of the work that comes out of your guys' laboratory. I think it's fantastic. So thank you so much.
Speaker 2:Thanks, troy. Thanks, I really enjoyed it. Thank you, thank you, thank you.