Why Do We Feel Pain? | The New World of Pain Management With Deirdre Nazareth

The world of pain management has significantly changed in the last 2 decades and whilst pain medication can have some positive impacts, it is unlikely to solve the root causes of pain.

Pain expert Deirdre Nazareth introduces the new world of pain management. We cover questions such as 'why do we feel pain?' and 'why do we not feel pain equally?' Deirdre also shares tips to help you manage your pain better without medication. 

If you are looking for more tips to manage your pain better, download our free guide here: https://www.functional-medicine.associates/5-steps-for-managing-your-pain. It will help you to understand your pain better and empower you to make lifestyle changes that will make a real positive impact for the long run.

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Transcript

Intro Speaker: 0:00

Welcome to functional medicine bite sized the podcast where Pete chats to experts in the field of Functional Medicine and Health giving you the listener pearls of wisdom to apply on a daily basis

Peter Williams: 0:20

So welcome to this episode of Functional Medicine Associates you can hear the sort of sigh in my breath and that's because I started recording this episode and then forgot to press the record button so Dede I fundamentally, because we're going to speak to Dede Nazareth today, one of the brilliant people not only from a point of view of systems thinking functional medicine, but a real specialist with regards to pain management. Dede welcome I know you're going to slap my hand for that. I really apologise. Yeah, I'll take that one on the chin. So as I say, let me introduce Dede, she is a colleague of mine, a really incredible, incredibly gifted practitioner over a brilliant systems thinker, and a real specialist in pain. I would like to introduce her background to just give you some idea she has an original background in biochemistry. That's correct, isn't it Didi

Deirdre Nazareth: 1:13

Bio-psychology.

Peter Williams: 1:15

Even better already systems thinking on that one. And then she has gone on to be a naturopathic doctor, doctor of osteopathy. And her most recent thing and believe me, Dede is just always on courses. But one of her key aspects was the MSc in pain neuroscience at the prestigious I think one of the great places around the world to do that, which of course is King's College because there's some, I suppose, sort of professors there who were at the forefront of how we understand pain. And I met Dede again, we're, we chatted about it, I think we met, we met roundabout 2010, I remember it, it was a balmy night in Dallas at one of the IFM conferences. And we're actually with your dad. Yeah. And we sat around that table, probably drinking way too much. But we were, we were high on the course we were, we were high on the really lovely temperature that was in Dallas. And that's sort of where it all started our, our relationship. And then you were, of course, one of the certainly early adopters, to become an IFM certified practitioner in the UK. And we've been sort of working together as associates for several years now. And really, today's episode is really about pain, because clearly you have a very deep knowledge of pain, but it's maybe pain that is how we understand it now, and maybe it's quite different from how many people understand pain. So, again, listen, apologies for me messing up the first 20 minutes from that, but shall we start with what is pain?

Deirdre Nazareth: 2:55

Yeah, it's a it's one of the questions that a lot of people are asking me, and I'm also explaining too like we said, with where, where I did my pain masters with Dr. Mc Becker,and he's worked with David Butler and Laura Mosley, who are some of the top leading pain experts in the world. And a lot of the information that you see online is actually produced by their labs, and mainly, the two books that a lot of people refer to, in modern pain understanding is Explain Pain and Explain Pain Supercharged. But yeah, I had the priviledge to study with them.

Peter Williams: 3:36

Those books are actually really good for general public, isn't it to get that?

Deirdre Nazareth: 3:41

Yeah, that's what they were designed for. Because you know why we're doing this podcast too, is because even still today, despite how, you know, it's been 10 years or 12 years since I've done my master's degree. There's still this understanding and mainstream awareness of pain as as being defined back by like, how Descartes would have described pain that you felt something, the stimulus went up to your brain and came back down as Oh, you have pain. Without in very linear, there's no like interaction along the way. Whereas actually, we know that's definitely not the case now, that not all things produce pain, and also some things produce pain that aren't even there, which, it's how do you explain that? So it comes with understanding concepts and really being open minded to accept more of the philosophical reasonings behind pain and like consciousness, awareness, all of these things that can contribute to someone's pain experience. So when we look at what models have been used in the past, and these are like structural pathological models, they don't actually really give much explanation of what's going on, they may actually just almost be a scapegoat. Because there's something tangible for the person to not only look at, but also to blame it on. And that can be quite problematic, especially when it comes to like a surgical intervention, say, you know, quite commonly you go to see someone because you have back pain, and then they give you, and you've had chronic back pain for years, and it's quite debilitating, and you can't function and it's interfering with your day to day life. So you think, Oh, I'm gonna get surgery. So you've had the MRI, you've had the investigations, they all point to degenerative, you know, issues or a prolapse or something that's quote unquote, "causing your pain". So what happens when all the emphasis has been put onto that disc or multiple discs, or even degenerated bone area, you have the surgery, and your pain is actually worse. This is just one example of how having that kind of linear thinking does not necessarily come with the outcome that you expect, we're putting too much emphasis on a structural model that actually, we know is, is not reliable, because as I said before, there are things that can, you can have pain without having a peripheral input. And we see that with respect to phantom limb pain. Sure. So we understand that actually, rather than it being linear, I know the International Association of pain for the study of pain, they came up with a definition that, again, is like a paragraph. But basically it was, it's defined as an unpleasant sensory and emotional experience that's associated with actual or potential damage. But even to expand on that, that's still quite simplistic. It's not necessarily taking into account how your brain is interacting with your environment. So Lorimer Moseley did that in the paper in 2003, where he said, it's not just an unpleasant sensory and emotional experience associated with actual or potential damage, it's actually a multi system output from the brain that is produced when it perceives that there is danger. So to the body tissue, and then action is required to alleviate that pain. So now we understand that pain is being produced when the brain perceives a threat. So that could be multiple different inputs at once. Or mentally, there could also be a back issue, you know, there's not necessarily the reason why the back is hurting is not necessarily because of just the disk. Yeah,

Peter Williams: 8:05

so I think this is a really important point, can you cause I suppose this is one of I suppose the downsides to modern diagnostics, because I suppose if you looked at any 50 year olds back, you're going to see probably quite a lot of pathology, some, some people with bulging discs, that for some people that they could walk around for the rest of their life and never ever experience any pain. And can you just talk about the sort of evidence on that what you were saying about successful back surgeries? Because I think that really opens up the discussion that you're having, aren't you is that you can have multiple surgeries, and it actually doesn't solve the problem.

Deirdre Nazareth: 8:42

Yeah, exactly. So it comes back to really understanding and people who are implementing treatments for chronic for anything chronic, really should explain this phenomenon that you can change, you should exhaust every non invasive possibility first before just relying on surgery because as I said, if if we're going to follow this structural pathological model, that the the tissue is causing the problem, and that actually it isn't, and you do a surgery, then that actually may exacerbate the issue. But we need to understand that inputs back to what I said about it's a multi system output or to multi system production. So it's not it's different parts of your brain that are producing this response and the response is coming from multiple inputs. The input could be even the explanation that the person is giving you about the condition. So we've heard terms like herniations, prolapse, bulging, all of these, these terms, do not have a positive connotation with them. If we were to explain things in a more palatable way where you know, okay, so herniation what is a herniation, herniation is really like a wrinkle on the disk on the inside because your your disk is made up of the same tissues as your skin, just in different in varying amounts. So largely water and fibrin, elastin, collagen, you know, you've if you've listened to any skin lotion advert, these words will pop up, you know it's protein. And if you don't get fluid into a disc, when like you're sitting in a plane for long periods of time, or you're stagnant, you're not moving, you are going to risk having this disk ah, fibrillate or wrinkle, just like your skin would. It's an age related change, that's not necessarily going to produce pain. And so like, as we said, if you were to X ray my spine, you'd probably see lots of bulges. But do I have pain from them? No, that's just, the reason why I don't have pain from them is probably down to all of the things that I do consistently. And when I did have pain, it was really when I had a lot of stress in my life. And I was dealing with the stress that actually helped me manage the pain. But you know, we'll go into that in a little bit like how someone who can who is suffering from a chronic condition that is debilitating how they can see the path forward by doing small things, small changes that make an overall greater cumulative effect on their livelihood.

Peter Williams: 11:40

So if I can expand on what we're talking about, because I think we can safely say we've had some very difficult pain patients through no fault fault of their own. And it's difficult not only for the patient, because they want an answer, and they want to be out of pain. But it's difficult for us as practitioners to be able to take them down that pathway, but also get them to understand that actually, maybe their pain is, as you say, is much more involved. And maybe a lot of their pain is to do with, you know what's going on with their life. I think you used to use the word, your brain'interprets' danger. And that might send out brain signals now that could come from anything, couldn't it? And you know, it's always interesting to see that the sort of the story behind the story behind the story of patients when they come in is that there's always something going on that is either stressing them out at the same time. I mean, it's incredibly rare that we see someone who's just in who's in pain without some kind of danger signal being set off through whatever, you know, it could be work, it could be relationships, it could be lack of sleep as you say you name it. But what's also clear isn't it is that pain is completely individualised to an individual but also to the situation as well. Can you expand on that?

Deirdre Nazareth: 13:00

Yeah, so I'll just use a quote that I read off an article and his name is Mr. Alister, James Flett, but he said "anything that is detectable or accessible to the brain and relevant to the evaluation of danger to body tissue has the capacity to modulate pain". So all contributing factors should be considered in all pain states. That, so that means acute or chronic. So again, and then it goes into you know, we we talked about this a little bit before that, when you feel pain, pain is a signal of something that needs to shift. So the brain is telling you something needs to move. The action is the one there's one m o like Laura Lorimer, Moseley says in his paper, one Mo, which is action, what needs to be done, what needs to be changed? Where is the danger coming from or where is the quote unquote, tiger in the life or the you know, the thing that is causing the alarm bells to go off. And that's the way we need to view when someone has a chronic pain condition, you know, with the patients that we've seen, that are complex, it's the complexity of childhood, in addition to all the years that they have accumulated till when they've come in to see us, all of those potential inputs throughout their life that actually changed their brain to see that pain is the thing that for whatever reason, is being manifested. And there could be motivation in that there could be things that are driving that response that go beyond just, I want to get, you know, I'm sick, maybe they maybe that is a form of comfort for them. Maybe that's giving themselves definition in a way that nothing else has, maybe it's giving them importance. And this is not to say this in a condescending way. But that's just to understand that how complex pain, in fact is. And there are so many more factors that go into it. Think about babies, you know, our kids, kids are very good at that. In fact, they know, the minute that they say they're sick, you might get off work, oh work, school, and they can really put that one. I mean, I know I've tried it before, when I was a kid, but I basically needed to have a limb dangling from my body in order to miss school, there was no way I was missing school. So you know, it comes down to motivation, you know, is it something that is advantageous at that time for that organism to feel pain? And if it is, then you will? And if it isn't, then you won't?

Peter Williams: 15:58

So I like what you've just said, because I think this is the sort of, I don't know where I stole this from, it's probably the IFM it could have been Pat hanaway. But, you know, he said, your biography is your biology. And so that sort of completely summarises everything that that you've said is that, you know, people with chronic pain are an amalgamation of everything that's happened to bring them to this place

Deirdre Nazareth: 16:23

I mean, but even acute pain, pain in general, because pain is not something that is coming from the tissue. If there, there is some peripheral input, it's how your response is, that determines, and that response is an amalgamation of everything that makes you who you are, you know, it's like, you can learn how to change your response by your cultural experience. And by the way, your parents viewed pain when you were a kid, if they reacted, or they overreacted. And they made you constantly worrying, you will have more propensity for a chronic condition because of the greater fear the greater worry around that. So people can walk on coals and people can like flagellate themselves and not necessarily feel pain from that. That would be an acute sensation, right? That's not chronic. Yeah. You it's all about the response. And it's all about changing that response. And how do you change that response is by daily practice, and, you know, first of all, knowing that something needs to change. And secondly, then, daily practice, because what I do is pain management, it's not pain cure, yeah, you can cure your pain, by in a way of like getting it to a level that is manageable, and a relative zero for you. On those, you know, there are days that you may have a flare, and okay, if you do then you have the steps in place to manage that flare. But no one, you know, it's not about coming up with a cure. Because whoever does that is going to be a billionaire.

Peter Williams: 18:13

Can you just go into that from a clinicians perspective? And I mean, because I think what we're, any clinician in this area who's listening will find difficult is that it's generally you know, the perception of the patient coming in perceiving that they're coming to see someone who understands pain that's going to solve it for them. And me and you know very, very well that it's an incredibly multifaceted, very difficult thing to deal with. And so as you say, it's tough on the patient when there's no real fundamental answer for them. And they're going to have to do a lot of work because they have these preconceived ideas, maybe that if you take x, it's going to solve y. And that's quite difficult for us, isn't it? It's quite difficult for for the patient. And it's quite difficult for us to be able to, I mean, it's not something we can solve overnight. It's a question of there's a huge, multi faceted strategy that is going to need to be developed. And I think that makes it worse for us doesn't it makes it sort of worse for the patient because they're not used to look, this is what we know, a lot of times patients just want x to solve y and that never solves pain, can we expand into just very simply because it's not really about acute pain, isn't it? And what I'm keen about is that, you know, chronic pain and what chronic pain is, because obviously, we see a lot of people where they're still complaining about pain of an injury that was done two or three years ago and really shouldn't have any consequences on the actual injury site. So can you talk about how you transition from acute to chronic and what really chronic is and what controls chronic pain?

Deirdre Nazareth: 19:52

So there are a few things with that you can actually transition from acute to chronic in a first episode of pain. It just depends on how intense that pain is and the intensity of that, that can that can signal and trigger intracellular mechanisms that then produce a chronic manifestation. But typically speaking chronic is anything that outlasts the normal length of the tissue that we're talking about, the healing time for that tissue. So that's one of the first steps that you can get schooled in is really understanding, what tissue am I dealing with? Is it ligament? Is it muscle? Is it highly vascular? Is it not? How long should I expect to have this injury for, and work around that and within that, so you have a framework of time where, okay, I should be better within six to eight weeks and past that, things don't change or things are getting worse, then we need to look into what things are you doing that may be contributing to that. So typically, we'd say probably any pain lasting longer than three months is considered chronic. And when we've had something for years, that obviously is chronic, you know, the thing is, your body is very good at healing itself, when it's given the right things that it needs. And that's not just down to seeing the person that's going to treat your pain. I think what is often forgotten about is how much diet lifestyle and all of those things that aren't necessarily put into the treatment, when you go and get a physical treatment done. Those things probably have more impact, and will probably help that treat that manual treatment even more than just cracking someone's back and saying, Okay, come, you know, come back next week and we'll do the same thing and there is an expectation on both parts. There are people who are reading things online loads of times, now who are coming in with lots of Google searches and saying, oh, I need to do this, this sounds like it should be good. So on the part of the practitioner, there is a lot of responsibility, because you need to understand where that patients coming from, and match your treatment to that expectation. So if I have someone that I would say I would normally do a manipulation for, and I very rarely do those now, I really do a lot of explaining in my sessions first, because I think it's very important to destigmatize exactly what we're talking about right now, which is understanding pain for the complexity that it is. Yeah.

Peter Williams: 22:41

And just to clarify that you do that, because you're at the forefront of understanding pain research. And that's why you're doing that.

Deirdre Nazareth: 22:50

Yes, and actually, in all of the pain research, and there's loads of articles on this, showing that understanding the physiology is a treatment in and of itself. And that actually, people with very significant chronic issues, do far better to rehabilitate themselves, when they have that understanding put in place first and foremost, before any other treatment is engaged in. So that's why this is so important to understand. And really to get across to people in the what in the broader world of understanding what pain is, is that it's actually much more involved. But it's not to say that it's so complex, that you can't do anything, why there are so many different treatment options that can be available to a person and so many things that they can do themselves. First and foremost, before they go into the line of oh, I need to get surgery or I need to get some really expensive therapy done, you know, that may actually not work. So, you know, we really need to be clear about how something that makes someone feel so out of control of their lives, they they actually do have a lot of ability to control not only the situation but their life and and going forward. So with chronic pain, even the term chronic it just sounds like oh, this is going to be forever. Even that in itself goes oh my god, I have chronic pain this is like and you know, there is some research that that's showing that chronic pain should be considered a neurodegenerative disease. I read some articles recently, you know, this is actually quite fascinating that we are moving towards that realm of how it's really a brain based condition. Yeah. And so continue,

Peter Williams: 24:48

Can you just go just explain to that because I think on my certainly limited pain neuroscience knowledge, we know that chronic pain, so let's imagine I broke my leg and two years later, I've still got a load of pain there but the majority of that pain is not down to the original injury or the site at all, it's actually the way the brain is choosing to communicate with things. Can you just explain that in more detail?

Deirdre Nazareth: 25:15

Yeah, so there could be also with when you have damage to a tissue, and there's scar tissue that grows as a result that can actually signal in its own way. So really, what's very important when there's a traumatic injury like that, where you have a break, or you have a cut or something that you know, like surgery that needs to heal, that you do it in the right way so that the tissue heals appropriately and actually comes out stronger than the parent tissue itself, in so that you don't get misfiring because scar tissue can itself actually cause problems down the line. And you can actually feel things in the scar tissue itself that, you know, as an osteopath, I work on scar tissue. But when chronic pain is involved, you are having a situation where your brain and spinal cord are responding to things that are not necessarily causing pain themselves. So you have a situation where you have non painful things can become painful. And you also have a situation where you have increased pain sensitivity. So you have something called allodynia, which is where non painful stimuli can actually be painful. And that can be seen like if you burn your hand, and you get a blister on your hand after the burn, the immediate area will be painful. But then, as time progresses, the sensation above the burn and below the burn will feel sensitive as well. If you've ever had a sunburn, you know what that feels like, you know, with when you put light clothing on, it feels like really irritating to your skin. And that's an adaptive process because your brain is protecting you from potentially threatening situations. So it will actually change the response profile of your nervous system so that information goes faster than it normally would. But when it's concerned in a chronic situation like that, where it's actually causing you to react to multiple different things, maybe even your environment, your normal environment, that's where it's no longer beneficial to the organism. So how we need to change the way the brain is responding in that case, we need to understand all the relative inputs that could be contributing to that response, and remove one by one like taking lots of thumbtacks out of the board and reducing it down to just a few where they can say okay, I don't have that situation anymore. I'm not responding to that thing. I don't have fear attached to this movement, I don't have fear attached to an idea or a thought, which, with chronic conditions, fear and fear avoidance are two things that make the body more immobile, and make the brain more sensitive, and create a situation where you're hyper vigilant to the pain. So the focus is like extreme focus on everything that's going on in your back. So now, if you think about how your brain sees things, anything that is related to your back, if you look at in terms of like we said the pain is unique to the person, there are multiple brain regions that correspond to that. You know, I say the usual suspects like the movie, but there are certain parts of the brain that will light up in people who have pain. And then in chronic conditions, there are more give or take depending on that person. So we have different parts of the brain that have to do like your frontal lobe, your somatosensory cortex, and your parts of the brain that are part of your limbic system, which is your motion and fear based parts of your brain and memory. So these parts of your brain all contribute to producing this pain response. And when it's chronic it is more effective, your brain is more effective at producing a pain response because it takes less to trigger that response. So back to what I was saying about this somatosensory cortex, your entire body is represented on your brain in a virtual way. It's like a it's like a virtual map.

Peter Williams: 29:41

Yeah, and this is the map. This is the map that you would see that sort of has all the different, you know, oversized hands, you can see this online can't you.

Deirdre Nazareth: 29:49

Yeah, it's a sensory homunculus Yeah. And it's depicted in a way that makes the body parts that have the most innervation so the most largest number of neurons, which look bigger. So if you looked at this picture would look like this kind of ape like person with really big lips, really big hands and the rest of the body parts are relatively small in comparison, because that's showing you that your hands are really important. And so your lips and so your certain senses around your ears and your tongue, because this is how we sense our world. If we don't have high amount of innovation in our in those parts of your body, you don't feel things as much. So why a small paper cut would feel really painful on your hand is because your hands are important. And that importance goes into on an individual basis if someone injured themselves, and they have a chronic condition, say you said you'd like you broke your limb, you broke your leg. And two years later you have you still have pain from it. If you were a football player, that pain would be really exacerbated because your entire livelihood is dependent on your ability to function and play and play well. Because it's not just about, you know you like to play, it's your entire future livelihood and how you see yourself is dependent on you being able to play and that's where most chronic pain patients are not your little ladies in Zimmer frames, I don't like using that term. But, you know, it's it's actually athletes who have a huge amount of importance placed on their ability to function well. And if they can't, that high drive, there are certain personality traits that go into chronic pain as well. So you know, very,

Peter Williams: 31:52

can you just just sort of touch on that for us? Yes, it's definitely something that we definitely see, don't we? And can you also touch on pain from a point of view of, you know, emotional pain, you know, and, you know, the generation of pain through, you know, I could think about certainly relationships, I can think about stresses and strains of work and family life and all that sort of stuff, and how that just those aspects of daily living can actually generate pain.

Deirdre Nazareth: 32:24

Absolutely. So you know, there is a huge amount of identity that goes into what you're able to do. Even if you're not an athlete, you define yourself by your hobbies, your interests, these are all things that, you know, we individually say, Oh, I am someone who likes to do this. And I'm someone who likes to do that. If you can't do those things that takes away your identity, and how do we understand who we are. And this is the philosophical part, how we understand who we are, and what we like, is when we can't do those things. And this is where pain gives us an understanding of consciousness and certain personality traits will actually predispose someone to chronic manifestations because of the importance again, so if someone is hyper stressed, a type A personality, perfectionism, and these personality traits don't necessarily just come out of nowhere they come from, you know, very, there's a lot of research to show that childhood traumas can lead to this type of personality trait. And actually, childhood trauma or adverse incidences in childhood predispose someone to chronic pain later on in life. Sure. And couldn't

Peter Williams: 33:49

Can you just because that literature is incredibly strong. So in a sense, is what's happening is that something traumatising, um that happens, particularly when we are when we were young, potentially rewires the brain in a different way to interpret the outside world. And is that where the problems start?

Deirdre Nazareth: 34:11

And of course, if you think Yeah, go on

Peter Williams: 34:15

An if of course, if you have susceptible genotypes, like you were talking about, you get an exaggerated response on top of that.

Deirdre Nazareth: 34:22

Yeah. So what makes someone develop chronic pain is not just about the incident, the injury, it's all of the things I said that make you unique, who you are. So your genetics play into that your gender plays into that your culture, where you learned about pain, how you learned about pain, how your parents respond to pain, how your loved ones respond to pain, your hormones, your hormone fluctuations, your diet, your lifestyle, these are all just many little parts of what will predispose someone to that and child's, adverse childhood incidences are known to change the brain, in a way reorganise the brain again to be in a constant state of alert or heightened sympathetic response. And part of training and treating chronic pain is to, to recognise where that chronic condition may be response from childhood incident.

Peter Williams: 35:27

And again, that sort of makes it difficult for the clinician, because I think we've had several incidences in the past where it's pretty clear, the patient absolutely does not want to go there. Yeah, and that's obviously got to be handled by an appropriate practitioner or clinician as well. And I mean, and that's something that we don't do. But we definitely recognise that that's problematic for this patient. And, you know, maybe they need to take some degree of help on that side. But you also understand why they don't want to go there.

Deirdre Nazareth: 35:59

Yeah, I mean, because you know, pain is not, is uncomfortable, pain is not something it's just, it's a discomfort. However, you know, with respect to adverse childhood traumas, and even any kind of situation, trauma doesn't have to be significant, and horrible, like abuse, I mean, or anything like that. God forbid, it's just what happened and it's the story that you told yourself around the incident that happened, or the story that your brain continuously perpetuated. So, yes, that can be from horrible abuse. But it can also be from someone calling you stupid, and you just believed you were stupid for the rest of your life. Because, you know, your brother did like in my case, said, called me dummy. So and then you're, it's almost like you seek to validate that statement, because someone else says that, and then you go, Oh, I must be stupid, because now this person said it too. And so then you are almost like selecting the, preferentially selecting those statements as you go on in life.

Peter Williams: 37:10

So does that does that answer the question why you're always on courses, then?

Deirdre Nazareth: 37:14

Probably, yeah. There is a limiting belief. I you know, there's a very, I'm very much of the the person that believes I have some level of imposter syndrome. So constantly doing courses to prove otherwise,

Peter Williams: 37:32

I will definitely say I'm, I'm I'm similar as well, that I mean, again, there's massive impostor syndrome there. I think what we're gonna have to do on this, because I'm just looking at the time is that we're definitely gonna have to do more, because one of the, I think we'll probably have to do a second podcast because we haven't really touched any of the sort of biochemistry, any of the sort of immune activation, gut microbiome, barrier breaches, both gastrointestinally blood brain barrier aspects. And I think what we should probably do is do that on a, because we see a lot of that don't we see a lot of people who are fatigued, in pain, depressed and they're depressed all the time, because physiologically, they may be inflamed, and their immune system is highly activated. And you know you see that right across the spectrum of many of the chronic diseases that we're dealing with. But we should do that in because that's, that's quite a big subject. And I think we should probably do that on the secondary one. Yeah,

Deirdre Nazareth: 38:28

We definitely don't have time for that. But in the sense that, how do you understand pain? And what can you do about it? So we

Peter Williams: 38:37

So can we can we bring you into, I suppose, a similar question, what is what are the consequences of long term pain? And does that change the body? And does that change the brain?

Deirdre Nazareth: 38:50

Yes, so chronic pain changes the brain and how does it do that, so we have changes in the brain that occur mood wise. So I think that's probably one of the biggest impacts that it has on us. So anything long term like that is going to impact your mood, make you more anxious, make you more depressed, and in fact, those are two of the things that predispose you to chronic pain. So it's like a vicious circle, then, you know, increased stress in general, you have fear, increased fear catastrophization, these are all again, mood changes that can actually make the person start to fear their surroundings and become more and more isolated, more and more depressed, more and more hopeless. And, you know, this is a vicious circle that can propagate and keep going until, you know, horribly, you know, this is a horrible fact about it, but people in chronic pain are at higher risk of suicide for that reason, okay. And there are things that we can do in a in a way that will help people gain control and that's what I'll touch on in the second. But so you have changes in mood, and then changes actually in the brain structure. So there have been a lot of papers to show that there is a decrease in the volume of grey matter in the brain. And that is, Grey Matter is basically when you look at a picture of a brain, and you see like the white part in the middle, and the grey bits all around the circumference, the surface, grey matter is that, so grey matter is basically the surface of the brain. And it's abundant in the front of the brain, the cerebrum, the cerebellum, the brainstem, and the spinal cord. And basically, it's there to process information from your sensory organs and other parts of grey matter. So it has a lot of high concentration of neuronal cell bodies, and glial cells that help detoxify the brain. And it helps, it's there to help humans function function normally, it controls our movements, retains our memories and regulates emotions, among other functions through the signalling and transmission between those neurons that are existing there and other parts of the body. So this means that when you have chronic pain, and I just said that it changes the brain structure, you actually have, you know, there's a paper by researcher Vania Apkarian who showed that chronic back pain causes decreases in the prefrontal cortex and thalamus of grey matter, lessening about 11%, which is quite significant. That is basically saying that that's the same amount of grey matter that you can lose in 10 to 20 years of ageing, right. So the longer someone is in pain, the more grey matter they will lose. However, the caveat to that is it's not irreversible, it can be changed when you have adequate treatment applied. So how can

Peter Williams: 42:06

So you're suggesting, so just to be clear then, someone in chronic pain has increased risk of ageing more quickly, but probably increased risk of dementia or Alzheimer's? Yeah,

Deirdre Nazareth: 42:17

Yeah so back to what I said basically, someone in chronic pain. So those areas of the brain that are diminished in the grey matter means that patients who have chronic pain have problems with memory processing, learning new things, keeping focused attention on a task, problem solving and finding solutions. So these are all parts of the brain that are associated with dementia risk and early Alzheimer's, in addition to other neurodegenerative diseases, because you also have motor control and coordination issues that can be affected, that's according to your day to day activities and movements. And, you know, small fine movements that require more coordination.

Peter Williams: 42:58

So even more important, again, with one of your strategies is that people in pain should move.

Deirdre Nazareth: 43:01

Absolutely. So what you know, this will kind of go into what can people do,

Peter Williams: 43:10

Shall we get into that what I mean and again, what I think because we're gonna have to do a definitely a another podcast on this, but what would be the, you know, what would be the general things that you would guide someone you know, general public listening to this podcast is in pain needs a new strategy needs a new structure? What would you say? And of course, this has been said by someone who is at the forefront of understanding pain science.

Deirdre Nazareth: 43:38

Yeah. So I would say first of all, they should go and see someone who, or pick up a book like Explain Pain, watch TED talks on pain topics by Lorimer Moseley and David Butler and, and really look at information that can explain the neurophysiology because as I said before, that is one of the biggest treatment therapeutic options out there.

Peter Williams: 44:05

We'll definitely put these in the show notes.

Deirdre Nazareth: 44:08

CBT is a form of talking therapy that can link your thought processes to the impact that they have on your actions and physical sensations in the body. You know, having good CBD can actually develop healthier coping strategies. There's also graded exposure therapy and graded motor imagery. So what can you do when you can't move something you can actually visualise it visualisation is huge in this and you, you know, you can do it in a way where you go into a deep meditative practice. Deep visualisation taking say if you can't walk you visualise walking if even if that causes the pain to be felt. Again, you can break down those movements into smaller visual steps.

Peter Williams: 45:01

So in a sense a bit like, so I love watching the athletics but I particularly love watching the long the high jumpers because they are visualising the jump before they've gone. And I know, on the in the sport science literature, we know that increases your chances of having a successful outcome from it. So is it a similar process?

Deirdre Nazareth: 45:22

Yeah, absolutely. So, you know, you're basically driving blood to the area of the brain that is associated with those movements, those neuro tags, you know, you're basically activating those neuro tags by your visualisation strategies. And then when you actually can progress from doing visual movement, then you can actually do the movement, which is with graded exposure therapy. And that comes from actually, there, there's a few steps that you can do in order to do that you can write down in least fearful to most fearful tasks that you want to do, but you can't do and then make a plan of action of how to address those tasks, starting with the least fearful because as you build more confidence, and as you build success in doing these small tasks over time, it's like the Pareto principle, the 1% principle or the you know, celebrating your small wins, these are actually changing your your brain to facilitate positive pain free pathways. So you're not actually attaching fear and a fear based movement to that, or pain to that pathway.

Peter Williams: 46:42

So even some degree of plan and some degree of strategy, I'm assuming that's going to have a pretty significant placebo effect as well.

Deirdre Nazareth: 46:50

Yeah, but you know, placebo effect is still an effect? I agree. Yeah. Good effect, and how do we know that most of these things are not placebo effect? Actually, I would, I would love to take onus and take all the responsibility. And, you know, for someone getting better, but the reality is, a lot of what gets the person better is their belief in you. And also, if you're a nice person, it really doesn't matter how many degrees you have. Especially, if you're not, if you're an asshole,

Peter Williams: 47:22

Good point, I think there's a couple of things when we've said, you know, I think we know pretty early on that some people are going to need external help to what we can do, because we can't be an expert in every single area. And so sometimes when we send them off, because a component of their chronic disease and pain, we, you know, by our experience, we know is either being driven from past trauma or something, and you say to them well, have you tried CBT? And they come back and say, No, it was rubbish. Is that because it was just the wrong time for them? Or was it the wrong therapy? Or was it the wrong person?

Deirdre Nazareth: 47:59

It could be all of those things. But you know, this is where you have to come up with other strategies, there isn't just one way to skin a cat, you know, back to the whole discussion at hand, which is where what is pain, if we were to say that every single person with flat feet had to get orthotics, and that's what was going to help their pain, then you would just walk into boots and go, Okay, I want the, the remedy for my flat foot pain, and then you would find it and then everyone who had issues with heels or you know, could walk in and get the treatment for that we know that's not the case. So we have to come up with multiple strategies that not only take into consideration the person's expectations, but also what they may like. And we have to kind of sit down with them and say, What do you like, what can you do? What can't you do? Let's mould the treatment to the things that you like. And you know, you can do because if you go and give someone something like salsa dancing, and they're like, I hate dancing, I don't know why this person gave me this as a treatment, they're not going to do it. And that comes down to compliance and that's going to affect your overall strategy. So I would say the tips, you know, basic, basic tips that are actually so fundamental in treating any kind of pain condition. One is movement. Even if you can't move, you can do something where you break it down into one minute, or, you know, like Dr. kharrazian says, if you need to just lie on the floor and just move your arms like a dead bug. That's what you do if you need to just if all you can do is lift your head up off the pillow, that's all you can do then that's what you do for as long as you can do it without exhausting yourself and then do it multiple times. And then you know movement in terms of what I understand, and what I appreciate as an osteopath is that all tissues need a good fluid flow, they all need good blood supply, they all need their nutrition from a very basic cellular level. So if you are not giving those cells, what they need, so outside of the treatment, like getting a manual treatment, if you're not hydrating yourself, if you're not, if you're drinking alcohol, and you're smoking, and you're taking drugs and doing all these things that actually dehydrate yourself, then obviously, or you have pollution or you're you've got internal or external pollution in your environment, that's going to impact your pain as well. Yeah. So that's another thing.

Peter Williams: 50:42

I think on the second podcast, we could get into that in a little bit more detail, I think on that side.

Deirdre Nazareth: 50:48

Yeah. But you know, planning your routine, I think planning routine around structuring your day where you can increase and participate in as many vagal toning exercises as you can, is so key because we already said that, if pain is a multi system output from the brain, that is sensing danger, your dangerous system is your sympathetic nervous system. That means you're in heightened sympathetic. If you're in heightened sympathetic, your body works in such a way that you can't have your parasympathetic on at the same time. So if you are heightened sympathetic, that means you're not engaging your parasympathetic nervous system at all. What does the parasympathetic nervous system control it controls pretty much every single organ. So you have from your tongue movement down to enzyme production down to motility to swallowing, production of all your enzymes, you know, desiccating properly even urinating all of these things have, are under control of your parasympathetic nervous system, which is in control by your vagus nerve. Your vagus nerve is what comes out of your jugular foramin in the throat, part of your neck, of the skull. So all of the things you may have heard like singing, singing loudly, gargling, gag, stimulating your gag reflex can impact your vagal nerve, but also certain movements like stretches that I use with clients, even cold water therapy, meditation, graded movement, as I said, this is these are all ways to improve your vagal tone,

Peter Williams: 52:38

I think what you're saying there aren't you is that you're trying to take a nervous system that is more in fight or flight to more in rest and digest. Probably a way of thinking about it.

Deirdre Nazareth: 52:46

It's called rest and digest for a reason. Because you produce everything that's needed for resting and

Peter Williams: 52:52

So I think that's definitely something digesting. So that's hormones and sleep, think about like, you know, most chronic pain patients can't sleep and there is a direct relationship between heightened pain sensitivity and lack of sleep. So that would be my next thing is to improve everything around sleep hygiene that you can and then go into your diet and lifestyle. You know, there are nutrients, key nutrients that could be missing in someone who has a chronic pain condition. And it may not it's a chicken or egg situation, you don't know if they were deficient in already or if it is a deficiency as a consequence of their chronic pain. Sure. So we know that chronic pain can give you leaky gut or a leaky gut can also give you chronic pain. You know, there is the peripheral component there. So I would say like making sure that your diet is very good and anti inflammatory as much as possible. And making sure that you have key nutrients like B vitamins, which are good for nerve health, and magnesium, which is good for the nervous system, overall nervous system health and fat soluble vitamins like A, D and K. That's just very basic. But you know, to get into the more personal aspects, you can do testing and genetics testing even to see what you may be deficient in that maybe making you more inflamed or making you more prone to chronic pain. where those last bits is where we can definitely explore on a second podcast, because again, I think that does relate, as you said, the risk from increased anxiety and increased mood disorders, obviously increases your risk of pain long term as well. They all seem to be interlinked. And you know the mechanisms that might be driving that we see quite a lot, don't we from a point of view or if you say microbiome, which we've not touched on, but how that communicates with the brain as well and neuro inflammation. I think that will bring us to a second podcast. So well done.

Deirdre Nazareth: 54:55

I'm sure I mean it is a vast topic, but yes, I would just say that you know Key Points is chronic is not forever, you can definitely do things to change, like we just said, focus on those what seemed to be basic, but it's in the simplicity that gets broken down that leads to more complex cases.

Peter Williams: 55:15

But isn't that the case? Isn't that the case that I think for most of these disorders of chronic disease, the fundamental basics are, it can't be that easy, is it? That they're going to be the key players the key cornerstones of getting you better? And the answer is that people are looking for a different answer. And sometimes, you know, when you say, well, you need to do more movement. I mean, that's quite difficult for a lot of people to do, you know, it's like, oh, well, where am I going to get to do that in my day, it's like, well, you know, let's not spend 1000s and 1000s of pounds on testing that may not bring you back and give us you know, too, well certainly give us a lot of data and give us a bit of picture to look at, but it may not be as good an outcome as just getting you to move a bit more. And I think that has to change, doesn't it, this understanding of just how important these fundamental basics are?

Deirdre Nazareth: 56:06

Well, just to back to movement, I mean, it was thought that you shouldn't move when you have back pain, but now we know that's the worst thing you can do. Because not only are you you're you you're stopping input to an area, you are taking away all the things that can help you detoxify and improve your pain sensitivity. From a from a nutrition point of view, you're missing out on the lymphatic system, on the blood flow, on the you know, when you get off a plane, the reason why your skin feels like like a ryvita biscuit is because you've basically dehydrated from the inside out. And you need that movement to get you know why your ankles swell and why your fingers swell, because that lymphatic is just stagnant, it's it's moved out you need that counter parallel force that is produced by your ankle movement, that is the primary pump for your lymphatic system from a distal end. From a breathing end your diaphragmatic breathing is the your abdominal diaphragm is the primary pump for it in your middle of your body. So if you can't move, you can breathe you know you can breathe to get the fluid moving. Just like I said, you know you whatever you can do even if it's lifting your head off the pillow, that's all you can do you do that as many times as you can.

Peter Williams: 57:29

Yeah, that is a great place to finish. We'll definitely do this again. I think it's like everything. It's a massive subject that you could go on for days on end chatting about. And we'll definitely do a second one we'll definitely dig into some of the more nuances some of the stuff we're understanding about microbiome, the gut brain axis and how that can be a catch 22 neural inflammation, which I know you're pretty damn good expert on as well. So my good lady, thank you so much for your time this afternoon. And I will put the notes to those books on the show notes so that people can look for them as well, because I think they are really great books from a point of view of just just simplifying a pretty massive subject into sort of layman's terms. Dede thanks