Unpacking: How Your Brain Can Change Your Pain

Megan: 00:00:00

Anybody that's selling you a magic bullet for persistent pain is lying or not educated enough to understand it. So I think that is, I mean, we do, we live in a drive through society, right? People want the quick fix, they want it yesterday.

And that's not how this works, unfortunately.

Intro: 00:00:22

Welcome to Unpacking Pain, a podcast dedicated to understanding the complexities of chronic pain, what causes it, how it affects our lives and what we can do about it.

Join doctor of Physical therapy and pain science researcher Dr. Megan Steele and me, Holly Osborne, a chronic pain sufferer, as together we explore the biological, psychological and social aspects of chronic pain and create community and understanding in the process.

Holly: 00:00:57

Hi, Megan.

Megan: 00:00:57

Hi, Holly. Happy to be here.

Holly: 00:00:59

I just finished a little meditation before this episode. That's what we're going to be talking about today. So if it takes me a minute to sort of pull my brain together, you'll know why.

I'm just very, you know, very meditated and mellow right now, which I love.

Megan: 00:01:15

Wonderful.

Holly: 00:01:16

But that is the theme of our episode today and the conversation that we're really eager to dive into on this podcast because we talk a lot about the challenges and the complexity of pain.

And there is certainly, I think, a lot of acknowledgement around the three legged stool here, the fact that it's not just physiological, but there are social aspects and psychological aspects. So how do we, how do we take advantage of the fact that that chronic pain has a psychological component?

How can we actually leverage the role of the brain in helping us get through chronic pain and find some relief on this journey?

And I'm lucky enough to have Dr. Megan as a partner in crime here because she's one of the practitioners who not only acknowledges the importance of the way that the mind can play in and mindfulness visualization, a bunch of things we're going to talk about today, but she also understands the science behind it and she's done the research and continues to research. So I'm very eager to have her kind of unpack this with us today. Is this a juicy topic?

Megan: 00:02:34

Absolutely, yeah. I'm really excited to talk about this.

Especially, you know, as you've mentioned in the past, for the people that are really evidence based and they don't want to talk to anybody that's saying things that sound sort of spiritual, energy work, that type of thing.

And for some time, I think, you know, mindfulness meditation has kind of been in that camp and people have thought about it in that way and really there's relatively new evidence, but a growing body of evidence of robust science to support these things like mindfulness meditation, yoga, nidra, body scanning, these types of things. So I'm really excited to dive in today.

Holly: 00:03:17

Yeah, this is, this is gonna be, this may even need to be a two parter because there's so much to get to, so. All right, well, you know, first I'd like to start, like we often do, with kind of a baseline question in that. Is this our psychology at play?

When we think about these sort of alternative methodologies, things like bringing meditation in, things like breathing techniques, is that affecting the brain in terms of a psychology angle, or is it mood that we're affecting? Or is that all the same thing? Can you help us understand what it's kind of where it's hitting and why it would even help pain?

Megan: 00:04:00

Sure, absolutely. So the answer, the short answer is yes to that.

And a more nuanced answer is that when we're thinking about things like mindfulness, breath work, vagus nerve stimulation, we're not solely thinking about the mind and we're not solely thinking about the body. There. The vagus nerve starts in your brain stem, actually in an area below your conscious awareness and extends throughout your body.

And so some of this mindfulness will be from, or some of the effects of this are from the bottom up and some of it will be from the top down. And so I think that's part of why I find it to be so interesting because it is really truly mind body medicine with evidence behind it.

Holly: 00:04:54

Has this evidence always been around or is this just now? Are we just now starting to see the numbers?

Megan: 00:05:01

Well, it depends on who you talk to.

So there have been religions and spiritual practices that have been around for hundreds of years that we've not really thought about as evidence based practice. But it may be that they knew much before we did.

And when we think about spiritual healers and things like that, potentially they were using some of the mindfulness meditation techniques that we're now aware of, the mechanism behind how and why they work.

Holly: 00:05:36

That makes, yeah, that, that makes sense to me because these, a lot of these practices like acupuncture have been around for thousands of years and in some cases acupuncture is used in lieu of it. Tell me if I'm, if I'm just reading bunk science here, but it's used in lieu of anesthesia in some surgeries, so it has to be powerful. Right?

This can't just be in our mind, so to speak. Is that fair to say that?

It's like you can't cut someone open sans anesthesia and use Acupuncture instead, if it's not actually doing something biological. Sure.

Megan: 00:06:14

So I'm not aware of that study where they used it instead of anesthesia, but there have been anecdotal reports of like Buddhist monks who meditate during dental work and with things like root canals, they don't have any anesthesia because they've trained their minds to quiet that noise. So there is something to be said for this. And some people have, you know, it's more anecdotal reports of these, these experiences.

That being said, acupuncture for a long time was thought of as kind of a sham type of treatment. And maybe there was a lot of placebo going on. And that's in part because it's such an individualized experience.

And in order to prove anything in the literature.

Well, we don't really prove anything in the literature, but to demonstrate efficacy in the literature, you have to get a large enough group of people with the same problem, you give them the same treatment, and then you also have a group of people that are the same, either age matched or injury matched controls where you give them either nothing or a sham treatment. And that's how you say, okay, this is doing something more than nothing or it's changing things more than chance alone would.

And so it took a long time for acupuncture to, to do those types of studies.

Holly: 00:07:47

You know, it was wild. And I'll have to look this up.

To share on a future episode, I mention the acupuncture in lieu of anesthesia because it was offered to me in my fifth shoulder surgery. Wow. I went to a totally different doctor. Number five was down at USC with Dr. James Taboni.

And the anesthesiologist who met me pre op was mentioning that he was going to check on my insurance form. You know, he said, I actually have to indicate which anesthesia I'm giving you.

We talked through a bunch of options and I said I didn't even realize there were different flavors of anesthesia. Like you're going to tell them which one I took, which, which flavor or variety.

And he said, in fact, not only are there different like so called flavors of anesthesia, I could even select acupuncture instead of on your insurance form. And I was like, wiggity. What I back up. I didn't even know that was an option.

So it might have just been through this particular insurance plan that I had. And he as a practitioner has to make mention of that because it is an option for me. But anyway, I don't want to go down that rabbit hole too much.

But it was wild. I mean, that was like a head spinner. I was like, doc, you are introducing too many things. You know, 72 hours before surgery.

I don't even want to think about, like, okay, too many options now.

Megan: 00:09:12

Yeah, yeah.

Holly: 00:09:13

But I, you know, I am such a believer in alternative practices and actually really don't even like the phrase alternative practices. But sometimes it's necessary to say that phrase because it helps others tune into what you're talking about.

It seems like most of the phrases around it are, around this kind of practice are almost a little bit disparaging, a little pejorative. Like we say, woo, woo, and, you know, left field, new age, ironically, even though some of these practices are ancient.

Megan: 00:09:46

Right.

Holly: 00:09:47

New age. And what do you find as a scientist and as a medical, you know, practitioner in the medical field?

What is the openness of most of your patients to this? Do they come to you and they want, you know, doctor, Megan, fix me first. And then it takes some time to get into that alternative stuff. Sure.

Megan: 00:10:12

It really depends on who you talk to. And at this point. Well, my whole practice has always been a word of mouth referral system.

And so I find that that works really well because by the time they get to me, they're already primed. You know, they used to say, go see Megan. She's gonna push on your belly. It's weird, but you'll feel better.

That was when I did a lot of visceral work. And now they say, go see Megan. She's gonna work. She does this thing where she talks to your nervous system. It's fine. You'll feel better.

You know, and so sometimes by the time they get to me, they're a little more. More ready for those things.

But again, just like when we were talking about the difference between men and women and levels of openness and things like that, sometimes they say, I'm not quite ready to talk about that. I'm not interested in that. I'd like to see how far we can get with traditional physical therapy. And I'm happy to do that.

I'm happy to meet people where they are and say, if this is what you want, I'm happy to do that. And then at some point, we reevaluate and we say, okay, you're this much better. Maybe 50%, maybe 75, whatever it is.

Do you mind if we try a couple other things and maybe we can get that last bit?

Holly: 00:11:24

Yeah, I think a lot of us have that exact cadence or sort of chronology in our journey Is that we're not having a sprained ankle and then just sitting down and visualizing it feeling at night. Right.

There may be some people who immediately go to that, and that's wonderful, but most of us follow a fairly traditional western path in seeking medical support first. And then when we get only part of the way there, or we're not satisfied that we've overcome our pain, things can start to get frustrating.

We can lose patience. And that's when we start. Our defenses actually come down, and we start to say, all right, I'm not going to actually hold these things at bay anymore.

I'm. I'm actually going to open myself up to the possibility of some alternatives.

How do you explain for anyone who's listening, who thinks, okay, that's me, I haven't. I'm feeling frustrated, but I haven't started yet. How do you start?

Patients who have not experienced alternative practice because there are so many modalities. Is there a place that you begin, like, let's say, what's really an elementary, like, visualization? Breathing. Where do we start?

Megan: 00:12:44

The easiest place to start is breathwork. Visualization sounds easy, but there are people who cannot visualize, and it's a spectrum.

Most likely, there are people who are really good at visualizing, and there are people who are not at all. And so that's not always a great place to start. And it can be triggering for some people. So breath work is nice.

It typically gives you a pretty good response very quickly, and so people are encouraged by that. You know, I think about the difference between tennis and pickleball. I feel like breath work is pickleball, where you can have success early on.

And mindfulness meditation is tennis, where you have to work a bit harder before you start to see progress.

Holly: 00:13:29

Oh, what a great analogy, actually. Yeah.

I think that it's intimidating for a lot of people when they think about meditation, and they have this image of a guru on a rock whose meditation lasts two hours. And they can endure, you know, blistering heat and buzzing mosquitoes and so forth. And.

And, you know, I think many people also quit meditation because they think they're doing it wrong. You know, I hear all the time, I'm just not. I'm just can't do it.

When actually the irony is when they say they can't do it, they were actually doing it exactly right.

Megan: 00:14:05

They were doing it right exactly. And I actually heard a researcher speak at a pain science conference in Europe earlier this year.

He talked about that, and he studies mindfulness meditation. And it's Been shown to be a reliable option for chronic pain for some time. The problem is that you need to do 45 minutes a day, every day.

The training is an hour and a half just to get started. And we live in a drive through society. Oh, yeah, right.

Holly: 00:14:36

That ain't gonna work.

Megan: 00:14:38

I want the quick fix, I want the pill. I want this to be over yesterday. And so he actually started studying brief mindfulness meditations to see if that could work. What did he find?

Could we get?

Holly: 00:14:56

There was a shorter session.

Megan: 00:14:58

What he found was that you could actually do it in 20 minutes a day, six days a week.

Holly: 00:15:06

And that still sounds like a tall order, if I'm being totally honest.

Megan: 00:15:10

Fair enough, Fair enough.

Holly: 00:15:13

So talk us through the breathing part, since that's. That's pickleball, right? That we can. We can get out there and start searching, swinging it around.

Even if it's not perfect, we're going to get something out of it. What is, before we get into any kind of techniques or anything, what's that doing for us? Just from a really baseline perspective, why is it.

Why does it help?

Megan: 00:15:33

Yeah, so breath work, especially when you're doing deep abdominal breathing, you're engaging your diaphragm, and that, that does have some stimulatory effect on the vagus nerve. And what happens there is you shift your body and it. We're on a spectrum again when we're talking about our nervous system.

So we're thinking about fight or flight being on one extreme end of the spectrum, and rest and digest being on the other extreme of the spectrum. And you're always somewhere in between. Right. But when I take deep abdominal breaths, that shifts me closer to that rest and digest. Side, side.

And that's where healing happens. So that's where your body has a sense of safety.

You're not pumping adrenaline and cortisol and epinephrine and norepinephrine through your system, getting ready to fight or run or give a presentation or those types of things.

So being able to shift over into that rest and digest helps you with sleep, it helps you with hormone production, it helps you with glucose processing, and it helps with pain. And so part of what breath work does is just allow your nervous system to go into the rest side of things.

Holly: 00:16:53

And rest enables healing. Rest facilitates that.

Megan: 00:16:58

Exactly. And that also is an area where your body can have a sense of safety.

And so typically, when we think about chronic pain, we're no longer, again, thinking about tissue damage. We're thinking about threat detection.

And so if I can shift my nervous system out of that threat detection place, even for a brief period of time, my nervous system will have a positive response.

Holly: 00:17:28

Okay, so are we saying that one of the. There are lots of ways to practice breath work and moments in time to do it.

But should we understand from what you're saying that in a flare up moment we can potentially gain some relief by getting our brain and our body back to safety?

Like we're experiencing that flare up and it's ruining my day, but if I can carve out five minutes for some breath work, that my brain might read the situation differently and then feel the pain differently.

Megan: 00:18:05

Absolutely. And really, mindfulness is not about achieving a goal like minimizing pain. It's about learning how to relate to your pain differently. Mm.

Holly: 00:18:18

Okay, so tell us more about that. Why? Why is that helpful or important?

Megan: 00:18:23

So breathing and mindfulness, which is really just about paying attention to your body, allows you to kind of step outside and observe how your pain functions, how it functions in your body.

You can notice your response to pain, which is part of the pain, and then your body's, your thoughts about the pain and then your body's subsequent response.

And so patients report that after learning mindfulness meditation, they learn how to control their thoughts and feelings about their pain, which then helps control the phys, the physiological response in their bodies.

Holly: 00:19:03

Okay, so they kind of. So we ride. The body and mind ride together. Correct me if I'm wrong, but I'm thinking they ride together for good and for bad, certainly.

Okay, so when I'm upset because when the. A pain flare up isn't just a pain flare up, it's upsetting for most of us.

Megan: 00:19:22

Absolutely.

Holly: 00:19:23

It's disruptive. It's. Here we go again. It's. What did I do this time? Oh, this is still here. Right. And so then it activates all these additional crowded thoughts.

You might even start thinking about what you're not going to be able to do. I'm not going to be able to get on that plane tomorrow. I'm not going to be able to play in that soccer game tomorrow.

I'm not going to be able to pick up my three year old tonight. And that has to exacerbate things. But the, what I'm hearing is really good news. And Dr. Megan and I've experienced it.

I just don't know the science behind it. And you're saying that it's true that likewise the brain and body will travel together toward better, toward calmer.

Megan: 00:20:02

Yes, right, exactly. And so it's, it's. They sometimes you Hear it referred to as skillful awareness.

So how you respond to information coming from your body, how you respond to the internal signals of your body and how you learn to self regulate those symptoms.

Holly: 00:20:24

What about also the correlation between stress and anxiety and pain, how pain can spike up? And so it's not just when we're having a pain spike, but maybe we're not noticing our pain at the moment, but we're super stressed out.

Like we're just, you know, we're kind of in a really heightened state. The cortisol is pumping that day.

I know from experience and from others have told me that if they have a really stressed out episode or high anxiety, their pain might show up with a vengeance later. And so can we almost do some sort of preventative breathing and mindfulness so that we offset what's.

What, what happened from that stress and the, the potential of pain to kind of show up and be like, haha, I saw you freaking out this morning. Now I get, can we almost like.

Megan: 00:21:18

You'Re gonna pay more.

Holly: 00:21:22

Gargamel?

Megan: 00:21:23

Yes. And to that, to some extent that is true. And so we think about like really high levels of epinephrine.

Like I'm in a very stressful situation, my child is under a car and I have to lift the car up off of them. There have been reports of, of parents doing that for their children. Right. They don't feel pain in those situations. Right.

Their level of hormones and stress, hormones and adrenaline, everything is so high. But on the way back down is when their body says, oh, remember when you lifted that car? Yeah. That can be significantly.

What, what stress does is it heightens the sensitivity of your nervous system. So you, you perceive pain, pain at a higher level.

Holly: 00:22:11

Okay, yeah, I, it's got to be a pretty common scenario.

You, you get through something stressful maybe in a 24 hour period and then there's this kind of letdown almost where now the body will allow itself to have that migraine or have that, that pain shoot up.

It's like you couldn't in the moment because you were, there was a high stakes situation happening, either a job interview or a, whatever it was, you were presenting something. I've had that at a conference before where I presented and I was just, you know, so amped up to get up on the podium, do it right.

Hopefully, you know, come off and have impressed people. And then I get on the plane to go home the next day and I'm just aching. Is that, is that a common scenario?

Megan: 00:22:57

Yes, absolutely. So in the moment you're Having so much adrenaline that you don't feel it, but it will, will kind of show up later on.

I don't know that there have been studies specifically on preventative pain management in those situations, but across the board, mindfulness, breath work and meditation have been shown to decrease pain responses. And so in this study that the San Diego researcher did, and his last name I'm going to butcher it is Zayden or Zeden.

He used breath work as his sham meditation because he didn't want people to say, oh, well, you're lying down in a quiet room and you're focusing on your body. Like, of course everyone's going to feel better about that. Like, in what world do we ever do that for ourselves? Right?

Holly: 00:23:53

I wish.

Megan: 00:23:54

And so he used breath work or the pickleball of in this situation as the sham meditation to say, well, is it just the lying down and the breathing, or is it the fact that we're tuning into our bodies and focusing on it? And sham did have a really positive effect on pain, and so it can be used.

But when they did mindfulness meditation, and these were people with low back pain who had pain evoked by a straight leg raise, which is the test that we do to tense tests like nerve tension, when these people at rest had 4 out of 10 pain, they demonstrated 90% improvement in pain after 6 days of training, 20 minutes a day of mindfulness meditation.

Holly: 00:24:46

Okay, so it's going to take a little bit of effort. It's not an immediate magic bullet. Right. But it's like almost kind of building up a muscle, if you will.

Megan: 00:25:00

Absolutely. And anybody that's selling you a magic bullet for persistent pain is lying or not educated enough to understand it.

So I think that is, I mean, we do, we live in a drive through society. Right. People want the quick fix, they want it yesterday. And, and that's not how this works, unfortunately. No.

Holly: 00:25:22

And you know, if that, especially if we are on a chronic pain journey, it's already so complex from, from even just what we've talked about in our last few episodes. Gender roles, society's expectations, who your boss is, your socioeconomic stat, you know, all of these things are playing in to our chronic pain. So.

So it is laughable when someone presents a magic bullet. It's, it's like, yeah, we haven't even begun to unpack that. But I'm very encouraged that there is an addition.

There's a whole playing field of, of methodologies that we can all tap into and experience an improvement because of. And it's not just in our minds. But let me ask you this question. What if it were just in our minds? Isn't the placebo effect kind of awesome anyway?

Like, what. What if something, you know, somebody told you. You know, what really works for me is to smell fresh lemon, you know, freshly squeezed lemon.

And while I'm, you know, whatever. They describe some scenario and you're like, yeah, I have no idea how that can be helpful to you.

If they heard somewhere and they believed from someone that that was going to be helpful for them and it's helping them, I say, bathe in the lemon juice. I don't freaking care. Dump it over your head.

Megan: 00:26:48

Like, you go, yeah, absolutely. And I talk to my students about that, too. Is.

You know, we think about placebo effect as a negative thing, especially when we're thinking about research. But in clinical practice, you can use placebo effect to your advantage. And I just. Because you're using the scent. Example.

I have an example of a patient that I worked with who had incredible knee pain. And she had had it for years. And she was actually a young woman who had a very well. She was well educated. She worked as a veterinarian, actually.

And she had so much knee pain at work, but really on the weekends and in the evenings, not really at all, with the exception of when she had to go to work the next day.

Holly: 00:27:36

Oh, now we start to get to the root of the problem.

Megan: 00:27:40

Yeah. And so she worked on a lot of things, like the ergonomics of her workstation. She had people helping her and things like that.

But it was a pretty toxic environment that she was working in because of the management and some of the other things that were going on there.

And I asked her, you know, where she felt the best, where she felt like the safest and the warmest and the most comforted and safe and all of those things. And for her, it was church. It was her place of worship. And so this was during COVID Everybody still had masks on. And I said, what?

Holly: 00:28:17

What?

Megan: 00:28:17

Do you have any of those scents at home, those essential oils? And she said, yeah, I love essential oil. I think she did orange oil. And I said, so. So here's what I want you to do.

I want you to put orange oil on the inside of your mask for two weeks in a row when you go to church. And she did that. And then I said, okay, now you're going to wear the orange oil mask to work. And her pain was significantly decreased.

Holly: 00:28:42

Brilliant. That is brilliant.

Megan: 00:28:44

And so you could call that placebo or you could call that associative. Learning. I call it associative learning because I'm a pain scientist. But, yeah, we're not there.

Holly: 00:28:54

The real words. We like that. Yeah.

Megan: 00:28:57

And so what we taught her nervous system was orange oil is associated with safety and comfort and warmth and, you know, my spiritual home. And so every time she went to church, she tried to do some orange oil.

Even after masks were done, she would put it on her wrists and behind her, you know, where you put perfume. And so continually. She ended up leaving that job eventually.

But that's one of the ways that you can use associative learning with scent to say, I'm going to help my nervous system come down to a place of safety.

Holly: 00:29:32

This is really neat because we're taught we've now already talked about mindfulness meditation. We've talked about breathing. We mentioned visualization, which we can talk a little bit more about, maybe even aromatherapy or smell therapy.

All of this seems to point. Whatever the modality is, it all points to kind of the same thing, which is enabling your system to calm itself down.

Is that kind of fair, or am I oversimplifying?

Megan: 00:30:02

No, you're not oversimplifying. I would say maybe even like a little bit more nuanced interpretation would be bringing your nervous system into a sense of safety.

Holly: 00:30:14

The safety piece. Yeah. Okay.

Megan: 00:30:17

Yeah. And that's really what the difference is between acute pain and chronic pain. Acute pain, we're thinking about tissue damage, where's the injury?

Chronic pain, we're thinking about threat detection. So am I anticipating a threat, or have I had a threat in the past?

So, for example, the vet going to work, she's anticipating the threat the night before going to work. And this is one way to help her nervous system say, we're safe. And the.

The researcher in San Diego actually used MRIs when he was looking at people doing mindfulness meditation. And so you can see what areas of the brain tend to light up.

And in people who are in chronic pain, we have less activation of what we call the default mode network, because it's never just one area of your brain that lights up. And your brain is never completely off. It's never black. It's never shut off. But default mode network is a happy place of your brain.

It's kind of like the daydreaming place in your brain. So those areas that light up are not associated with, like, cognitive thought.

You know, it's like that the part of your brain that lights up when you drive home and you, like, pull into your driveway and you go I do not remember driving home.

Holly: 00:31:37

Were all the lights green?

Megan: 00:31:38

Because they must have been at home. Right. Because that's your default mode network saying, we don't need you, we don't need your conscious awareness. We got this, we'll handle it.

And sometimes this is what people describe as like flow states when they're in sports and things like that or doing other things in a flow state. It's like you're not having to do a lot of heavy lifting cognitively. It's just kind of like happening on.

Holly: 00:32:08

A sort of a happy hum. It's humming along.

Megan: 00:32:10

Exactly. And people who experience chronic pain, they do not do that a lot.

But what they noticed when they put people in an MRI is that they had responses in their areas, medial prefrontal cortex or thalamus, that showed greater default mode network activation.

Holly: 00:32:35

After practicing some sort of a mindfulness or breathing.

Megan: 00:32:39

Okay, correct. And then. And when they were doing the mindfulness. So breath work and mindfulness are different. Mindfulness is paying attention on purpose.

And so it's hard for people because sometimes they say, okay, I'm supposed to clear my head, head of thoughts. Right. And that's really not what you're meant to do. You're meant to allow the thoughts to come in and allow them to go back out. And so.

And then I focus my attention back to my breaths. And with people who are in chronic pain, a lot of their.

The areas that light up in their brain when they're anticipating pain or when they're experiencing pain are below their conscious awareness, so underneath the cortex.

And when you have them focus on their breath, the somatosensory cortex lights up, which is where we process acute pain or where we process the sensation, normal sensation in our bodies. And so what you actually can see is different areas of their brain lighting up, which can be really positive for people in chronic pain.

Because as we talked about in, I think the second episode, what oftentimes happens is I fire that same synapse over and over and over and over and over again. And now I'm allowing other synapses to connect and fire that are associated with neutral or pleasant sensations. And that can be really powerful.

Holly: 00:34:11

Ah, this is. Okay, so we've. We've got to rebalance what the brain thinks. Thinks about. Right. So we're. We're trying to.

Because I think you've said in a previous episode that we're humans, can't help it, we're a little bit wired for negativity and that we're looking for a threat state.

I Mean, that's help it since, you know, since we were here on Earth, that's we have to kind of look out for threats, and we have trouble stopping that. But what we can do is use leverage, our own sort of internal medicine mechanisms.

Megan: 00:34:45

Absolutely.

Holly: 00:34:46

That part of our brain talking more and more frequently than the negative.

Megan: 00:34:51

Absolutely. And that's kind of the thought behind gratitude journals, Right. The more I practice gratitude, the more I'm primed for things to be grateful for.

Oh, yeah, yeah, you're.

Holly: 00:35:03

And you're looking through that lens.

Megan: 00:35:05

Absolutely.

And again, with people who practice mindfulness, we see greater activity in their right interior, interior insula and their putamen, which has to do with reward processing.

So there, there becomes a feedback loop in the positive direction of the more I practice meditation, the more I get this kind of internal sense of reward and the more I want to do it again. And so, you know, there is a learning curve.

Like you say, it's hard in the beginning and it can feel like you're failing, but the more grace you give yourself and just the more practice that you do, the more likely you are to get to this stage of reward in your brain. Yeah.

Holly: 00:35:53

There's a treasure trove just waiting for us to tap into.

And again, and I think it's worth even restating, it's hard for a lot of people to be willing to tap into that treasure trove or even consider that it's there. As long as there is kind of a traditional or western medicine road for path for them to follow.

It's like, as long as, you know, if I, if I'm aware that there's a cortisol shot that's available to me, if I, you know, think I could do another round of physical therapy with, you know, someone who's not a practitioner like you, you know, but who's more, you know, just really kind of focused on the, the physiology and doesn't blend in, know. And, and there's another surgery, there's another pill, there's another. And so that tends to be the road that we walk.

And then when we get to the end of that road is where a lot of us then go, oh, God. Okay, so I've run out of Cortis cortisone shots for the year.

Megan: 00:36:52

Right. They don't give you more than three a year.

Holly: 00:36:54

Right, Right, exactly. Ideally, yeah, no, I have friends doing five, six a year. And I'm like, who's, who's giving this to you? That's totally inappropriate.

But anyway, and, and that's fair. Like, you Said, we're a drive through society. We're. We're so pressed. We're trying to just get back to our lives.

And so no one's going to fault you for wanting that. That cortisone shot or wanting that, that gabapentin or whatever is handed to you.

But what I would say is, whenever you feel ready to even dabble, to even explore, do and just go slowly. Because when people throw themselves into meditation practice, like Dr. Megan said, what happens sometimes? Is it like boomerangs back on you?

Like, it feels impossible, it feels too hard, it's overwhelming. 20 minutes a day does feel like a lifetime when you're doing something that you don't love.

It's like, what if they told you you had to floss your teeth for 20 minutes a day? We would all be walking around with tooth decay. Be like a, hell, no. Like, I'm not flossing for 20 minutes.

And so if it's not something that you really enjoy and get a lot of immediate gratification from, 20 minutes can feel like an eternity. Yeah.

So I would say, and Dr. Megan, I want you to kind of correct me on this if this is wrong, because we were talking about getting back to a loss of threat detection, like a safe place where threat detection can be tamped down or released. Could any of us really just sort of brainstorm a bit about what does make us feel safe, what does reduce a sense of threat?

For some people, it might be, honestly rearranging their spice drawer.

Megan: 00:38:41

Right.

Holly: 00:38:41

Where it's like, hey, when things are out of order, I feel chaotic. Yep. When I go through an exercise of putting a junk drawer back in its place or a spice drawer back in its place, I feel a sense of safety and calm.

Is it. So could it be as simple as that?

Again, not saying this is the magic bullet, but could this kind of practice and benefit be derived from something as simple as reorganizing or spice drawer? If that gives you a sense of safety.

Megan: 00:39:11

Yeah. I don't know that the spice drawer scenario has been studied specifically yet, but.

Holly: 00:39:16

There'S not ten studies on this.

Megan: 00:39:18

There are other mindfulness activities that you can do to bring yourself into that sense of safety. You hear this with people who do things like quilting and cross stitch, but mindfulness can be something as simple as mindful walking.

You don't really, you know, after 18 months or so, you don't have to do a lot of cognitive thinking about walking. Right. And that can be a mindfulness activity. When people get really good at a certain Sport, they can do it. Mindfulness, Ly and so.

And that can also be another area, a great opportunity for visualization, like you say. So if I can't necessarily participate, swimming is another one that just came to mind.

I have a swimmer right now that will just do lap after lap after lap, and she's like, that is my happy place. That's my nervous system regulation zone.

So these things tend to be bilateral too, which is not surprising because it activates both sides of your brain, which can be calming. It may have, you know, some of the same effects as EMDR therapy, where they're stimulating both sides of your brain.

But visualization can be a really great.

This can be a really great opportunity for visualization, especially for someone who is in enough pain, where they cannot necessarily participate in their mindfulness activity of I either organizing the spice drawer or playing sport or things like that, I can go there in my mind. I can. For those that are good at visualization, I can go to church in my mind if that's the safe place for me. I can visualize the person that I love.

That is my social support, and that's been shown to reduce pain. Um, so there are many different ways that you can use visualization, which is a form of meditation, in order to improve your physical pain.

Holly: 00:41:33

I had an experience once where I was taught to visualize cotton balls. Fluffy, puffy, light cotton balls just kind of collecting like a little.

Like a little tribe collecting around my hurt shoulder and just imagining it being so light and so easy and puffy and kind of floating around. And I do have to say that, you know, in.

In moments where I was in very acute, sharp and shooting pain, I didn't always want to think about the cotton balls. Right. Sometimes we push it away, don't we? And it's. What, what do you think is happening in those moments where. Let's say that we're. We're bought in.

We know that the mindfulness can help us or the visualization or what, whatever it is, the practice that's helpful. When we resist, which I think is a very human condition. Why would we. Why. Why would I not grab that support there at the moment that I need it?

Megan: 00:42:36

That's a really good question. I mean, there are a lot of reasons that we resist in life.

You know, doing the things that are quote unquote best for us or quote unquote right for us in those moments.

And sometimes I think it has a lot to do with the fact that when you've been dealing with something for a long time, you're sick of having to do the work, and why can't it just be easier? And why do I have to be someone that has to do this type of thing all the time?

Why can't I just be, like, this person sitting next to me that doesn't have to visualize cotton balls in her shoulder or doesn't have to take essential oils to church?

And I think that, you know, one of the things that's so powerful about things like group therapy or like, social connections, where you have a really good understanding about what's going on with someone else, is if we all put our problems in a pile, they say everyone would reach in, run, and grab their own problems first.

Holly: 00:43:44

Right. Isn't that true?

Megan: 00:43:47

Once you hear we're not right? Exactly. Like, oh, I thought you were doing great, but now that I know, I'll deal with my hurt shoulder over everything that you got going on. Right.

And I tell my students, you know, no one promised an easy life.

So part of this is that we're all working through something, and on some days, you're going to feel great about doing it, and on some days, you're going to say, forget that. I'm not going to do that today. And that's okay. I think giving yourself the grace on those days is really important. Yeah, you do.

Holly: 00:44:30

We're not a good parent every single day of the year. We're not a good eater every day of the.

I don't even care, you know, no matter how fit you are, and you're dedicated to fitness, you're gonna fall off. Right. That's just the human condition.

Megan: 00:44:44

Yes.

Holly: 00:44:46

Yeah, you're. That's a really good reminder.

Megan: 00:44:49

Yeah. I love the. I cannot remember the book, but they talked about being a good enough parent. There's no such thing as a perfect parent.

There's a good enough parent. And I think that's true for patients as well. You're not going to be the perfect patient because no one is.

But can you be a good enough patient that you're doing the work 80% of the time and 20% of the time you eat cookies or whatever?

Holly: 00:45:16

Right. Yeah. You. You kind of help yourself through other means, and there's just no judgment around that. Right. It's like, no.

No one can understand what it's like to walk in your shoes.

And, you know, I found that there are just those days where the pain is going to hang around and either you're not going to do the work, or even if you do the work, it just. It's. There's just not a breakthrough. And I, I actually really appreciate what you said, Dr. Megan, about nobody promised us an easy life.

And I think that that's.

It's a real sort of emotional push and pull for people where it's like we, we are taught to love ourselves and to advocate for ourselves, and we deserve all of these things. And yet the reality of living is that it is all cyclical. There's highs and lows. Nothing stays the same for very long. Everything is in transition.

I mean, we're on a ball called earth that is literally spinning right now. And so nothing is going to stay the same for very long.

And one of the things that I learned to do, and I don't know if it's really a form of mindfulness so much as just tapping into yourself, is when I'm in moments of out of control pain and I don't feel like I can do anything particularly healthy about it. I actually have been known at times to do something that feels crazy, like listen to yourself in that moment.

And you know when they say, like, the people in the old days when they'd get horrible news, like in biblical times, they'd rend their garments, they'd like, tear their shirt when they, you know, had devastating news. And that has happened to me once before where I had a day in my home where I was, you know, working from home and it was kind of pacing the halls.

I could not get rid of my pain. And it reached a point where I didn't know whether I was going to scream or burst out laughing. It was like bubbled up so over the top.

And I remember running out into my backyard and I was wearing a blouse that had buttons at the time.

And I ripped the blouse and thank God no one was filming and like ripped the thing open and the buttons popped and like I had a total like, wwe, you know, like wrestler moment where like the shirt went flying. And Is that something I'm gonna do repeatedly?

Megan: 00:47:35

No.

Holly: 00:47:35

But did it clear something in that moment? Did it give me the acknowledgment? It was like, sometimes you need to acknowledge to yourself self what you're going through.

And don't, don't shove it under the bed, don't curse it, don't do anything other than say, yeah, this is really effed up.

Megan: 00:47:56

Yes.

Holly: 00:47:57

Like, this is absolutely out of control to the point where, like, I could laugh about this or I could scream about this, or I could bite the head of a chicken off Ozzy Osbourne style right now or whatever. And there are those moments And I encourage. Encourage everyone to behave through that. Like, please don't pick up a baseball bat and go hit someone.

Like, you know, keep it. Like, let's. Let's keep it legal here, you know, or at least in the.

Megan: 00:48:22

You know, let's not party anyone else.

Holly: 00:48:23

Or yourself in the process. But good reminder.

Yeah, but what do you think might be happening from a brain perspective in that sense, Megan, where we're like, you know, might be the equivalent of, like, punching a pillow, you know, or, like, what's that about? Is. Is that, like, where we've reached a breaking point and it just needs to come out? Like, is that a healthy thing? Yeah.

Megan: 00:48:45

And it's what it sounds like to me.

Is any kind of a suppression, whether you're suppressing emotion, you're suppressing your sensation, you're not really eliminating it, you're just pushing it down for a later date. And you can only suppress for so long.

And so if you were someone that did kind of a graded exposure and you allowed yourself to feel the pain and to observe it and follow it and move through it like you would with an emotion, you likely wouldn't have that buildup. But maybe because you had to perform at work and you had to do life tasks, they got to the point where I'm having to suppress, suppress, suppress.

And then at some point, it boils over.

Holly: 00:49:33

Yeah. And I think in those moments, if you can allow yourself whatever that looks like. Is that a cry? Does it come out as a big cry?

Does it come out as, you know, you take the arm that's not hurting and you punch the hell out of a pillow? Is it like, you know, me, where I had my Hulk Hogan, you know, moment, like ripping my shirt off?

Um, you know, I think that is also a very real and a, you know, and a very, you know, potentially appropriate part. I mean, I think what. What you said, Dr. Megan, is really the point, which is you get nothing out of shoving the feeling down.

Megan: 00:50:12

Right.

Holly: 00:50:13

And you might have to do that in the moment because you're at a wedding. Sure. Or because you're, you know, meeting your child. Child's teacher back to school night. All right, let's not do Hulk Hogan in front of the teacher.

Megan: 00:50:24

Yeah, yeah. Get CPS involved.

Holly: 00:50:26

Quick. But when you find a moment, you've. You've got to find a way to let it out.

And if that moment has passed, maybe that does look like some breathing before you go to bed that night. Maybe that does look like some meditation on your Saturday morning instead of getting up and going For a run.

Megan: 00:50:43

Yeah. And there are also some people who feel like there's.

And I am one of them who feel like if you have a stress response, it's nice to complete the cycle.

So, for example, we think about when we go into fight or flight today, it's because somebody sent me a horrible email or they said something across the conference table and I can't lunge at them or I can't run because we live in a quote, unquote civilized society, depending on the day and depending on where you live. And so you sort of bring yourself back down, but you still have had this release of some of these stress hormones.

And so in order to complete the cycle, maybe I stand at my desk and tense all my muscles and relax, or maybe I run to the end of the parking lot and come back to do something that kind of completes the fight or flight cycle in a way before I fully really try to bring myself back down. And that may be a strategy that can be very helpful for people who had these explosions of symptoms that they have, have an outburst around.

Holly: 00:51:58

It makes a lot of sense when you talk about that cycle and completing the cycle, because going back to sort of all roads on this episode are leading back to that place of safety and threat detection again.

And if we can, whatever it takes, you know, within, again, you know, the laws of civilized society to bring ourselves full circle and back into that resting place. It's. You're just activating that healing, that internal healing capability.

Megan: 00:52:27

Yeah, absolutely.

Holly: 00:52:28

Yeah. So tell me about the word because. And it may be actually that we've already essentially described this, but I. What is interoception?

Like, maybe we've already covered it by talking about mindfulness. Maybe it's just a fancy word for all the stuff we've already said. But what. What does that word actually mean?

Megan: 00:52:48

The definition of it is changing all the time, but really it's your internal awareness.

So you have your nervous system that processes sensory information from your body that's external, and then you have internal information, internal sensory information, and that's interoception. And so how do I know when I'm hungry? How do I know when I have to go to the bathroom? How do I know when my stomach is a little achy?

Those are all interoceptive cues that you get from your internal body and your internal system. Okay.

Holly: 00:53:26

So it's almost like if you're practicing mindfulness, your interoception might be dialed up like you. You might be even more in tune with those internal messages that are showing Up. Can we actually ignore interoception? Like, can we.

Can we turn the dial down on it?

Megan: 00:53:47

Oh, absolutely. Yeah. And so I oftentimes give the thought or the example of the tag in the back of your shirt. Have we talked about that before?

Holly: 00:53:56

I like that analogy.

Megan: 00:53:57

Yep. Yeah. So if you reach back and feel, sometimes you'll find out that there has been a tag there all along.

But were you aware of it before I asked you to go back and reach for it? And most of us are not. And that is part of our brain that says, don't bother me with that. You know? Yes.

I'm getting signals from your body all day, every day. All day, every day, your body's saying, don't bother me with that.

Just like you have so many nerve endings in your digestive system through your vagus nerve. Your brain is getting signals all the time, all the time, all the time from your body. Most of the time, your body's saying, not my problem.

Don't bother me with that. Until your body says, hey, we have to go to the bathroom. Then your brain says, oh, I will pay attention to that one.

Holly: 00:54:44

Right.

Megan: 00:54:45

And so you're constantly getting signals all the time going both ways, but most of them are coming up from your body through the vagus nerve. 80% of the fibers go up and 20% go down. So your.

Your brain is being bombarded with signals from your body all day long, but most of them do not reach conscious awareness. Mm.

Holly: 00:55:07

Okay.

And so would it be fair to say the more we're practicing mindfulness, AKA awareness, being kind of tuning in, that the more of those interoceptive messages, we might. We. We might actually pick up on more.

We might be sort of tuning to a frequency that's gonna allow us to essentially experience more of that versus kind of ignoring it. Like, there. There's actually entire days where I'd been in pain, and I didn't know it. I. Or I. It just didn't rise.

And the way that I know that I didn't know it is that someone told me, sitting across from me, your shoulder's been up at your. Like you've. You know, or. Or that I'd been standing with my arms crossed the whole time, and someone say, are you cold?

But the way that I cross my arms isn't like this. I actually hold. I hold my vulnerable spot. I hold this shoulder. And so I'm standing in conversation. Someone says, are you cold?

Like, why do they think I'm cold? Oh, I dropped my arms. Now I'm feeling it. Like, oh, geez, how did I miss this? This thing is throbbing.

So in a way we kind of try to actually this goes back down to like the shoving away, the pushing down and ignoring like sometimes that pain up and it's like, not today, Satan. Yeah, it's like a mindset actually, where you achieve very little.

You might get through that parent teacher conference, you might get through that presentation or that difficult conversation. Yes.

But eventually we're, we're advocating, I think we're saying, you know, you really need to allow for the moments of mindfulness where you bring that back up in your consciousness, you work through it, you ask yourself, you know, how, how can I get back to a safe and unthreatened place?

Megan: 00:56:54

Right. And what you're describing is actually a form of dissociation. So you disconnected from your shoulder and you kind of shut that signal off.

Like you knew there were signals coming from your shoulder, but you, you had to do whatever it was you had to do. And so you shut off awareness of it.

And the interesting thing is when you have people who've been in pain for a long time draw a self portrait, they oftentimes omit the area where they've had a lot of pain because they've completely disconnected from it. And you'll hear them use distancing language like that back or that knee or that shoulder.

And the research does show us that actually if you bring that back into your conscious awareness and you observe it and you allow yourself to feel the sensations, you're more likely to have a positive outcome than if you were somebody who said, I'm constantly going to push that away or push it down or distract myself from it.

Holly: 00:57:52

Yeah, this is really encouraging. And I, and I think that we're going to need to do another episode, you know, to continue to unpack this because.

Well, not only because there's more to say about this and there are more nuances and areas to explore, but also because I have a feeling that a lot of our listeners need to hear this twice.

Megan: 00:58:10

Right.

Holly: 00:58:11

It's not even just replaying this episode, but we need to keep this conversation and this idea sort of front and center because again, goes back to the three legged stool. We're probably not going to solve chronic pain by just addressing physiology.

We're going to need to create, you know, sort of a holistic approach here. And this is not natural for a lot of people. You don't just wake up and you don't just, you're not born a meditator. So.

And one of the things I really want to explore in a future episode with you, Dr. Megan, is when people are getting treatment of some kind. Either they're going to their physical therapist or they're going into surgery or they're, you know, whatever it is that they're pursuing.

I'd love to talk a little bit about the role of almost pre game, pre gaming, like athletes do.

Megan: 00:59:04

Yes.

Holly: 00:59:04

When they visualize themselves going, you know, over the hurdles and around the track, like. And I have a story for you and our listeners next time.

It's almost like, I call it, like the tale of two surgeries where I had one surgery where I really prepared and one where I just didn't. And boy, did they go wildly differently. So there's more to say here.

But, Nan, am I just grateful that you are here to shed the validation and the credibility on this so that we know, like, hey, you know, it sounds difficult, you know, to take the time to meditate or you don't want to learn to visualize. Okay, guess what? The science backs it up. So, you know, be, be willing, be open, stay open.

Megan: 00:59:47

Yes, the science backs it up. And the side effect profile is pretty much zero.

So if you're somebody who's worried about side effects from things like medications, at least that's something you don't have to worry about here.

Holly: 01:00:00

Yeah, no, no kidding. Versus try getting that sixth cortisone shot and see what happens.

Megan: 01:00:05

Yeah. Not my recommendation, certainly.

Holly: 01:00:10

I'm no doctor. But as always, thank you and I look forward to that next conversation.

And as we close out, like, like, we always like to say, you know, as long as you're breathing, you can.

Megan: 01:00:23

Change your brain, therefore, you can change your pain.

Outro: 01:00:31

Thank you so much for listening to this episode.

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You can get in touch at unpackingpain@gmail.com and we'd love to hear your thoughts or questions, your stories, even topics that you'd like us to cover in a future episode. Together, we're fostering community as we shed light on the realities of living with chronic pain and discover new ways forward.