Why does pain fade for some people but persist for others long after an injury?

Dr. Derrick Sueki joins Holly and Megan to explain how memory, associative learning, and emotional cues can influence chronic pain. Using examples from Pavlov’s conditioning research and his clinical work, he explores how fear, anger, sadness, loneliness, and shame may amplify pain responses.

The conversation also covers the difference between acute and chronic pain, why communication between patients and providers often breaks down, and how understanding a person’s “pain language” can support treatment. For clinicians and people living with chronic pain, this interview offers a practical reminder: empathy, safety, and hope can be important parts of the healing process.

Guest: Derrick Sueki, PT, DPT, PhD, GCPT, OCS, FAAOMPT

Dr. Derrick Sueki graduated from the University of Southern California receiving his Doctorate in Physical Therapy. He completed the Post Graduate Certificate Program in Physical Therapy at the University of South Australia with a special emphasis in Manipulative Therapy and Pain Mechanisms. In 2016, he successfully defended his PhD dissertation studying the role of memory, trauma, and injury on pain and muscle responses.

Since 1999, he has been a primary instructor in the Department of Physical Therapy at Mount Saint Mary’s University and in 2015, he accepted a professorship in the Department of Physical Therapy at Azusa Pacific University.

Dr. Sueki is a chief editor of two orthopedic textbooks, Orthopedic Rehabilitation Clinical Advisor and the Orthopedic Physical Assessment Atlas and Video. In addition, he has authored and contributed to numerous chapters in orthopedic and rehabilitation texts, and peer reviewed journals.

Dr. Sueki is currently serving as Chair for the Orthopedic Specialty Council and serves on California State Physical Therapy Association's Research Council. Since 2001, he has been a primary therapist for the Association of Volleyball Professionals and current serves as their Southern California Medical Coordinator. In the past, he has also served as a consultant for the Chapman University's Women Basketball and Volleyball programs. He is a certified Orthopedic Clinical Specialist and a Fellow of the American Academy of Orthopedic Manual Physical Therapists.

Dr. Sueki is a noted leader, author, researcher, and expert in the field of chronic pain and the pain sciences having presented at both the national and local levels. He is currently on the work group to develop practice guidelines for physical therapy management of chronic pain.

Knight Physical Therapy

Links to interesting things from this episode:

• “The Five Love Languages: How to Express Heartfelt Commitment to Your Mate” by Gary Chapman

The big question that a lot of times we have, that's really the million dollar question that we have as a, as a community is why do some people have pain and it goes away and then some people like yourself, it has to be.

Tends to stay a little bit longer.

Yeah.

And so it's been a question that we grappled with for a long, long time.

And so really the answer lies in the fact that it's not always just a physiological response that we're looking for.

The physiological response may be the things that are there at the beginning, but oftentimes there are things that occur in someone's life that allows them to hold onto those responses for a longer period of time.

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.

Welcome back to the Unpacking Pain podcast.

Today's special guest, as you heard from the introduction, is Dr. Derrick Sueki, a multi hyphenate educator, researcher, clinician, board member, etc. Etc.

And people sometimes ask me, you know, gosh, Megan, you have so many jobs.

And I say, actually, I don't, but I know someone who does.

So thank you so much, Derrick Sueki, for joining us today to talk about your research and pain science.

Oh, happy to be here.

You know, I've.

I've been a listener since episode one, I think, and so I'm very honored to be on your.

Your podcast and I love the work you guys are doing, so thank you for all the work you're doing.

Oh, we're so lucky to hear that.

Thank you.

Thank you.

That is very nice.

Gosh, loyal listener turned guest.

See, that's all it takes.

Y' all just stick with us and one day you too can be in Dr. Derrick's seat.

Yeah, dreams do happen.

Share to dream, everyone.

Well, it's so great to have you here today.

And I especially love.

Before I jump into my first basic question, can you tell us, Megan, how you know Dr. Sueki?

Like, you guys have history, right?

We have history.

We go way, way back.

So he was one of my instructors in my DPT program when I got my doctorate in physical therapy in 2012, and we stayed in touch throughout the first few years as a new grad.

And he asked me if I would come and do a guest lecture in one of his classes, and that kind of really ignited my interest in teaching.

And then I actually worked in his clinic for a bit and got to do some mentoring of students and working with other clinicians, and that was amazing.

And one day he said to me, you know, you probably want to think.

About getting your PhD.

And I said, oh, sure, someday, as I.

As I.

Sounds hard, right?

Exactly.

Like another five plus years of education after the nine I've already done.

I don't know.

I'll think about it.

And then, sure enough, here I am six years in.

And a fun fact for our listeners.

Derek Swicky is one of the people that actually walked me down the aisle at my wedding.

So once you are in, I don't let you go.

I'm like, we're gonna be together forever.

I love that.

How sweet.

You saw Megan in a wedding dress.

I'm so jealous.

You got to be here.

It's been an honor.

She's a big part of my life.

Gosh, I've always been proud of her, and I think she does.

Oh, my gosh.

This is, like, very tender, y'all.

Like, I feel, like, very blessed.

No, this is going to.

Loving.

Such an emotional episode.

Oh, my God.

This is so beautiful.

Well, okay.

I mean, I hate to, because I feel like we should tell some wedding stories, but maybe we leave that for the after show.

So, you know, not to get down to too much business here, but, Dr. Sueki, would you just back up and just let our audience know, first of all, how you came around to pain research, particularly focusing on chronic pain.

Why? Why did that light something up for you?

Yeah, I think it's really interesting.

And I think that's interesting to know the lens in which your speaker's speaking, because it gives you kind of give a framework on.

On, you know, how I look at the world.

Yeah.

And so I think Megan knows that the way I look at the world is through the eyes of an architect, as I was actually an architect for 10 years before I became a physical therapist.

Like a building architect.

Like, I was thinking, okay, body architect, like, orthopedic architect.

But you're talking drawing and houses and things.

Yeah, like drawing in houses.

I had actually was the one of the lead architects for El Pollo Loco in the Central coast for, like, 10 years and things like that.

But.

Stop it.

That's cool.

Yeah.

And so it's through that lens that I looked at started.

And so really, I got into physical therapy because I wanted to make more of a difference in people's lives.

And so at the beginning I thought I wanted to get into psychology, but at that time, psychology was a little more difficult to get into.

And so I thought, well, I did a lot of sports and I did a lot of activities.

So I said, well, how about if I get into a physical therapy?

And so I start to dip my toes in that.

And it hooked me.

And so I've been with it ever since.

And so then the question is, well, how do I get into the pain science component of stuff?

And really, my spark came when I went to go study in Australia.

And so I studied in Australia for a year, and I did one of my postdoctorates there.

And so my postdoctorate in Australia, I met a guy named Laura Moseley and another guy named David Butler, who are teachers in my program.

And they were just starting to introduce people into this world of pain sciences.

And so through my association and knowledge with them, they kind of lit another spark.

And so I came back and started to get more into the pain sciences and went on and got my PhD.

And so now I've been spreading the word ever since.

So when you think back to your origins as an architect and now as this pain researcher and someone who knows the body inside and out, does it help to kind of think about it the way that you thought about engineering and structures and stability and things like that?

Is that kind of the connection?

Yeah, it's a good starting point for a lot of things, because when I look at people, I don't necessarily always see arms and legs and backs.

I see circulatory systems as plumbing, and I see electrical systems as nerves, and I see structure as arms and legs.

And so I look at from that context and.

And then I look at the brain as the computer that runs it all.

And so.

And when we start to take a look at the pain sciences, we start to understand that it's this interaction between all of those that really start to impact how someone goes along and lives their lives.

Yeah, it makes a lot of sense.

I love that metaphor.

Or is it an analogy?

I don't know.

You PhDs tell me, but that makes.

A lot of sense.

Wrong PhD.

I'm not an English PhD.

Wrong subject.

So, okay, there is.

There's something that I saw that you tend to, that you focused on or you've specialized in.

And I have a really kind of maybe dumb general question for you.

So I understand that your research focuses on pain and memory, and you're looking at other factors as well that contribute to pain.

How the heck does memory come into the play?

What's.

How is that a factor?

Yeah.

So I mean, having been a longtime listener of your pod, I realize that you've already covered a lot of things where you talk about like the biology of things and you talked about the psychology of things and you even got into the social factors that drive it, really the, the commonality of it all.

The thing that drives it all is the fact that there's a memory that's held.

And the thing that, the big question that a lot of times we have, that's really the million dollar question that we have as a, as a community is why do some people have pain and it goes away and then some people like yourself, it has to be.

Tends to stay a little bit longer.

Yeah.

And so it's been a question that we grappled with for a long, long time.

And so really the answer lies in the fact that it's not always just a physiological response that we're looking for.

The physiological response may be the things that are there at the beginning, but oftentimes there are things that occur in someone's life that allows them to hold on to those responses for a longer period of time.

And so it's those longer period of time that were really interesting.

And that's the million dollar question is why some people hold onto it and some people don't.

And so that's kind of the research, what we take a look at.

And we're finding in the research that it's really about memory and it's a, it's about the memory that people hold.

And so as we start to take a look at memory, we have to understand that memory has a purpose.

And there's different types of memories that occur as well.

And so just to keep it simple, you know, we have memory.

And the basic premise of memory is to help keep us alive.

Okay.

If you put it down to the very basics, we have a lot of different type of memories.

Like we want to have a memory of our favorite hamburger so we can go back there again.

Right.

But if you're looking at survival and all of us want to survive, then the basic understanding is that memory is there to help us to survive.

And so if we start to look at pain in that context and we start to look at injury in that context, then we're going to hold on to memories longer if there's a need to survive or if it threatens our life or threatens our survival.

And so we hold onto it.

So that we can react in the future if that thing ever happens again, so that we could respond more efficiently, more efficiently, more effectively, and, and more quickly.

And so that's one of the reasons that we have this memory.

And it's a special kind of memory.

When I teach and when I lecture, a lot of times, when we start the learning modules, we start to talk about the different types of learning that occur.

And there's really two types of memory.

There's the memory that you do in school, or you're studying books and trying to learn your arithmetic, and you're trying to remember, if that's an analogy, and all these different type of things, right?

And so you put that in your memory.

But that's really in the forefront of your brain.

It's that part of brain that tells you facts and knowledge and things like that.

But there's another type part of the brain that really is responsible for survival and for your daily operations.

Like you don't have to think about your heart beating, you don't have to think about breathing, you don't have to think about blinking your eyes or things like that.

Those happen automatically.

And that's controlled by another type of part of the brain.

And when we look at the pain science, that area of the brain that's responsible is that area that pain often impacts.

And so then leads us to understanding and questions about why are they related and how do they relate.

And so when we really start to take a look at memory, it's a subconscious or unconscious type of memory that we're.

We're worried about or concerned about.

When we look at people with chronic pain, like people who have chronic or persistent pain, then we're not saying, hey, why do you have persistent pain?

And someone will go, I don't know.

That's what I'm coming to see you for.

Right?

But the body knows and the brain knows.

It just can't translate that over verbally to you.

But it can do so in a lot of subconscious things, like the way you breathe, the way your eyes twitch when something happens, the way you get a nervous flinch or things like that.

That's your body trying to talk to you.

And those are all some of the responses that occur in response to the memory that occurs.

And stop me if I'm going on too deeply, but I'm fascinating.

As we start to take a look at this learning, it's a special type of learning.

It's a learning that's subconsciously driven, like I talked about.

And it's unconscious systems that are or Subconscious systems that get impacted.

But it's really a type of learning that has its roots back in the 1900s.

Actually, there was a famous pain researcher, or not pain research, but researcher in general.

And most people have heard of him.

He did studies with dogs.

Really mad at Descartes.

Different one.

I could talk about Descartes if you like, but it was close.

We're still mad at him too.

You're acting the wrong part of the memory.

Okay.

But if we start to take a look at it, it's a.

He ran a Nobel Prize for this work.

And his name was actually Pavlov.

Oh, yes.

And so Pavlov, what he did is a study.

And he did a study with dogs.

And he didn't do just one dog.

He did, I think, 12 dogs or 13 dogs.

And.

But he wasn't very creative.

He was smart and genius, but he wasn't not creative because he named all his dogs Bear.

So he goes bear one, bear two, bear three, bear four.

And he ran.

Ran all these studies.

But the interesting thing about his study is what he did is he took sensors and put it in the dog's saliva gland, and then he gave him meat and he measured the amount of saliva.

And you go, wow, look at all that saliva bear 7 had.

Right?

And then what they did next is he goes, okay, I'm gonna ring a bell.

Ring a bell.

Ding, ding, ding, ding, ding, ding.

And looked at saliva.

And they said, well, no saliva, Right?

But then with his study, he.

What he did is he gave them meat and rang the bell at the same time, and it produced saliva.

And they did that a number of times.

And after a while, what ended up happening is that the dog would salivate just to the bell, and so you didn't need to have the meat anymore.

That was the first of experiments that they call classical conditioning.

Now we've expanded that line of work to include other things so it's broader.

And now we call that more classical condition, but associative learning.

And so the concept of associative learning is that things can be paired together and become associated together, hence associative learning.

And so pain is really an associative learned response and involves memory.

And so what happens is that very rarely are we injured in a vacuum.

Like, if you remember back to when you were first hurt, or when a patient or listener thinks back to when they were first hurt, there's probably also sights and sounds and emotions that were linked with that as well.

Now what happens is you get that pain signal that goes in and you get all this stuff about vision coming in, smells coming in, sounds coming in, emotions coming in.

And so they got all get processed in the brain together.

And so what happens is as they get processed, they get paired together.

And so as they get paired together, then what happens is they can be produced again, just like Pavlov, you don't need the meat anymore.

You can have the bell that produces saliva.

In pain, you don't necessarily have to have the injury anymore.

You can have these other stimulus that not necessarily causes pain, but can increase the pain perception in people.

And so that's how they're kind of linked together.

That is so fascinating.

And now I'm.

It's funny, like, sometimes I need to hear things a couple times and it really starts to imprint.

I remember Megan talking about, maybe even last season about associative and learned responses to pain.

And you mentioned Megan freshly cut grass as just an example that maybe, you know, someone was injured on a soccer field that, you know, had the.

Where the lawn had just been cut.

And forevermore, on an involuntary basis, freshly mowed lawn might conjure something up for them.

But I'd love you to say more about what, what that does conjure.

So, Dr. Sueki, you were saying, like, it doesn't necessarily bring on the pain, but it brings the pain response or it, it can trigger a.

A what?

Will you unpack that a little bit more?

No.

Great question.

Thanks for asking it.

Bear with me.

I'm an architect.

I use architect analogies sometimes.

Oh, that's better than a sports analogy.

So feel free.

Okay.

Take it.

Now, a lot of times our patients come in to me and I tell them that your house is on fire.

And so as their house is on fire, I tell them a lot of times that I really have two jobs when I'm working with them.

One is to put out the fire.

Second is to keep it from coming back.

Now, when we have a fire, I tell the patients, really what's going on in your body is that I believe that you have a fire going on.

And that's the biology of things.

Like maybe you have a little tissue injury that's going on that's been there for a while, but there's things that are going on that are keeping it from getting better, things that's keeping it from healing, and things that are amplifying it.

So in this instance, the fire has kind of like gasoline being poured on it that's enhancing the flame.

That's helping to grow more brightly, to experience the more intensely.

And so when we Start to take a look at pain memories, and then things that get enhanced, like the smell of grass that you guys were talking about, really smell of grass is kind of like the gasoline or the sound of a siren in someone who has been in an emergency, or the sound of a gunshot in someone who's been in a traumatic accident and things like that.

The sound itself, if everything is healthy, probably would not cause the symptom reaction, in this case, pain, but it will enhance it.

And so the evidence at this time is that these associative cues are more enhancers.

There is more of the gasoline that occurs.

Most people still have a little flame burning.

But when I talk to my patients, oftentimes you can hear me say over and over again that, you know, I have two jobs.

I have to find the gasoline, and then we have to put out the fire.

And so a lot of times when I'm talking with my patients, a lot of times when I'm telling my students and teaching, and then it's my job to get them to understand that we need to find the gasoline because we can't put out the fire while gasoline is still being poured on it.

So the first step is to find the gasoline, get rid of the gasoline, and then we can put out the fire.

I love that analogy.

Great.

Can you talk a little bit about what happens when something's gone on for a really long time?

Sometimes you may not even need the gasoline.

There may be a part of it that's a prediction of the gasoline.

Is that right?

Well, and to a certain extent, I. I think the evidence is still mixed on that at this point.

I think that most of the evidence that's out there definitely demonstrates that certain cues can enhance or pour gasoline onto it or pour more and more gasoline onto it.

Whether you can start a fire by just simply pouring gasoline on it, I don't know if we have quite that evidence yet.

That's not to say that it's not true.

I just don't know if the evidence is as solid on that quite yet, because it'd be kind of like me taking a can of gasoline and pouring on a stick and saying blaze.

Right.

There's a potential it could spontaneous combust like that, but I just don't have the research to back that up at this point.

I don't know.

Did that answer your question?

Yes.

And I was also kind of talking a little bit about some of the predictive processing that goes on in somebody who's already got a fire burning, or at least embers.

Oh, yeah, really?

Pain serves a couple roles.

We talked about its role in protection and how memory is super, super critical for that.

But when we have memory, really we have memory that occurs to help us to predict things that's going to happen in the future so that we don't get hurt.

Now if we look at our injuries, say I was walking along and I stepped on a Lego.

And that's, I often use that analogy.

Even though my kids are a little beyond Lego, I still have those memories of it.

And so I'm walking in a dark room and I, I step on a Lego.

Then the first time I, I step on it, then what happens?

It shoots pain up my, my leg and into my brain and I jump off the Lego because it hurts so much, because you got this really stiff piece of plastic that doesn't give at all.

And you step out, you go, ouch.

That's your first experience you've ever had with pain.

And so what happens is the body gets that piece of information.

It says, oh, I need to get off that thing and I pull my foot off of it.

Now the next day I'm groggy again, walking in the middle of the night and I start to step on something and it feels square and then I go pull my foot off of it and I go, oh, I'm going to pull my foot off.

Because I've learned my lesson.

I've now had a prediction.

But then I look down and say, oh, that was a marshmallow or something like that, right?

But still your brain has learned to predict because it's learned from past experience.

So your initial response or initial reaction to a novel pain is often reactive, but after that it becomes predictive.

And there's certain things that become that drive that prediction.

And so some of those things that drive that prediction is how much it threatens your life.

Like if it's very life threatening, then your brain is going to say, I better store this and hold onto it.

But if it's not, if I just stuck out, stepped on the Lego and never stepped on it again, then the brain would dump that memory and say, I don't need to hold onto this because it's not important, important to me.

But if I stepped on the Lego and after I stepped on the Lego I pulled my foot off and then I fell down a flight of stairs because of that, then I would say, okay, I'm going to hold on to that memory more solid because look at the long term consequences of that occurring.

And so what we're finding is that the memory that's Developed really forms this predictive response that occurs and there's actually coding and things that happen in the brain to help us facilitate that response.

Is there a correlation between how our brains hold on to these memories specifically related to pain, and how the brain handles fear?

And specifically, I'm thinking about, let's take a five year old who maybe had a little bit of a scary interaction with a dog and now they've decided all dogs are bad.

And anytime they're walking and see a dog, it's like, mommy dog.

You know, even though this could be the sweetest, you know, little poofer of all time.

Conversely, or maybe it's not conversely, but again, no English majors here.

What about the person who has no problem with fear and they go skydiving or they go like rock jumping and they've hurt themselves a bunch or even.

Let's just take a skateboarder.

I see those guys and gals are busting themselves up all the time, bless their hearts.

Like they're fearless, right?

They bust an elbow, they get back on the dang skateboard, they go see a bigger bull, they ride down it.

So is there an intervening factor here around like how an individual even processes fear or is this pain memory showing up in all of us and then the brain, personality decides what to do with it?

Like seven different questions that we can start to parse off in that.

Lots to unpack there.

I'm sort of infamous.

Let's start with the final.

We'll start with the basic one where you talked about fear being associated with things.

And fear is one of the emotions that we're finding that can be correlated and drive some of it.

I think most fear is probably the most studied and probably the most solid evidence that associations with these injuries can cause longer term impacts with people.

We're learning that it's probably not the only one that can drive it.

But fear is a big one.

And this learning that occurs, that can occur any life, the stage of life, it doesn't have to happen as a youth or as a, as an older person.

I, I know that you guys think you talked about this in episode four or something like that with pediatrics or something like that, or, or three, when you were talking with pediatrics.

I love you, Derek.

Where, where you were starting to talk about things like white coats and things like that being associated.

And so, you know, there's a fear response that drives that and, and, but fear is also contextual in a certain extent.

It's.

You take fear from your environment and surroundings and so like when you're talking about the pediatric cases, the thing that drives that is not necessarily the child's experience because they've, it's novel for them.

It's the reactions of the parents and things that drive that.

And so fear is, and pain is really contextual.

It depends on the context in which it drives it.

And so really when I lecture, I talk about, really we have a window of opportunity to make changes in people.

And most of the research on this has not been in pain sciences, but it's really been driven by research done in trauma and especially like post traumatic stress and things like that, where we learn that these memories which are life threatening to a lot of people, whether it be pain or post traumatic stress symptoms, they are stored longer term in people so they could come back over and over and over again.

But in some people, because post traumatic stress is similar to chronic pain from a certain perspective where both of them go through acute phase, there's acute stress disorder and there's acute pain as well.

And so what happens is everybody goes through acute pain or everybody goes through acute stress, but only a certain population becomes post traumatic stress or a certain population goes on to have chronic pain.

So what's the divider?

And so the separator has a tendency to be this storage of long term memory.

So in people with have acute pain and it goes away, they've had the pain, but they didn't store it long term.

And the same thing with stress and post traumatic stress, they didn't store it long term.

And so there is a little window through the research in post traumatic stress.

We find that window is somewhere between 30 days and like 60 to 70 days that you have an opportunity to get your comprehension of the situation, to downregulate, to say, oh, this wasn't life threatening, I'm going to be okay.

This doesn't have to impact me the rest of my life.

And so it's changed the way we kind of rehab people.

And if we can get people quicker and earlier and we can start to get people to understand that pain is a signal that tells you something was injured or threatened, but it doesn't have to impact you the rest of your life, you're going to be okay, you're going to be okay, right?

And then that'll help downregulate and then pretty soon the brain says short term memory, empty trash, let's get rid of it.

Rather than say okay, let's put in long term memory so that it could come back and be stored for a longer period of time.

And Your question about fear.

Fear is one of those things that can.

Can be one of those things that makes it hold on for a longer period of time, but it's not the only thing.

Gotcha.

So I could be having a grand old time at a barbecue and get hurt.

And that's different than if I was in a horrifying, like, same injury.

But it, you know, happened in traumatic versus happy circumstances, can impact the pain experience.

And then interestingly, how you go on to treat the person.

Am I hearing that right?

Yes.

And how you start to help people on their journey to get further.

Yeah.

One of my favorite lessons that I learned from Derek, that I also teach to my students is number one job on day one with your patient is to get a day two, first of all, which I think we've talked a little bit about on here, and number two job is to convince them that they can get better.

And this is a solvable problem.

And that to this day remains one of my favorite things to tell people, because sometimes we're the first person to tell them that sometimes.

You probably can attest to this, Holly.

You're hearing about all the test results and the imaging and everything that's coming back, but, you know, how many people told you, like, this can get better?

No one, including my physical therapists.

And so that's why I'm so pleased with the research and this and the mindset that you're bringing to the table.

I mean, I was told right off the bat that we'll work as best we can to rehab you, but the shoulder has to be replaced.

And so right off the bat, you're thinking, I'm in for a long life.

But I think it's really beautiful that you're taking much more into account the whole person.

It sounds like both Dr. Megan and Dr. Derrick are thinking about that gasoline piece, where I think in the past, a lot of us have been treated for the fire, and everyone is just looking at the fire and they're not thinking about that gasoline piece.

So.

Yeah.

Yeah.

And I think probably, Holly, when you first were injured, there was so much focus on the biomechanics and the musculoskeletal system.

There was less of an awareness and maybe less education around the biopsychosocial model.

And so I think, in my opinion, when we treat somebody that is, like, with that has chronic pain, like someone who's just biology, just an acute pain, tissue damage, I think of it as throwing logs on the fire.

I don't know.

I'm not someone who makes fires or engages with them in many ways.

I've seen people chop wood.

I've seen videos of it.

But I don't know.

Would you agree with that, Derek, that you know too much too soon or treating an chronic person like an acute person is maybe in your analogy, throwing gasoline on the fire.

Maybe my analogy throwing logs on the fire.

Yeah.

I think that sometimes people have the best intentions, but when you start to take a look and you start to treat everybody like they have a fire going on, then you're actually adding kindling to the fire and helping it grow kindling hotter and faster.

Because I do build fires when I go camping.

Clearly, Megan and I are like trees.

Like, yet that would be kindling branches.

And so it can happen, grow faster and farther.

And even though you're.

You're doing the best to try and to fix somebody, it really.

I think the.

The beginning of understanding and treating people is understanding that acute pain and chronic pain are two different animals, and they require two different approaches.

If somebody came to me with a sprained ankle at day three, I would treat them a certain way.

If someone comes to me with a sprained ankle at day three years, I would treat them different.

And the issue is, a lot of times people only have one approach, so they throw everything at people and hope that the person fits within their model of treatment.

But in reality, having an understanding that they're two different animals that need to be treated two different ways is an important step in helping people beyond and further along the journey.

Yeah, and I think, like, you were talking about things being stored in the body or, you know, I may not necessarily have the verbiage or the understanding.

You know, there's a lot of issues, at least I would say in the United States and probably other countries about health literacy.

And, um, I had an example for myself.

You know, even as a someone who talks about and thinks about pain quite a bit, I have a hard time recognizing when I have certain kinds of pain.

For example, the other day I had a headache, and I was like, why am I so irritated?

I'm so annoyed.

I'm so frustrated.

Everything I would.

Dropping things, and I just was, like, so annoyed.

And then finally it dawned on me, like, oh, I have a headache.

I get headaches so rarely that it just doesn't really, you know, register with me until much later.

Do you think.

Do you think that's part of the problem sometimes in communicating between patient and provider?

I think communication is always probably the biggest issue as you start to try and make a connection with People.

I know you've done an episode on building reliance and building a relationship with people.

And so building a therapeutic relationship, a trust relationship, a relationship where you are helping somebody, but you are walking the journey together is an important aspect of things.

And so being able to connect with somebody, to be able to let them know that you understand and that your.

Your goal is to help them understand, too.

And so when I talk to people, I often say that I'm not the person that's going to heal you.

You're going to heal yourself.

But I'm the person who's walked your journey a million times with my patients.

And this is your first time walking.

And so let me show you the path to get you there.

And let me show you some of the reasons why you may be experiencing some of the things that you're experiencing.

And so building that relationship, having the language, being able to understand is important.

And so trying to develop that relationship and that understanding is where a lot of times we falter in our understanding with people.

And has this kind of led to the evolution of your research now where you're looking into your.

What you're calling pain languages?

Yeah, it's definitely been a stepping off point for that.

You know, it comes from my role as a physical therapist, but also my role as an instructor, trying to find ways that I connected and saying people would often ask me, well, how do you.

And how do you connect so easily?

That's probably my superpower with patients, is being able to understand a patient and where they're coming from and the things that they're dealing with fairly quickly and being able to be the person that they need me to be to help them along their journey.

And so I'm not the same person with every patient I treat.

I'm the person that they need me to be.

And so being able to have a language that connects with them.

But then when I go and teach, how do I teach other people to be able to do this?

And so that's been the evolution of my.

My.

My research as it is right now.

Do you mind if I do an illustration with you guys?

I. I haven't never done this before.

I'm going to try something out, definitely.

Please do.

Okay, so we have Holly and we have Megan.

And do we get to close our eyes?

You can if you want, but.

And so I don't know if you've ever seen, like, what car each of you drives, but I'm going to take that out of the picture.

And so I'm going to say if you Have a friend or significant other that you think about what kind of car they drive.

Okay, so we're going to start with Holly.

You can't say what kind of car it is or what class of car it is, but I want you to describe the car you're thinking about to Megan and see if Megan can guess what car it is.

Ooh, fun.

Okay.

This car sits a little bit higher off the ground, and it's great for taking through the snow.

My husband takes it to Tahoe and loads his snowboards in the back and up top.

And it can really push through a lot of debris and even roll over logs and things if it has to.

So what car does she drive?

It's sounding like an SUV at least maybe a Jeep.

I want to say Jeep Grand Cherokee, but I just.

I feel like that's a biased response.

So that's where my mind went.

Very close.

Okay.

And then Dr. Derrick, do I give her, like, another.

What kind of car is your...

Okay.

He drives a Forerunner.

Okay, so you were really close.

Yeah.

Now, Megan, you think of.

We're gonna do something a little different for you.

I want you to think of a meal you ate yesterday, and I want you.

I'm assuming you ate yesterday.

Oh.

Oh.

Oh, no.

Okige.

Yes.

Got it.

Got it.

Okay.

And I want you to describe what you ate to Holly.

But you can't.

You can only use taste and smell.

Mm.

Okay, so what about texture?

You need a texture, too.

Okay, so part of it was crunchy and.

And savory and salty.

And then there was a little bit of umami flavor.

And.

I.

Wow, this is harder.

There was some crunch.

I think I already said that.

And a little tanginess in parts.

Okay, can you guess what she ate?

Okay, I'm gonna ask if it was.

A.

Maybe like a wonton chicken salad.

Oh, that's.

I wish I had eaten that.

Now,.

Cliff bar.

I had a burger with fries.

Oh, dang with fries.

Numbers.

And so, you know, I, I. I asked you to do this as an illustration, and I never tried it before, but, you know, oftentimes patients are telling us things and they're describing things to us.

Now Holly was describing something a little bit more concrete.

And so, you know, she can tell the function of things and how it's sat.

And she can give it little categories and things like that.

If I had allowed her to say, oh, you can tell what kind of class it is.

You know, it's an suv, and you just start to narrow it down, and you'd be able to describe it and Pretty soon you guys would both be seeing the same thing.

Like if.

If Holly said color is the forerunner that your.

Your husband drives.

What color?

Great, great.

So if I say gray forerunner, you already know what that looks like.

And.

And Megan can visualize that, right?

Yeah.

Now, Megan is trying to describe something to you, Holly, that's a little more difficult because it's taste and smell and texture.

Right.

And so those are things that she's trying to get you to understand, and she's trying to figure out what it is that I've taste and feel, and then she's trying to portray that over to you, and it's getting you to see the same thing that she sees.

Right.

And so you were kind of close, but.

Close to close.

I always focused on the positive.

I always focus on the positive.

But if Megan had said, well, it's something you eat at lunch, then that would narrow you down a little bit more.

Or something that was.

Had meat in it, then that would narrow you down more, right?

Yeah.

Oh, sorry, sorry.

Please keep going.

No, and so I go, that is an illustration of some of the challenges we have as.

As for me as a physical therapist setting and a patient coming into me, she's.

Or you or whoever is trying to explain to me how something tastes or what their food that they had by only describing these sensations that they have.

Right.

Smell, sights, sounds.

And they're trying to explain that to me.

And then I'm trying to, on my side, going from my context, going, you're going crunchy.

That's a wonton salad, Right?

Chicken salad.

And so you got a completely different picture of what.

What's going on.

And then for me, it's like me trying to make a burger but having an image of a chicken salad in my head.

Right, okay, I'm following you.

Yeah.

And so that's the challenge we have with pain, is that people are trying to describe what they're feeling, what they're sensing to the therapist who's coming into it with their own chicken salad vision of things.

Right.

And so the patient's describing a burger, and you're thinking chicken salad.

And so they're describing their pain.

And you're looking at.

Through your lens of your experiences with pain, and you're trying to get an idea of what they're trying to describe to you.

And so I said, I found that there's just such a disconnect, so it's hard to connect, and it's hard to help them move forward past that.

And so we.

We came across this.

This thought that maybe we need to start to start developing categories to help us understand what people are experiencing so that we can know.

If we know it's a lunchtime thing we eat, that helps.

If we know that it's something that's cooked, then that helps.

Right.

But we know it's something we put cheese on it helps.

Right.

So I start to look at models and.

And one of the models I look back at took from my own experience when.

Back in.

When I was getting married and things like that, which is a while ago now.

And we had to go through premarital counseling.

And our pastor brought out a book that he had us read, and that book was called Love Languages.

And love language was all about.

Your spouse will sometimes have a different love language than you.

Where your spouse may like words of positive affirmation, and you may like acts of service, or you may, like, touch or something like that.

And so you go up and give your spouse a massage all the time, and the spouse is going, ah, stop touching me.

Right.

Or the other person or she's their spouse is just saying.

Or your partner is just saying, can't you just tell me that you appreciate what I do?

Right.

And so,.

Of course, I would say I. I would like to get a support group for people who.

Who are words of affirmation, love language.

But their partner is a acts of service.

We need, like, a whole mismatch love language support group.

Because I.

It also cracks me up.

Like on Instagram, you saw this woman who was like, this is what it looks like when your love language is acts of service, but your husband's is touch.

And she's looking at this filthy living room and kitchen that he has not bothered to clean, but he's, like, all rubbing up on her, and she's like, you're kidding, right?

Like,.

Understand.

Yeah.

And that's how our patients are sometimes.

Right?

They're saying, stop cleaning my house.

I want you to give me words of affirmation.

Totally.

Yes.

And so being able to understand what their pain language is is important.

So that as a therapist, you're not always just giving them what you think you like.

Right.

Wow, that's really breakthrough.

I mean, that's pretty awesome, because I have to guess that the patient's ability to describe things for you both as practitioners is a key that unlocks things.

And some patients are really verbal and others aren't.

And some we all have, like, learned language.

Like, what's dull pain to me might not be dull to someone else.

So if we can agree on a language Together, it's like, this is what spicy pain means to me.

This is what dull pain, this is what sharp pain.

This is what, you know.

But, I mean, bless us all.

But we.

We patients, including you guys, you know, had your own injuries and so forth in the past.

Like, we're not the most reliable storytellers of our own pathology always, are we?

So this is.

This is amazing to create a shared language between patient and provider.

Yeah, I think a really great example of this was when I was working in Koreatown.

I was living in downtown la, and it was just a shorter commute for me, and there was a large Korean population, and they would often describe their pain as sour.

Oh, I remember you saying, yeah, as someone who did not grow up learning Korean as my first language, I was.

I would look at the translator and I would say, sour.

And I would say, what does that mean?

And they would say, sour, Sour.

And we just were never.

And I would go like, you mean like this, you know, like puckering, like.

And they were like, yeah, you know, I already told you that.

Right?

That's like that social piece that comes into the biopsychosocial model.

Even, like, how.

Like how we've been influenced culturally or even just in our own family.

And that's language sometimes that we might bring into our practitioner and, you know, we might even downplay something like, you know, because that's what our parents sort of taught us to do.

I'd be like, yeah, you know, it, like, it hurts in there, but, like, not that bad.

And then, like, you move the patient, they're like, ah, you know, or whatever.

It is, you know, a lot of the things that we learn, we learn contextually.

And we take in all these things from our.

The people who are most influential on us, that we learn their responses.

And unfortunately, these days, the people who are most responsible for us or most important in our life influential oftentimes aren't the people who are with us.

And sometimes it could be you can learn about pain from the television set or.

And the movies you watch or the media you're watching.

And all these things are influencing how we learn about pain, how we perceive pain, our responses to it, and they.

They change our pain behaviors over time.

I think I learned my pain language from Hulk Hogan, and that's probably not a good thing because the guy was, you know, he.

He'll tell you himself, he was on steroids the whole time and probably wasn't feeling a whole lot of anything, but it was just like, he'd get hit over the head.

With a chair and just be like, oh, yeah, yeah.

You know, the hoax.

Can I try to do for a while, shake it off?

Yeah.

And, you know, I always talk to my students about the fact that my mother was an ER nurse, and my brother and I would joke about, you know, you had to be bleeding from a major artery in order to be excused from school.

If it was a minor artery, you put some pressure on it and you walk it off, and you get to school, you get on the vibe.

Yeah.

And then.

So that's the whole.

Your job as a therapist is to listen to somebody's story.

Everybody has a story to tell.

And the things that they focus on, the things that they stop on, the things that they bring up to you are the things that they're waiting for somebody to finally interpret for them.

Right.

They've been talking, but they've been talking in a foreign language to you, to the people.

And they're longing for someone who finally speaks what they speak and can interpret.

And so.

And that's built on all your stories that you built through your life that go in to make up who you are as a person and your responses.

And the fun thing about what I do and what Megan does is we get to play detective every day.

And so.

And no two people are the same.

Everybody's different.

And so trying to find what these connections are.

And for me, once I find these connections, trying to figure out what pain language that they have so that I can.

Then if someone's.

You had used fear, which is one of the pain languages, I would say that my first job at building that relationship with somebody is to be a place where they do not fear, they feel safe.

So all my interaction with that patient at the beginning is about safety and giving them safety.

That's a beautiful thing, and that's how you start to utilize.

And then.

So it's not just understanding.

It's understanding the environment that you have to create for them in order for them to heal and recover.

Do you imagine that this.

The pain language that you're building will become even perhaps an offering that all of us could access in clinical offices?

Like, could this become sort of the new lexicon that we can tap into if we want?

I could pick something up in a physical therapist's office that maybe gives me some options to choose from.

Like, right now, I can choose from 1 to 10 in my circle, the pain and face.

But it would be so cool if you flip over the back of it.

And it's like, if you want your doctor to know that Your pain is sharp.

It's like this.

If you want the, you know.

So tell us a little bit about how it's manifesting.

Yeah, I mean, the research is, is.

It's really growing quickly.

Actually, I have a.

A team of researchers that I work with, and a group of them is starting to look at different things with pain languages.

And, and we're going through the literature, and so far in terms of our languages, we've identified four or five that are really well supported in literature.

And so so far, the ones that are most supported in literature is fear that you talked about.

So if someone, if you're listening and you're talking and your patients telling stories that are talking about fear being afraid, and you could just understand that they're fearful, you can understand that fear is probably not the fire, but it's the gasoline.

Right.

And so you're saying, is that the only gasoline or.

Well, there could be others too.

And so the second most supported is anger.

And so I'm listening as someone's telling their story, and I saying, is it fear?

Is it anger that they're manifesting?

The third most common one is sadness.

That's pretty well supported as well.

And then the fourth one is loneliness.

Those are the most supported in terms of association between pain and when you bring on situations.

And when someone feels fearful, someone feels angry, someone feels sad, or someone feels lonely, it changes someone's pain responses, which tells you it throws gasoline on it.

Right.

There's a fifth one that we're looking at that we think is.

But the.

The evidence is not as well supported, and that one's shame.

And so those are the five we're starting to build off of in terms of our language at this point.

We don't.

We're.

It's just a.

The beginning.

It may grow more, or we may can dance a little bit.

But these are the languages that I'm teaching my students and the people who listen to me to try and look for.

So when someone's talking to you and I'm trying to establish a rapport with somebody and understand their story, I'm listening and I'm trying to say this is patient fear, anger, sadness, loneliness, shame.

What's their language?

Because as it starts to manifest and starts to become more apparent, then I start to say, oh, I gotta be safe or I gotta be peaceful or I gotta be more joyful or I gotta be more supportive, like, I'm always gonna be there for you or.

Or.

Yeah.

So you could see how we're trying to provide that environment.

So that I could start to connect and lead them to where they need to be.

And so kind of to Holly's question, you know, and maybe more to your point, Derek, about this being more of a subconsciously learned piece, if I'm looking at an intake form, I'm not necessarily going to connect my anger.

So kind of even going back to my example of I was really frustrated and then realized I had a headache, I didn't necessarily really connect those things.

Right.

So as a patient.

Yeah, exactly.

And, you know, developing a tool, a survey tool to help understand these.

It's something that's further down the line, and it's something that is not on my radar quite yet, but it's.

The first thing is to try and establish what it is, the things that we need to survey in people.

And that's where we're at in the process right now.

But I can see in the future having tools like you were talking about to be able to help people, clinicians and patients understand what they're going through a little bit more.

But to Megan's point, sometimes it's stored in our subconscious and we're not aware of it.

And it's.

Many times it's not true until the person starts to.

To share their story with me that I can start to say, oh, that's something that we need to start to take a look at.

And a lot of time it's not through this, the language.

It's through the subconscious language.

Like, someone starts to talk and about something, and all of a sudden their breathing gets more shallow and.

Or somebody's.

Their eye starts to twitch or their hand starts to.

To oscillate.

These are subconscious responses that the person's not even aware of, but it's the person's subconscious language saying, listen to me, listen to me, Come on.

I'm yelling as loud as I can and nobody's listening.

And so that's when I start to see these cues.

I go, stop.

What are you feeling right now?

What are you.

What's.

What's going on?

What are you thinking?

And some.

And then as they start to think, for some reason I'm feeling scared now, or.

Or things like that, or.

And so we start to help them think through the process.

And, you know, my job is not necessarily to uncover it on that day, but to help people get to understand the associations together.

And sometimes it's.

The best breakthroughs come on when they go home and they say, oh, I understand what the difference is.

And then they come back and we could go, okay, let's figure out a way for you to start to change.

This is remarkable.

I mean, I. I just.

I think the implications here are enormous, especially because I'm imagining that even if the pain language takes a little while to establish, just the very fact that you are listening out for it changes the level of empathy and connection that's being exchanged Right.

Energetically in that room.

And second, secondly, once you've identified that person's pain language and you start to work with them in a way that meets them where they are, I'd be curious to see if you start to find that that pain language shifts over time.

What started as anger can soften and truly become sadness is usually anger is kind of covering up fear or sadness.

If the person is lonely and they start to form a sense of community with you, Dr. Swake, like they're seeing the same patients maybe every Tuesday, your clinic, or whatever it is that may lead them to realize that loneliness gets taken care of and what's really there is sadness or some fear.

So you're just allowing those unseen parts of the pain come forward.

Yeah.

And I love the way you brought that across.

And we start to develop the process or the model or the framework even a little further, where a lot of times these core languages are not what our patients actually express.

Our patients sometimes will come in and they'll express a secondary language.

And the secondary language are form off the primary languages.

So the secondary language may be something like despair.

Someone comes in and just is in despair, and that's the secondary language off of helplessness.

Or someone may come in with things like anxiety, and that's a secondary language off of fear.

So what someone experiences anxiety or someone's experience is despair.

Someone experience like betrayal.

Then you start to say, okay, that's what the patient's experiencing.

But really at the root of that is for, like, betrayal is anger, or despair is helplessness, or anxiety is fear.

So as I help my patients try and work through it, I say, ooh, this patient's really anxious.

And.

And then I can go, okay, anxiousness is fear.

I need to figure out what is causing that fear in them.

And if they can understand what's causing the fear, there's power and knowledge, and so then they can overcome it if they understand.

And ultimately, my goal with patients and I share this with my students a lot of times is that with this memory that's developed, patients go back and they get triggered and they relive it over and over and over again.

It's like Groundhog Day over and over.

And over again.

Because what they do is they go at night, they fall asleep, and in the day, they open up a file, and they open up that file for the incident, and they say, oh, I look at it and there's the instructions of what I do every day for that file.

And so what happens with our patients as they go through and start to recover is that they don't relive it anymore.

It's not that we take memories away.

Memories aren't erased.

We used to think that memories were like a pencil that you can go and erase it and it's gone.

But we now know it's like ink.

It's there for forever.

But what happens is we're not taking away the memory.

We're taking away the fact that they respond a certain way to it.

And so right now, my goal is, when I ask people, tell me about what you're experiencing.

Tell me what you're seeing and feeling right now.

They say, I'm feeling.

I'm in this situation.

And I say, stop a second.

Take a look.

Are you looking at this instance through your eyes?

They go, yeah, I'm looking through my eyes.

I go, our goal is to get it so that you're looking at it like a bird or through person so you can see the event that happened, but you don't have to relive it over and over and over again.

And so that's when I know we've made the change.

When they say, oh, I see this, but I don't have the same responses anymore.

It's still a part of me, but it doesn't define me anymore.

Wow, that is very hopeful.

And I find sometimes I say that as we're toward the end of conversations like these, because what you're establishing here is something that is not only going to help people get treated, but actually I think helps people feel very seen.

And that is half the battle, I feel like, you know, so, gosh, I want to thank you for the work that you're doing.

I mean, both of you.

And it's really special to meet you and have this conversation, Dr. Sueki, because I can see a lot of where Megan's insights and wisdom and warmth and even humor around how she practices and things come from you.

And I can see why you two are two peas in a pod and why you got to walk her down the aisle.

But as a pain sufferer, I'm just heaps and heaps grateful to both of you and in awe of the work that you're doing.

So I can't thank you enough for coming on our show and enlightening us and teaching us about this.

I think it's going to give a lot of patience out there or sufferers hope, and I think it's hopefully going to give a lot of practitioners the kick in the butt to, you know, let's like, step it up and, you know, be more like Megan and Derrick if you're not.

And if you are, you know, look at, look at what's coming your way.

It just keeps getting better and better.

Yeah.

Thank you, Holly.

That's very kind.

And I think, um, you know, not only do Derek and I look very alike, we, we, you know, we treat very alike.

And I'm, I'm very much informed by everything that I've learned from him.

And so I think maybe my final question would be for any of the clinicians listening, if you had kind of one piece of advice for them that they can use when working with someone that, you know is, is complex or chronic or really challenging, what, what would you say to them?

I know that's hard to kind of boil it down into just one.

Yeah.

I think that the, the biggest thing you can do for your patients is to help them understand that there's hope.

People often talk to me and they say, well, I can't do this, I can't do that.

I can't do this.

I used to be able to do this.

And my response is that you're missing three letters that are very critical letters, and those letters are Y, E, T. And so you can't do them yet.

And so our goal is the Y, E, T to get you to be able to do the things that you want to do.

And the hope is that we can help you get there.

And so for most clinicians is giving somebody a sense of hope is your most powerful tool.

As you start to go through, it's not about whether you choose the right technique or say the right thing, but it's being able to understand somebody and to be empathetic with them.

I think you both have that in spades.

Thanks.

Thanks, Holly.

Well, that's actually a great segue into how Dr. Megan and I like to sign off in our episodes.

And so as we prepare to do that, thank you again, warmest thanks to you and just for being generous with the way that you practice, Dr. Suecki, and the way that you share your knowledge.

Thank you so much.

And thank you to you also, Dr. Megan, as always.

So this is how we like to end it.

It's just like what you said.

If you're listening and you've been living with chronic pain.

Do not lose hope, because as long as you are breathing, you can change.

Your brain and therefore you're you can change your pain.

Amen.

Awesome.

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