What if the pain you feel long after an injury has “healed” isn’t a sign that your body is broken, but that your nervous system is stuck in protection mode?

Dr. Megan and Holly break down what’s happening in the brain and body when pain lingers, scans look “normal,” and daily life starts to shrink. They explore how chronic pain and emotions are tightly linked, and why anxiety, depression, shame, and even hyper-empathy so often travel with long-term pain.

You’ll hear about the shift from acute to chronic pain, how the brain’s “pain map” can smudge and spread, and why pain can move around the body even when there’s no clear structural damage. They unpack the boom-and-bust cycle of pushing hard on “good” days and crashing afterward, the heavy toll of masking and “performing okay” for others, and how shame and hopelessness can quietly take root alongside physical symptoms.

Most importantly, Dr. Megan offers practical, science-backed ways to begin lightening the emotional load of chronic pain:

1. Understanding functional vs. structural pain and why that distinction matters for your recovery
2. Recognizing how anxiety and depression can amplify pain - without blaming yourself
3. Using small, realistic goals to build evidence that pain and depression are “lying” about what’s possible
4. Reframing flare-ups as part of a non-linear healing path rather than proof of failure
5. Leveraging simple tools like movement, breath work, and gratitude to gently retrain the brain

If you’ve ever felt like your scans are “fine” but your life is not, or wondered whether your emotional struggle around pain really “counts,” this conversation offers clarity, validation, and a grounded sense of hope that change is still possible.

Links to interesting things from this episode:

1. “No Mud, No Lotus: The Art of Transforming Suffering” by Thich Nhat Hanh

Part of the problem that makes it a little hard. And physical therapists often joke about this, that, like, oh, somebody got better. It's because they are on a new medication and they got worse.

And that's because of what you did last time. Right? But we're so attuned to the pain that we're not always attuned to the absence of pain.

Welcome to Unpacking Pain, a podcast dedicated to understanding the complexities of chronic pain, the 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.

Last episode got into so many interesting areas, and if anything, the challenge for me was like, keeping just sort of on the thread because there were so many questions firing in my brain.

And I think that it was a really interesting overview that you gave us on how the nervous system and the brain are affected by chronic pain and how things can almost become a loop around the fact that, you know, those of us in chronic pain are almost expecting it to come.

We're fearful of it, we're anticipating it, and that can almost, you know, signal that we should feel more pain, that we will experience and perceive more pain. And I, I think that what we really want to do today is start going deeper into how pain affects our mood, how it affects our emotions.

I think one of the things that totally fascinating last time, Dr. Megan, was what you explained about fear and how it starts to show up as a loop in the body, which kind of leads us to anxiety. I guess fear and anxiety can often really ride together. Let's. Let's get into that a little.

A little more deeply, maybe, starting with one question that I have, which is, does pain create anxiety? That wasn't there before, but like, can.

Can it make us an anxious person or are we more likely to experience more pain because we are already sort of wired as an anxious person? Or, or I hate saying anxious person. Maybe we just experience anxiety. Does that make us more prone to feeling pain?

Or is this really a chicken and egg situation?

Yeah, and that's a great question. And the answer, of course, is it depends.

So part of how our nervous systems and our bodies learn about pain is through our past experiences with pain.

And so when we have a experience of pain, especially during certain times of our brain development, physical development, and emotional development, that can sort of set us on the path of someone who has a little bit more of an awareness or a tendency to attend to all the signals that are coming from the internal body and that are coming from the external world.

So, like, I really liked what you said about anticipating pain, because if we go back to the definition of pain, it's that unpleasant sensory and emotional experience associated with or resembling that, associated with actual or potential tissue damage. And if we think about the purpose of pain, it's to protect us. And so the potential tissue damage. Exactly.

That's what happens when people shift from acute pain to chronic pain. It's no longer about the tissue damage that I'm having in my body. That's that six to eight week tissue healing with acute pain.

Now I'm more in threat detection mode with chronic pain. So I'm looking out for the potential of tissue damage.

And that's what we see really, with people who have that comorbidity of anxiety and chronic pain.

Okay, Whoa. I mean, that. Let's, let's stay there for, for a little bit because there's so much to understand there.

So it sounds like the tissue damage may be behind us, maybe in the rear view, or we may have technically healed on some level, but that damage that was done and even the healing process is, has the potential to make us now anticipate future pain.

Absolutely.

Okay.

Is that why sometimes we don't feel like a doctor or a medical professional is, Is always acknowledging or able to understand why we're still in pain? Because, hey, you passed the window. Like, your knee looks pretty good from this mri.

Absolutely.

And I hear that very consistently from the patients that I work with and even the subjects in my research, is that they're telling me my scans are clear. They're telling me everything looks, quote, unquote, normal, but still feel this pain.

And sometimes, as practitioners, when we explain the fact that your nervous system is looking out for potential tissue damage, that can sound to someone like, this is all in your head.

And they also may be on a little bit more high alert for that type of information because they may have heard that before from providers in a way that is sort of dismissive and that can be very painful. So I want to be clear that I'm saying that I recognize that this pain is real, even though the tissue damage has healed.

Most oftentimes we see tissue damage heal in about six to eight weeks, with the exception of bone, that heals in about eight to 10 weeks.

But because anxiety creates a physiologic response in the body that increases pain perception through sympathetic arousal, you can actually have some physical muscle tension that you're holding onto when you're in that state. And that hypervigilance, I like to. To kind of liken it to, you know, your pain is listening.

And with toddlers, I always equate everything to toddlers because I have a toddler. I want you say, turn on your listening ears. Right? Okay, Turn on your listening ears if she's not listening. Right.

Like, I need you to pick up your toys. Like, right, let's turn on the listening ears and, and pick up your toys.

So what we find with people in chronic pain is that their listening ears are on. They are on. And they are on so strongly that they're ready for anything. Right. And okay, you can kind of see this in some people.

Like, I don't know if I'm going to be able to sit in that chair for very long. I don't know if I'm going to be able to get on that plane. I don't know. I sit in the bleachers.

There are a lot of things where their nervous system is saying, I need to look out for potential signals that my body's going to send me that say we're not.

Okay, is the pain, is that signal. And even that, that pain that goes on, is it always in the same spot? Yeah.

If we, we busted our ankle in three places, like, is that where it's gonna always show up?

Not always.

And that's a really important thing as well because I have people that I see every day that say, you know, it used to be here and now it's here, or it's. There's some evidence that shows us there's something called cortical smudging that can happen where, you know, your pain was in a small area.

But over time it started to spread. That map in your brain that represents that area. And so you no longer have like a clear outline or a clear picture of where that pain is.

It's sort of smudged or spread out. And the other thing that happens is because it. Your nervous system is body wide, system wide, you start to notice pains in other areas.

And even like a minor discomfort in an area can be amplified when your body's in this state of hypervigilance, hyper awareness or protection. And so often people will say to me, oh, it was here and then it was here, or it's here now it's here. And. And students often struggle with this.

New grad. Physical therapists say, you know, last session we were treating the right knee. Now we're treating the left knee. And then we're going to the ankle.

Now we're going to the foot. And I'm like.

Time out, hang out.

You know, you don't want to be chasing the pain. What are. What is this that connects all of these things?

And, okay, if you start with the nervous system, then you can peel off that layer, and then you can go into the systems that are or the areas that are most important. And that way you're not just kind of chasing pain all over the place.

Okay, that's. Oh, sorry. Please.

I also talk to people about how that's actually really good news when the pain doesn't stay in the same place.

And it doesn't sound like it would be good news, but if you had a structural problem and every time you bent forward, you pushed into that structural problem, that would tell us that, you know, maybe you do need to have the X ray. Maybe you do need to have the mri. Maybe you do need to talk to the surgeon.

But the fact that it changes tells us that it's less likely structural and it's more likely functional, which for me, a person who does not wield a scalpel is a much more solvable problem.

Can you tell us a little bit more about the difference between those? That's very interesting. Functional versus structural. Structural. Okay. What's functional pain?

Functional pain is just that pain that's not identifiable on scans. They're not seeing it on the mri. They're not seeing an CT scan. They're not seeing a structural problem like arthritis or a herniated disc. Gotcha.

Those types of things. Okay, so like, when we think about, like, functional digestive disorders, we think about ibs, Right? There's no definitive test for ibs.

It's based on your symptoms.

But when they do a colonoscopy, they don't really see any structural issues versus something like ulcerative colitis, which has structural changes to the colon.

Aha. Okay.

You know, I have a little story that's not so much a story, but just a memory of different moments when I was at my peak of exhaustion and just, you know, frankly dealing with the pain, which just felt like too much at times in my life, I learned how to mask and move on. And then I would find that a tiny little injury, like a. A very surface level cut on my finger that maybe came into contact with some lemon juice.

And now I am crying and very upset because it almost conjures up this whole feeling of like, I'm just. I'm just a hurt person. I'm I'm, you know, it. It's almost like the thing that kind of the straw that breaks the camel's back.

It's the thing that pulls you back into a pain place when you're fighting so hard to just kind of keep moving through life. And it's like, I don't have time for this. I don't want to feel these things.

And then you bump your elbow in just that wrong place, and it just, for me, would unleash this bigger, deeper feeling of, like this eruption almost of emotion would come out. Is that common, uncommon, like, what's going on there?

Yeah, absolutely.

So I like to think about that in terms of bandwidth, you know, so if I am a normal person, I have this amount of bandwidth, and so then I can deal with irritations and frustrations and minor bumps and traffic and all the things. Right. But if I'm dealing with a screaming toddler and my back hurts and I'm late for work, my bandwidth gets smaller.

So then my ability to tolerate these daily inconveniences or discomforts gets a lot smaller.

And for someone who's, like you said, working so hard to put on the face or get through the day or all of those things, it can feel like a complete failure. Right. Everything is done and I'm over it. And yes, like, what's even the point of working this hard? Yes.

And that's also some of the masking that people oftentimes will do with depression, where they say I have to put on this face to go to work and to interact, but really on the inside or underneath or behind it all. And I'm feeling very differently. And it's a lot of work for me to have to sort of do this and show up in these ways. That's.

That's really interesting, too, because we've. We've talked about fear and anxiety, and now depression is. I mean, that's. That's kind of now. Now you're really in my kitchen cooking with gas.

Because, yes, the anxiety piece, I think, is. Is part of the experience. That's something that I can. That I can. You know, I have a lot of stories about that.

But the depression element was almost harder at times because the anxiety at least gave me action. It was like, I'm. I'm aware I'm up. I'm alive in this world. I'm. I'm.

You know, I'm right versus depression was almost a slowing down, a deepening, a bottoming of things that, you know, would.

Would come also with physical and mental exhaustion is that Is, is depression coming in with chronic pain because anxiety preceded it and we, we get exhausted from our fear and anxiety, or is it that we're sad about being in pain or is it like kind of out of our hands? It's just something chemical that's going on?

That's a really great question. And I don't know that science has a definitive answer for that yet.

But what we know is that depression increases your chances of developing chronic pain and chronic pain significantly increases your chances of developing depression. So somewhere on the order of 85% of people with chronic pain also experience depression, which makes a lot of sense. Right.

When you think about some of the connections between depression and chronic pain.

So if I'm unable to participate in my life in the way that I want, I'm starting to lose my social connections with the people that bring me joy and make my life worth living.

Those are a lot of things that we see very commonly with both and part of the European Federation for the Study of Pain conference that I went to earlier this year in April of 25. The whole point of the conference, the title of the conference was the comorbidities of Chronic Pain and Mental Health Disorders.

And they talked about exclusively revealed about anxiety and depression and chronic pain because it is so prevalent.

I, I even remember seeing at one point, and I think it was even offered to me, is it a class of antidepressant or a particular antidepressant that is given often to people in chronic pain?

And I can't remember, I ended up not taking it for whatever reason, but it was thought to be almost like an add on or another layer if you're already on something for depression.

Oh, huh.

Yeah, there's, there's a layering of this additional type of antidepressant that is really geared toward people who are suffering from chronic pain. And it's supposed to help alleviate a little bit of the pain and alleviate a little bit of depression and they kind of like go together.

As you were describing. Is, is this, are, are.

So this symposium you went to or this conference you went to was all about that, but how come practitioners or how come like an orthopedist is not mentioning this or a neurologist, you know, is not also in that same appointment at least asking us about our depression? Why do we have to figure this out on our own?

Yeah, that's a really good question. And I would say a big part of it has to do with the fact that Western medicine is very biology based and true. Yeah.

But it's only in the last probably 15 to 20 years that research is really definitively demonstrating that our mind and our body are connected. And medical schools have not adopted this. Physical therapy schools are partly adopting it.

And that's part of where I teach a chronic pain course to the doctor of physical therapy students at Mount St. Mary's where I went to PT school. We talk a lot about this, but it's not taught at all physical therapy schools.

And in part because there's a scope of practice issue between physical therapy and psychology where we don't want to step on anybody's toes, they don't want to step on our toes, and so on and so forth.

But really what my big goal ultimately, and there are others in the field that are pushing for this as well, is for us as physical therapists to recognize we're already doing a lot of this mental health work in our practices.

And you know, you're not calling it cognitive behavioral therapy, but if you're challenging someone's strongly held beliefs and you're helping to change those, are you not practicing cognitive behavior?

Yes, exactly.

If you're working on the physiological responses of anxiety, this from the signals coming from the body, are you not working in a way that you're treating the anxiety? So it's part of what some physical therapy schools are going towards and others are in some ways. But it's a road.

And I think the way in part of it as well is the fact that all physical therapy schools, like medical schools, require evidence based practice. And so we can't teach anything that hasn't been demonstrated in the literature enough.

So you can't ace an entire course on one study or things like that. So as the science gets there, then we can start integrating this into medical practice.

And the way that I've done it in my practice and I know other practices have done this, is having a questionnaire on your intake forms.

Here's something now that I'm wondering is like, I almost want to get a permission slip to go back into physical therapy. Even though PT is years behind me. It's like I, I probably would not be.

And I think a lot of us in chronic pain would not be approved for physical therapy at this point. Right. Because the injury is behind us.

We already went through the rehabilitation we have sort of blown through the kind of limitation that either our, you know, our insurance provider allows or, you know, if I went back to talk to my shoulder surgeon right now, I would almost have to exaggerate and tell her that I'm in a great deal of pain now every day and want to go back into PT in order just to get somebody to. To help me, you know, with this. Like, I think that's one of the challenges is that when we're left to sort of deal with this stuff on our own.

So I'm wondering if you have any advice around if you're not lucky enough to be, you know, receiving physical therapy at this point, is there something that we can do for ourselves or is there even a way to ask for, for the help again and say, here's why I need to be back in pt? Yeah. What do we do if we're sort of past all the doctor appointments?

That's a big question. And I think if there are things that you are wanting to do that you're not able to do, that's a reason to get pt.

Okay.

You have a level of discomfort. You know, it doesn't have to be 7 out of 10 pain. It can.

Yeah.

And this is where we as physical therapists are terrible at marketing ourselves, but we do a lot more than just post surgical rehab and recovery. We can help people get back to the sports they love. We can help people get back to their activities of daily living.

Yeah. Yeah.

With some of the strongly held beliefs around this, and some of that may need to be outside of your insurance model. Like you said, if you went back to your doctor, they may say, okay, I'll give you a prescription for this.

Maybe you've reached your limit of your insurance or those types of things. But there are physical therapists in all 50 states that you can see without a prescription.

Okay.

Depending on your insurance, you may or may not be able to use your insurance for those visits. But there are physical therapists that are treating in this way.

I'm hoping eventually to get a list so that you could look them up online and see who are the physical therapists that really have an understanding of this mind body connection that I could maybe see. But there are a lot of things that we can do to help you get back to where you want to be. And I think when.

When we're thinking about anxiety, that's a little bit easier for a mind body physical therapist because we can help those physiological responses with things like breath work, vagus nerve stimulation, mindfulness Meditation, challenging some of those strongly held beliefs, and movement manual therapy as well. But.

But in terms of, like, home program, you would do movement, and then depression can be a little bit harder because depression and chronic pain are liars. And you touched on this a little bit last time where there was a point at which you felt like, I'm not going to get better. Yes. Right.

Can you talk a little bit about that?

Yeah, I. I think that there is a helplessness that you start to feel. And because you have been through so many different, either surgeries or you've seen so many different types of.

Of practitioners, and you're not getting better. And so it becomes this feeling of, this is just my life now. I have to make room for pain in my life, and I'm never going to be the same.

And you start to almost count up the things that you've lost and the choices that you've made. And so, yeah, I appreciate you asking about that too, Dr. Megan, because it's something that is really hard for people to talk about.

It's one thing to talk about your bum knee or that bad back. Um, it's a whole nother thing when. When someone asks you how is your knee?

And the knee is okay, maybe getting a little bit better, but you have still some depression or the anxiety is still there. It's like, no one's really asking you, how's your depression when they ask you how your pain is.

And I don't know that they're ready for us to answer that. It's. It's like I've had experiences with some people where I, you know, if I kind of go into that a little bit, they're just.

You can tell in their face. Like, I was not prepared to make space for this conversation. I was going to ask you if you're.

If you prefer Advil or Aleve, you know, so do you find sometimes that it's like the people who are experiencing this whole depression element of pain that. That they're also not getting recognized for it in their own lives. Like, it's not coming out and they're.

Not able to talk about it.

Really?

Yeah, absolutely. And like, depression, chronic pain has a shame component.

Oh, wow. Okay.

Yeah. So there's. There's something that feels like. Well. Well, first, let's define the definition between shame and guilt. So guilt is I did something wrong.

Shame is I am wrong.

And with depression and chronic pain, oftentimes people over time internalize the messaging that I'm broken, something is wrong with me, and I'm never Going to get better. And that's exactly. Yeah. And that's where I say that pain and depression are liars because we know from episode one.

Or you may be sick of hearing me say this by now, probably I said it in episode two because I'm obnoxious. But as long as you're breathing oxygen. Yeah. Your brain can change, right?

Oh, Dr. Megan, you have to keep saying that. If you stop saying that, I'll make you start saying it again. So ne. Yeah. So there's no limitation on that one. That is the huge message.

Yeah. That's the message in depression as well. You can change. It takes time. It's sometimes a long road and it's not often linear, but you can't change.

And that's where I want to say to you, chronic pain and to you, depression, you're liars. And I know the truth, which is that people can always change their brains. You can change your thoughts. You can.

You know, sometimes there's chemical things that also need to be addressed as well. But movement changes the chemical makeup in your brain. Breath work, meditation, mindfulness, these all can change things.

And what we find in depression, more so than anxiety, is that I need to find the thing. You know, sometimes I'll have. I love it when people come in with their family members or their friends who are there to help them.

And oftentimes I incorporate them in the treatment because there are things that they absolutely need help with. And then there are things that you need to start handing off to this person.

You need to say, I know you can do more than you're doing and I'm going to let you do that. Because as you said, some of that learned helplessness that can happen can keep you stuck.

As you start to come out of that, I'm going to start handing things back to you and you're going to start broadening what you can do. There are going to be times where you say, not today, Satan. Yeah. And.

And then there are going to be days when you say, actually, I can do a little bit more.

This is true. Yeah.

And so finding those things to grab onto, I think of it like the rung of a ladder. Right. I got myself out of bed today by myself. Rung of a ladder. I got myself to and from the bathroom today without help. Rung of a ladder.

And then I just start climbing up that ladder and I get myself out of that pain situation. So it can be really, really hard when. When there's a co existence of chronic pain and depression.

But if you can get somebody to find a shred of improvement, of positivity, of hope, that's. That can be that first rung of the ladder that you can start to climb out.

That makes a lot of sense because you almost need evidence.

Yeah.

When you are in the pit and you're convinced and this is not just depression that rides with chronic pain. This is all, you know, probably true of all depression.

Depression is that you don't believe that it can get better, like we said, and you almost don't even want to try. It's, it's that the, the motivation is. Isn't really there after a while.

But if there's evidence to the contrary, you know, sort of in spite of that depression, if something, some glimmer shows up, you know, what actually really helped me when I was in a. In my kind of worst phase of things was to recognize that there were going to be days that I called possible days and impossible days.

And if I woke up and I felt too dark, too down, I knew that was an impossible day. And I removed the pressure or expectation from myself that I would try to grab that next rung. And I waited for a possible day.

And maybe it was four days later, sometimes it was 14 days later, but there was a possible day, and I would take that little glimmer of possibility and grab that next rung. So I sort of had a deal with myself, an agreement that if it's a. An impossible day, you're off the hook.

I'm not going to expect you because I'm just going to end up feeling worse that I didn't do anything.

Anybody eliminated shaming yourself.

Okay, that's huge. Yes.

You didn't Polly, you again, how you always are, right?

Totally. And it's like after, you know, umpteen years or however of being in pain, you. You do start to feel like you're the problem child.

You know, you are like, you know that. Okay, I need to sort of. That's where the masking comes from and the pretending.

And so if you, if you know that, your agreement with yourself is that if there is a possible day where it's even a shred of possibility, that you have to go all in, you know, on those days. But another question for you about how depression starts to work in these areas.

I noticed as well that my awareness of other people in pain and other suffering in general went up.

And by the way, and this is maybe a topic for another episode down the road, it goes on the list of reasons why I'm not upset or regretful, that I've been on this pain journey.

There have been things, magical, amazing things that have happened in my life and ways that I've been changed and that I think many people feel changed because of chronic pain. And it's true of anything in life. It's like Thich Nhat Han's book, no mud, no lotus, right?

Like you gotta go through the crap sometimes to get to something beautiful. I do not regret that my empathy as a human being went up a hundredfold.

But I'm wondering about whether we become almost more sensitized to all suffering and that can contribute to depression. It can be a very hard world to look around. I see someone walking across a crosswalk and they're visibly struggling.

And I think to myself, what must it have taken for that person to get up and put on pants and run a comb through their hair and get in a vehicle or get on a bus and make this trip? And I'm sitting here complaining because my shoulder is aching again. Come on. You know, and so that. That can sort of contribute to the.

The shame and the suffering. Cause it's like I'm looking, I'm empathetic and I'm seeing pain everywhere. Is that part of the hyper awareness that.

Do you.

Do you think that goes along with it?

I think it can be. It can be for some people that are more empathetic or more like maybe porous to what's going on around you.

There's some evidence, and most of this comes from resident doctors who are really stressed, really overworked, and really tired in their medical training. And what they find is when they're in that state, their empathy levels go big down because what they're dealing with is so much for them that.

Oh, really?

You're a seven out of ten? Well, I'm a nine. What do you have to say? But for some people like yourself, like you were saying, you recognize what it is to struggle.

You recognize what it is to get up and show up each day and get to work or whatever it is. And that can be really challenging.

And that's one of the ways that we as physical therapists need to learn how to protect our mental health when working with people in chronic pain. Because you can burn out really, really quickly, I bet. Yes. As a new clinician, almost burned out completely. I almost said this is too much for me.

It's too hard. And I learned over time I need to be able to protect myself because that's how I can help more people.

So ultimately, I think my why outweighed some of the depth of connection that I needed to have with people all the time. I didn't need to be thinking about them every day in between their sessions. I didn't need to be emailing them, how's it going?

Every day, you know, it was like, right, right. I need to have a level of.

And that, that goes back to, you know, giving some of the onus back to the person and saying, I'm going to give you these things to do. You're going to work on it, you're going to practice. I know you're not helpless because I know you can do it. And I want you to have that opportunity.

I don't want to take that opportunity from you. So I think it really does vary. And I think the best clinicians are incredibly empathetic and have the ability to separate.

What's going on with you does not have to be what's going on with me.

And I think if you decided to get into physical therapy, which I wholeheartedly support you, you, you would have to have that skill set that's really huge.

Dr. Mega.

I think, I think this not only is like, it's a great call to future PTs out there, but it's also a reminder to people in chronic pain that this is a critical component of your healing. And if your PT isn't bringing it up, you've, you've gotta find it too.

Like, you, you need to tap in to these sort of psychological components of your healing in order to, you know, push back on a lot of the things that are those changes that are happening in our brains and in our bodies. Right.

So this is really validating to those of us who have a hunch that we may be feeling some anxiety or some depression or some changes in our brain chemistry. You're validating that that is absolutely legitimate. It is part and parcel on this chronic pain journey and that it's important to find that support.

And look here I was even. I've been to physical therapy probably. I don't know, I've done maybe 10 or 11 tours and rounds of it and even I'm still, I should have a punch card.

And even I'm still sitting here thinking that I don't qualify for PT anymore because my last surgery was, was a few years ago. So I'm pat. Like, I can't get it now. So I think this is a really great call to all of us who experience a limitation in any way. Like you.

I love that you said, Dr. Megan, if you can't do something that you love to do, you don't have to necessarily toss that out.

Yes.

Yeah. Like, make it your goal. Yeah.

And sometimes we see that on the anxiety side of things, you know, I'll say to people, well, you know, what is it? What are you hoping to get back to? Or what. What was it you were doing before? And sometimes people will say, I just had somebody.

So orange theory comes to mind. I don't have anything against orange theory, but somebody was injured in orange Theory. And I said, well, how do you do now in orange Theory?

And she said, great, I don't go anymore.

Like, that's not what we wanted.

So there's healing and then there's fear, avoidance. And so if that is something you want to get back to, then, yes, let's absolutely work on that. Let's make that a goal.

Okay.

I want to go back to something that you said about, you know, when you have.

You give yourself permission not to try to push through those days and not to try to guilt yourself or shame yourself into doing XYZ on the days where you just simply cannot.

Right.

And then you wait for a good day there.

There's something called the boom and bust cycle that as people are coming out of chronic pain and what oftentimes will happen is, you know, I had so many bad days in a row, and the list of things to do around the house or at work has piled up. So then I get to that good day, and I try to do all of it right.

I vacuum the entire house, I clean out the fridge, I go to the grocery store, I do six loads of laundry. I do. And now I feel terrible after. Yes, right.

Exactly.

Part of the recovery or the way out of chronic pain is recognizing, okay, I feel good today. How much can I realistically do without aggravating my body?

Right.

A tissue damage, nociceptive, acute on chronic exacerbation, we would say, of what's going on for me. So oftentimes when. When people come back and say that to me, like, it happens so frequently that I'm like, oh, great.

You know, it tells me two really important things. Well, first I ask, is the pain the same? And oftentimes it's not.

Oftentimes it's more like a soreness or an ache because I've used muscles that I haven't been using and. Or I use them so much more than I typically do. And so I'm like, yes, this is great news.

Not that you're in pain, not that you're in a new type of pain, but that you were not afraid to move. You were saying new things, you weren't afraid to get back to those things that you had been doing. This is great news.

The other great news is muscle soreness is a super solvable problem. And he will oftentimes say like, yeah, I did take some Advil and I actually feel pretty much, you know, quite a bit better today.

And part of that is because you've caused some inflammation and then you get the anti inflammatories involved and things tend to improve. And I'm like, yeah. And so you've taught yourself that, number one, it's not gonna cause irreparable damage to move and to do these things.

And number two, I'm not afraid to do these things.

I can teach my nervous system that I can stretch, I can expand some of the possibilities of what I thought were possible and then I can contract again as needed.

And so part of that is that non linear line of healing where I say, okay, I had a little bit of a backslide because I did too much, but I'm still the trend line of bad to good is going in the right direction. So I haven't come all the way back to baseline.

I'm so glad that you named this that, that you've called this out, this boom and bust cycle. It's so common and it's hard to avoid because as you said, stuff starts building up, you know, that maybe you strung together six, seven days.

This used to happen to me at work all the time, you know, where I would scooch out a meeting, you know, let's say Tuesday's a bad day, so I moved all my Tuesday meetings over to Thursday. Well, guess what? When I get to Thursday. Yes.

Yeah, you're stacked, you're double booked, you know, and, and I think one of the things that's really challenging too is that when you do get back out into the world, right, let's say that your depression, you know, and your pain has kept you down for a few days or a few weeks or whatever it is when you jump back out into the world. Oftentimes we sort of jump back into our previous energy level. And I mean energy as in like your aura, what you give out, right?

And you greet someone with a smile and hey, Jeff, how have you been? And you know, hey Amrita, like how, you know, how was your trip to Tahoe?

And that is part of that masking because it's like, I'm having a good day, I'm going to capitalize on this. So I'm going to throw all my energy back out There the problem is that that's not the real me now.

So what we've done is we've signaled to everyone around us that we're just the same Holly, we're just the same operita, or we're just the same, you know, who we were, and they're none the wiser. Yeah. And now two days later, God forbid. But, you know, if you're back in a bust period, it's like, well, what happened? What happened to Holly?

You know, where'd she go? And that is an unsustainable, you know, it's like you can't, you just can't keep showing up.

I, I think that's where some of the depression comes into play of like, I'm almost living, you know, too.

I'm like this Hannah Montana situation where it's like, you know, I'm like a rock star out there in the world and then I come home in a very different mindset. So what, what do we recommend? What do we do about that boom and bust?

Do you think that on the days where, you know, it's the possible day that we need to consciously limit how deep we go into things and what we try to tackle?

Yeah, absolutely. Just like you would have kind of a conscious awareness of all the tasks that have built up at home or at work.

So to recognize, all right, Thursday is going to be a good day. I'd love to vacuum the whole house, but maybe I'll do two rooms and two loads of laundry and see how that goes.

And then over time, you can build up your endurance for the social outings and the physical work around the house and the work at work and things like that. But it doesn't happen overnight. And that's what can be hard for people.

And that's sometimes where your social connections and your community around you need to have an understanding of the fact that you're kind of coming out of something new and different and how they can support you in those ways.

That is a big one. And in fact, that I, I would love to make that the focus of our next episode.

I think we've, we've talked about that, the two of us, and I think we've got to bring that conversation out to our listeners because when we started episode one, you mentioned that social environment or social makeup is one of the three legs of that three legged stool in how we look at and understand pain. And I am so curious to learn from you about what that means, our support system, how that support system looks.

How do we ask them to show up for us, you know what.

And, but just even backing up in what that social circumstance is doing for or against our pain and our healing journey, and I think that's going to be really fascinating.

But to, to put a finer point on the depression piece, that has been a big part of our conversation today, one of the reasons I'm so encouraged for you to be talking about how to get out of the boom and bust and how to, you know, kind of start journeying forward a piece at a time is because I know from experience that if you accomplish a little bit, the depression is, is now seen as the liar. Like have. Dr. Megan, you said depression's a liar. We prove it. That's evidence that it is lying to us.

If we accomplish something, if we had the, the energy to go meet a friend for lunch or we finally had the ability to, to walk for 20 minutes, you know, without, without stopping, that can have an enormous impact on that depression and helplessness that we're feeling. Because you're starting to see, like, ah, you lied to me, you, pain, you know, depression. You, you liar. I can't do this.

Absolutely. And I often ask people, you know, if they tell me something that they have as a strongly held belief, I'll ask them, do you have evidence of that?

And, and do you have evidence that counters that? And if they can't find it, sometimes I'll help them, you know, well, didn't you have those 10 days without pain?

And weren't you able to walk, like, you say, 20 minutes without stopping, without any repercussions the next day? And can we start to build on that part of the problem that makes it a little hard.

And physical therapists often joke about this, that, like, oh, somebody got better. It's because they are on a new medication and they got worse. And that's because of what you did last time. Right.

But we're so attuned to the pain that we're not always attuned to the absence of pain. Because. Yeah. Should I say that again? That's big.

Say it again.

We are so attuned, our nervous systems have to be attuned to pain to keep us alive, that we're not always attuned to the absence of pain. And people will sometimes come in and say, I don't know if I'm getting better.

I don't know, am I just here because I like you and it feels good, or am I really getting better? And I'm like, let's check the board. So I'll go back to your first day. And I'll say, are you able to do this? Is this still a problem? Is this.

Oh, well, actually. Oh, yeah. Well, okay. All right. Yeah.

And then you start to recognize, okay, things are getting better, but because oftentimes when my pain is improving, my world starts to expand like we talked a little bit about last time, and now I can't go to lunch three days in a row and out for drinks on the third day. And now I can't walk two miles like I used to five years ago. And so the goalpost changes sometimes.

And so we're not always attuned to these small wins along the way improving.

And that's where sometimes a physical therapist or a talk therapist can come in and remind you, like, actually, remember, this used to really be a problem for you. And so that they can help you to see some of those smaller wins and start to string them together.

That's a big deal.

I just, I. I love that notion, you know, that if we can recognize the absence of something, that can be just as powerful as recognizing, you know, when something positive has come into our lives. And it's almost like I think about cleaning my kitchen.

I don't.

You know, I don't walk down into a clean kitchen and go, wow, is this clean? But I notice the mess. Right. And so, you know, we're kind of attuned to look for that mess and notice that mess and notice that pain. And that's.

That's all related back to what you've taught us so much about now already in a short time, about how we're wired to notice that we're hypervigilant. The nervous system is on high alert. You know, the synapses are firing overload on. On pain.

And so it kind of makes sense that we're noticing when it's there, but when it's not there, we're like, huh?

What?

Like, so that. That is a big deal. There's just so much that we continue, you know, to learn here in that aspect.

I love that you're highlighting all this for us, giving hope.

Yeah. And one of the ways that's been demonstrated to help us to recognize some of the positive changes and those smaller wins is gratitude.

Oh, that's big.

If I start to have gratitude for the small wins, if I start to have gratitude for the clean kitchen, I'm training my brain to have more of an awareness of those things as opposed to what my default is, which is to have awareness of the things that I need to keep me alive. Yes. Danger and threat and discomfort. And disgust and those types of things.

You know what's also really powerful about what you just said, and this is, I think, for everybody to remember, is that having a gratitude practice isn't just about, you know, lighting a candle and having like a lovely, you know, me moment. If, if that doesn't appeal to you or doesn't that's not your jam in life or your cup of tea.

Remember this, that it will change the grooves in your brain. It rewires, right? So what, what fires together, wires together.

So if you are consciously practicing gratitude, your brain is going to be picking up on more and more signals of what's going right in your life.

So even if you don't think of yourself as the kind of person that's like, you know, sits down and, you know, writes to yourself in a journal, you know, which I, I have been and I, I, I all for journaling.

But even if that's doesn't sound like you do it from the scientific perspective, do it from the perspective of knowing that this mechanically, physically will start changing your brain and you might not might, you likely will stop paying as much attention to pain and you'll start noticing the absence of it.

Yeah, absolutely. Or you could do it out of spite, like I do most things and do it just to prove me wrong. I journal for 30 days and see what happens. Guess what?

Yeah, exactly.

This is so awesome. I can't wait for next episode we're going to jump into. You mentioned the social circle.

Like I said, got brimming with questions for you around all of that.

So excited to talk about the third leg of the stool, the biological. We've talked about the psychological, we talked about today and we're going to talk about the social aspects and the social contributors to pain.

So more exciting info to come next time.

And like we say at the end of every episode, Dr. Megan, fill me on the second part here.

If you're still breathing, your brain can change.

That's right. It is never too late. So thank you for joining us, Much appreciation and we'll see you all next time.

Thank you so much for listening to this episode.

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