Chronic Pain Chronicles with Dr Karmy
Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and the latest medical innovations, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
Chronic Pain Chronicles with Dr Karmy
Episode 22: Interview with Dr. Andrea Furlan - a Physician, Researcher and Educator on Lifestyle Based Approaches to Pain Management
Dr. Andrea Furlan is the closest thing we have to an influencer in the field of chronic pain management.
She is a content creator who has a very popular YouTube channel and an author who has written several books for patients with chronic pain.
She is also an educator who has developed programs for healthcare providers.
Join Dr Karmy for an interview with Dr. Furlan, where she discusses what she learned about chronic pain after practicing in the field for almost 20 years.
Dr Furlan's Website: https://www.doctorandreafurlan.com/
Dr Furlan's YouTube Channel: https://www.youtube.com/@DrAndreaFurlan
If you have any questions for Dr. Karmy, feel free to email us at karmychronicpain@gmail.com
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So imagine that you're living now in a house where you can't get out of the house'cause you can't get out of that body. You are feeling the pain. You tried for 20 years, you tried all kinds of treatments. The pain is spreading and the volume of the pain is turned up. No wonder they have depression, anxiety, they can't sleep, they can't concentrate. They call this the brain fog, fiber fog. These people that have this kind of nociplastic pain, they tell me, doctor, I cannot even read your book. I can't watch your videos. I can't exercise. I'm fatigued all the time. No wonder it's like living in a house that the alarm is out of walk. You need to call the alarm company, not the electrician, not the fire department. They come, they will regulate the sensors. Hello, uh, this is Dr. Karmy for Chronic Pain Chronicles, and today with us we're lucky to have Dr. Andrea Furlan. She is both a physician and a researcher. And an educator at University of Toronto University Health Networks. And , hello, Dr. Furlan. Hey. Hello, Dr. Karmy. It's a pleasure to be talking to you today and to your audience. Thank you so much for inviting me. So I guess just in a way of a, a little bit of introduction a lot of physicians I've interviewed came from, uh, other countries. We had someone from Italy, we had someone from Ireland. Uh, we had someone from Israel. So you also didn't start in Canada? No. Can you tell us a little bit about, you know, how you started in medicine and maybe even, how you got to Canada and maybe a few thoughts, how the systems are different? Yeah, so I did my medical school and residency in physical medicine rehabilitation in Brazil at the University of Sao Paulo. And, uh, right after I finished residency , I was, uh, married, uh, you know, my husband is, um. Brazilian, he is an engineer. And, we didn't have kids. We were just, uh, you know, in our early late twenties. And we, he, this, he had this idea to immigrate to Canada because he was in the IT information technology world. It was easy for him to apply to get a visa. And I came, uh, with him without having a medical license here. So I started doing research. We came to Canada in , December, 1997. That's a long time ago. And then I had my kids here. My, my son and my daughter are Canadian. They're born here. And then I started, uh, doing research. I love research. In, my early years I did a lot of work with the Cochran collaboration, doing Cochran reviews, meta-analysis, writing guidelines, and it was in 2006 that I, I was offered a position at Toronto Rehabilitation Institute at UHN to do a clinical fellowship, and then after that fellowship I became an assistant professor with a medical license to practice physiatry in the pain clinic. And now I am full professor at the University of Toronto in the division of Physiatry , department of Medicine. So that was my career. I started with research, transitioned to clinical practice, but I never stopped doing research. Even after I got my medical license, I was still doing guidelines. I was the author of the first Canadian Opioid Guideline that was published in 2010. Then after that, um, 'cause I was invited to talk about that guideline all over the country from Coast Coast in Canada, uh, I, I noticed there was a really big gap in medical education and I started, uh, implementing Project Echo, which is a, a community of learners. We are funded by the Ontario Ministry of Health to teach primary care providers who are interested in chronic pain. Opioids prescribing. So I've been doing Project Echo for 11 years now. Every week. I am in front of a Zoom, like this one here that we are using today. It's not just me, it's my team, my interprofessional team. And we discuss cases of chronic pain and opioids , presented by anyone who is in Ontario, like a, a healthcare professional. This is only for healthcare professionals. So we are trying to teach the medical professions, how to diagnose pain properly, how to examine a patient and choose the appropriate interventions. I've, I've been doing more education lately. Mm-hmm. And of course I noticed that the general public also needed to learn. That's why I opened the YouTube channel in 2019 and wrote books.'cause I think it's important, this communication between healthcare professionals and people with chronic pain. I guess just a couple of comments. One is it's actually not very easy for physicians, especially if you're trained outside of the US to actually get Ontario license to practice medicine. So that was quite a brave move, let's just say. And, guidelines. There's lots of different organizations putting out guidelines. Cochran Review, which is actually a Canadian initiative as far as I know, is one of the most respected. And the reason for that is, I think at least in part, is because it's not partisan, unlike some guidelines which often are created by a journal that sort of has a specific view the world and certain incentive to promote that particular treatment or that particular approach to things because most of the physicians who submit to the journal, that is what they do for a living. Uh, Cochran is sort of more of, at least in my mind has always been a little bit more, , less prone to bias just because they have a very rigorous way that they approach the data and how data should be analyzed. Yes. They're more neutral, not perfect, but they're more neutral. Mm-hmm. So usually I give Cochrane reviews more weight than reviews coming from other journals. Not that other journals are bad, but, uh, I think Cochrane reviews has one of the highest standards out there. Yeah, you're right. Yeah, it's, uh, actually started in the United Kingdom. Cochrane. Archie Cochrane was a physician in the United Kingdom, and uh, so it's in his honor, but it's an international organization. And Canada had, many, many years of contributions because the government of Canada funded many groups. Now they don't fund anymore. So there are no groups in Canada anymore doing Cochrane reviews. Let's move on to your role as an educator and , one of the things that maybe not all patients are aware of, or I think as practicing physicians, were very aware is that not all types of pain are the same. First of all, obviously there's acute pain and chronic pain. With chronic pain being defined essentially as pain that persists after all the tissues have already healed, typically takes two to three months for tissues to heal. So if your pain is there afterwards, three months, it's not going to heal any better with resting, it becomes a much more difficult problem to treat. But on top of it, there's more than more than one reason why the pain persists, and that is why there has been a classification for different types of chronic pain. Can you touch a little bit on that? Yeah. You touched on, a lot of terms here that people usually confuse and even my colleague physicians, they don't have that clear in their mind, and I understand why, because there are, you know, you can classify pain to acute and chronic, which is basically by time, but you also now can classify a primary and secondary pain. And that is, uh, is the pain primarily in the pain system or it's secondary to a condition a disease. And now there are also mechanisms of pain. And this comes basically from neuroscience of pain. Because in the last, I would say 30 years, I graduated from medical school 32 years ago. And at that time we didn't have the tools that we have today to study pain. And it's amazing. Dr. Karmy, I am a pain specialist, so I, I go to all pain conferences, I read all the journals. I subscribe to Ping, and I, and I cannot keep up to date with everything that is being published trying to explain pain. It is exploding this area of science. So I'll try to explain here the things that I, I understand and, uh, I, I like to talk about the mechanisms of pain because if you understand, and this could be acute and chronic, so , the mechanisms are basically what is wrong? Why is the problem? Because pain is pain. We all know what is pain. It's that unpleasant sensation. It's a sensation. It has to be unpleasant. That's the definition, because otherwise, if it doesn't affect the areas of the brain that are responsible for emotions, that's the limbic system. It's not unpleasant. It has to be a sensation, like the vision is a sensation, but it's not unpleasant. You don't feel pain when you are seeing some things. But pain is like, could be a touch. It could be a prick, it could be a cut. It could be a too hot or too cold. We have sensors. We don't have sensors for pain in our body. We have sensors for danger, and when those sensations come to the brain activate the limbic system, then the person will say, this is pain. So all pains are interpreted by the brain and the brain gives a meaning. So the way that, the mechanisms of pain go, like, uh, there are basically three mechanisms that your brain can sound the alarm. That's basically the same thing, has an alarm of a house, the same thing. So if you have a house and you install, an alarm system, you want that alarm system to alert you, to wake up. You in the middle of the night making noise that is unpleasant if there is something wrong with your house, right? So this could be a fire in the kitchen. So that's why you install smoke detectors in the kitchen. You don't detect a fire, you detect the smoke. So the smoke detectors will say, well, maybe there is a fire, and then signals, the alarm goes off, but then you need to do something. That information has to go to the alarm company, which is probably in downtown, where somewhere the person there needs to see, okay, there is a signal coming from the kitchen, and it's the signal coming from the smoke detector. Therefore, the alarm company will say, I think it is a fire in the kitchen. We'll send the fire truck to the house. So they send the fire trucks, the fire department, the ambulance, the police, because there was an interpretation. So that's when our pain system is functioning the way that it was designed to. It is supposed to alarm, so it's supposed to generate pain is in the brain again. So the brain will interpret the sensations, including the vision . If you look at your hand and your hand is not damaged, but there is some sensation coming from your hand, the brain has to interpret and say, what is going on? My hand is saying that it's not being burned, but I'm feeling burned here. So the brain gets confused. So the brain has to interpret. So if there is a fracture, if there is an appendicitis, if there is a toothache, an inflamed tooth, if there is a rheumatoid arthritis with an inflamed joint or a gout attack where you see that redness. So your brain will say, okay, this is acute pain. This is nociceptive. The, the name for this kind of pain is nociceptive, which means there is a damage. I can see the damage. I'm going to send the fire truck, the police in the ambulance, and which means the orthopedic surgeon or the surgeon, or you would take an antiinflammatory and uh, your pain will stop. So that's nociceptive pain. We all know that kind of pain, right? We all know we all had a toothache or something. Right? Yeah. So that sounds like mostly acute pain. Yeah, but not always. Not always. Yeah. So because acute pain can also be different, can doesn't need to be nociceptive. We'll get there. So the second mechanism that we can have to generate pain, again, think about the pain is generated in the brain. So the second mechanism is, let's go back to the alarm of the house. Let's say that there's a, a burglar, a thief that wants to enter your house and they know that your house has an alarm. So they go and cut the wires. They cut the wires, they communicate, uh, your house to the alarm company. And that will create a short circuit somewhere. Or imagine that you turn the switch, the light switch of your kitchen, and there is a short circuit between the electrical wires and the alarm company wires. And every time you turn the, the light of your kitchen on the activates this smoke detector and it calls the fire department. So there is a problem in the wires and the alarm will sound because if someone cuts the wires or if there's a , short circuit, the alarm will sound of your house again. So you can have pain that is neuropathic. So neuropathic pain is if there is a short circuit somewhere in your body, if there is a damage to the wires, the nerves, the neurons that carry that information of sensation. So now we have two types, nociceptive and neuropathic. Yes. And you see the treatments are different, right? If your alarm of your house is going off because there is a short circuit, you're not going to call the fire department. You call the electrician. Sure. So , but in your analogy, the alarm company is actually the brain and the wires and the sensors is actually the nerves. Yeah. That transmit the signal to the brain. Exactly. Exactly. So let's go to the third type of mechanism. That's one that, I would say it's not new. We have this third mechanism for thousands of years, but it's just lately, uh, in 2018 that the International Association for the State of Pain, coined a name, gave baptized this third mechanism with a name. It's called Noci plastic. Some people call neuroplastic, but it's okay as long as you use the word plastic because it involves plasticity. And why it was only possible in 2018 is because now we have the tools to find where is the problem. So Noci plastic pain is the third mechanism. Which means there's no fire in the kitchen. There's no short circuit is the alarm of the house that is malfunctioning. So you have to call the alarm company and say, you know, the alarm is going off all the time. It's constant. This is this is the most common type of chronic pain is neuroplastic. So these are people who have pain. Think about fibromyalgia, so they have pain all the time. It's annoying, it's constant, it's everywhere. They tried everything for nociceptive pain. They tried everything for neuropathic pain, of course they didn't get better because that's the wrong treatment. So if you have an alarm of your house now that is going off all the time. Let's say, how can you live in that house? It cannot even concentrate if the alarm is woo going, making noise all the time, all the rules of the house. So now if you go to the kitchen, it's the alarm of the kitchen. You go to the bedroom and it's the alarm of the bedroom. You go to the basement, there's no place in your house that you, you cannot listen to that noise annoying. Not only that, but Dr. Karmy, we know that nociplastic pain, the volume of that sound is amplified. So imagine that you're living now in a house where you can't get out of the house'cause you can't get out of that body. You are feeling the pain. You tried for 20 years, you tried all kinds of treatments. The pain is spreading and the volume of the pain is turned up. No wonder they have depression, anxiety, they can't sleep, they can't concentrate. They call this the brain fog, fiber fog. These people that have this kind of nociplastic pain, they tell me, doctor, I cannot even read your book. I can't watch your videos. I can't exercise. I'm fatigued all the time. No wonder it's like living in a house that the alarm is out of walk. You need to call the alarm company, not the electrician, not the fire department. They come, they will regulate the sensors. Sometimes it's the sensors that are oversensitive. The way I explain to my patients is, you know, imagine a, a birthday cake that you have a kid is turning one and you have only one candle, and that when you light that candle, it calls the fire department and it's makes a big noise. It, it damages your party. That's what's happening to you. It's so rewarding because I can show to them. I put a little bit of pressure in their skin and they say, it hurts. It hurts. I say, yeah, that's because your sensors are super sensitive, like they are sounding the alarm of pain with a tiny little pressure. We need to regulate the alarm system, so I call myself this specialist in the alarm system. So that's the third type of chronic pain. Are there any others? Yeah, so the ISP, the International Association for the Study of Pain, they say there is the nociceptive, neuropathic neuroplastic, and then paying off unknown origin. Like you can still, you know, examine the patient and you don't find anything nociceptive, nothing neuropathic, nothing neuroplastic, and then you say, um, you have pain from unknown origin, which. I rarely, I, I always find some kind of mechanism and actually I find mostly mixed kinds of pain. Sometimes a person has one in three, two in three, or all three. What about internal organ pain? Which category does that fit into? Yeah, so visceral pain , can so inflammatory pain, if a viscera is inflamed, like an appendicitis, a cholecystitis. Then, you know, it's nociceptive but it's interesting that visceral pain, the way that the brain interprets, because the brain doesn't have a good localization of that pain. It's going to create referred pain. So anything, our skin is very mapped. It's very well mapped in our brain. Like if I prick my skin anywhere, my face, my lips, my tongue, my hands, my brain will localize that very well. But anything that is under the skin, including muscles and tendons, including organs, viscera is not well mapped in the brain. So we have a referred pain. Sometimes a person has appendicitis and they may feel pain in the shoulder or in the back. Uh, a person may have a heart attack and, I always joke, I say the, the heart is a muscle and the person doesn't come to emergency and they say, I'm having pain right here in the medial, wall of my heart or in the lateral wall of my heart. They usually say it's in my jaw, my back, uh, but the problem is in the heart. But referred pain is usually at a distance. Even muscles. We know the trigger points in the muscles like trapezius, even though the problem is here in the in the top of the shoulder, the referred pain of that muscle will travel through, up in the head. So, but it's, it could be nociceptive. If, there is an injury there, like a trigger point. A tiny trigger point is a nociceptive kind of pain. There could be sensitizing and transforming into noci plastic. We need to remember that Any pain there is nociceptive or neuropathic can sensitize the pain system. And that's what you mentioned in the beginning. You said chronic pain is pain more than three months, six months. So that after the period that, that it was supposed to heal and now it didn't heal. And, uh, now the pain is spreading an area, which means that now the pain is transforming from a nociceptive or neuropathic into nociplastic pain. So we also have nociplastic pain in the bowels. That's called irritable bowel syndrome. We can have noci plastic pain in the the bladder. That's called interstitial SOEs or chronic bladder pain, chronic painful bladder, chronic prostatitis, like they go to 10 urologists and they have pain in the prostate. They try all the treatments that you can imagine for nociceptive or neuropathic pain, and the pain is still there. It's constant. It's a nociplastic pain in the prostate, in the bladder, it could be in the bowel. So viscera also can have nociplastic pain. That was sort of my, I guess my next comment I was going to make. Very often you see people with fibromyalgia that, in addition to fibromyalgia, will have irritable bowel syndrome, and maybe they'll even have interstitial cystitis, so sometimes some pelvic pain. And uh, what I find personally at least is the treatment for internal organ pains tend to be more difficult than treatment for sensitization of muscles and joints and outside, uh, things. Do you have any thoughts and treatment of, uh, internal organ pain as opposed to musculoskeletal system pain? I agree. I agree. And um I would say , I don't, I don't get a lot of those internal organ pains in my clinic 'cause I'm a physiatrist, so people tend to send to me more that are musculoskeletal or neurological, uh, conditions. So I see more people who have pain after a stroke, after spinal cord injury, after multiple sclerosis or after a fracture. And they, they are not progressing well. So they send to me and then I say, well, the pain is now transforming into nociplastic. So I don't, I don't get referrals specifically for pelvic pain, but my patients complain of those, like they have abdominal pain, they have, uh, cystitis. Then what I tell them is. First, make sure that there is no surgical, no treatable causes that is inflammatory. Like I don't wanna miss like an inflammatory bowel disease like Crohn's disease or ulcerative colitis. So make sure that you don't have those conditions. And then if that has been excluded, we can treat with the same way that we treat neuroplastic pain from other origin.'cause the treatment is the same, is retraining the pain system. It is. Retraining that alarm is fixing that alarm system that is triggering and amplifying things all the time. So it doesn't matter where the, uh, the pain is, the treatment will be the same. To make another comment, just from my general observation for doing this for over 20 years, I will often tell patients that especially fibromyalgia patients, is that often they get diagnosed with medical, serious medical conditions later than an average person. And the reason for that is that pain is the way that our body tells us that something is wrong. But often if you have fibromyalgia and you are always in pain, often the family physician will dismiss. Then you know, the pain is just part of their fibromyalgia. So it's really, I think, difficult for them to have early diagnosis for serious medical conditions. I will actually typically sort of try to teach the patients, to try to understand what's normal for them and what looks different and you know, especially if the pain starts to have some additional nine pain symptoms in particular to perhaps, you know, advocate for themselves a little bit more when they're talking to their family doctor. But in general, I do find, uh, patients with fibromyalgia get diagnosed later than patients without fibromyalgia. You are totally right. Yes. I also have , that concern that, uh, I, Dr. Karmy, this is so important, what you just said, so important because I think the patients, for them pain is pain and for them it's hard to differentiate where the pain is coming from. So it is our obligation. We, as doctors, we need to make sure we examine the patients. We are, you know, doing the physical exams like family doctors, you know, you cannot just dismiss them if they come. Five years later and say, oh, this is all fibromyalgia. No, you need to do your due diligence. You need to do your physical exam. You need to order your labs. Make sure that you are excluding, because they may have something new that is happening. They need to be investigated. Not every time that they show up with pain. And also I think that's really important that the patients. Receive education about fibromyalgia. What is fibromyalgia?'cause they can help themselves. They can say, okay I had a flare of pain, my back. But you know, it's related to, you know, I had a fight with my husband last night and now I'm super stressed. I didn't sleep well last night, so I'll try to relax today. Calm down my pain system, which is regulating my alarm. See if this goes away. And if it doesn't go away, then go to your doctor. Uh, maybe you develop something new like could be an inflammatory arthritis, could be ankylosing spondylitis, could be lupus, it could be something else, but. I think we need to educate the patients that those other disease, like lupus, rheumatoid arthritis, enclosing spondylitis or something else, they have other signs and I like when I am examining my patients, every single thing that I do. I talk a lot during my physical exam because I'm telling them, I say, I'm looking for signs of lupus. Oh, I didn't find anything. Oh, I'm looking for signs of a neuropathy. Oh, I didn't find anything. So I, I'm reassuring them. I'm looking for this and I didn't find, I'm looking for this, and I didn't find I'm, I did this test in your shoulder and I didn't find any signs of impingement. So then they know in my head, I'm excluding things. I'm not just touching them because I wanna torture them, so I think it's important for the patients to know we are doing our due diligence. I put my hands on my patients. A lot of physicians these days, they don't touch their patients anymore. All they do is order MRIs. They say you can't diagnose on an MRI.. But, uh, the other thing I will often tell patients because they know pain, obviously everybody's pain factory, it's up and down day to day, month to month, based on a million different things that seem to impact it. Nobody's pain is stable, but usually after a while people know what their normal is. What are their normal fluctuations and pain? So what I, one of the things I'll usually tell them when they sort of, uh, you know, worried about a particular flare up of pain is have you had this kind of pain before? And this is something you had for the past five, six years, on and off. Chances of it being something life threatening becomes a lot lower than this is something you experienced for the first time. People often say, yes, I had pains before, but this feels different. So that's the types of pains that I think, you know, more investigating because it's very hard to give them hard and fast rule. You don't want them in the emergency department every day because they have pain and they're worried, but at the same time , you don't want the delay diagnosis. So, the closest I come to is to say , is this something you've ever experienced before or is this something that feels like it's new and different? Absolutely. Yeah. So important. So we talked about different types of pain. So then the question is, well, how often do these types of pain occur? So we've got the nociceptive, we've got nociplastic, we've got neuropathic, and then, then we got, uh, pain of unknown origin. So is there any research on that? Yeah, there are, and it really depends on, uh, where you do the research. If you go to my clinic, probably you will see a lot of nociplastic pain there, but that's because a lot of people refer that kind of pain to me, it's not because it's the most common type. If you go to, a different clinic, like a physiotherapy clinic in the community, maybe they see more nociceptive because people seek them first. So it really, we don't know the statistics globally. Like I say, which one is more common because it really depends where you are. You are collecting that data. But in all the pain clinics and , among the chronic people, like chronic pain population. Uh, and there is even neuroscience because Dr. Karmy, if you had been following the new advances of functional MRI mm-hmm. Of the brain. It's amazing. I love, it's so hard to understand those studies, those papers, but it's so amazing 'cause a functional MRI is an MRI of the brain and the brain stem or the spinal cord. But it's different from a picture. It's different from that MRI that we do like black and white. That MRI from like the spine or the brain, black and white and gray, that we see. It's a picture of the brain. A function MRI is is in color and it's like a video. So it's a video of your brain. It is like a how it is functioning. It shows you which areas are light up, which areas are connected. We can see connections between neurons. It's amazing. And now that there are having these tools, more and more laboratories in the world, they are seeing that most people with chronic pain, like pain that is lasting beyond that period of acute pain that you would expect the tissues to resolve are a hundred percent nociplastic. Because in the brain you can see the areas of nociceptive would be more the ous, I think it's the posterior insula that activates when you have acute pain, you see the somatosensory cortex, which is the localization of pain. And in chronic pain, you don't see those areas activated. You see the limbic system, you see the anterior insula, which is responsible for the emotional aspect of the pain. The unpleasantness, you see the amygdala light up. You see the areas of the brain that are more, they look more like depression. So the brain of a person with chronic pain has more similarities with a person that is suffering from chronic major depression than a person that is having acute pain, they're very different. The computer can tell. If the person is in acute pain or chronic pain because it's so obvious in the functional MRI, so we know. Yeah. So that's why the treatments that we use for acute pain, they don't work for chronic pain. So just to clarify, obviously nociceptive pain can also be chronic if, yeah. You know, there's a disc compressing, say a nerve or osteoarthritis of the knee. So there can be chronic nociceptive pain, so when you, but there's also chronic nociplastic pain, uh, or even chronic neuropathic pain. So, what you're seeing the studies where they, just looking at patients with nociplastic pain when they did this dysfunction, MRI or they just took all patients with all types of chronic pain and that's what they saw. Amazing question. So , the first studies, they took a look at chronic back pain. So they, that was, uh, I think the first studies that we saw published on this were , 2004. So we know this since for more than 20 years. And Dr. Vania Apkarian from Chicago, he is, uh, the pioneer of doing this. And in the beginning he was doing only with chronic back pain. Now we have studies for everything, complex, regional pain syndrome, arthritis, migraines, irritable bowel syndrome. Yeah, so the computer can distinguish, like just by imaging if this person is having osteoarthritis, CRPS or back pain, for you to have an idea. And this is computer machine learning, like they need a lot of data, right? It's also interesting that we are not using those images to make the diagnosis yet., Uh, my opinion is that although on average the patterns can be used to separate people in pain, people without pain, people of different types of pain. Uh, you need an average of a very large number of people. If you look at anyone, individual person, then it sort of falls apart. In other words, there's a mean, and then there's a standard deviation in terms of how far people are from the average. And in this particular case, a lot of people can be very far from the average. You're totally right. That's the reason we don't use functional MRI because the person may be having pain. If they say they're in pain, their pain is real, and the functional MRI doesn't show anything, and then they will be labeled as malinger or lying or liars. So that's because of ethical reasons. In the studies we use the average. But we don't wanna make a false accusation that, oh, your functional MRI is not showing anything, therefore you're lying. That would be a terrible use of functional, MRI, which is possible because the brain may not show those images because the computer cannot detect everything. But the, if the person is saying they're in pain, you should believe what they're saying. So I guess part of the reason is functional M MRI is just not good enough to use as a diagnostic tool. It's good enough to use as a research tool, but not as a diagnostic tool. If it had 99% accuracy, we would be using it. Yeah. Yeah. I think that's the next question people ask me, why don't you do a brain image of my brain and tell me what kind of pain I have? It's because, um, can I tell you a story that I think, uh, it'll illustrate really well why we are not doing this? You probably know in 1998 there was a report in the BMJ in the uk. So a doctor wrote this case report. What happened was there was this construction worker, 28 years old, I think he was working construction, wearing his boots, and then suddenly he stepped on a nail, you know those long nails, like a 10 inches, I don't know how many inches, but very long. So he stepped on the nail, it transversed his boot and he looked at his foot and he could see the tip of the nail sticking out, on the top of his boot. He started screaming. His colleagues tried to remove the nail, but every time that they tried to remove the nail, he screened, so they took him to emergency. So the emergency doctor is the one who published the case and they had to give him fentanyl intravenously and midazlin. So fentanyl to remove his pain and midazlin to sedate him, , so they could remove. So they removed the nail and then they removed the butch and there was no injury to his skin. The nail had passed between the toes. Okay. No, no, not even a scratch. No tissue injury at all. No tissue injury at all. So this was a, a classical example of acute nociplastic pain. Because who, first of all, I have patients who criticize me or on they write comments on my social media post saying that I'm crazy and I'm telling that the pain is not real. I'm telling them that the pain is imaginary. I say, no, no, no, no. Nociplastic is very real. Who is going to say that that construction worker did not have real pain. He had real pain because his brain saw, that's what I'm saying. The brain is always integrating the sensations, the brain, the vision, saw the nail, his skin probably noticed, you know, there was a touch sensation, so the skin probably noticed that something was there. So he got sensations from the skin. He got his vision, he got his colleagues around him screaming. So he, he had some, auditory feedback, so vision, sound, sensation. So when the brain integrated, all of those sensations sounded, the alarm of pain, that was acute nociplastic pain. Brain is guessing at things. Always, so that's the message. The brain is always guessing if there is a danger or not. If the brain decides that there is a danger, it'll sound the alarm. And if you don't do anything about that alarm, it'll amplify. It'll make the alarm louder and louder and louder and louder. That's central sensitization. So let's maybe, I guess to the crux of the matter, and that is we have all these different types of chronic pain and patients will often go to pain clinics where things get done to them. Where like in my case, you, you know, my type of clinic, we do a lot of treatment of patients with nociplastic pain with things like nerve blocks, trigger point injections, et cetera. But there's on top of it, often that's not sufficient. That can, might move the needle in the right direction, but I find in general it is not sufficient to really give people high quality of life where they really able to do what they wanna do to do. So, you know, I think a lot of the focus is on what can patients do themselves to make their life better, make their pain less severe. And that goes back to things like lifestyle interventions that goes back to mind over matter approaches, even go to things like exercise, and then goes back to maybe even supplement. And then of course , what it sounds like you're telling me is that depending of what type of pain you have, these lifestyle approaches will differ. So, do you have any sort of takeaways, any insights that you can share? Yes. Absolutely I have, this is what I spend most of my time, uh, doing. Uh, I would say those nerve blocks injections. I also indicate, and many of my patients, I send them to my colleagues who do interventional. If I identify a nociceptive or neuropathic pain, they're great. As I said to you, many patients have mixed pain, but for noci plastic pain the treatment is completely different. It's completely different. You need to think again about the the mechanism. What, why is the brain sounding the alarm when there is, you know, no danger in the body. There's no short circuit and no, no damage. So the approach we use is first, uh, diagnose that this is the kind of pain. Say you have nociplastic pain. You do. I have no doubt that you do. So even though the pain is coming from this region of your body, the damage is not there. Your brain still thinks that is damaged because there was a memory of pain there. But let's stop focusing there. We now need to think about how can we calm down this alarm? So how can we retrain your alarm system to stop sounding the alarm? So the first session that we spent with them. We explain the neuroscience of pain. We give them like these examples that I give to you, the alarm, the candle, that lights up, the alarm, and they calls the ambulance, the fire truck so they understand. Okay, so you know, a person with fibromyalgia or person with CRPS or a person that has chronic back pain, but they're not responding to blocks anymore, they're not responding to, neuropathic pain medications, it's because their pain now is nociplastic. So you need to stop focusing treatments in that area. So you need to say, enough, I'm not going to do more injections. I'm not going to do more blocks. We are going to stop doing things there. We are going to retrain your pain system to understand. You are going to convince your brain that ar that area of your body is strong, it's healthy, can move normal. You can do anything you want. You can dance, you can swim.'cause I examined you.. You don't have any damage there'cause they're afraid to move. Like for 20 years they were told, don't move the lower back. You're going to damage more. Now for them to unlearn and redo. This is all synapses Dr. Karmy, we are using neuroplasticity. That's why the name is plastic because if the brain created those synapses to protect you like it's not your fault. The brain just created those synapses and sounded the alarm to overprotect it. Now we need to create new synapses here to say your brain, you are safe. You can actually do anything you want. There is no restriction. Dr. Karmy, I had never had so many good results in my pain clinic. Then after I started approaching nociplastic pain this way, I have patients that with a few sessions, they ask me, but Doctor, I was told that I could not do anything. I said, no, you have, you have my permission. You can do anything. What do you wanna do? I wanna dance. I said, okay. You're going to write here when you're going to dance. How many times they come back to me, Dr. Karmy? They say what a difference, what are now, they started moving again. So now what a transformation. Dr. Karmy. Now these patients, they come back to me and they say, I'm moving again. I'm leaving again, and I'm taking care of myself. I know what to do. So now they understand the principles of nociplastic pain is basically to calm down that nervous system that was amplifying pain, that was central sensitization to retrain everything. So activating the vagus nerve is essential. A good night of sleep is essential. I teach them how to open the brains inner pharmacy. I say you have a powerful pharmacy inside of your brain. Let's open that one. You need to release those endorphins, serotonin. You need to release that dopamine endocannabinoids. You can produce your own endocannabinoids. And how do you do this is with healthy lifestyle, as you said. You know, keep moving. Start moving again. Sleep a nutritionals diet. Lose some weight. If you're overweight, quit smoking. Reduce alcohol, 'cause alcohol and smoke are terrible for your pain system. Uh, and work on your emotions because a lot of our brain will sound the alarm of danger because we are stressed. If you're hypervigilant all the time, then your brain is going to sound the alarm. Also if you carry traumas PTSD or adverse childhood experiences, this means that your brain, when you were growing up was used to stress like a, a child that grew up in an adverse childhood environment. They trained their brain to detect danger. How they did, that's how they survived. It's a survival mechanism. So now they are an adult that is looking for danger everywhere and trying to overprotect you. Guess what the brain is going to do with a minimal sign of danger. Oof is going to sound alarm. So that alarm could be a tachycardia, like a heart heartbeat. It could be a fainting episode, it could be a panic attack, but it could also be a pain. Pain in the neck, a pain in the back, a pain in your shoulder, pain here, but the brain will try to talk to you, to tell you slow down, calm down, take care of yourself and you may use the pain, has a language to talk to you. Ah. Dr. Furlan, also has a lot more ideas and details about this topic. She , uh, written several books and she has a very popular YouTube channel that provides a lot more information about this. Thank you, Dr. Furlan for joining us on the podcast. Thank you so much, Dr. Karmy. As you see, this is my favorite topic to talk. I could be talking to you forever and ever, , but I wish your audience, the best and I hope that this, uh, information will help them to understand better what's going on in their bodies. Thank you so much for the work that you do and disseminating all this knowledge. Thank you. So what are my final thoughts? Well, first of all, I wanted to clarify a couple of things. Dr. Andrea Furlan is an academic pain physician and in the context of academic pain centers high frequency nerve blocks are not used. Typically in academic centers, nerve blocks are used for compressed nerves or inflamed joints, so they're primarily used for nociceptic pain. Typically the injection is performed with x-ray or ultrasound guidance, and typically the injection is performed only once. If the treatment is repeated it is typically repeated in three to six months, or sometimes nerve blocks are just used diagnostically to figure out if a nerve is a source of the pain, followed by destruction of this nerve with radiofrequency ablation. This is in contrast with high frequency nerve block system as practiced in the community setting. High frequency nerve blocks done on weekly basis are actually used to reduce peripheral and central sensitization or, uh, nociplastic pain. High frequency nerve blocks actually work in a complementary fashion to mind over matter techniques. Nerve blocks are trying to reduce the pain signals that are bombarding the brain and causing these anatomical changes in synapses and sensitization where as mind over matter approaches are trying to separate the pain signal that the brain receives from the anxiety response that these signals generate, which actually make the pain the unpleasant sensation. Both of these approaches can be helpful, and both of these approaches can change or reverse the anatomical changes in the brain. However depending on a patient, some respond only to nerve blocks and have no response to mind Over matter approaches. Some respond only to mind over matter approaches and have no response to nerve blocks. And then there's the group that have a partial response to each. So my typical advice to patients when I see them is not to dump approaches, which through trial and error they found useful in the past, before adding a new approach, but rather wearing on new approaches. And to the old approaches, which they found helpful over time. Obviously, if the old approaches did not help the patients at all, then those approaches can be stopped. In the unlikely event of the new approach being so far superior to the old approaches that the pain almost completely goes away, then of course they're welcome to get rid of everything and just stick to the approach, which works the best. But the most common situation is that patients with nociplastic chronic pain use a combination of different approaches to improve. Also, I do not want to leave you with the impression that if you just tell yourself that you have no pain and start doing all the physical activities you used to do before the pain started, you will have a, good outcome. The point is that nociplastic pain is not a pain you are imagining it is a pain caused by anatomical changes in how different nerves are wired up together. And if you just go back to doing activities you used to do before the pain started, you will have a very severe flare up of pain, which could last weeks. A more realistic approach is to just start with very light activities and light exercise, and then gradually increase it by 10% every couple of weeks as long as you don't get a flare up after the activity. So while in the long run, setting a goal to participate in certain activity is reasonable. The short-term goals should be realistic and based on your current activity levels. It is a slow progression, kind of like training for a marathon, rather than just waking up one day and saying to yourself, yes, I can run a marathon today without any prior drink. So to sum up I think that Dr. Furlan created a very valuable body of information on how you can take charge of your pain, and I would encourage you to look at her YouTube channel and perhaps look at some of the books that she has published. She is also a practicing physician, so if some of these approaches resonate with you, you can also ask your family doctor to refer you to her for an assessment. I do not know whether or not these approaches will work for you. But they have no risk, and therefore, in my mind, they're worth a trial. Thank you. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.
