Unpacking: How Social Factors Shape Chronic Pain Journeys

Megan: 00:00:00

What was found is that it's not your race that contributes to your predisposition for developing chronic pain. It has so much more to do with your zip code.

Intro: 00:00:18

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

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

Holly: 00:00:53

Hi, Megan.

Megan: 00:00:55

Hi. So happy to be here. I can't believe we've made it to episode four.

Holly: 00:00:58

I know, it's just rocking and rolling and we have so much still to unpack. So I'm really thankful to anyone who's listening and stepping on this journey with us.

We're just finding so much passion in these conversations and so much that we want to cover with you all. We almost can't. We probably can't have enough episodes to, to like, get through everything we ever want to discuss.

So we're going to keep it going as long as you're with us. And last episode I thought was such an important thing to dive into and, you know, it's not going to be the only time we talk about it.

But just to revisit for a moment, we really dove into the psychological elements of things.

You know, rare chronic pain shows up in our brain chemistry, the changes that we go through and how it starts to impact things like depression and how we experience anxiety. I just, you know, again, I feel like it's such a big topic that we're probably going to pick it up again in the future.

But I'm so glad we sort of segued into that at least.

Megan: 00:02:06

Yeah, absolutely. And I want to clarify that when I talk about the pts of the future and the fact that they incorporate psychological principles into their practice.

I don't mean to say that I think physical therapists should be talk therapists, but I, I think if we really are truly practicing the biopsychosocial care that we hope to and claim to and oftentimes just give lip service to, we need to recognize that people have thoughts and feelings and cognition and emotions that are contributed to from their pain and contribute to their pain. So, you know, sometimes physical therapists like to say, oh, no, no, I don't deal with that. I'm a neck down physical therapist.

And, and really, if you're practicing whole person care and holistic care, you can't really separate the two.

Holly: 00:03:02

Yeah, I really appreciate that.

I, I've found from personal experience that when there is an acknowledgement of my mood, my feelings about my pain by a practitioner, be that an orthopedic surgeon whom with whom I'm consulting, or a PT who I'm working with on a weekly basis, it change is my relationship to them. Very much so. And, but I also, but I hear you.

At the same time, I understand you're saying this is not a replacement, it's not a one to one, you know, but it's not a zero sum game. I think one of the things that we've started to touch on and we'll expand into particularly today, is that it takes kind of an entourage.

It takes a village. Right. So it's your physical therapist, it's the talk therapist, it is your family, your support system around you is all of those things.

Megan: 00:03:59

Absolutely. And really, for a long time we said there's physical pain and then there's emotional pain. And those two things are different.

And now we know that they are very intimately connected.

And if we hope to recover from things like persistent pain, it's very likely that we'll need to draw from all three pieces of that three legged stool that you mentioned.

The biological or the physical body, the psychological or the cognitive emotional body, and the social factors, which is what we're going to talk about today.

Holly: 00:04:34

Yeah, I think it's really powerful that we're having these conversations because I think for a lot of people suffering from chronic pain, they're trying to get away from it and it can sometimes become almost counterintuitive to go deeper into your feelings. It's like, no, I'm trying to, you know, get a break from this. I'm trying not to keep this at the front and center.

And yet, you know, I think what we're, what we're really Learning from you, Dr. Megan, is that for persistent pain over time, that chronic pain that we really do have to open ourselves up to the emotional side of things, the psychological leg of stool.

Megan: 00:05:13

Right. And, and not to go too much into last episode again, but I, I often relate it to people like that term paper that you're avoiding. Right.

You know, it's due at the end of the semester and it's kind of hanging out there in the back of your mind and in your mind it just gets bigger and bigger and bigger and bigger and bigger until you sit down to start writing it and you realize, oh, it's not that big scary monster that I had built it up to be in my mind. And maybe I Can start to tackle this bit by bit.

Holly: 00:05:48

Yeah. And I feel like 10 times out of 10, we always wish we'd just started sooner. Was like if I had just, you know, so it's start anytime. Start today.

Let Dr. Megan and me help you kind of step into that.

But as you said, we've got three legs on this stool, and we went deep inside the mind last time again, we're, we're going to continue to explore those topics in future episodes, but for today, we're actually going to kind of step outside of the mind and go into our social network, our social surroundings and all of those social factors that comprise that third leg of the stool in that sort of tri. In that sort of trifecta model around understanding chronic pain.

So can I first start, Dr. Megan, by just asking you to help us understand why social factors even fit into this equation? Why is that the third leg of the stool? Sure.

Megan: 00:06:50

And I think maybe a good place to start would be to define social factors. What are the social factors that contribute to chronic pain and also chronic disease?

And so some of these things are your living status, is it stable or unstable, your health insurance or lack thereof, your language and, or potential cultural barriers when dealing with healthcare, your employment status and job satisfaction, previous pain experiences, and how you've observed your primary caregivers deal with their pain in the past. Social expectations. So expectations from your family, from your culture, from the world around us, and your social support systems.

So who helps you, who gives you that support? Who gives you that emotional support? Those types of things all contribute on both sides of the, of the pain picture.

Holly: 00:07:57

And do we know that based on, like, where, where did this kind of start? How, how did pain research start really even identifying that these social factors were at play?

Was there kind of one catalyst or one thing that opened it up in the beginning, Like, I don't know, like geographic location or something like that?

Megan: 00:08:20

I don't know that this was the first thing that opened it up, but I do know that race played a role. So when we're trying to figure out who has more pain, is there more prevalence in one type of person or not?

We do know that women, by and large suffer from chronic pain. They make up about 70% of the people that suffer from chronic and persistent pain.

s,: 2000

By some genetic factor, is there a biomarker that we could identify and that would drive some treatment options? And so they looked into this and they found actually that white women were not the most commonly affected with chronic pain.

They were the ones who had access.

So they were the ones that were showing up in clinics because they had healthcare and they had the ability to take time off work or, you know, get someone to help with childcare, those types of things. So these were the people that we were seeing.

And so it was that bias of, well, these are the people that are showing up, so this must be the population. Right.

But it turns out when they dove into the literature that actually people of color, this is in the US Are more likely to experience chronic pain. And then they did different types of data analysis with these studies where they said, well, maybe there's a factor in this that contributes.

And so can we look at the data again and see if we can ferret out if there's something specific? And what they found is when they controlled for socioeconomic status, so they took that factor out.

Chronic pain seems to affect all the races equally. Yes, you are right to give a. Hm. There.

Holly: 00:10:38

Wow.

Megan: 00:10:39

Okay.

Holly: 00:10:39

This is huge. This is really important.

Megan: 00:10:42

I thought that was kind of interesting as well. And I posted a bit about this on my Instagram. My Instagram is Pain Science, Prof.

Holly: 00:10:50

Pain Science Prof.

Megan: 00:10:52

Okay. Yeah, sure.

Holly: 00:10:53

I. Yeah. Because even though I follow you, I don't know what I. I wouldn't. Wouldn't know how to tell someone how to find you.

Megan: 00:11:00

Then there was literature that analyzed that literature to say, well, can you really take socioeconomic status out? Can you. Can you take that out of someone's existence?

When certain groups, at least in the United States, have been systematically kept from these higher income brackets, you really can't. And so what. What was found is that it's not your race that contributes to your predisposition for developing chronic pain.

It has so much more to do with your zip code.

Holly: 00:11:42

Okay, this is blowing my mind. So zip code.

I mean, we've mentioned, we talked about geographic location in general, and I was thinking from really macro perspective, like cultural, which is part of it too. Certainly in certain parts of the world, pain is. It's shameful to express or to, you know, to. To show pain.

But we're talking now almost kind of more micro. Like, we. We can really pull this down to a map in even one particular geographical region, like, say, the.

The San Francisco Bay area, where you have a huge chasm. Right. Like there's a zip code that has tons of money, and right next to it might be a zip code that has none of the.

Megan: 00:12:28

Right.

Holly: 00:12:29

Yeah.

Megan: 00:12:29

And it's not that hyper specific.

But what we see is larger swaths like the southeastern United States have a much higher prevalence of chronic pain, a much higher prevalence of opioid addiction, and they have lower socioeconomic status and lower education levels.

Holly: 00:12:53

So it, the socioeconomics are part of the zip code element.

So what, you know, and like you're saying it may not be as minute as a zip code, but we're, we're seeing, you know, sort of these trend lines that, that roll alongside socioeconomic status. What are some of the reasons why just to really unpack this and make sure we're really giving this.

The, the respect that this important topic needs is what are the parts of socioeconomic depression or disadvantage that would actually make someone more susceptible to chronic pain? I mean, one comes to mind, like access to doctors, just, you know, like, or insurance. But tell, tell us more about that.

Megan: 00:13:42

Yeah. So living status, access to healthcare, things like food deserts. I used to work in like northern Orange county, kind of Santa Ana, Garden Grove area.

And I had a patient once who said, all of my food comes through a window. Oh, wow.

Her living situation was such that she was not really able to go into her kitchen and her home because of some of the factors that were going on in her house. And so she had to get all of her food outside of the house. And financially that meant that all of her food came through a fast food window.

And we know that food contributes to inflammation.

It contributes to glial cell activation, it contributes to neural inflammation, all of which ramps up chronic pain and contributes to things going on longer than they would otherwise.

Also, just the fact that there are these chronic stressors, we don't have exactly a perfect understanding of what types of stress lead to what types of disease. But we do have a fair body of evidence that's growing that shows us that chronic stress puts you at higher risk for many chronic diseases.

Heart disease, diabetes, as well as chronic pain. We talked a little bit last time about the bandwidth. You know, if my, if my window of tolerance is here, then my bandwidth is pretty good.

But if I'm stressed because I don't know if my job is secure, if I'm stressed because my home life is insecure, my housing is insecure, I don't have a support system, all of these things contribute to a lower bandwidth.

So a seemingly minor injury might then become much larger because it's not allowed to heal, because maybe I Don't feel comfortable taking time off of work or I don't have access to healthcare. So I can't get care for this until it gets to the level where maybe I need to go to the emergency room. And then it's become a much bigger problem.

Holly: 00:16:02

It occurs to me as you're.

As you're describing this, that the more stressed we are, particularly when it comes to money or job insecurity or the combination thereof, that the last thing we tend to do is focus on ourselves. That is the first thing that can fall by the wayside. It's like, you know, and I've experienced this just on a much less serious level.

Things like, you know, depression and chronic pain kind of taking over. And I think I didn't have time to clean my house right now. I'm not, you know, I'm not paying attention to the, you know, this. Is this the last thing?

Or I don't have the energy, you know, or. Or money or ability right now to go get body work, even though I really need it. So when.

When an individual or individuals are facing serious economic, socioeconomic challenges, they're going to put themselves last until their body won't put up with it anymore.

And then to your point, they find themselves, like, really behind the eight ball now, instead of coming to see a practitioner, when they're in, you know, more treatable phase, they're deeper in.

Is that what you tend to see is like, once they are getting treated, you know, individuals who are challenged like this or are in, you know, maybe arguably worse shape, you know, with their injury at this point.

Megan: 00:17:31

Absolutely. And I talk to people about it, like, if.

If it was a cavity, you know, and if you took care of it when it was a small cavity, I don't know, is it $150 now? But if you let it continue and progress and progress, that decay spreads. And now you need a root canal. And that's a much bigger issue.

And that takes longer, and that's more painful. In the case of chronic pain, the longer I suffer with something, the more my nervous system learns that pathway. That's right.

Holly: 00:18:06

You taught us that a couple episodes ago. Yeah. Okay.

Megan: 00:18:09

And so pain is a learned response. We learn about it through our past experiences. We learn about it through watching our caregivers, and we get more efficient at it.

And so you need less and less stimulus to sound the alarm or to send that signal. And so the longer I go with something, the more sensitized my nervous system is. And typically it takes a little bit longer to kind of Walk that back.

Holly: 00:18:43

Well then we're really dealing with this vicious cycle because to your point, food, the food sources may not be of the highest quality or the healthiest. And by the way, my little caveat, when I make a face about food through a window, it isn't to demonize fast food per se.

That's, that's not my intention. It's really more, I cringe because I know how negative an effect that food has on a body in pain.

So particularly just that, that driving that inflammation. And it's like I just, I just, I, I feel the pain. I almost can feel the effect of what that food does, you know, on the body.

But so it's, it's like kind of going in this full circle, it's this perfect storm really of, you know, socioeconomic challenges or depression can mean little access, whether it's to practitioners and, or insurance, combination thereof, healthy, non inflammatory foods, even just the ability to take half a day off to go see a doctor or the wherewithal through all of that mental stress to say, I have to prioritize myself, I'm going to take care of myself. So you know, I, where can, where can people start around that with, you know, are there other tools and things that they can leverage?

You know, maybe at home, you know, as they're starting to find their way through the chronic pain journey and someone says, look, I'm not made of money and I don't have tons and tons of time.

You know, even, even people who aren't struggling terribly social economics economically still feel a deficit in terms of, you know, their abundance of, you know, time and money. Like we all, you know, except for maybe Jeff Bezos, we wish we had more of it. And you probably hear that in your practice to some extent.

Are there some things that you try to tell your patients who you can tell, even if they have the means, they're just not dedicating enough time and resources to their wellness. How do we fix that?

Megan: 00:20:57

Yeah, absolutely. And I think like you say, the, the research is shifting this way, it's taking some time.

But there is more and more research coming out that helps to understand how we can help people. There was just an interesting study that came out that I was alerted to on my LinkedIn in my biannual checking of my LinkedIn account.

At least you do. I should do that more often. But it was titled Integrating the Multidimensional Data analytics for Precision Diagnosis of Chronic Low Back Pain.

So that's a mouthful.

But basically they looked at the variables that contribute to people I either A, getting better and recovering or B going into chronic low back pain after an acute bout of low back pain. So they, and they put them in order of importance of how important each factor is in contributing to chronicity of low back pain.

Number one was social function, and number two is psychological well being. Number three is an intervertebral disc herniation at L4, L5.

And we can put this, this paper in our show notes so that people can look it up if they want, but social function is number one. And that I think having an understanding of that and having a recognition of that as a clinician is really important.

And I talk a little bit about this too on my page of some of the social prescriptions that I've given to patients in my practice, one of which is going to the local community center and getting involved in a dance class, in a quilting class, in a book club. Whatever it is, it doesn't have to be a high cost situation, but you need to have some sense of community.

Holly: 00:23:01

Okay.

Megan: 00:23:03

And what the research shows us is that having a social support system tends to buffer against some of these chronic pain changes.

Holly: 00:23:15

So this could actually, I mean, is it too bold to say that community or belonging is medicine?

Megan: 00:23:23

I don't think so at all. I don't think so at all. And I'm hearing more and more clinicians, physicians and otherwise talk about social prescription.

We are social beings and we need to be around other people.

And that's partly why we saw such terrible outcomes during COVID We saw people's neurocognitive decline that was so much more pronounced than it would normally be, especially like elderly people that were very isolated. We saw people dive into depression and we saw chronic pain exacerbate tremendously. And social support really does act as.

There was a. I'll put a systematic review also in the, in the show notes about how social support buffers against chronic pain. And the mechanism that they think this happens through is the activation of the safety centers in our brain where it's same.

Holly: 00:24:31

Okay, now I'm really tuning. Okay, so it's not just as simple as community and belonging, which are very, very deep.

But, but, but actually, scientifically or biologically, there's something happening to the brain.

Megan: 00:24:46

Yep, absolutely. And only recently have we been able to find out why that is. And chronic pain really is an activation of our threat detection system most often.

Holly: 00:24:59

Right.

Megan: 00:25:00

And so this makes sense as to why social.

Holly: 00:25:07

Like belonging and connect.

Megan: 00:25:09

Yeah, social support.

Sorry, I could not find that word that makes sense as to why Social support would buffer against this because it helps us to not go into that threat detection mode.

Holly: 00:25:22

I, I find this so fascinating and so inspiring, honestly, because it is really hard sometimes to break yourself out of a cycle of aloneness and self protection. And it's like I use the phrase I get low. Well, when I get low in terms of feel down, I also get low, as in like a ski tuck.

You know, like, I physically feel that it's time to kind of curl inward and protect myself. And I almost wait for the storm to pass and you know, there might be a friend in the neighborhood who's willing to go on a walk.

Or I look at my dog and I know that he could use another walk. And I tell myself, tomorrow when I feel better or the next day when my pain gets better, I'll go do that because I'm not okay today.

And it's the hardest thing for us sometimes to actually open ourselves up when we're in that very vulnerable state. And I'm so grateful to you for explaining also what's happening kind of biologically or whatever the right word is in the brain.

Because when we're in pain, that lack of safety is, you know, that, that sort of danger, danger, danger signal is firing. Right? So it's like we feel like I, you know, okay, now it's time to protect myself.

We're not thinking about, you know, going on a walk, but maybe what we need to do is reframe social support as instead of a nice to have. It is a almost like a medicine.

We're saying that it is going to have an actual impact on your brain function which will impact how you are experiencing pain. Have I gone too far there?

Megan: 00:27:17

You have absolutely not gone too far. And that is absolutely true. And I want to just give a quick tip for anybody that's feeling that kind of self protecting curling in.

Well, I do want to say two things about that, actually. So number one is we think about posture a lot as physical therapists and we blame a lot of things on posture. And oh, your neck hurts.

That's because your posture's bad. Da, da, da, da. It makes me like furious with my students when they try to say posture because I'm like, no.

In part because a lot of times we assume postures to protect or to avoid pain. And so you can't say posture is the cause. That's like saying anxiety is the reason.

Like, well, why do you have anxiety and why are you assuming that posture? So that's my little soapbox on posture. But we can Unpack that another day.

But what I wanted to say about when you're feeling that I need to pull in, I need to isolate, I need to wait for the storm to pass.

One quick, safe potential option is because our brains are also so incredibly powerful, we don't actually have to physically be with our safe person or the person that gives us the warm and fuzzies. I can simply close my eyes and visualize the person that is my home, that is my safe zone, that is my heart, whatever you want to call them.

And that has been shown to lower your pain experience in the moment. Wow.

Holly: 00:28:54

So that visualization, I mean, it's almost like it reminds me of. There's a. Dr. Tara Brock is a, a professor and sort of psychosocial, cognitive. I'm probably not doing her full service.

She wrote Radical Acceptance and has led some incredible talks. She' a really sought out professor in the United States.

But what she has talked about is the power of visualization in calming that kind of screaming inner child.

And so when we're upset or when we're finding that, you know, we feel that we can't sort of stop the brain from replaying something negative over and over. She leads us through really powerful visualization. And it's almost like we need to take that same principle and apply it to the screaming pain. Right.

So it, I might use that technique. I might have used that technique after, you know, someone cut me off in traffic.

But you're also saying, let's use that technique when our pain is flaring up. It's, it's almost kind of the pain, the chronic pain equivalent of being cut off in traffic. Something spikes, you're in it, you're feeling it.

And if you just can't make it out of the house that day, or if it's not practical because of your work schedule, your kids, your household, your, your everything. You're saying, Dr. Megan, that we can visualize, visualize that relationship, that, that companionship.

Megan: 00:30:30

I don't know that that research has been done yet, but I, I think that if you can think about the person or you think about a time when you were with that person or things you like to do together, I think that can be really powerful. They have also done research with strangers.

And so they had someone in an MRI that gave them a pain stimulus and they had someone that they had just a very brief interaction with. And even having some, someone around that they didn't have a close relationship with lowered their pain perception in the moment.

It was improved when it was someone they loved. And it was improved when the relationships were deemed healthy and that they had been going on longer.

So there is some evidence to support it should be someone that you really have a great positive relationship with. But having someone there has shown to have an impact as well.

Holly: 00:31:31

So I'm wondering if we could chat a little bit about how we're supposed to handle or the complexity of handling social relationships while living with chronic pain. Because sometimes our relationships do suffer, or it's the thing that we don't mean to let slide. But it does slide. Right.

But, you know, we could be that. And it's likely that we're also dealing with job stress, which we also. We also need to talk about.

It's a big piece of this whole social factor element. But so there's job stress and there's, you know, kids and responsibility in the household and financial stress.

All of that can sometimes, even without chronic pain, put a strain on a friendship or a community, and you just lose touch with people. Even more so when you have chronic pain, sometimes we lose the.

I don't know if it's ability or just inclination to talk about our pain with the people in our social network. I think because of the fact that chronic pain sticks around for a while and it becomes a stale topic, if you will.

It's not like something major that happened in life, like a, you know, if. If a friend of mine had, you know, some.

Something really difficult happening with one of her children, it was an episode, you know, that took place at school, and it was, you know, creating a big issue. I'd continue to follow up, but probably two years later, I'm not still thinking about what happened with her child on the playground that day.

We're not still talking about that.

And sometimes chronic pain just sort of fades in to the background of everything, and we forget, number one, if we're not in pain, we forget to ask a friend, how. How are you doing with your pain? And number two, as the pain sufferer, we kind of zip it. You know, after a while, it's like, I'm. It's been years.

I'm not going to keep bringing this up. Do you think that that's part of it? That sometimes chronic pain sufferers really stop talking about it? Yeah.

Megan: 00:33:43

And. And a lot of that has to do with, you know, how comfortable you feel with your social circle and how comfortable they feel with it.

You know, if they're a friend that's there for the good times and they want to go on vacation, but they're not a friend that's you know, really wants to help you through the tough stuff.

That's probably not someone that you want to visualize when you're trying to help yourself in a pain flare, but especially with chronic pain, because it oftentimes is an invisible problem. It's really hard for other people to understand, and especially if they have never experienced that themselves.

And then sometimes, you know, they want to give you things that worked for them.

And that's something that I hear pretty consistently from people who've suffered from chronic pain is, oh, you know, they're telling me to do the hot packs. They're telling me to do the ozone.

They're telling me about this, that and the other that work for their cousin, sisters, brothers, uncle, niece and nephew in Michigan. You know, like, that can be really hard. And so I think some of the narrative around it now has been helpful. Things like spoonies.

I don't know if you're familiar with that term.

Holly: 00:34:57

What's spoonies?

Megan: 00:34:58

So people are using it with things like chronic pain and chronic fatigue. So they say, basically, I have a certain number of spoons every morning that I am given, and I can use them however I want.

But when the spoons are gone, they're gone. So I need a spoon to shower. I need a spoon to get the kids ready for school.

I need a spoon to, et cetera, et cetera, get myself ready, whatever it is. And then they say, I'm out of spoons today. And that can be one way that you can relate it to your social circle of, you know, I'd love to go.

I'd love to be able to attend this, but I woke up with only three spoons today. So.

Holly: 00:35:43

I really like that idea. And I use a different metaphor of a gas tank. So whatever kind of works for you. But I think we have to.

We have to really think about if we're living in chronic pain, how to explain to the people we care about and who care about us. We have to explain to them how we want to be seen and talked to. Honestly, it's. It's a. It's a. It's a hard sometimes conversation to broach.

But we find that often friends who know that we're suffering naturally want to fix us, right? That it's. It's not because they just want it to go away. They don't want it to be a problem anymore. They want the problem. It's.

It's really because they. They want to have agency in something that can actually feel quite. They can feel quite helpless.

And I find that's Oftentimes why I'm hearing, you know, these, these suggestions of, oh, my brother is dating a woman who went to high school with the number one shoulder doctor in the country.

And if I had a buck for every time someone's told me they know the number one shoulder surgeon in the country, I, you know, have an all expense paid trip to Fiji. So, you know, the spoon thing is really interesting.

I mentioned I use a tank of gas, which is, I feel like living with chronic pain means that I can still rev up, you know, to, and use all my horsepowers and really fire, but I only have a half a tank, so I'm gonna poop out faster and my car is gonna end up having to pull over for a pit stop before anybody else. And so it's about like, if I only have a half a tank of gas, you know, how many stops can I make? Sort of like your spoons, right?

It's like I can go to that dinner party, but that is going to use up my entire tank today. And so you have to kind of think about that.

But back to expressing that to friends and family and actually even co workers, which I want to segue into in a moment about work, you know, career and that part of your social network, how might we phrase it, Dr. Megan, where we might find ourselves in conversation with someone who cares and say, look, there are going to be times where I'm going to mention my chronic pain and I need you to know there's no need to try to fix anything that I, I just need you to.

Megan: 00:38:16

What?

Holly: 00:38:16

I need you to listen. I just need you to be there. You know what, what's an example of.

Megan: 00:38:21

I think that's a perfect way to say it. You know, I'm, I'm not looking for help. I'm looking to be seen. I'm looking to, for a witness. I, I. Could you just sit with me in this?

And like you say, not everyone can or is willing to do that. And that's more of a reflection of what's going on for them, which is hard for us not to say, why don't you care about me enough? Right?

But really, someone may say, this is above my comfort level. This is above my tolerance level. I may have had a sick family member growing up or I just may be so terrified of illness.

You know, there are many, many reasons why people can't, cannot be your witness in that moment. And it's also okay for you to have a boundary to say, I can't. I have a hard time being around you when I'M not at my best.

Holly: 00:39:20

Ooh, that's pretty powerful.

I think there's an element that we have in some relationships and some friendships where there's an element of performance, you know, where it's like you, you do want to show up as your best self.

It's not because it's not a genuine relationship, but because, you know, maybe that's just the energy that you share with this friend is that you kind of bring your best selves to that, that beer that you grab.

You know, once a month, guys get together, you know, after a game or women get together for lunch or what, you know, not trying to gender our activities, but you know what I'm saying, where, you know, you, you may not see each other frequently enough. And so when you get together, you really want to bring all your positive energy.

And I find that really exhausting if I have to skip over, you know, multiple times. Like, I always need to kind of show up with my A game in a certain friendship.

And if I happen to be having an off day about pain, it's like, gosh, I, you know, I'm gonna have to kind of mask this. And that gets really exhausting.

So I love how you expressed that, where you can let somebody know, hey, I'm, you know, I'm not, I'm not at my best today. And sometimes I, you know, don't, don't really know how to show up in our friendship when I'm not at my best.

And it could really open up an interesting conversation. Actually. You may be inviting your friend to share something about themselves.

And like you mentioned Dr. Megan, their upbringing or something where you find that, you know, they had a really sick parent or a vulnerable, you know, whatever it is in their culture that just made talking about pain wrong. Right?

Megan: 00:41:03

Yeah.

Holly: 00:41:04

I think for spouses also, like the fact that you live with that person. If you do live, you know, full year around with your spouse, they see and they can pick up on the suffering without you even having to mention it.

And so sometimes it just ends up being this low lying thing that's just kind of running through the relationship, but it's never getting talked about because it's just ever present. And we have to sometimes grab moments to actually bring it back to the surface.

You know, I have to remind you, my husband, who's so supportive and so loving and aware and evolved about all this, but I still have to remind him sometimes, you know, when a day is particularly difficult for me, you know, so it doesn't just kind of fade into the background.

Megan: 00:41:54

It is. It's really hard for people who are not going through it themselves.

And it's just hard for people to understand if they don't have a personal history with chronic pain. And even for people that have a history of chronic pain but aren't in pain in that moment.

You know, oftentimes we think when you're done with being in pain or when you heal from chronic pain, you're going to have this hallelujah moment where you throw the crutches down and you dance in the aisles and I'm free. Yeah, really. More often you say to someone, oh, how's that?

And they go, oh, yeah, because we're so attuned to pain, because that keeps us alive and helps us survive, that we're not always attuned to the absence of pain.

And, you know, parents always joke or moms always joke about, like, that's the, the ability to forget is how you get to have more than one kid, right? Exactly. And can you imagine all of the pain and injuries that you've sustained throughout your life if you had like a vivid memory of all of those?

You'd be afraid to leave the house.

Holly: 00:43:06

Oh, yeah. I wouldn't cook. I wouldn't have a dog. I wouldn't, you know, you, you'd kind of grind everything to a halt. Yeah, you're. You're so right.

So this is also comes into play big time.

I sort of teased it a moment ago around career and workplace because don't the statistics show we actually spend more time with our co workers than even with our own if we are married or have a roommate?

So I have navigated this, this tightrope actually, and I'd love any input also that you have, Dr. Megan, to really help people understand how important it is to bring your full self into your job and your, your career. Even if it doesn't, it doesn't mean that you're showing up for every zoom call letting everybody know that you're at a pain level eight today.

But it, but it does mean being very aware and in tune with how your work stress and how your work relationships are impacting or playing a role in the way you experience pain. Was there not some study you told me about that? The correlated back pain with a bad boss?

Megan: 00:44:23

Yes, actually.

So there have been studies that have shown that you're more likely to suffer from chronic low back pain if your level of work satisfaction is considered lower.

And there was actually a systematic review that showed greater levels of co worker support and general work support to be associated with Less time to recovery after an injury and earlier return to work.

And so, yeah, it's not surprising that these people that we spend more time with sometimes than our immediate families and most often it's our largest source of stress. Unless you have kids. No, I'm kidding.

Holly: 00:45:07

Club second.

Megan: 00:45:09

Yeah. That it's going to affect our lives.

And if, if and when we're able to see the connection between our stress levels and, and our physical pain, then we can have a really big impact on them. And whether or not that means I need to set firmer boundaries at work or I need to go so far as to find another line of work depends on the person.

But really recognizing that stress load from your social situation, social factors in your life, including your employment, have an impact on your physical pain.

Holly: 00:45:47

Yeah, I've, I've lived it and I really, I really empathize with that. That's another vicious cycle, right, of showing up for work and the, and you're in pain.

You're you from 8am onward, you're, you know, already feeling it in your neck or your low back and then the day just continues to kind of hammer away at you.

The one piece of advice I would give is someone who's been walking that for a long time is that you don't gain anything by withholding your pain or your pain story from your co workers. And again, I'm not advocating, you know, having a sign on your forehead that says sufferer.

It is your own journey, it is your own person, it's your body, it's your experience.

However, there may come, there's very likely to come a day where you do need time off, whether it's, you know, to, to go to physical therapy or you're going to need to let your boss know that you have a limitation that is not the moment necessarily to introduce the concept of your chronic pain. And so I encourage anyone who has, you know, a steady working relationship with a boss and, or coworkers to find something in the middle.

Doesn't have to have to happen on your first day on the job, but you don't want to wait until a year and a half in when you're about to start physical therapy or you're, you know, you're taking on some commitments with regard to your wellness.

That's not necessarily the moment to say, hey, so we've been working together for two and a half years and something that you don't know about me is that I've had, you know, seven surgeries or eight. Whatever the person's story is. I've tried that route. And it is difficult, I think, for everyone around you to understand. You know, why was I never.

Did you never feel safe that you could tell me about this? You know, does this mean that for the last two years you've been sitting in meetings in terrible pain?

And even the days that, you know, I yelled and was, you know, when this is someone else saying, like, I, you know, that day when I was horrible to you and you poor thing, we're sitting there in pain, I didn't even know.

So, you know, I think that that's really crucial also because the masking that we do, you know, just to kind of exist out in the world sometimes when we're in chronic pain is part of the exhaustion.

And so the more authentic you can be, and it might even just be like as simple as the one sentence phrase that Dr. Megan kind of gave us with regard to friendships a few minutes ago. It might be that you sort of practice this.

One line with your co workers is just to say, hey, just, you know, I've, I've got, you know, some, some old, you know, kind of funky issues with my knee or, you know, I've, I've had a bit of a history with some fibromyalgia. I'm dealing with it. It's nothing for you to have to respond to.

But just as an FYI, you know, there, there might be times where I need to, you know, kind of take care of myself.

And I find that when you mention taking care of myself, that is such a diffuser because it is almost impossible to argue with that whether you have a deadline or a big client or whatever is happening. If you say to someone, I need to take care of myself, I defy that person to tell you not to.

And if they do get the hell out of that job, you are, you are reporting to the wrong person. You are in the wrong job or maybe, you know, right career, wrong, Wrong team, wrong company.

Megan: 00:49:17

Yeah, potentially. And I think those are really good ideas. Definitely to not spring it on them at the last minute of, you know, night before surgery.

I'm going to be out for the next few weeks, I forgot to mention. But I think it depends a lot on the person and it depends a lot on the job. I think you had a handyman that you found out later on was suffering.

Oh, yeah, you know, that, that's actually.

Holly: 00:49:43

And that brings us right back into kind of the zip code and the socioeconomic, you know, all of these social factors kind of blending in.

I was living in a condo about 10 years ago and had this really cheerful handyman who was showing up for work, you know, putting on his best smile every day. But I could almost kind of tell that there was something. There was something underneath that. That smile.

Just, I. I'm an empath, and I could kind of sense that there was some suffering underneath it. It was like, this is a veneer.

And one day I heard him, you know, sort of, you know, sort of moan or let out this painful sound in the room he was working in. We had a conversation. He revealed to me that he had severe, severe back problems. He'd had a couple surgeries.

Things were being held together with pins. And I looked at him and I said, roger, how are you showing up on the job here every day?

And you've never mentioned this, and you've been working on our bathroom and our kitchen for, you know, a couple of months now. You've never mentioned this. And he said to me, I have to just swallow it, Holly.

I just, you know, I can't afford to think about it, because if I don't work, I don't get paid. And in that moment, I had to really check.

Check my privilege, check my sort of my circumstance, and recognize that I was in a salaried job at the time where I had benefits and I could take paid time off, you know, and even take a medical leave, you know, if and when necessary. Roger had no such luxury. And, you know, so I. One thing that I'm kind of wondering, Dr. Megan, is like, when.

When someone like Roger has that grin and bear it, you know, and I'm gonna push through it, is there some way that he's actually inuring himself or he's. He's becoming less affected by the pain? Or do you think he feels it every bit as much and he's just shoving it down?

Or is there a possibility that because his circumstances don't allow him to step away from the work, could he actually be building up sort of a mental muscle of, like, not feeling or experiencing the pain as much?

Megan: 00:52:05

Yeah. And part of the answer there is it depends, right? It depends on a lot of things. Like, he recognizes that he doesn't have an option there.

And so part of it is he's not really going to tune into that. He's not going to say, okay, let me really see if I can feel this, and maybe do, like, a somatic tracking exercise of observing and following.

That's not an option for him.

Holly: 00:52:33

Right.

Megan: 00:52:33

He's got to get done what he has to get done to get through the day.

And so potentially he is contributing to, you know, I think a lot about, like dancers and gymnasts, certain athletes have a different kind of a relationship with pain. And sometimes we would call them like a high pain threshold or a high pain tolerance, meaning they feel it, but it's not going to stop them.

And part of that is because they start to recognize pain as par for the course. Pain is a normal experience. Pain doesn't mean I'm causing damage. Pain doesn't mean things are breaking down.

It's just part of, you know, dancing on point or doing this jump for the 8,000th time today.

And really those people are interesting when we think about and talk about studying chronic pain, which, you know, just a reminder, pain is a subjective experience and so everyone experiences it differently. But when we look at groups and we look at dancers and gymnasts, we see that they tend to have higher thresholds and higher tolerances.

And that may be because they've somewhat normalized the pain experience. And that may also be what your handyman has done as well.

Holly: 00:54:01

That makes sense. Yeah, I think he's, he's. It's probably a combination, you know, of a couple of those things.

Like, he seemed to me to be someone who just kind of had this mind of over matter, you know, approach. And he, he said, you know, I don't feel it all the time. You know, I don't. I just get to work and, you know, work just sort of overtakes.

And I think he also worked with music in his ears. He was like a ZZ Top guy, right. And so he kind of found his groove and sort of learned how to get through it his own way.

And really interesting what you mentioned too, about dancers. I was recently watching this really, this Amazon series called Etoile.

It was from the creator of the marvelous Mrs. Maisel, in case you liked that show, Amy Sherman Palladino. And this is a really kind of interesting look at the life of ballet dancers in New York and Paris.

And what's cool about the show is that they actually cut in between the episodes with B roll of real professional dancers unwrapping their toes.

Megan: 00:55:08

Oh my.

Holly: 00:55:09

The toenails is things for me a lot. I mean, football players would even look at a ballet dancer's feet and, and think, oh, my God, I'm so sorry, I couldn't do that.

So there's, there's all kinds of, you know, sort of mental strength or whatever that can come along and, you know, help us mitigate. But it sounds like again, this is just leading back to those Social factors. Maybe they learned that growing up.

That was the dance te culture who, from a very young age, you know, was kind of pounding that mentality into their mind. It could have been a parent. It could have been, you know, their. Their peers that they grew up with or their culture. So, you know, I think that it's.

It's something we're going to continue to talk about. We'll. We'll come back to this.

Because those other factors that you listed in the beginning of this episode, we didn't even get to touch some of those. I think we need to come back on some of that.

Megan: 00:56:07

Definitely.

Holly: 00:56:08

Always. And as a little teaser for where we're going next, you know, something that you touched on today around.

We actually both kind of mentioned visualization and interoception and kind of going into the mind.

We're gonna go back inside the mind in the next episode, and we're going to talk about the power of visualization and, you know, sort of everything in that realm, whether it's meditation, whether it's breathing, you know, what can those techniques mean for chronic pain and what are they actually doing to us when we're. When we're doing them?

Megan: 00:56:43

Really powerful stuff. Absolutely. I'm really excited to get to that topic.

Holly: 00:56:47

Stay with us. There's so much more to unpack around chronic pain, and I like to kind of end the episodes again with the reminder that Dr. Megan always gives to me.

Inspires me. Hey, as long as you're still breathing.

Megan: 00:57:01

You can change your brain, which can change your pain. Exactly.

Holly: 00:57:07

So, yeah, keep on, keep on keeping on, my friends.

Megan: 00:57:10

I'm keeping on. Yeah.

Outro: 00:57:15

Thank you so much for listening to this episode. We appreciate your tuning in and being part of the unpacking pain experience. If this episode helped you, please share it with others.

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