One of my favorite topics in massage school -> Pain Science! I am fortunate to have had a very nerdy research-driven teacher for *one semester* who also favored this topic. Here’s a summary of a Huberman Lab podcast episode I recently revisited. In short, as it relates to the practice, soft tissue manipulation, of course, helps with pain reduction- as does love, distraction, and our own pain / memory associations & histories. Plus more on where to ‘locate’ and how to ‘manage’ pain below! ❤

• Pain is a complex and subjective experience; it’s highly individual because it involves an emotional and sensory component
  • Increased anxiety increases pain
  • Early experiences with pain can change perceptions of pain (for example – if you grew up in a violent household, your perception of pain will likely be much lower than someone who did not)
  • Pain can be related to stress (and affect particular areas…)
  • Memory is often associated with pain – for ex. if you had a rough biking accident and injured your back as a result, your back may ‘flare up’/ hurt when you are stressed
• One of the biggest predictive factors in pain and treatment response is catastrophizing – (which raises the question, for me, if you say ”hello pain, i welcome you’ does that lessen your perceived pain – the answer is yes as they later point out…)
• “Pain inhibits pain” – Dr. Sean Mackey
  • (except for folks with fibromyalgia and specific chronic pain conditions)
  • simple example: I get punched during sparring and the next round, I’m kicked in the ribs. The kick to the ribs dulls any pain associated with the first strike. Pls don’t try this at home!!
• Dr. Mackey suggests that pain requires a whole-person / holistic approach: “pain is pain”– if you attempt to dissect it into many layers (e.g., emotional pain vs physical pain, etc.), you differentially place value (this is fascinating and I agree); you may even demonstrate a value judgment as a practitioner. Because pain is complex, he advocates for treating the whole person instead of being concerned with these nuances.
• Behavioral tips for managing pain: good nutrition (avoiding foods that are triggers for inflammation for ex), healthy eating, and enough restful sleep, you may choose to use a healthy distraction (reading, movement if you are able, a phone call, etc) However, note that more pain is often experienced at bedtime as there’s no distraction.
  • Food plays an important role in pain onset and management; keep a journal and pay attention to foods that set you off
  • If you’re in love, you’re in luck! New love is an analgesic (specifically, looking at a picture of your significant other), pets, touch, and tissue manipulation around the pained area, all work as analgesics

Introduction

Dr. Sean Mackey, M.D., Ph.D. (@DrSeanMackey), Chief of the Division of Pain Medicine and Professor of Anesthesiology, Pain Medicine, and Neurology at Stanford University School of Medicine (bad a$$). His clinical and research efforts use advanced neurosciences, patient outcomes, biomarkers( :/), and informatics to treat pain.

In this episode of Huberman Lab, Huberman and Mackey discuss what pain is and the various causes, protocols for controlling and reducing pain, how our emotions influence pain, and more!  

Host: Andrew Huberman (@hubermanlab)

6:13 – Understanding Pain

• Pain is a complex and subjective experience; it’s not all bad, it serves to keep us away from harm
• Pain is incredibly individual because it involves an emotional & sensory component – it feels like it makes everything harder to parse out
• The financial burden of pain: chronic pain has a financial toll on society, responsible for about $500 billion per year in medical expenses
• How pain is perceived:::
  • Pain starts with a stimulus; nociceptors sense stimuli and send signals to the spinal cord and brain
    • “What goes on in your shoulder is not pain – that’s nociception. Those are electrical signals, electrochemical impulses being transmitted and that is to be distinguished from the subjective experience of pain that you have.” – Dr. Sean Mackey
    • This distinction is critical to understand because our brain serves functions of emotions, cognitions, memory, and action – all of which shape signals coming in and playing a role in our experience of pain (what is interesting to me here is that our body experiences said ‘pain’ and based on our past experiences and memories of pain we then filter through a sensation of pain. This may explain why for ex, people who are heavily tattooed can feel nearly fall asleep while being tattooed. we already know what to expect, we’ve done it before, the context tells us we are safe, etc. So then, what happens when we have a soft tissue injury? Does it ‘bother’ us less?)
• Pain is not a 1:1 relationship nor is it standardized – the way you experience pain from an injury is different than the way someone else with the same injury will experience it; this makes it hard to relate in both directions

13:05 – Pain, The Brain, & Intervention

• Pain is a distributed network involving different brain networks and regions
• Non-steroidal anti-inflammatory (NSAIDs) drugs (e.g., ibuprofen, acetaminophen, naproxen, aspirin) are not technically pain killers, they’re anti-inflammatory
• After an injury, the area becomes sensitized which sends us a message to protect it
  • NSAIDs reduce sensitization
• Inflammation is part of the healing process and pain is subjective – how do we know when it’s right to intervene?
  • Threshold for when to take action against pain: when you can’t perform activities of daily living to the standard you are used to (this is a great measure; in medical anthropology, we would say ‘what do you need to feel well? what is holding you back from doing x? how can we work together to determine a way for you to return to doing x?’)
  • Please don’t take painkillers to dull pain and then misuse the area injured (too common)
• Newer evidence points to the idea that we may be inhibiting the natural healing process by blocking inflammation through the use of NSAIDs
  • On the one hand, you have something that is dulling the pain; on the other hand, we’re seeing delays in healing times of fractures and broken bones
  • Pro Tip: sleep is critical to your healing!!! – take the lowest dose of NSAID you can get away with
• There is huge variability in which NSAID works for you – as a sober person I won’t take pain killers of even accept them so I’ll go to ->
• Baby aspirin (81mg) acts as an antiplatelet agent; at higher doses of about 325mg it’s an anti-inflammatory
• Caffeine: caffeine can be used effectively for headaches and migraines; it can also potentiate the analgesic response
• CBD probiotic water / CBD+THC topicals
• Arnica

32:34 – Mechanical Pain Reducers

• ((( If you bump your head, there’s an instinct to rub it — so massage away; &….the same instinct to suck a cut/ bug bite is how fire-cupping originated )))
• Studies show that cursing actually works to reduce pain – even better than using non-cuss words (makes sense to me god damn it) one thing that the east coast has figured out…
• Rubbing and shaking (massage) activate touch fibers which reduce pain
• Cold water changes the signals in the spinal cord and reduces the nociceptive signals (if you’re in a cold plunge, your injuries will hurt less as your signal responses are slowed down…)
• Kissing an injury activates touch fibers and positive emotionality which reduces pain (this is SCIENCE folx)

38:56 – Pain Threshold

• Pain threshold is a stimulus intensity that results in the first onset of the experience of pain
• Hot and cold both work until they become extreme in either direction and then become unpleasant
• Men and women have different pain thresholds: in general, men have higher pain thresholds for things like heat ( I damn sure don’t believe this) – BUT, there is a lot of overlap on the curve –
  • The difference is similar to the average height of a man is 5’8” and the average height of a woman is 5’6”, really not that different
• Much of nociception is the same – it’s how it’s shaped within the brain that creates our experience of pain
  • Increased anxiety increases perceived pain
  • Early experience with pain changes perception and subjective feeling
• Conditioned pain modulation: pain inhibits pain – induce pain at a site away from the site of injury to inhibit pain in the original site
• You can raise your pain threshold with a lot of cognitive training; exercise also increases the pain threshold (absolutely true / experienced)
  • Actual published anecdote: pain threshold is higher in male college students whose pain was administered by a good-looking female (duh)

53:30 – The Role Of Heat & Cold For Pain

• Cold reduces inflammation; nerves also don’t fire as quickly when they’re cold; therefore cold reduces stimulation and the experience of pain
• Heat increases blood flow, relaxes muscles, and increases blood flow to muscles
• There’s huge individual variability as to whether you prefer heat or cold – both are safe within reason, so don’t overdo either
• How cold should cold be? Cold enough that it numbs; it might sting at first but a cold you get used to

1:00:54 – Tools For Pain Management

• Meeting pain versus distraction from pain are both effective mechanisms for dealing with pain
  • Distraction: distract yourself from the thing causing you pain – read a book, go for a walk, etc. work to get your mind off the pain
    • This is why pain is usually felt more at night – there’s no distraction
  • Leaning into pain: mindfulness can help you address the pain from a nonjudgmental point of view – mindfulness-based stress reduction can reduce anxiety, pain, depression, etc.
    • Cognitive reframing about the pain can help, too – is the pain damaging, or does it hurt but is not harmful? This serves as a foundation for cognitive behavioral therapy * I would advocate for somatic therapy, hakomi, or MBSR – I personally think CBT is unhelpful – can we call for a body-based therapy plz??!!
  • Different approaches work for different people depending on the circumstance
• Learn to distinguish the difference between being hurt and being injured
• Understanding the distinction between hurt and harm:
  • Sometimes there is a fear or anxiety around an injury – it’s important to examine whether the injury will get worse with repeated activity
• In most chronic back pain, for ex., movement will not cause harm but there is fear
• Food plays an important role in pain onset and management; keep a journal and pay attention to foods that set you off
  • It’s important to log because if get repeated exposure you’ll feel the pain every time, more and more
  • Gut infection can change the way you respond to foods in the future – you can get sensitized to foods, even if they’re normal foods
    • There is a debate about whether this is a public health problem now, it happens so frequently

1:12:38 – Emotional Pain

• One of the biggest predictive factors in pain and treatment response is catastrophizing
• Anger makes pain worse
  • “Anger out” is expressive, yelling, screaming
  • “Anger in” is boiling, simmering, seething – “anger in” is worse
• There are over 200 medications that can be described for pain as off-label treatments (woof)
• (let us call for metabolizing this anger through movement, writing, yelling into the ocean, etc)

1:29:00 – Bodily Pain

• Somatic pain has a clear path – you hit your thumb with a hammer, and your thumb hurts; somatic pain can come from muscles, tendons, ligaments, etc.
• Visceral pain is not localized – like a stomachache – you can’t point to one area
  • Visceral pain example: many people with pelvic pain have lower back pain because there’s a convergence on the spinal cord so there’s pain perceived in both
  • Another example: heart attacks often come with left arm pain
  • These examples show ‘referred pain’ or ‘reference pain’ where you feel the pain somewhere other than the original site
• Neuropathic pain occurs when there’s damage to a peripheral nerve or the central nervous system; this pain is shooting, stabbing, shock-like, burning
• Psychological pain or pain associated with memory: sometimes pain can be related to stress and experiences of stress – the brain is not a passive recipient of information and experiences
  • The brain controls how much cortisol is released – chronic stressors impact tissue and cause real pain
  • There’s a lot of memory associated with pain – a lot of pain manifests based on memory; for example, if you injured your back in a car accident, stress may cause your back to hurt – that should be a cue to reduce your stress, not get surgery
• The impact of love on pain: early love/relationships are almost addictive – they engage the same neural circuitry
  • Love is a wonderful analgesic! The more in love you are, the less pain you feel when you look at their picture
  • Love works on reward-based circuits to reduce pain

Skipping Opioids and Cannabis Sections

2:18:12 – Pain Management Therapies

• Six broad categories of therapies:
  • 1. Medications
  • 2. Nerve blocks & minimally invasive procedures
  • 3. Psychologic therapies
  • 4. Physical & occupation therapy approaches
  • 5. Acupuncture, bodybased therapy, nutraceuticals
  • 6. Increase in agency – education, learning skills, self-empowerment
• Acupuncture can treat pain but we don’t know exactly how it works; it engages brain regions which may cause central change – it’s worth a try
  • There are studies comparing true acupuncture to sham acupuncture
  • How to choose an acupuncturist: word of mouth and referral is always best
  • Medicare now pays for acupuncture
• How to choose a physician: word of mouth and referral is always best; if pain is complicated you are better off with a tertiary referral service
  • You can pay companies to inflate ratings so be careful how much weight you put in that
• Chiropractic work has mixed data; avoid rapid spine adjustments and high velocity manipulations – the risk is small but it can cause stroke
• Tip: ask yourself if you’re getting durable benefit or it just feels good in the moment
  • Use tools to get engaged in activity and address underlying biomechanical issues
• Physical therapists are crucial to get back to an improved quality of life and function; find someone who can work with you on goals, pacing (you will have good days and bad days), safe activity
• Pain hits the brain and involves everything you’ve lived through; what happens to you early in life changes your wiring – pain psychology teaches people skills and helps chip away at pain
  • Recognize unhelpful thoughts and patterns around pain
  • Learn relaxation and breathing techniques – our sympathetic nervous system gets revved up when we’re in pain
  • Cognitive behavioral therapy works (don’t forget there are body based therapies tooo!!!)
• Dr. Mackey’s wish for pain management field: enact cultural transformation and change the way pain is assessed; put forth national pain strategy based on high quality data