CBT Tools to Address Chronic Pain: It is NOT all in your head!

Welcome everybody to this presentation on the biopsychosocial impact of pain and strategies for prevention and intervention. I'm your host, Dr. Donnelly Snipes. In this video we're going to review the effects of pain including depression, anxiety, circadian rhythm disruption, grief and self esteem problems, will explore mitigating and exacerbating factors and identify primary, secondary and tertiary prevention activities. Everybody has pain. Sometimes I challenge you to find somebody who has never felt pain. And I know there are a couple of There are some people out there that have a particular genetic composition in which they don't feel pain. But most people feel pain. Our bodies however, are incredibly resilient. Knowing your pain can help your care team. We talked about this some in the video on assessment and case management of pain. But it's important to be able to tell them is the pain acute or chronic? And as behavioral health professionals we want to be able to evaluate this as well. Is the person experiencing something that started last week or something that they've been dealing with consistently or even on and off for months or years? What is the quality of the pain? Is it stabbing, itching, throbbing, aching, burning? Is it constant or intermittent? So obviously we know what constant is. It's always there, intermittent. It may only be there when they wake up in the morning or when they're trying to sleep at night or when they do a particular activity. Is it stationary like you have an ache that's right here in your shoulder or is it radiating? You have pain that's like shooting down your arm and is there any numbness or tingling? The reason we ask those questions as behavioral health professionals is because we are going to ideally help people structure their distress tolerance skills to be able to recognize what is normal pain for them and be able to cope with it as opposed to being extremely stressed or anxious every time they experience pain. So we want to understand what living in their body is like so we can help them figure out how to live that highest quality of life. In terms of prevention, there are three types. Primary prevention means prevent the pain from happening and this can mean preventing flare ups or helping the person avoid getting a pain condition at all. Generally, by the time they come to us, they already have a pain condition. So we want to help them prevent flare ups and reduce the frequency and intensity of their flare ups. Secondary prevention, we're preventing the pain from getting worse. So when they're having a flare up, secondary prevention is targeted at mitigating that preventing the flare up from getting intolerable. And tertiary prevention prevents the pain from causing Other problems like depression, anxiety, or addiction. When you think about the body, think about it in quadrants, the right side and the left side. If you think about your spine, that's your perfect example. The right side and the left side both have the same muscles and they work to help you with your mobility. But if one side gets stronger than the other, it's going to pull and may cause the other side to spasm. Which is why it's important to have balance both right and left, because you don't want your right and left side arguing about who's dominant. You want them both to be equal. The same thing is true for front and back. Now, interesting, interestingly, the way the body is designed, our front and back aren't a 50, 50 split, but that's something between you and your trainer or your physical therapist. The take home for us is to recognize that the strength of the bicep is going to affect or be affected by the strength of the tricep. And you want to have balance between the bicep and the tricep. If you have a really strong bicep and a really weak tricep, then it's possible that you can do a really powerful move with your bicep and rip that tricep right open or cause it to come, cause it to rupture, and that's worst case scenario. But it is important to recognize when there's imbalance, there's often spasming. That's the take home. We want to emphasize proper ergonomics or form at work, home, in bed, at the gym. And if they spend much time in the car, in the car, when they're sitting on the sofa watching TV for an hour or two hours. That doesn't sound like much, but it can be enough to trigger spasming in particular muscles or to antagonize some pain that may be there or increase swelling. So we do want to encourage people to pay attention to their ergonomics. When they're at their desk, are they able to sit and put their feet flat on the floor, or are their feet out there dangling in midair? Do they have a good supportive chair or do they end up feeling like they've got a sore back at the end of the day at work, you can often reach out to your human resources department for ergonomics assessment. At home, a little more difficult. Physical therapists are people who are very good at helping you identify proper ergonomic interventions. For example, mattresses, pillows and chairs and things like that. People need to be encouraged to remember to Exercise bilaterally. What you do to the front, you need to do on the back. What you do to the right, you need to do to the left because you don't want to have one side being much weaker than the other side. Stretch frequently, this is an exercise and stretching are obviously going to be governed by what the medical team says. But generally stretching is encouraged after working out. And stretching or gentle movement like tai chi or yoga can be really helpful for maintaining mobility. When we don't move, our joints actually get stiff and that stiffness can contribute to pain. As providers, as mental health providers, we can help people recognize and increase their motivation to move. You know, yeah, you may not want to get up and do it, you may not want to, but let's look at all the reasons why it's going to be helpful and what can we do to help you make it tolerable. Walking a mile may be overwhelming. Walking around your living room three times, that may be doable. So we want to help people figure out ways that they can accomplish their goals in ways that are they're motivated to do. People should not over train and it's important to often to remind people of this because they will overdo it. If they're feeling good, they may say, oh, I feel good doing this, so I can do an extra 20 minutes or 30 minutes of house cleaning or gardening or whatever it is they're doing. And, and while it may seem like a great thing and it may feel very liberating cognitively and emotionally, they may, if they overdo it, they may set themselves back. A lot of times the recommendation is, for example, if you're just getting back into shape, maybe you've been on bed rest for a while to do something for a certain period of time like 30 minutes, and at the end of 30 minutes, stop the next day. If you feel good, then when you do it again, maybe you can do it for 40 minutes. But at the end of 40 minutes you stop and you gradually build up until you get you find out what your threshold is. Eat a healthy diet with omega 3s, vitamin D and antioxidants. This is another thing that we can't prescribe for people. We can help them recognize how a healthy diet's important in pain management and inflammation management. But only a registered dietitian or a medical provider can prescribe nutritional changes. RVNS is respiratory vagus nerve stimulation and TVNS is transcutaneous vagus nerve stimulation. RVNS happens when we trigger our vagus nerve through slow, controlled diaphragmatic belly breathing. When we do that, it triggers the relaxation response. They've shown that triggering the relaxation response also promotes the release of chemicals and things that are associated with pain reduction. TVNS is transcutaneous and that is when you use something called a TENS unit and I actually don't have mine here today, but you put little patches on wherever the pain is. And well, TVNs, they have little clips for your ears and that can stimulate the vagus nerve through the auricle branch and that can help promote relaxation and pain management to a certain extent. TENS units are also helpful not only for TV and S, but for transcutaneous electronic nerve stimulation. And they've shown that TENS units actually are associated with an increase in anti inflammatory cytokines and pain management chemicals just in general in the area that is being stimulated even hours after a treatment. So that's kind of interesting. Stress management is really important. When we get stressed, we trigger that HPA axis, our threat response system. When that is triggered, we, especially if it's triggered frequently, chronically, it loses its ability to suppress pain and suppress inflammation and it actually ends up promoting pain and inflammation. Likewise, when we get stressed, what do most of us do? When you're stressed, you tense your muscles. Whether you're grinding your teeth, you're clenching your fist, you're storing it in your back, we tend to have more muscle tension when we're stressed. Alcohol reduction, I didn't say abstinence because that's not a goal that a lot of people are going to embrace. Some people will more power to them. That's great. The more you can reduce it, the better. But alcohol has been found to contribute to systemic inflammation and actually reduce people's pain threshold as it leaves their system. So initially in the initial sort of buzz phase, they may feel a little less pain, but as it leaves their system, they've shown that it actually reduces their pain threshold and promotes systemic inflammation. Now that's primary prevention in behavioral health. There's not a lot we can do to completely help people prevent a flare up from occurring, except for helping them address their treatment plan, their medical treatment plan and manage their stress. Secondary prevention, we help them deal with flare ups or even ongoing chronic pain maybe. And there are a lot of people who have pain every single day, but most days, on a scale of one to five, it's about a two. It's annoying, it's there, but it's not debilitating. When they have a flare up, it may be just overwhelming. So we can help people manage pain. Pain interferes with enjoyment of life and Pain management can improve quality of life. The first step is diagnosis, helping people figure out what is causing my pain. Sometimes when we have pain, you know, we know that, oh, my body's telling me something's wrong and, and then they start getting really stressed and fearful and anxious about it. Worse yet, when you go to the doctor, if the doctor can't find any particular cause for it, if they are invalidating, that can contribute to a person's frustration and anxiety and sense of helplessness and hopelessness. So it's important if somebody is presenting with chronic pain or even acute pain and they aren't involved with a medical care team or they've tried and they've been shunned by their current medical care team. We need to help them self advocate, we need to help them feel empowered to cope with whatever's going on and live their highest quality of life. Encourage people to keep track of their pain, keep a daily log. Anything that they think might be useful to the treating physicians is also probably going to be useful to us because we can help them identify things that make them more vulnerable to flare ups. We can help them identify things that they may be doing that are contributing to mitigating or lessening their pain. Helping people understand their pain, it means understanding their exacerbating factors, what makes it worse, and their mitigating factors what helps them feel better. When you create a treatment plan for somebody, there's a complex equation. Obviously when somebody has chronic pain, it's helpful if you can get them to sign a release so you can communicate with their treating physician to understand what are their limitations, what is the course of this? A lot of times we don't have medical background so we may not be able to understand, you know, is this something that's likely to get better? Is this something that is going to gradually get worse? Is this something that is going to have flare ups and remissions like colitis, what causes it? So understanding exactly what's going on with the person can help us help them. It can also help us help them gather information because a lot of times their treating physician may not be providing them a whole lot of information. And if they want more, we can help guide them toward valid, reliable resources. We want to identify their pain therapy goals. What is it that you're hoping for? If they're hoping for completely being pain free most days of the year, that may or may not be possible. And we need to help them develop something that's realistic. Identify what they may be doing or willing to do in order to achieve that goal and then treat the cause. Make sure that we are encouraging them. If they've got chronic pain because of a physiological condition that they are following through with their medical treatment plan. Available treatment options include pharmacotherapy and medical interventions, psychosocial interventions and complementary approaches. So let's start with pharmacotherapy. Pharmacotherapy is using medicine to control pain. Medicine can be great. However, a lot of times pain medicine is just subduing the pain. It's not actually treating the underlying issue. So just masking pain may not be helpful for a person. It may be if they can get the pain under control, if it's something that they can dampen a little bit so they can have a higher quality of life, that may be a treatment goal. Some of the pharmacotherapy can be over the counter and some is prescription. And there are special programs available to assist people who cannot afford their medication. This is so important for us to know because to date, unfortunately, and I've been in the field for 25 years, to date, I have never run into a doctor who is actually aware of patient assistant programs. Patient assistance programs are offered through the pharmaceutical companies. So if you have a patient who's on a medication that is produced by AstraZeneca, you would go to AstraZeneca's website and search for patient assistance program. If they have one, and most of them do, it will pull up their patient assistance program. What medications are included and what the person has to do. All of them that I know of involve the doctor filling out a very, very simple one page form and attesting that the person cannot afford their medication. A lot of times the pharmaceutical company will then provide the medication either for free or at a very, very deep discount. Using programs like GoodRx or programs on the formularies for different pharmacies can be very, very helpful as well. Some pharmacies have a list of drugs that they offer a 30 day supply for $4 or for $7 if the patient doesn't have mobility issues. Sometimes they can get better prices for certain medications at certain pharmacies. It's not always. Just because one pharmacy has really good prices on one medication doesn't necessarily mean they're going to have it on every medication that patient takes. Now, a lot of people don't want to have to go around to three different pharmacies. I get it. But it is important to recognize if affording their medication is a significant barrier to treatment compliance. There are three classes of analgesics, non opioids, opioids and what they call adjuvant analgesics. Tylenol and non steroidal anti inflammatories like ibuprofen are available. Non opioid medications to help people deal with pain. Opioids provide relief by attaching to opioid receptors. Unfortunately, when people take opioids, the body stops making their natural painkillers. They're what they call endogenous opioids. Over time, the body reduces the amount of opioid being left let through the the system, which is what we call tolerance. And this, with opioids, can happen after only several days. It's not something that you have to take the opioid for months or years before you develop tolerance. Tolerance in opioids develops really freaking quickly. When a person stops taking opioids, the body takes a few days to start making natural opioids again. So their pain threshold is markedly decreased when a person has been taking them chronically. And then if they stop cold turkey instead of weaning down, then they may experience more pain, more aches, more discomfort for a period of time until their natural pain management system kicks back into gear. Adjuvant analgesics drugs or medications in this category include corticosteroids, muscle relaxants, topical analgesics, things that you rub on like Icy hot and lidocaine. Local anesthetics that can be administered either topically or through like nerve blocks. And they've also found that drugs for anxiety and depression that impact serotonin levels, or drugs that impact sleep, sleep which impact cortisol, GABA and serotonin levels, may also be useful for pain management. Why is this? They hypothesize that serotonin is involved in the pain threshold. So if serotonin is low, then pain threshold may be low. As serotonin goes up, pain threshold goes up. We also have seen in the literature when people have anxiety and depression, their stress response system is hyperactivated and that can contribute to systemic inflammation, which can make their pain worse. So controlling the dysphoric mood as well as making sure that serotonin is within bounds can be helpful. We also know that when you increase serotonin, you're not just increasing serotonin as if serotonin increases, it impacts the levels of every other neurotransmitter and some hormones in the body. So there is a complex symphony that's going on. Complementary therapies or mind body interventions. Prayer is helpful for some people if they have a higher power. Prayer has been shown to be helpful and comforting and useful for distress. Tolerance as well as anxiety and depression reduction. Guided imagery. Oh my gosh. I have an entire video on guided imagery for pain management. There are so many different things you can do guided imagery. You can have somebody envision their pain. Let's say they have pain in their arm and they envision their pain glowing bright red and then see, have them envision a knob where they're turning down the intensity of that red. So it's going from a glowing bright red to almost imperceptible. Pilates is another intervention that has been shown to be helpful. Aromatherapy has been shown to have some aspects that increase levels of serotonin, dopamine and gaba. So the relaxing essential oils have been shown in some cases to be somewhat helpful with for people with chronic pain. Now it's not on here, but they've also shown, and this is really fascinating to me, that in people who have had surgery or who are recovering from a major injury, when they are in the hospital and stuck in a hospital bed and what have you, their pain tends to be higher than if they are able to get out into nature and actually experience nature, not just look through a window. They hypothesize that there are certain terpenes or aromatic compounds that are emitted from the plants that may assist with stress management and pain management. It's kind of interesting. They've done a couple of studies that have found that patients in a regular hospital room versus patients in a hospital room that have live plants in them tend to do better. They've also looked at the difference between patients in a regular hospital room versus patients in a hospital room where they can either watch through a high def TV or virtual reality nature scenes and they're exposed to essential oils that are derived from plants. That doesn't work as well as the real thing, but it's better than the treatment as usual or the hospital room alone, which is kind of interesting. Biologically based therapies also include dietary supplements and nutrition, as I mentioned earlier. Omega 3s, vitamin D, those can be very helpful in pain management. Now both of those have side effects. So it's not something that we are going to recommend to our clients or prescribe. But letting them know that a registered dietitian or their doctor may be a great source of information about ways they can reduce the inflammatory nature of their diet and therefore reduce their pain can be helpful. Manipulative and body based methods now, manipulative means actually manipulating the body, not cognitively manipulative. Chiropractic care, massage and physical therapy have been found to be extremely useful a lot of times because it helps relax muscles, it helps balance out muscle imbalances that are causing spasming, and it helps increase mobility so the person is not as stiff all the time. And I talked about the TENS unit earlier. That can be very helpful. You can get them offline now. They are no longer by prescription only and they have been shown to be very effective at helping people modulate pain, whether it's carpal tunnel pain or back pain. And your doctor can advise on where to put the little pads if you need guidance. Energy therapies include qigong, healing touch, Reiki, therapeutic touch, and acupuncture or acupressure. And these are more Eastern medicine sort of interventions. But there is a fair amount of research. You can go onto PubMed and search for each one of these. And chronic pain, there is a fair amount of research that indicates that these all have their own benefits. Now, is therapeutic touch, for example, going to work for everybody? No. Each person is going to have to individually tailor their treatment to identify what is going to be most helpful for them. Guided imagery Color imagery is what we already talked about. Imagining a color such as red and shrinking, fading or dispersing that color. Symbol imagery. If you think about how the pain feels, does it feel like a knife sticking into your joint? If so, imagine pulling the knife out of your joint and throwing it away. Or does it feel like you've got your hand or that body part on a hot stove? Imagine pulling that body part off the hot stove or turning the stove off. On a slightly different approach, you can also use scenic imagery. Using relaxing. Guided imagery to help a person transport themselves to a place that is calming and relaxing can help turn their cognitive attention to something else. So they're not focusing on the pain, they're not focusing on the discomfort, and it gives them a little bit of a break. Altered focus is another technique. Instead of focusing on the pain, such as a pain in your shoulder, focus on a different part of your body. So if I've got pain in my shoulder, I. I may start tapping on my thigh or wiggling my foot and focusing on that even though my shoulder still hurts. If I'm turning my attention somewhere else, then I am not sending all of my attention toward that pain. It doesn't mean it's going to heal that thing. It means it's giving me a cognitive break from it. And tertiary interventions? Tertiary interventions means helping prevent the person from developing other problems. If they start with pain, we don't want them to develop depression or addiction or Other pain syndromes, if they start with depression, we don't want them to develop concurrent pain, for example. So in terms of chronic pain, we know that it impacts people's energy and their sleep and their sense of personal empowerment. And a lot of times their, their attitude. When you're in pain for a while, you can develop a pessimistic outlook. So helping them identify what can we do to address your fatigue? And instead of focusing just on how you think about pain, let's look at what are the specific symptoms that are bothering you right now and how can we either, how can we mitigate those so it improves your quality of life? Let's look sleep disturbances, let's look at your sleep hygiene. Let's look at what other options might be out there. This may mean making a referral to a sleep specialist. Hopelessness, hopelessness and helplessness. We can help people develop a sense of personal empowerment so they can identify what they can versus what they cannot control. And remember I mentioned, when people are under stress, it reduces their serotonin often and increases their pain. So if we can help them mitigate their pessimistic, negative, hopeless, hopeless thinking styles, we may be able to help them reduce their threat response system, their HPA axis over activation and help trigger the more calming, relaxing, pro mood neurochemical balance. We can help people with mindfulness. If they become more mindful of what helps and what hurts, then they can be more proactive and purposeful in how they live their life. If they become more mindful of not only when they're hurting, but when they're not hurting, they can start to see that they are not hurting all the time, every single day, or they're not hurting at a 10 all the time, every single day. So mindfulness can be helpful. Good sleep habits. As I mentioned, we can review sleep hygiene. Circadian rhythm maintenance. This is different than just good sleep. Circadian rhythms are set not only by light and dark, but also by what we do, our social activity. So if a person is staying inside in the dark, on the couch all day long, their circadian rhythms are probably going to be kind of out of whack. Helping them set their circadian rhythms is important not only for sleep and melatonin, but also for their libido, for their immunity, for their pain management. We want to help them identify things they can control and they're good at. Encourage them to eat healthfully, to support their neurochemical functioning. If they have anxiety that things won't get better or that it's getting worse or about the consequences of their pain. Those are things that we can process in session. We can evaluate the actual facts for and against their fear, the probability that the worst case is going to happen, and what aspects that they have control over. In terms of addressing anxiety. Helping them avoid caffeine and nicotine, which can contribute to anxiety related responses can be helpful. Educate themselves about the disorder and the probability that things will get worse. If you've got a torn rotator cuff, if you follow the recommendations of your doctor, what is the probability that it will get better and what is the probability that it will get worse? Keep a log of your good and bad days. Practice distress tolerance skills and those Remember I use the mnemonic tags thoughts that are distress tolerant instead of saying I can't deal with this saying this sucks but I can get through it or and I can get through it. A stands for activities that may help distract your attention or provide happiness, relaxation, some sort of pleasurable sensation in addition to or in spite of the pain. G stands for guided imagery and S stands for sensations, whether it's cold or hot or soft. Sometimes when people have pain, pressure feels good. Sometimes when people have pain, a hot bath or a cold bath feels good and use challenging questions to address anxiety provoking thoughts and challenging questions. Again asks people what are the facts? Not what is your gut saying? What are your emotions? What are the facts for and against your belief? What other things might you not be considering that are impacting this situation? What's the probability that if you do what you can address the things that are within your control that your worst case scenario is going to come true? Guilt. Guilt is a big one and we haven't talked a lot about that one. But a lot of times when people have pain, when they hurt too much, they may not be able to do the things they used to do, which means they may need to cancel on friends for going hiking or they may not be able to walk the dog as much or go to their kids soccer game and they may feel very guilty, very angry at themselves for not being able to do that. Guilt. Not only are you angry at yourself, but when people are feeling guilty about something, it can also cause them to lash out at other people and push them away so they don't disappoint them like they disappointed themselves. You know you'd be better off without me. Just go on. We can help people think about how they would want their child or best friend to feel if they were in that position. We can help people get rid of shoulds. I should be able to do this today, you can only do what you can do. They need to focus on what can I do? Maybe I can't go on a six mile hike, but maybe I can have my friend over for dinner. Or maybe I can go walk around the mall with my friend for 20 minutes. Decide whether it's worth using your energy to be mad at themselves and the entire world. Is it worth stewing on the anger and the guilt over this situation? Or is there a better way to use that energy to help them move toward their rich and meaningful life? Sort of associated is grief and the stages of grief, denial, anger, bargaining, depression and acceptance. But we see people when they're in chronic pain, they may go through a stage of denial. You know, it doesn't hurt or this will get better, it's no big deal. And they ignore it for a while. Then they make it to a point where they can't ignore it anymore and they get angry that it hasn't gotten any better. They may switch over to being depressed and feeling hopeless and helpless. Sometimes they just skip over that bargaining place. If they start feeling a little bit better, they may drop all the way back into denial. See, it's not really that much of a problem. I'm fine, I can do whatever. And then it flares up again and they get angry and then they get depressed. Eventually, if they have a chronic condition, they may. It may be helpful to come to a point of acceptance, of integrating that in saying, okay, this is just the way it's going to be. How do I integrate this into my narrative? How do I integrate this into who I am so I can still go be the person I want to be? I may just need to make some modifications. We need to help people work through the stages of grief for each of the losses that they've experienced because of the pain, not just I've got chronic pain, so I need to grieve, but we need to look at each loss. Physical health. If they can't do things that they used to do, how is that impacting them and grieving that? If they used to be a marathon runner and they can't run anymore, there's a grief process associated. If they used to stand on their feet all day long at their job and they can't do that anymore, they need to, they may need to grieve that their self concept may change. If they used to feel like they were 10 foot tall and bulletproof and now they've realized that they're not, that may impact them. For me, coming to the realization as I've gotten older. That I'm getting older has been a process. Recognizing that I'm an Accepting that I'm not 20 anymore is one of those issues that I thought tooth and nail for a long, long time because my self concept was kind of tied up in a lot of the things that I used to do and being able to do them the way I did when I was 20. If they lose their job because they can't do it anymore, a farrier, for example, who ends up with back problems and can't bend over anymore to change the to to handle the horse's hoofs, they aren't able to do their job. They may be able to manage other people who are doing the actual hands on work, but that may not be quite as fulfilling. So they may have to grieve that and freedom. If somebody has chronic pain, either because of the medication they're on or because of their pain, they may lose some of their mobility and that can be devastating to people and dreams. And this kind of goes along with self concept. But if you envisioned yourself being this person who was 80 years old and still running marathons, you may have to give up on that dream or at least modify that dream in order to accommodate the reality of the present situation. In terms of mindfulness, alternate focus can be really helpful. When people are constantly thinking about the pain and how to relieve it, they're paying attention to it. It's almost like having a pain and going, hey, don't forget, it's still there, don't forget. So when they start focusing on something else, it actually causes their brain to send different signals. Deep belly relaxation. Breathing through the pain can be helpful. That triggers that vagus nerve, it triggers the relaxation response and it triggers the release of anti pain chemicals. If you want distractions can be helpful. Sometimes when you're in a lot of pain, there's not a lot you can do. If you broke your arm or if you've got a toothache and you can't get into the see the dentist for another four hours. Sometimes it can be helpful just to have something else to focus on. And then one moment at a time, reflecting on what's going on in this moment right now instead of saying, I don't think I can make it four more hours until I can see the doctor saying okay, I need to make it through this minute and then this minute and then this minute. And before you know it, it's almost time for your appointment. Radical acceptance. Help people recognize that life can be worth living even with painful events. This is that acceptance and commitment therapy, living in the and okay, I've got this chronic pain and I still have a lot of things in my life that help it be rich and meaningful, even though I have that chronic pain. It's important to help people recognize that rejecting reality doesn't change reality. Rejecting the notion that, hey, I can't do that anymore doesn't change the fact that you can't do that anymore. Changing reality requires accepting reality. So once you quit rejecting reality and you say, okay, it is pain is, then you can say, how can I improve the moment? How can I make this a little bit better? How can I mitigate it? Pain can't be avoided, and refusing to accept reality can keep you stuck in unhappiness, bitterness, anger, sadness, shame, or other painful emotions. I've mentioned several times that stress can intensify pain. Think about when you've gotten stressed. Stress can cause digestive upset and pain. When your HPA axis is active, that threat response system, it says no time to rest and digest, we gotta go. So it will speed up. For a lot of people, the activity in their digestive system and chronic stress actually alters the microbiome of the gut. So you're actually changing the bacteria in your gut as a response to stress. Stress causes back pain. It can cause migraines and headaches and jaw pain from clenching your teeth. Interventions help people recognize how problematic stress can be. Meditation can be helpful, and there are dozens of different types of meditation. Not every meditation is that stereotypical meditation where you're sitting, crisscross applesauce. Meditation can be very, very helpful because it encourages people to be more mindful and aware of the moment. Distract, don't react. Helping people identify strategies when they feel really upset or when they feel really stressed out to distract themselves until they can get into their wise mind. That stress response, if we don't feed it, tends to dissipate in 15 or 20 minutes and help people identify their most important values and decide whether stressing over whatever it is they're stressing over gets them closer to or further away their version of a rich and meaningful life. Sometimes when people have chronic pain, they may experience social support loss because they change their activities, because they can't go hiking or do whatever anymore because of their pain or because they're just too exhausted, they're not sleeping well, medication side effects, whatever, whatever it is. And as a result, sometimes they may lose some of their social support because their friends are going to still go out and do that other stuff. So they may Feel like they're left behind. They may withdraw socially. They may have social supports who don't understand. They don't realize that, hey, when this person's on this medication, it makes them really dizzy and exhausted, or as a result of this injury. This person can do this, but not that. Communication is really helpful. Encouraging people with chronic pain not to say, well, I can't do that and leave it at that, but to say, unfortunately, because of my pain, I can't do that anymore, but, but I would love to do this, this, or this. So providing alternatives, providing options, and helping other people understand, it's not that you don't want to, it's that you can't. And sometimes people who are in chronic pain and feel helpless and hopeless may inadvertently push away their supports because of their sense of helplessness and hopelessness. They may complain and then refuse to be treatment compliant. And the social supports, the family, the friends, can get really frustrated and not know what to do. We want to help people recognize what is it that you can do to nurture your social supports. Help them identify ways to modify activities or develop new mutually enjoyable activities. Encourage them to join a support group and address mood issues for a lot of things, like fibromyalgia, for example, There are support groups of people who understand what that going through that is like. They have had similar experiences which can be very validating. Help people address their cognitive distortions. For example, if they say, nobody will want to hang out with me, so since I can't do this anymore or I'm always in pain constantly. We can help them address some of that extreme language and again, encourage them to practice living in the and self esteem can be impaired when people are in chronic pain. Help them explore how they feel about the difference between who they want to be and who they are. Another activity I've done sometimes is to have them define or describe what a good person is like or what they look for in a friend. And then after they've done that, I say, okay, now which of these characteristics do you have now? Because a lot of times in that list they don't say, somebody who can go rock climbing every weekend and somebody who can, you know, lift 50 pounds. You know, there are a lot of other characteristics that they look for. So this can help them recognize that, yes, you may not be able to do this anymore. However, there are other characteristics that you still possess and have to grieve the loss and recognize what you have. Sedentariness, weight gain and reduced libido are also other physical problems that are associated with chronic pain. And this can be due to the pain itself due to exhaustion or HPA axis or that stress response system getting out of whack. When we're under a lot of stress, our body says, you know what, not really time to procreate. So many people experience reduced libido. It's important to understand how that is connected to your stress and or your pain, because when people recognize the connection, they feel more empowered to start to address it. Help people work with their doc to identify ways to move more effectively. Be less sedentary. They've got a lot of gadgets, for lack of a better word, that you can use to that put put in front of your sofa so you can pedal or put on a tabletop that you can use your arms in order to keep circulation going and in order to keep your joints mobile. And we can help people address emotional Eating when people are in chronic pain, they may eat in order to trigger the release of dopamine and endorphins. And they may eat because they're bored, they may eat because they're sad and they want to quell their emotions. In terms of circadian rhythms, when people have chronic pain, many times they won't get out of bed or not get out of bed in a timely fashion. They may stay inside in the dark all the time or sleep too much. And sleeping is especially problematic in people who are on intense pain medications. Encourage people to get out of bed at roughly the same time each morning. Get dressed in day clothes. Even if they're not going anywhere, getting out of their jammies helps a lot. Turn on lights and sit in front of a window or get outside to get their day clock started. The pineal gland will help trigger the wake up response for your circadian rhythms. Likewise, when it gets dark, it triggers the let's go to sleep response. So getting the lights on is very helpful. If you must take a nap, keep it under 45 minutes to avoid messing up your sleep schedule. If you keep it under 45 minutes, you're less likely to go into deep sleep, so your circadian rhythms are less likely to get all mucked up. Pain is inevitable. Many people struggle with chronic conditions including tmj, migraine depression, fibromyalgia, and just generally non specific pain. Pain impacts your mood, your thoughts, your attitude, your behaviors and your relationships. Addressing pain will help people reduce related anxiety, depression and anger. Pain management comes in kind of two flavors, medical and non medical, and when you put the two together you get a much more robust pain management program. Pain management requires a comprehensive approach addressing physical causes of pain, mood, social supports, as well as sleep and circadian rhythms.