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Part 1: Holistic Pain Management: Pain Origins and Assessment
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The agony of chronic pain is a huge burden on many, on both a personal and societal level. Today, in part one of Holistic Pain Management, we welcome back Ananda Mahoney, an expert in the assessment and treatment of pain. In this episode, Ananda takes us through the neurobiology and theories of pain, various assessment tools and the issues of pain in our society. Ananda also discusses what worsens and what alleviates the sensation of pain, and we'll gain some insight into integrative treatments which can offer help, especially when orthodox measures fail to relieve pain.Find out more: www.fxmedicine.com.au*****DISCLAIMER: The information provided on FX Medicine is for educational and informational purposes only. The information provided is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you learn here raises questions or concerns regarding your health.*****
this podcast is brought to you by vitally vitally is the first comprehensive patient order system in Australia stocking all the major brands including Melo Jennings biosuit achill orthotics and many herb by America plus 30 more it's been custom-built for naturopaths nutritionists and integrative practitioners vitally works in three simple steps add your patient prescribe products and dosage info and finally your patient orders vitally takes care of the rest vitally frees up your time allowing you to focus on your patients to learn more visit vital ly [Music] this is FX medicine I'm Andrew Whitfield cook I joining me on the line today is an undermining an under works with people who are struggling with chronic ongoing pain that's caused by a wide range of conditions such as neuropathy functional issues such as migraines IBS and fibromyalgia and autoimmune or injury related pain amongst others a naturopath for 20 years ananda has been in clinical practice for 12 years and has now a specific focus on chronic and acute pain management and under the interest in pain management emerged out of the frustration of seeing patients receive inconsistent treatment and the use of isolated pain management strategies rather than holistic care Ananda is a nutrition lecturer at endeavor college of natural health and is a clinician in two successful integrative practices in Brisbane she has a passion for education and continued learning which has led to her undertaking postgraduate studies in human nutrition at Deakin University and more recently to a master's in the science of pain management at Sydney University to align more closely with her special interest in clinical practice Ananda is a member of the Australian pain society and the International Association for the study of pain that's the I ASP welcome back to FX medicine a number how are you going yeah great thanks for having me Andrew it's a real pleasure to talk to you today it is our pleasure to have you back because you give us such fantastic practical clinical information but today we're going to talk about a bit of a pig of a subject and that's natural pain management yeah so just how much in pain are we as a society yeah well it is significant global burden and specifically untreated or poorly treated pain and if we talk about chronic pain because that's probably more my area of research and and and study it is a little bit difficult to quantify because there's a natural history of pain it fluctuates and there's acute exacerbations and with other variable factors associated with pain you know apart from biological and biomedical aspects but psychological and social aspects so these have different influences and pain at different times but if we kind of put a definition around chronic pain which is commonly and widely accepted and used in Australia its payments persisted beyond expected healing time or pain experienced for three months or more and sometimes that's a very arbitrary cutoff yeah but if we look at that then it's approximately one in five adult women and one in six adult men have persistent pain and there's multiple causes and many of the causes are unclear and in fact about seventy percent of people with pain can't trace the start of their pain to a single event and yeah so it's not like umm someone said although I bent over and I felt my back go and since then I've had chronic pain you know I injured myself and since then you know often it's quite and insidious onset or you just the person can't identify what brought it on on what this specifically contributing to the chronic pain and it's also associated with other health issues is multiple comorbidities such as depression insomnia anxiety and these of course just add to worst quality of life you know apart from the pain itself if we're talking about one in five women and one in six men which I've kind of say that's significant and given that low back pain is a significant cause of chronic pain how much of that one in five one and six is low back pain compared to other forms of pain in I was reading some work in further New South Wales health and they looked at 23 percent of women have I know so I think it was still 23 percent of women have chronic pain right or identifies chronic pain in New South Wales but globally lower back pain is the number one cause of disability and that was from 2012 the lamps reported on that and you know fourth was neck pain 6 with other musculoskeletal pain and 8 with migraine so that you know global causes a disability we've got chronic pain having a significant burden there Wow that you know that really stunned me how low back pain and other forms of sort of musculoskeletal pain of much higher than migraine I thought my brain would have been right up there yes well migraine tends to custom in women more than men so it might be that you know if we're looking at women it might have a higher incidence but across you know the population migraine has a lower impact than although back pain and other musculoskeletal pain you know just in Australia look if we by 2050 they predict that they it will be quite to about 34 billion dollars a year in economic cost so you have this kind of individual burden but then also this is really significant economic burden coming through and I want to talk later about the economic burden reaching further than just you know accessing pain management because indeed there's this issue of dependence and and even addiction and therefore possibly crime in certain individuals so I'm just wondering about this the how far-reaching the issue of I'll blame them now the opioids we've got a massive issue in our society with the opioids but I wonder how far reaching that those issues are beyond just medication yes they are significant and unfortunately a lot of those modern modifiable factors they contribute to a poorer outcome so I talked about modifiable factors like if we just say pain itself there's a lot of secondary outcomes associated with pain but there's also you know factors that a prognostic of a really poor long-term outcome and those poor relationship low social support and medication reliance there amongst those poor outcomes or poor prognostic outcomes so unfortunately they just feed into them you know more disability and quality of quality of life issues in the individual as well so so you you say that you know the reason that you've got this passion for helping people with chronic pain is because you've seen them being not necessarily mismanaged but but let's say they haven't been giving the best management isolated pain management I think you've termed it rather than holistic care do you think it's because of a lack of knowledge of what happens with people in pain by their normal caregivers if I do and I think that goes across the board from GPS and conventional medicine to complementary medicine across the board I don't necessarily think that we have a really good understanding of the inputs and the drivers of chronic pain and therefore we treat it in a unimodal way so a person might be going to their GP for pain or they might be going to a massage therapist or did that they might be doing both but there's no communication between those health care providers which means it's still effectively it's you know modal treatments right and if we look at how chronic pains treated one of the biggest factors that's involved in better management and quality of life is pain education yeah yeah so and pain education comes at concepts like pain isn't in chronic pain pain isn't associated with damage so if you exercise and you feel pain people will often have excessive rest days because they post that exercise because they're in pain yes and that may stop them with activity but they may think I'm doing death a better way pain subsides and I better be careful about how much activity I do in the future because my back's stuffed I saw it on an image and I've got no my discs are generated so if I do exercise and it you know further damages or degenerates my discs then I'll have voice problems in the future right and that is frequently not the case you gotcha gotcha gotcha so fulfilling yeah yeah yeah so the sort of avoidance of the healing activity because of a concern of a furthering of damage yes but unfortunately that's a message that they're getting from a lot of their health care providers right and that I guess just comes from the fact that pain education isn't widely known or in theory it might be knowing like the biopsychosocial model pain which is the common adopted model is not necessarily being put into place in practice and so the models there and the theory might be there but it's not being used effectively all people just don't know about the model and don't know about how pain actually works chronic pain works or manifests and therefore treating it as a danger I mean oh sorry I'm a trauma or damaged base that it's been driven by trauma or damage rather than by safe central nervous system plasticity and changes okay but I'm kind of jumping ahead there how should we be assessing pain like you just mentioned the biopsychosocial model I'm familiar with things like the Womack the Western Ontario pain scale you've got the visual analog scale which to me is a little bit droll I prefer the facial pain scale that's used in kids and I actually think that's relevant for adults for anyway but you've got all these other ones that I just don't know about I've heard of them FLAC pain scale the jack the Abby pains got never heard of them what's their relevance all they're part of a pain assessment workup and it's really important to have that fine data so that you can measure the gravity of the problem and chart progress or lack of progress and and even communicate to other healthcare professionals you know my patient has a pain intensity of nine out of ten on a regular basis that's important information to communicate so that that's the importance of perhaps something like the visual analog scale or the pain face-to-face of scale or even a numerical rating scale and I don't really think it matters which one you choose as long as you're consistent with your use within the patient and within that one patient right yeah so to me that the consistency is more important than the actual scale don't change the goalposts yeah that's right but if you're looking at all of those um questionnaires and measurement tools there are some really good ones to use and as part of a workup and a lot of them gather a whole lot of that data and say the brief pain inventory is a one-pager and it's it's got you know pain intensity sensory descriptors it also brings in aspect of associated symptoms and Moon and Kapton sleep and activity they're quite easily to get hold of and to use they're not complex for either the patient or you to interpret and they're available from New South Wales health and the pain management network going to have a huge amount of great resources so you definitely don't have to reinvent the wheel when you come to looking at gathering data you can just go and grab a couple of their resources and incorporate them into your pain assessment yeah so that would be a really good at least one to start with until you become until you feel comfortable about other maybe more specific is that right Louisville Womack would be more specific for the arthralgias is that is that correct oh yes that's right so the why Mac you'd only use of people with arthralgias and but the visual analog scale or some other kind of pain intensity rating scale you'd probably use for all people in chronic pain yeah so there will be pain I'm sorry scales that are specific to a particular disease state great so we'll definitely put some of those measurement tools if you like our measurement resource up on the effects medicine site and particularly that one that you mentioned the brief pain inventory thanks for that yeah so I just wanted to mention them when you're doing a pain assessment it's more it's important not to just get the kind of physical characteristics of the pain but associated symptoms so fatigue and nausea it affects on quality and sleep and so activity and sleep and move all of those coma comorbid associated conditions because they interplay with one another the worse you sleep the working mood the worst your pain or the worth your pain and what you need so there's that kind of and the other thing is which you may not be able to get all in one concert obviously but some of the other drivers of pain perception such as beliefs about the cause of pain and expectations of pain management and pain treatment and coping strategies or lack thereof you know they're really important for ongoing management of pain you know what is this patient's expectations of treatment and pain management when they come insect in and where are they getting that from already and how can I contribute to meeting their expectations or even their expectations will be elicited yes and like I've got to say I have this unbelievable story from a naturopath who used to work with Victor Chang so I'm gonna I'm gonna recount that now and she told me that she she was in her in Victor Chang's team and they went over to China I think it was to show them different ways of surgical of cardiac surgery and there was an older lady who was a high anesthetic risk and the and anesthetist says said I'm sorry I can't anis the Thais this lady and so Victor Chang said I'm sorry we can't operate and the Chinese surgeon said no no it's okay she's gonna have acupuncture and they know no you don't understand we're gonna have to crack this lady's chest and they went no no you don't understand she's gonna have acupuncture so there was this debate almost going on and they said no no you don't understand apparently this lady Haggard I had acupuncture I was wide awake and had no Payne now part of that would have been I believe you know I believe that belief you know obviously has a very powerful part to play in our experiences absolutely but I do believe that acupuncture certainly had a role to play there in in medicating that lady outside the opioid system which is interesting but I just I was flabbergasted when this naturopath which is a nurse naturopaths recounted this story to me so therefore this leads on to my next question what's what's pain oh look I'm going to give you the ISP definition which is um met took many years I'm sort of to actually define which is it's an unpleasant sensory and emotional experience associated with actual or potential tissue damage so that that's a definition of it and if you see there it talks about the sensory and the emotional so recognizing that we can get you know heartsick in emotional pain it talks about actual but also potential damage and if I was going to simplify what pain is in one sentence of you know from that definition is pain depends on the balance of danger to safety signals and yeah yeah so if we talk about potential tissue damage I'll just relay this full story and um this is a story that you can watch on YouTube and it's by Laura Lorimer Moseley and he's one of the foremost researchers in pain and Adelaide I think it's in Adelaide I'm not sure if it's Adelaide University but in Adelaide and he's a physiotherapist and has done a huge amount of working and understanding and working with chronic pain and he relays his story as an in kind of indication of that idea of potential tissue damage and the imports of dangerous signals aren't all about the actual tissue trauma and so he was walking on hubs on holidays and it was Bush walking and here no open-toed shoes and he felt this kind of scratch on his foot and he looked down and didn't see anything but it became very soon apparent that he had been bitten by and that was quite dramatic and he had to be rushed to hospital that took a while for recovery and you know he got over that I mean and fully recovered but a couple of years later he was walking through the bush and maybe not the same environment but a similar environment and enjoying it at a stick flipped up and scratched him on the ankle and he had intense an immediate response that was grabbed his ankle he was in really bad pain and he was jumping around and killing and he probably tells history slightly differently but this is my interpretation of it and when he finally kind of pulled his hand off he saw that he just had a superficial scratches a little bit of superficial blood on his leg and it certainly wouldn't normally elicit that level of pain perception but of course he had really strong danger signature that his previous experience and so that amplified that import or that danger import which then his brain interpreted as a really really big noxious and dangerous event and his body responded in kind so all you wives out there don't belittle our hurting finger stories it's I'm going to use that video but it is a really interesting thing to note because like I've seen that in kids um you know I've used it in my children the old distraction that okay it's just a scratch and they don't bother it particularly with very young kids if they see you that your nonplussed about it they're just like no okay fine but if you go are you okay then the tears start and things like that and most parents would have done this that's okay and then I go oh he'll know that's really serious a little bit more serious and initially so I yes what about what about the the theories of pain though there was the pain gate theory and then there's the two gate theory I'm not sure that I'm familiar with that I'm not sure that I'm familiar with the two good I'm good at repairs at terminal gates very good briefly but I'll and I'll kind of move on to more current series because that was them melzack and warm in 1965 came up with the gait theory and it changed thinking at the time it moved paying from a really linear theory to a much more dynamic theory that involved the changing nature of the the nervous system central and peripheral nervous systems and it kind of incorporated the idea that the structure and function of both are shaped and constantly reshaped by activity within it and at each level the nervous system is continually amplifying or inhibiting signals and these arm can be dangerous signals or so noxious signals or non noxious signals but it's constantly amplifying or inhibiting these and in the brain ultimately interprets that as pain or you know it's just that okay that's safe it's not a strong danger signal yeah and it is really simply it suits the particular series so it's a non painful input to the dorsal horn such as I'm sorry I should say I made a mistake there we never talked about the input as being painful because it's not it's just a signal so it can be noxious or a danger signal but non noxious important to the dorsal horn such as touch vibration or pressure closes the gates to noxious input which then dampens down or prevents noxious is more traveling to the central nervous system ultimate the brain tense you hold your elbow when you've banged it yeah right yep all you rub it yeah so there's three factors that influence that and that's the level of activity of the nociceptors and they're the new neurons that transport noxious input or the activity of the a beta fibers which are the ones carrying non noxious input so those two and then the brains perception of the incoming peripheral messages and its response or discerning messages which facilitate the opening or the closing of that gate idea but this theory didn't really explain chronic pain or even the influence of previous painting experiences or gender differences in pain so the seahorse's came up with the neuro matrix theory in 1999 and that kind of recognized that there's an innate network of neurons in the central nervous system the neuro matrix and this is unique to the individual and impacted by physical psychological and cognitive traits and past experiences so therefore we can see that maybe cognitions or beliefs or behaviors might influence pain as well and the perception of pain gotcha yeah currently we now go buddy's biopsychosocial model I talked about and that looks at the complex interplay of all of the factors the physiological psychological and social cultural factors so from the biomechanical perspective or the physical it might be nice except –iv inputs or inflammatory imports or neuropathies or plasticity central nervous system plasticity and central sensitivity so recognizing the changes in the central nervous system they're associated with chronic pain but then beliefs mood previous experiences and the influence of peers and partners work environment and things like that and this goes across cultures as well I remember in nursing you know like the the the Asian cultures were very more stoic with regards to pain particularly females whereas you know I'm going to be this is so broad so stereotypical of course but but generally speaking the more Mediterranean type of of cultures would be more expressive of pain and and indeed would be more physical in their expression of pain the waving of the hands and and things like that sort of thing and it's not you know you've got to be very careful not to judge it you know is that person therefore not in pain because they're not showing it or are they just being really stoic and is you conversely the person who is throwing up there hands do you then trivialize their pain because you you know think they're whinging or playing on on your sort of heartstrings it is hard and you see pain is totally an individual experience and so we can't compare one person's pain to another person and they still don't have you know a definitive biomechanical test for an experience of pain you're getting closer but they don't at this stage not what about different age groups like you know and I'm not thinking just emotional or as you said that the input of safety versus danger signals but I'm I'm wondering about nerve impulses and neurological connections if you like to a noxious input yeah are there physical physiological I guess is the correct term differences in pain between different age groups or indeed maybe different cultures I guess that's the initial pain responses there's the end I think pretty much what I want to say to rather than two different groups feel pain differently do different individuals in different situations feel pain Durrani right so you really do have to look at that person's pain yeah look with the elderly you might see decreases in nociception and they may place less pain so and end with very young babies the nociceptors have an axpy you know properly developed into the dorsal Horn yet so you can do you know then they still feel pain but they don't feel that fire and noxious input by the nociceptors until a few weeks after birth right okay but you can still see brain activity in infants associated with pain on the EGS yeah and that's just that's they've just come up with that I saw that the other day that they're looking at that way of determining whether infants they're a young influencer actually in chronic or in pain based on brain activity yeah that's very interesting and you know what you just tweaked something about pain in the elderly I remember a warning signal and it was to do with appendicitis mostly you know the appendix is this forgive me the appendicitis pain is this may be a starting of a broad feeling in the abdomen and then over time it sort of localizes to the right iliac fossa but that's not always the case indeed one of the warning bills is that quote on quote the shocked octogenarian that's an eighty-year-old odd in no pain but septic shock so the the trick the thing there was no pain but there in sepsis so there's something going on with there nociceptive sensation yeah yes and that certainly with age may be a factor yeah so you mentioned things like people's association of a danger signal can we change that with techniques like meditation distraction I've mentioned in listening pain and I mean the classic one here is childbirth but what about other forms of pain like lower back pain we certainly can and I guess probably again I can do a quick description and then maybe put some context around why these techniques might help modulate pain the experience of pain so if we have noxious important a danger signal coming into the dorsal horn we used to think that was kind of just a relay station but it's actually akin to a brain with computational ability it's this kind of immense and sophisticated network of inter neurons that modulate those inputs and in and then it goes up to the brain and there's no single pain center there's 500 parts of the brain that light up it's you know 500 however many but a lot is 600 in my brain and under so in these multiple centers collaborate to produce pain but what can happen also is that the brain says well that noxious input coming in isn't as important and so I'm going to inhibit that I'm going to send down a safety signal I'm going to inhibit that import and bring about reduction in pain or analgesia or the brain can go no that's much more important input coming in and I'm going to facilitate those imports peripheral otherwise to increase the spread of pain by activating other prime cells and other nociceptors and the pain spreads so the thing that we're going to look at what are the factors that actually influence that perception and either that descending facilitation or inhibition and you can look at the neural interface there and look at the role of say glial cells and toll-like receptor for surveillance on those astrocytes in in the synaptic and the tripartite synapse is in them your immune interface and I guess I'm coming there because we want to look at how a psychological input can actually influence paying right perception and actually stimulate or be a dangerous signal yeah and just one way of looking at that is the neuro-immune interface and that so we've got this designer so I don't know susceptor and the second afferent and a little astrocyte wrapped around that and then the toilet for receptor so I talked like we said before and it's a basically a surveillance camera with a norm long memory for molecules associated with dangerous events and we've got Pam pathogen damage associated xenobiotic we've also got cognitive and behavioral associated molecular patterns where they then stimulate the release of molecules into the synapse that inflammatory mediators and the like or neuro chemicals that then either dampen down or force or so in this case talking about danger signals that increase the sensitivity of messages not just imports going to the brain so if we have previous experiences or focus on all the context of the situation like if what I'm trying to think of an example might be childbirth a woman goes in a very scared of the experience and she doesn't feel safe in that experience and minutes are protected projected labor then it might be that she's getting a lot of cognitive messages or camps yeah you know sending danger signals into a central nervous system which is then amplifying that pain let's say somebody had more of an influence in this cognitive associated molecular pattern would that maybe tease out the difference between somebody experiencing chronic pain and perhaps experiencing depression from that chronic pain versus somebody who might not have that influence and might have the chronic pain without the depression yeah it's all good yeah yeah it could be affect I mean there's a whole lot of other you know kind of cognitive patterns that might then become danger signals and this is a classic one that you read about in the literature with um pain um and that is catastrophizing so if a person catastrophize is before the onset of pain is the predictor for chronic pain right so even you know they've done this was surgery and they did it with breast cancer with you know so they looked at how what the person was like the individuals like in their degree of catastrophizing prior to the surgery and then whether that predicted they would be coming you know being chronic pain and there was a quite a strong association so and those certainly can be dangerous signals and if we look at the neuro immune interface and we're saying there are all four kind of thought processes to drive inflammation at that neuro-immune from interphase which then drives increased perception of pain what else does it drive apart from just you know that increased danger signals and little perceived pain it might be also influencing the the whole kind of central plasticity associated with pain is not just driven by that you know neuro-immune interface that we've got spinal imports Newell inputs immune inputs endocrine psychological so we start to see that this chronic pain is not just a peripheral issue it's not just about dampening down peripheral inflammation or stopping that noxious import from the periphery we've got to look at what are all of these factors that being associated with danger and interpreted as danger in signals in our body or in a central nervous system sorry and then I was interpreted as pain and what up what else could they be influencing yeah you know could they be influencing those kind of mobilities like depression and insomnia and reduce physical activity etc given that many caregivers and I'm going to blame the blame the allopathic model the the particularly the Australian medical model where a doctor is is you know they're on a time on a time treadmill and basically you've got X amount of time with your GP and there's just no way that a GP can effectively treat holistically given what you've just mentioned they're under the rush the person's in pain they want to get them out of pain and they need to see the next patient yeah expect them to do that they just don't have the time they don't have the resources and I don't mean to I think a lot of primary so healthcare officials don't have the understanding about what all the inputs are right yes but given that what they do then is basically fall into this rabbit hole I need to offer some Sakr to my patient now and the strongest one the best one is either going to be a paracetamol an NSAID or something stronger ie opioids and if somebody's in the chronic pain you know they've been there for long they want something now so there's that likelihood of the opioids being preferred even though there is a worldwide issue and it's noted in the literature that dr. right there and then just wants to help their patient but because of a time they can only help them in one way and that's to medicate or they go down the rabbit hole of trying to determine what is actually causing the pain and sometimes I think that's just like the hammer that's broke in the window we don't worry about the hammer we look at the broken right and so then they go down the path of imaging you know and that in itself is again a red herring right so do you know it's like when the common presentation might be someone goes in with pain and it's like well we need to find out what's causing this or do some imaging and then we need to give you some medication so we'll give you panadol or and instead or an opioid and so two things are happening we're giving chasing the the hammer or the cause which is often not clear and imaging is not associated with better recovery outcomes and in fact in one study it showed that it's associated with an 8 times higher risk of surgery and no not imaging and and then of course they're getting onto that medication cycle so ok that is a rabbit hole isn't it is it we'd always think about imaging giving a clearer picture these are full of the puns today I died but but not always it can lead to over treatment so I guess the me the big baddie of this is mammography not not to say that this is necessarily to do with pain but um it's just this intervention with an image might actually lead you to overtreat yes and that in this case there showed that with MRIs of lower back we associated with our back pain it did lead to I think a higher degree of intervention in the terms of surgery and thing about surgery is that you know there is significant there's something called fell backs fell what is it failed back surgery syndrome yeah yeah yeah so this actually surgery you know that that self alarm bells and you know sometimes it's unavoidable but I think in many cases it's highly avoidable not being any sort of an expert on this but it was just what I observed off of very few cases and you know some afterwards some outside of nursing and I just like certainly the older surgery I didn't have a great opinion of it I mean I would admit that there have been vast advances in surgery particularly in back pain surgery since then but I was just I was not impressed with what Heights or I'm not kind of saying one way though that's all bad it's all good but I think we need to very much see that as a last resort at higher level of intervention is the last resort not the first yes yeah or not the early early intervention and and certainly I think you know given that there's the cost of surgery and that the cost of negative outcomes of that one should always say as you've explained that you must really look at it holistically and if you haven't you're really doing another band-aid one which may cause unpleasant pain further on for the patient it also reinforces that whole idea and thing in many cases that the chronic pain of the back is associated with increasing damage or instability or my back is fragile and just reinforces those danger messages which then you know facilitate and amplify pain experiences so if we could say early intervention get in with some pain education and increased self-management techniques self-efficacy just as a starting point doing any other intervention if we could just start with those things would see improvement in outcomes yes so then at all there are the holistic care in an integrative care and we're more likely to see better outcomes so let's look at some of those integrative cares I was really impressed by a trial that was done in cardiac surgery patients elective cardiac surgery patients at the alfred indeed it was run by endeavor college or was run by the Alfred hospital but it included practitioners from endeavor college in Melbourne and they had incredible savings and benefits to the patients with pain management I think they even decreased inotropes after cardiac surgery by a foot massage great and they the reason was they the reason they had a foot massage was because they didn't want to be touching drains drips and cracked chests anywhere that was sensitive plus there was that intimacy issue but but so they decided on a foot massage just that just that being of human touch of safety of you know you call it a danger signal first as a safety signal somebody actually caring for you lessen their pain and it was dramatic yes fifty percent something like that yeah you know if we look at that as you say it's a safety signal in this care but there's also social and you know social connection isolation just you know isolation is associated with increased inflammation and parties if you just have social connection and human touch and that sends all those beautiful safety signals then yeah I can see why that worked Ananda I want to explore in depth with you what you do in practice with regards to interventions and I really think that's going to require a second podcast would you mind rejoining us for another podcast on pain management it would be an absolute pleasure I would really love to delve really deeply into this because I think it's I mean it's obviously such an important but you're such an expert who gives a damn holistically and I really do I just so respect you for the way that you work and the way that you care for your patients are I really thank you for what what you've educated me on today and also opening my eyes up for other ways in which we can help our patients with chronic pain thanks Andrew I think I love it it's difficult work sometimes office but you know but I really with people to to bring about those holistic changes you know using all of those areas that we talked about social biomedical and psychological I really do think that we have to use that in a very very live way yes so every practitioner if you haven't stubbed your toe yet go out and back yourself into a tree but I just you've given us such a salient point I really thank you for what you've shared today brilliant work thanks Andrew this is FX Medicine I'm Andrew Whitfield cook [Music] hi I'm Andrew Whitfield cook at FX medicine we strive to be clinically relevant for you so please get in touch with us if there's a topic you'd like us to explore or a specific expert you'd like us to interview you 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