Chronic Pain Chronicles with Dr Karmy
Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and the latest medical innovations, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
Chronic Pain Chronicles with Dr Karmy
Episode 25: Interview with Dr. Andrea Furlan Part 2
Dr. Andrea Furlan is the closest thing we have to an influencer in the field of chronic pain management.
She is a content creator who has a very popular YouTube channel and an author who has written several books for patients with chronic pain.
She is also an educator who has developed programs for healthcare providers.
Join us as we continue our discussion about what she learned about chronic pain after practicing in the field for almost 20 years.
Watch the video version of this episode here: https://youtu.be/DkxNZOdUeEY
Dr Furlan's Website: https://www.doctorandreafurlan.com/
Dr Furlan's YouTube Channel: https://www.youtube.com/@DrAndreaFurlan
8 Steps to Conquer Chronic Pain Book: https://www.doctorandreafurlan.com/book
Curable App: https://www.curablehealth.com/
Free Programs from Pain Canada: https://www.paincanada.ca/resources/resources-for-people-with-pain
If you have any questions for Dr. Karmy, feel free to email us at karmychronicpain@gmail.com
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Learn more about pain management treatments offered at our clinic: https://karmyclinic.com/
The goal is for them to increase their resilience, improve their management of pain, know themselves better. It's not for them to document their pain, it's for them to forget their pain. So those are the resources that I created over the years. Because I think our patients sometimes they go on Google and they wanna find something that will help them and who knows where they're landing because there are so many fake information and wrong information, not evidence-based information on internet is so dangerous sometimes. Focus on your goals, as you said. A lot of people don't have short-term goals and they don't have long-term goals, so they don't achieve anything in life because they're postponing. They say, oh, when my pain goes away, I'll start living my life, and that day may not come. Hello, this is Dr. Karmy and today for chronic Pain Chronicles. We have Dr. Andrea Furlan. This is the first time that I have somebody come back for a second interview on the podcast, and this is mostly a reflection of the fact that I feel that this is a very, very important topic. A lot of, uh, what we cover has to do with what doctors can do to you, but there's another component which is equally important, if not more important, and that is what a patient can do for themselves. Hello, Dr. Furlan. Hello, Dr. Karmy. Nice to be here again. Thank you for inviting me. Thank you for talking to us. So last time we sort of did, uh, an overview of chronic pain and one of the things that we discussed is that there's more than one type of pain. There's the nociceptive pain, which I think is what most of us think of as pain, which means that if you break a bone or you have a joint that's worn out and damaged, each time you step on that bone or on a joint, it hurts. Then we have neuropathic pain. That's also pretty familiar to people. That's your pinched nerve. So you have a disc that moved and compress the nerve that goes down your leg, and you have sciatica. That's, uh, neuropathic pain. Then you have I guess more rare types. There's, uh, sympathetic pain, like sympathetic reflex sympathetic dystrophy. But there's of course idiopathic pain, which means we don't know why it's there. The central pain, which is again one of those three rare conditions where pain is there just because of part of the brain that's normally receives the pain signals becomes damaged. Often very tough to treat. And then there's one type, which is, I think one of the more common ones, and this is nociplastic pain, which is pain due to sensitization. In other words, there is an anatomical change in the nervous system, but it's, it's a, or perhaps a chemical change in the nervous. System where you know, tissues have healed, but the pain signal becomes amplified. You use an, I think an analogy of having, birthday cake where the candle has fire, is burning. So there is some fire, but it's, you don't want the fire alarm to go off in that case. In other words, the signal is there, but the reaction to signal is well out of proportion to, you know, the signal itself. So we've got all these different types of pain. I guess when it comes to lifestyle interventions how does approach differ? Mm-hmm. Yeah. And, uh, there is, uh, one publication Dr. Karmy that I, I always refer to and I use a lot was , in 2022, a number of researchers put together a special issue in the Journal of Clinical Medicine and then , they looked at all the lifestyle modifications and studies and systematic reviews. The two editors of this special issue were Dr. Joe Ni. He's a, a researcher, scientist and clinician in Europe, and Dr. Philippie Ray, he is also a scientist and clinician physiotherapist. He was in Canada, but now he's in Brazil. He's originally from Brazil. So these two, they put together this special issue that I, oh, the articles are really good and I recommend anyone who is interested to read, 'cause they summarize all the evidence, the scientific studies. There are a lot of systematic reviews, meta-analysis. The key role of lifestyle factors in perpetuating chronic pain, and then the title of the special issue is Towards a Precision Pain Medicine. I like that because when we talk about lifestyle modification, you do need to personalize to the person, each patient that you see is different. And the main key factors they summarize in this special issue are what I talk a lot to my patients and in my channel and in my book, which is exercise, sleep, and nutrition. And nutrition includes weight management. There are other lifestyle modifications that we know of, like a smoking cessation, reducing take of alcohol, more socializing, less isolation. But I'd say if we could help our patients to change their behaviors, their habits in those three areas, exercise, sleep, and nutrition. There will be a lot of people that don't need us. So this is what we talk about when we talk about lifestyle modifications. But I guess, uh, my question is if you have nociceptive pain versus nociplastic pain, uh, versus neuropathic, uh. Are the types of exercises that you do? Mm-hmm. Is the kind of nutritional interventions that you do different or does they mostly overlap? Yeah, that, that's a very good question. And also some of our patients, they have, uh, mixed mechanisms of pain as well. Let's talk about, um, one very common type of condition that causes pain, which is arthritis. A lot of people, you know, getting older and arthritis, uh, can be osteoarthritis, which is a very slow inflammatory process. Destroying the joints slowly, slowly, but it does destroy the joints. Um, it's an inflammatory. We thought before that it was non-inflammatory, so osteoarthritis can be both or even three mechanisms.'cause we also know that, even rheumatoid arthritis, which is another type of more aggressive destruction of the joints, because it's a, a very strong inflammatory process, there's not slow. It's very acute and very fast also destroys the nerves around the joint. So rheumatoid arthritis can cause a neuropathic pain as well. But when we talk about arthritis, which a lot of people have those things, sleep, nutrition, and exercise will help all of those kinds of pain. Like, uh, all these kinds of pain will be improved, especially if the person reduces the weight. And we know even if they're not overweight, we know that, people don't need to be morbidly obese to have, pro-inflammatory substances. And sleep is related to weight, and exercise is related to weight, and nutrition is related to weight. So they're all related because we know people who don't sleep better. They tend to eat more and eat more during the day because they are fatigued during the day and , when they eat more, if they would eat healthy during the day, it would not be a problem. The problem is they eat a larger quantities of comfort food. Because they're tired and they need to be awake. And those are foods reaching sugar, salt, caffeine, preservatives, so processed and ultraprocessed food. So you see how it's a cycle one affects the other one. But going back to, should we do different advice to different people? Yes. Because first of all, we should ask our patients and we doctors do a very poor job asking about lifestyle. Behaviors we like to ask about, the medications they're taking and what are the side effects and, where does it hurt and then examine them. But we do a very poor job assessing systematically for sleep exercises and nutrition very poorly. So if someone, for example, has arthritis and they are not moving they're not exercising because it hurts or because they're fearful that they're going to damage more the joints, they may gain weight. Because you're more sedentary and if you gain weight, your extra fat tissues in the body are going to produce pro-inflammatory substances. Those are called cytokines. They're more than a hundred cytokines that the the body can produce, and the ones that are produced by the fat tissue are adipokines because they're produced by the adipocytes. So those adipokines will then accelerate the arthritis process if the osteoarthritis was kind of stable. Now you give adipokines, which are pro-inflammatory substances. Woo. You are putting gasoline on the fire and the destruction of the joints are worse. So now they're developing arthritis and arthritis faster, and then if they gain weight, it also affects their sleep because we know obstructive sleep apnea that a lot of my patients have is also caused by fat around the neck, and they stop breathing at night. So we, when I say personalized medicine, is we need to know what each patient is doing, what they have, where is the cycle, but basically for all types of pain. Nociceptive neuropathic, nociplastic. We do need to pay attention to lifestyle and behaviors. So, which is of course very fair. When it comes to diet, I think there is some evidence for Mediterranean diet and osteoarthritis. I've heard of other types of diets, anti-inflammatory diet. I don't know how different it is, for example, from , Mediterranean diet. So obviously it's better to have a healthy diet without processed meats and processed food. Things that are not an outta the box in general. But beyond that, is there, evidence of preference for a specific type of a diet or just Mediterranean is good enough. Yeah, very good question. I have some videos about diet on my channel, anti-inflammatory diet, which is very similar to the Mediterranean. Not a lot of differences. And then I have, uh, foods for nerve pain. And for nerve pain would be for the neuropathic pain. Let me talk about the inflammatory diet and the Mediterranean diet, uh, which are anti-inflammatory diet. So if there is any inflammation going on in the body, which is more like in the , areas of, arthritis, rheumatoid arthritis, lupus, autoimmune diseases. The recommendations are what to add and then what to remove. So there are a lot of things that the person needs to add to their diet, which are things that would combat the pro-inflammatory stage, and those would be reducing the amount of, unhealthy fats. And those would be trans fats, is that? No. No. But then including adding more the polyunsaturated fats and those are PUFAs and those are mainly omega threes and omega six. And where do we find omega threes and omega six? The other thing is also important, the balance. Not too much omega six more than omega threes. We need more omega threes than six, but we need both because both are essential fatty acids, which means our body does not produce, we need to eat them. My patients, they say fish is too expensive and it's full of, toxics in the water. I say try to eat fish that comes from natural sources like from the Atlantic or from the Pacific, not that are grown in farms. And those would be canned canned salmon tuna canned sardines. They have a little bit more salt than, uh, fresh fish, but they are very rich in those omega threes. And then of course, adding extra virgin olive oil, uh, because that's, uh, the best oil that we know for anti-inflammatory properties. And also vegetables, green leaves, dark green leaves. Like spinach, kale, those kind of things are very rich in nutrients that are antioxidants. So that's for diet. What to add to diet. We also know it's interesting in this special issue of the Journal of Clinical Medicine that I mentioned to you. There was a paper talking about women with, chronic pain. They did some research with them and they found that they eat very low protein, and we know protein is key for building our muscles or bones or tendons. And I don't know why, but older, the older women, the older they get, they tend to eat less and less protein. And there's a condition called sarcopenia that they lose the muscles. And the muscles are so important to maintain their health, their balance, their strength. So some women. Or men too, because if they don't eat protein, but it seems to be a problem more in women. If you don't eat protein because you need protein to heal. We are always building up our bones and muscles and tendons. You're already regenerating. And then they may feel fatigue and if they feel fatigue, they don't exercise that much, they don't sleep so well. So increasing protein and then the things should stop. The things should decrease, especially if you have chronic pain. So refined sugars is a no-no because we know they increase the insulin imbalance and are also pro-inflammatory. They don't do good through our body and also to our our brain, but also so re removing refined sugars, refined flours. Uh, refined rice, refined pasta. Anything that is white, we should be removing. Also, removing a lot of alcohol. So if people drink alcohol, it's a no-no. Maybe once every, you know, in a while, in a party. Another thing is reducing caffeine because we know caffeine activate the sympathetic nerve system, disrupts the sleep, which is very important for our wellbeing. And of course, if they , are not exposed to sunlight, natural sunlight. As we are not in Canada, we don't have a good exposure to sunlight. That's the only supplement that I recommend to my patients, vitamin D. Between one and 2000 units per day. So that's my, my recipe for most of my chronic pain patients. Gosh, I could go in two different directions here. What My personal experience in Canada, least when you do vitamin D levels in patients, especially if they're brown, most of them will have low vitamin D. So there's sort of two directions. Some people will just give them a set amount, whether it's 800 units or a thousand or 2000. Say just do that. Other people will actually measure vitamin D levels in the blood and they can push those vitamin D supplements a lot higher than 2000. Do you have a view on that? Yeah, no. When I did the video on Vitamin D, my channel and I reviewed the literature there is really no indication for higher doses unless if they have very severe conditions that they don't absorb. Because also we do have a lot of foods in Canada that are supplemented with vitamin D, milk butter, yogurt. There are a lot of , products cheese that are , supplemented with vitamin D. And there are risks, people taking too much vitamin D, they will absorb calcium exaggeratedly and then they can have other complications with too much calcium in their body. Because what a vitamin D does is basically act in the gut making all the calcium that you eat to be absorbed. So that's what they do. Just put the calcium from the gut inside of your blood. Also there is one exercise of mindful eating. Where they will do mind exercise while they're eating. Pay attention to what they're eating.'cause a lot of people just eat, eat. And in two minutes it's done. That's not ideal. You need to, you know, taste the food. Smell the food, take your time because nutrition is not just for your guts and your nutrients, but also for your eyes, for your smell to give you pleasure. It's one of those few minutes of your day that you can have pleasure and you should enjoy it. But sometimes they even eat in front of the tv. They don't even notice how much they are eating. So one of the exercise of mindful eating is to pay attention all the details of what they're eating, and then exercise too. There are physical exercise I talk about, movement. As you mentioned. Some prescriptions of exercises are different depending on type of pain. If the person has fibromyalgia, for example, which is a type of nociplastic pain, they will need to go very slow in starting their exercise therapy. Very, very slow. And then we talk in the book about your energy levels. How do you know your battery? You know when your cell phone has that battery marker showing how much you have battery. We also should pay attention to that battery. And not going to complete fatigue when you're exercising. If a person has migraines, chronic migraines, they should not be doing exercise when they're having the migraine. They should rest and wait until it goes away. But on the good days that they're not having a migraine, those are the days that they need to exercise and mainly aerobic exercises. So yes, the prescription of, uh, physical exercises are different for different types of pain. But the, bottom line is, exercise, sleep, and nutrition should be prioritized by us, the doctors who are treating them, but also by them because they're the ones who need to make those changes in their lives. I find with fibromyalgia patients, a lot of times, surprisingly, maybe the energy levels are lowest in the mornings, which is sort of the reverse of what most people have. And so they often don't like the early morning appointments. Yeah. Yeah. I have the same, yeah. Usually my, the missed appointments in my clinics are the first ones in the morning. And, uh, the other angle, which I know we're supposed to talk about lifestyle I'll give you my personal experience, rightly or wrongly. Over the years, I while I mentioned weight loss in the past, I also know the statistic that 95% of patients who lose weight gain at all back within five years. So in some ways, yes, I would mention it, but to my mind it was a little bit of a failure of our tools to get people to lose weight, to recommend something that 95% of people fail at, felt like just making them feel bad about something that's in part related to their metabolism. And so while I would certainly encourage them and mention it, I was sort of buying into this idea of fat and fit where somebody is, whatever the weight they are, but as long as they lead a healthy lifestyle and eat healthy. You know, that might be as good as they can get. But then of course, a few years ago we have a new medication called Ozempic, and all of a sudden all these people that couldn't lose weight started to lose weight. So what are your views on Ozempic? Yeah, I have some patients that are, because, they were very obese and, uh, they come back and I, I can barely recognize that, ah, you're the same person. You lost so much weight and there is still pain. So losing weight does not mean that the pain will go away. Again, that's depending, going back to the three types of pain mechanisms of pain. If the pain is nociplastic and it's a, you know, a problem of sensitization and a synapsis that is malfunctioning there, there's nothing wrong with the body. You know, losing weight will not make any difference. But when we are talking about a, a condition, a pain that is caused by a pro-inflammatory state, I found that they do get better. I, I actually had patients that they came back and they, they said my pain, they had Dr. Karmy, I had some patients that they, they were ready to go to surgery for knee replacement because they had bone on bone surgery, the bone on bone arthritis on their knees. And they lost weight and they don't have pain anymore, and they say, I cancel the surgery. So in some people is you never know which person will respond that way. But when the pain is mostly inflammatory, there is a pro-inflammatory stage , losing weight to lose those adipokines, but also lose the, amount of strain that they're putting in the joints make a big, big thing. Sounds like, obviously you start with a healthy diet and exercise, but if the weight is still there and if they have arthritis type pain, then ozempic is reasonable. I would say so. So maybe, dive in a little bit into some of the resources that you have and you've created a very large body of work over the years. Well first of all, I noticed your YouTube channel has different categories. It might have exercises for a very specific disorder. But then you have also the topics on diet so what is the best way of using your YouTube channel? Mm-hmm. Yeah. And I know people find it like confusing and they can't find the videos and so if they go to my website, there is an area and the website is just www.doctorandreafurlan.com. Then there is an area for members. It's free. They don't pay anything to become a member. And there I organize all of my content by topic. And I did this because I found, people were asking me, oh, where is that video for this? Where is that video for that? Do you have a video for this or a video for that? So go to my website. And then there, they're organized by body parts, by age of the person, by type of intervention. Um, so it's easy. And some of my videos have, handouts that I prepared, like summaries and they can download for free. It's A PDF, it's right beside the video that there's a thumbnail of the video and then besides there is , a handout. I have more than 50 something handouts there on the website. So I, I would say that's the easiest way to find my resources because even I, sometimes I have difficulty finding my videos on my channel and, I prescribe my videos to my patients and then I numbered all the videos. Now they are numbered from. The long videos, not the short ones. The long videos are number from one to 226, I think. And so I, I create a playlist for them. I say, go home and you're going to watch this and this and this and this videos in this order. So that's my playlist for you. And, they like it because it's personalized to them and they say, oh, this means I don't need to watch everything. No, no, not everything applies to you, but I want you to learn those things. And then there are my books. I have the two books and my first book, the eight Steps to Conquer chronic pain also has QR codes that connect to my video. So if they point their cell phone to the QR codes, it opens the YouTube video right away. And the second video is more like a journal. It's a, it's for them, it's a, it's not a journal. I would say it's more like expressive writing exercise. The title is You Are Unique and So Is Your Pain, because each person has a different pain history and the book has 90 exercises for them to write down and write some reflections, make some lists, discover something about them. The goal is for them to increase their resilience, improve their management of pain, know themselves better. It's not for them to document their pain, it's for them to forget their pain. So those are the resources that I created over the years. Because I think our patients sometimes they go on Google and they wanna find something that will help them and who knows where they're landing because there are so many fake information and wrong information, not evidence-based information on internet is so dangerous sometimes. And I would say what I recommend on my videos in my books are I do a lot of research before, try to be evidence-based. And it's my experience of 31 years treating people with chronic pain. So it sounds like one of the books is almost a, a little bit like, uh, writing exercise is more about mind over matter type approach. Exactly. This one here. I know your listeners who are on podcasts only listening the audio, they're not seeing this. Yeah. But this one has, a lot of empty space for them to write their answers. So I have prompts for them to write. That's why each book is going to be different from another book because what one person writes their story here will be completely different from another person with chronic pain. So each person is unique. That's why I gave this title for the book. And a lot of people with chronic pain, they're isolated. They don't have anyone to talk. Even if they have a counselor, a psychologist, a psychotherapist they may talk about, you know, cognitive behavior therapy techniques. But then I find, things that are more personal to you, things that you like, your hobbies, what do you wanna do? What do you see yourself doing in 10 years? How was your past? How is your future? What are the people. That are influential in your life. Those are things that sometimes we don't stop to think and they make a big difference in people's lives because sometimes doing an exercise, this is called expressive writing and doing expressive writings, not for everybody. Not everybody likes to write, but when they do, it helps them to to reflect on what they're thinking, what they're feeling, where their life is going.'cause living with chronic pain is not easy. As you probably know, your patients sometimes they're very discouraged. They have, it's not because they're depressed, it's because their life is around their pain. All they do is go to therapies. They go to clinics, and they go to appointments, and their life is lacking meaning, so the hope here is to provide them with an avenue for them to find meaning to their life, to find purpose and find their strengths, and find their dreams again, and find what is blocking them from doing it because let's say that the pain will not go away. And some people, especially neuropathic pain, when you mention central pain which is so terrible, like people who had stroke or people who had multiple sclerosis, or even people with spinal cord injury, sometimes that injury will cause a type of chronic pain that will not go away. And the medications will calm down the central nerve system, but will not eliminate. So in those cases, they cannot stop living because they have this, they still need to enjoy their life, and that's the purpose of doing those reflective exercises. Yeah, in general, just my observation is humans are goal oriented animals. They need goals to strive for and, patients with chronic pain who don't have a goal, even a small goal, but preferably a big goal, they don't do as well. It sounds like it helps people reflect. Yeah. Yeah. There are 90 exercises, there are 90 prompts, and some of those are oriented. What do you wanna do in the future? Where do you see you going? What are your hobbies? Make a list of things that, uh, will help you to get there. Yeah, so that's a big. And I also try to motivate them to be more physically active, to pay attention to their sleep. What are the things that make them sleep better? So let's move on to the other book. Uh, so how does it compliment the YouTube channel? Yeah, so the eight steps, uh, to conquer chronic pain, it's more like, to give them the knowledge, the information they need to be able to. I would say conquer. Conquer this condition. And when I say conquer, it could be, could mean different things for different people. For some people, conquering chronic pain means they're not afraid of the pain anymore. They decided to live their life, reach their goals, despite having pain. And the book will help them to achieve this. But for other people, if they practice maybe not all eight steps, but some of the steps, they will be able to reduce the pain density a lot. Which one? You know, the, the main step here in the, in the beginning of the first one is retraining the pain system, because they do need to have, . Some knowledge about the pain system. We talked about this last time. When I talk about the alarm system of the house and, in most people with chronic pain. If the injury, the damage, the sciatica, even the sciatic nerve, it heals and you don't have that sciatic nerve irritated for the rest of your life. But if the pain persists, now the pain is nociplastic. So the first step is retraining your pain system, doing those things to decrease the sensitization. And then the second step would be about their emotions. A lot of people. They don't realize how much our emotional state aggravate our pain. A simple example is this. If you have a fight with your spouse and you are super nervous, anxious and you wanna fight and you wanna kill someone your pain will be more vivid. You feel more pain maybe on the same day, but the next day and the next week because you are adjusting that stage of hypervigilance. The sympathetic nerve system is super active and more adrenaline, more cortisol, make pain more sensitive. So knowing your emotions, controlling your emotions when we are angered, depressed frustrated because most of the time doing those two things decrease the intensity of pain a lot. And surprisingly, the step three is sleep. Get quality sleep. Step four is nutrition and diet. You see, we're not even talking about medication yet. Mm-hmm. Because in my mind I say if you do those things, you may not even need to do steps six, seven, and eight. Step six is about medications. I'm not against medications. I prescribe medications, but sometimes they're not useful. Mm-hmm. We need to remove them because they're just giving side effects. Step five is about, our getting help from other people. Socializing, communicating. Well, I teach them to communicate with the doctors. How do you explain pain to your doctor?'cause you go to that pain consult, you waited so long, and then you wanna say everything that happened to you in the last 20 years. But the doctor doesn't have all the time in their life. How do you prioritize how you communicate? How can you get the best from your doctor? So step five is get help from others. How do you communicate with your family members? They don't understand what you're going through. How do you tell them that you need help? How do you communicate with your boss at work? How do you communicate, with everybody around you? And then step six is about medications. I explain all types of medications that we can use, including injections, including interventional procedures. And then number seven is about modalities, heat and cold and tense machine and exercises. What are the types of exercises? So it sounds like it's almost a framework, a way for patients to, a framework for how patients can approach their pain. Yes. One, I guess thing that I think is often difficult to do in a book form or in a YouTube video form is, counseling, things like, cognitive behavioral therapy, mindfulness therapy. There was a new one presented at PRT, pain reprocessing therapy, pain reprocessing. There was another one, which is just a very short intervention. Mm-hmm. Something relief, if I remember right from Stanford, recently developed. Yeah. But suffice it to say there's a lot to them. So I don't know, do you have any suggestions in terms of, obviously if people can afford it to go see a psychologist , is wonderful, but a lot of patients with chronic pain have very limited resources. Yeah. Uh, they don't really have access to these sorts of things. I don't know if perhaps there's some OHIP covered help for that, but also are there some websites, maybe even AI based, products that , would make it possible for patients to access? Yeah, I, I have the same problem. Unfortunately, if they have resources, then I recommend them to see a psychotherapist, a coach, a counselor. But if they don't, there are, first of all, there are excellent people on YouTube and Instagram that they offer those advices and lifestyle. And they're almost has Good, as a coach that will guide these people. And I interviewed some of them on my YouTube channel, real and Ugly in United States. She has an a fabulous Instagram and YouTube channel. There is also the curable app. From Curable it's an app they have to pay. There is an annual fee. It's not super expensive and, it's an app that delivers pain reprocessing therapy. I have seen people that they did themselves. There are also coaches. I would say the coaches are lay people who charge much less than a psychotherapist because they're not licensed psychotherapists. And this would be someone who had an experience of these therapies with some professionals and they had chronic pain, so they did, they experienced themselves and how their coaches for other people. And I would say this is very similar to AA for people who are dependent on alcohol, people who have alcohol addiction, alcohol use disorder. Sometimes they prefer to be in an AA alcoholic anonymous meeting, then talk to a psychologist because the AA people will understand them better, will have better advice for them because they know what it is to go through the withdrawals and the problems they have. And I would say for chronic pain. Lay coaches could be the future. And even if I would love to see maybe in the future, similar to aa, the chronic pain anonymous people who conquered chronic pain and they would like to provide advice to other people who are just starting on the journey. Uh, why not? Because, you know, and this could be very low cost and they only do some money, contributions, whatever they can pay, but I think this could be feasible, but we don't have yet. One of our mutual colleagues, Dr. Henry, has a pain support group. Ah. Which again, sounds a little bit like aa, but it's not, obviously it's not structured clearly. It provides certain social interaction. Yeah. Which is good for patients who are very isolated. Any thoughts on pain support groups? Either virtual Yeah, or in person? Yeah, I like, I know lots of those. For fibromyalgia, there is the Fibromyalgia Association of Canada fac. The website is fibrocanada.ca. I sent a lot of my patients with fibromyalgia to this website because they have a session there that says support groups. So they do meet. Yes. And they talk about, you know, they discuss topics, but it's not to provide that psychotherapy. It's more like a support. There is also if people who are not in Ontario. Probably your podcast will be listened everywhere in Canada if they are in the Atlantic provinces. There's the People in Pain Network led by Virginia McIntyre. She is great. She's a person that interviewed on my channel. She has chronic pain. She had many years of chronic pain and she's doing so amazing and she has this network, people in paying network. They also have support groups. And then in Ontario supported by the Ontario government, we have a portal and it's called the Poweroverpayingportal.ca. And in the portal there are lots of work. This is all free. The person enters in the portal, there's a portal for kids and teenagers with pain and adults with pain. So they have wonderful resources, courses, webinars, workshops, and also they have some group sessions for like peer support. So those are the free resources that we usually tend to send our patients with chronic pain. What is the level of evidence behind, lifestyle interventions? So, uh, first of all when I go back to that supplement and that special issue of the journal, there are many systematic reviews, which is a very high level of evidence, many meta-analysis, but when you look at the studies that they included in those systematic reviews and meta-analysis, the evidence is not like a randomized trial or high quality randomized trial because it's almost impossible for you to, it's not a pill that you can take this pill or take this placebo for three months and then we'll see the results. It's not the same thing. We can't randomize people to sleep better, not sleep better, or to, you know, keep walking and, exercising. So for exercise is a little bit better for weight management is a little bit better. There are evidence from animal studies that can also be extrapolated to human studies. So there are a lot of scientists that created models of animals with fibromyalgia, with sciatica, with central pain, with CRPS. So those animals have exactly the same symptoms that a person with fibromyalgia would have. So then they can test and for example, they had, rats that were with fibromyalgia and they put the rats to swim. And when the rats were the ones that were sedentary and the ones that were swimming, the ones who were swimming, the pain disappeared much faster. And the ones who were sedentary, they kept, you know, having chronic pain everywhere in their little bodies. But of course the emotions and the social context that humans have quite different from animals. But this is how hard it is to make, that type of studies in humans. But the evidence, I would say, nobody's going to content with the evidence because there are no studies even for cancer. Some of the studies in this special issue were for pain after cancer. And pain in children with cancer, pain in adults with cancer. And they showed that those lifestyle modifications even work for post-cancer pain, which we would not think about it. But we know that even exercises now is being considered as a therapy for cancer, not only to prevent cancer, but to improve the life expectancy after the person is diagnosed with cancer. And it's certainly a person with cancer if they have pain, is very stressful. Insomnia due to worries at night. So paying attention to all of those lifestyle changes is really important. They should not be neglected. They're difficult to do randomized trials, but there are lots of studies, animals and humans showing that those things work in experimental studies more than in randomized trials. I guess my true sense on this is that I think pain as a field is in some ways uniquely difficult to do good studies in, and yes, I look at the evidence, but probably I put as my equal amount of weight on my personal experience in the clinic and what I see works in the clinic. For an individual patient, if something works for them, I don't think they care what the level of evidence to support this is, especially if it's relatively safe approach. For pain, some people will go in cycles. Is it placebo effect or is it a real effect? But in clinic, it doesn't really matter as I think, fundamentally, if there's a reasonable reason to believe that something may work and the risks are relatively low I think it's worth a try, and especially for things that you're describing. They don't just help pain, they help health in general. So you know, they keep your heart healthier. They will keep your brain healthy. There is evidence that exercise actually causes stem cells. To be produced in the brain. Nothing to do with pain directly, but you know, these things are good for your health overall. So it's a little bit of a mm-hmm. No brainer. I think sometimes in pain management, there's a lot of focus on, you know, what does evidence say about this? What does evidence say about that? But ultimately I think, what's more important, that is what works in the clinic. Yeah. And we should be celebrating our patients when they come back and they say they made those changes because we need to incentivize them. Promote them doing this and celebrating, praising them for doing even tiny changes, uh, like this. Yeah. Anyway, thank you, Dr. Furlan for speaking to me today. It was a real pleasure. As I said, you're the first person I brought back twice because I think this is such an important topic. Thank you. Thank you again. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.
