Acute vs. Chronic Pain: Why Your Nervous System Gets Stuck in Pain Loops

Are you living with pain that just won't go away? You are not broken. Your nervous system might just be stuck. In this episode, we break down exactly why that happens and what you can do about it.

Pain is not a warning light on a dashboard. It is an output from your brain, produced when your nervous system decides you need protection. That means you can have significant structural damage and feel nothing, or zero tissue damage and experience debilitating pain. Pain measures perceived threat, not actual damage.  

In this episode we cover:

Why the acute phase is the most important window you have. Acute pain, lasting three to six months or less, is the easiest time to intervene. Less compensatory movement, less fear built around specific activities, and a much lower chance of the nervous system becoming chronically sensitized. Most people wait too long, and that waiting makes everything harder.

What actually happens when pain becomes chronic. Chronic pain, lasting six months or more, is a biopsychosocial phenomenon. Biology, psychology, and social factors all feed into the experience simultaneously, and the longer it persists, the more complicated it becomes. 

The four key mechanisms that keep people stuck:

• Central sensitization, where the brain undergoes real neurological changes that cause it to produce pain responses to stimuli that are not actually harmful 
• Fear avoidance of movement, where avoiding pain-associated movements makes the nervous system more sensitized and tissues less tolerant, deepening the cycle  
• Tissue tolerance changes, where offloading and avoidance cause real structural changes that lower the threshold at which pain is produced  
• Dysfunctional movement patterns, where compensatory strategies get wired in as the default motor program, making efficient and pain-free movement harder to access over time  

Why this is not a simple problem. Emotional trauma, financial stress from lost work capacity, being dismissed by clinicians, and systemic inflammation from poor sleep and nutrition all layer on top of these mechanisms and make chronic pain one of the most complex challenges in modern healthcare.  

And most importantly: there is a path forward. The nervous system is plastic. It learned these pain patterns, and with the right inputs, it can learn new ones. 

Whether your pain is brand new or has been with you for years, this episode will help you understand what is actually happening in your body and why the conventional model so often fails to address it.

Transcript

SPEAKER_00 0:00

My name is Mike Carroll. I own Uplift Licensed Massage Therapy and Wellness right in Kingston, New York. I'm a licensed massage therapist, strength coach, and a neurokinetic therapy practitioner. I combine all three of those disciplines to help people get out of chronic pain, get out of chronic injury, and create a long-term solution for their pain and for their injury. Most of my job day to day is working with people who are experiencing more of a chronic pain and a chronic injury. That begs the question: what is chronic pain? What is acute pain? When is it best time to intervene if you're experiencing any type of pain or injury? What is it about chronic pain that can be so sinister and tough to deal with in certain cases? What are the the different background things happening that make it really hard for certain cases to progress in a meaningful way where somebody's pain can drop significantly and they can improve quality of life? Now there's a lot of factors that go into it, which we will talk about today. First, I think it's important to define pain and talk about really what it is. So a lot of people have this misconception about pain that pain is information coming in. There's a little bit of confusion about certain terms and certain definitions. First things first, pain is not an input. We have certain receptors in our body that are typically for noxious stimuli. So basically, stimuli that are potentially damaging would be categorized more into like the pain section. For example, we have chemical receptors that can detect dangerous levels of chemicals. And if enough of those receptors are stimulated, then that information goes up to the brain. That information itself is not a pain creating signal. We have these receptors being kind of turned on all the time in our body, it's just not enough of them to be turned on. There is a bit of a threshold that you need in order for pain to be output. Pain itself isn't an input. There is not like a pain sensor. The closest thing that we have are like free nerve endings and no cceptive detection. And no cception is information, it's not an output. So pain is an output that the brain sends outwards in order to change behavior. Think of it as being an alarm system. Basically, the nervous system in your brain is going to take in all this information that it gets distillated. Depending on the information, the location of it, depending on so many uh different factors, your brain is going to take all that information, it's going to process it based on biologically what it knows, based off of past experiences, etc. If it deems that pain needs to be output, it will then output pain in the appropriate area. There's a lot of different things that your brain takes into consideration to be able to output pain. So it takes on past experiences, your emotional state, general levels of fatigue. If there is any meaning to the situation that the pain is surrounding, if something is extremely painful and it impacts your life in a negative way, that your likelihood of creating pain and increasing that level of pain is probably going to be pretty high. It's not just the tissue damage or the no-ciceptive input coming in, it's a lot more than that. There's a really cool story that illustrates this. There's a story of a construction worker, and from what I can tell, I think it's a true story. Basically, construction worker is working at a site, basically jumps off a scaffolding and lands on the ground. When he lands, there is a nail that goes through his foot and sticks out through his boot. He sees this and he feels the nail go through. He's like basically passes down pain, like immense pain, screaming, ambulance has to come. When he gets to the hospital, they can't do anything for him because he's just in so much gut-wrenching pain that they cannot settle him down to actually do what they need. So they basically knock him out. When they take off the boot, they end up finding that the nail actually didn't go through his foot, instead, it went in between his toes like this, and didn't penetrate anything. There was absolutely zero tissue damage. This person, based off of the information that he had that his brain was able to take in, determined that pain is the best output. It created this whole response from him. So there's no tissue damage at all. There's actually no like biological receptor going in, other than maybe some pressure changes and things like that, like something touching his skin, stuff like that. But there's technically no no-ciceptive input being put in. Basically, his nervous system assessed the situation, detected that there could be some catastrophic danger. The the long-term result of this could be death. We need to stop what you're doing and completely change what's happening. I'm going to send pain outwards to help facilitate that change. This isn't a glitch by any means. Like this is by design. Here's the thing you can have major structural damage that you can visibly see through imaging and have little to no pain, just like this story. You can have no structural damage whatsoever and have immense amount of pain. Pain isn't a measure of damage, it's a measure of perceived threat. When you can understand that, a lot of chronic pain issues can get resolved a little bit easier. Before we get into more of the chronic pain talk, let's talk a little bit, a little bit about acute pain. Technically, acute pain is defined from lasting three to six months or less. Typically, this pain is a little bit sharp, throbbing, stabbing, things like that. In a lot of cases, it could be really useful. Sometimes there is some tissue damage, and you need to lay off the tissue a little bit or at least do more conscious loading. Basically, the goal is like get off this thing. This is hurting. We don't want to risk if it's a bone break, we don't want to risk loading into this more, further breaking the bone, causing arterial damage, or getting some infection that's going to cause uh cause you to go septic. Again, it doesn't always happen when pain occurs. It's all about perceived threat. If you're doing something and you excessively load into something, either you just did did too much weight on something or whatever, or if there was like an unexpected load or unexpected movement that you had to go through, uh, your body might kind of put a big parking break on that because there's like a perceived threat that that movement or that load could cause damage. Other things might happen in response, like splinting of muscles to help kind of restrict you and like literally like stop you from moving, which sometimes that can come up as like a major spasm. In that acute sense, that can cause pain for some period of time, just because your body's literally trying to be like, don't do that. Like that was like way more than we're prepared for. Let's like bring it back a little bit. If there is tissue damage, your body is actively healing. If there isn't tissue damage, it's usually uh pretty uh easy to be able to intervene and to get that pain to come down. The acute phase, this like zero to three to six month phase is actually probably the easiest time to intervene with pain. There's a few reasons for that. Typically at this point, there's not as much compensatory movements that you've had to adopt to move around this pain. There is less fear-based associations with the pain. It's affected your life less, so you haven't had to give up things that you love to do, which then emotionally is taxing. You start to attach emotional response to this physical pain manifestation as well. There's less accrued tissue overload or potentially tissue underloading. Also, there's less central sensitization where your nervous system is hypersensitive to information coming in. It's likely that there will be less. Unfortunately, in this early phase, this is exactly when people are most likely to ignore their pain and just be like, eh, I'll just wait for it to go away. Because in their defense, in the past, that may have happened. That isn't always going to be a guarantee that it will happen. Intervening in this time period is usually easier to get the changes that people are looking for. It's usually a little bit quicker, a bit simpler, just more effective than just waiting for it to go away, because oftentimes that doesn't work. The general rule that I like to think about is if within six to eight weeks the pain that you're experiencing doesn't at least meaningfully go down or doesn't go like mostly away, then the chances of that happening, like later down the line, are probably going to be less. Especially if the pain is literally just getting worse throughout that whole time period. Again, pain is an output. Oftentimes you need to change the inputs that are being put in to alter the output that your brain is outputting. Tissue might need to heal, loading patterns might have to improve, movement quality might have to be restored. Your nervous system just needs new, non-threatening information going in. Avoidance and just medication alone oftentimes aren't um the answer in the long term. Now, chronic pain uh then goes longer than that. So the three to six months plus, I usually define it as being like three to four months plus. Because honestly, by that time, if things haven't changed and gotten better, then it's probably going to continue to get worse or at least just stay where it is. Now that's not always the case, but I'd say like a this is totally anecdotally, but uh just from my experience working with people, it seems that it just usually gets worse. Basically, now chronic pain. The alarm is stuck to being turned on or at least being hypersensitive to information. If there's tissue damage, typically that tissue damage has already healed, which again begs the question why am I still in pain if I don't have any damage to tissue at the moment? Like, why is my brain deciding to output pain as a response to whatever's going on? This is where things get again a little bit more complicated the longer that you have pain. In pain science, there's this kind of phenomena called the biopsychosocial model of pain, meaning that there's a biological, psychological, and sociological inputs that that modulate the pain experience. The longer that you experience pain, the longer that these things kind of intertwine with each other, there's this kind of there's a saying called what wires together, fires together, and that's really true. That all these things that that you're experiencing in that pain experience will start to blend, will kind of like get glued to each other. When you experience one, there's a likelihood that the other things will also pop back in as too. We're gonna talk about certain mechanisms that I think are really important to understand when dealing and working with pain. Now, this list is not exhaustive. I think that they're big levers to think about and to pull. These things are typically all happening at once. We're gonna talk about them individually because I think it's just easier to cognitively understand them. Keep in mind that each one feeds into each other. So it's not like you get one and then you get the other, you get the other. They're all kind of happening. One makes the other worse, that one can then vice versa, make the other one worse. It kind of becomes a bit of a mess, honestly. The first thing that I wanted to talk about was this idea of sensual sensitization. When you experience pain for a long period of time, there are some structural changes to the brain. The basically your brain has like this relative map of where everything in your body is. The longer that you experience pain, something called cortical smudging happens. The representation of these different things gets a little bit smudged. It's not as precise as it once was. So there's like overlapping information of regions that might contribute to some referral patterns of pain that might make it hard for you to proprioceptively understand how to move and maneuver that region. There's a lot of output motor-wise is determined by the input coming in. So if the mapping of these regions is poor because you've been experiencing pain for so long and it kind of smudges it all over, then the actual palpable output that you have movement-wise might actually take a hit from that as well. Most significantly, your central nervous system becomes sensitized to information. We're going to talk about a scale of zero to a hundred. Let's say for this specific movement, it would usually take around eighty levels of stimulus out of a hundred to produce a pain response. What happens in central sensitization is this where normally it would take you would be able to get up to 80 in order to produce that pain response, that number drops. So the threshold to create pain as a result of information come in gets lower. Therefore, even if the stimulus that your body is taking is not as risky and or just not as harmful in general, your body might still produce pain as a response because it is so sensitive to information that it just perceives it all as a threat and says, poop, I'm gonna create pain. The more chronic that pain becomes, the more likely that this process is going to happen. If somebody was told that deadlifting is bad, they should never bend over to go pick something up, then chances are that person is gonna have some fear surrounding movement. They're gonna avoid doing that movement at all costs. Right. And so the last time they did this, they had a pain response from it. So when they're just not thinking one day, they go to bend over and pick up the pen that they dropped on the floor, they go to stand up and they get this severe pain response. Chances of any tissue damage actually happening during that is probably pretty low. What's more likely is that their nervous system is so sensitive to that change of position that should, in in like a normal situation, should not produce pain. Instead, a big pain response is created because they're they're sensually sensitized. Instead of it going to 80 in order to produce a pain response, they're down at 40 to still produce that same intensity and same level of pain as a response to the information coming in. This becomes tough because this takes some time and a little bit of effort to be able to work through. When you're working through it, there's going to be good weeks, there's going to be bad weeks. Uh, the level of stress that you're experiencing in your life is also going to very much dictate the sensitization that you have, as well as a myriad of other factors because this is a biopsychosocial phenomena. Having this understanding upfront can be really helpful because it can demystify the mysterious aspect of chronic pain where like one day you're feeling pretty good, and the next you do this one thing it produces this huge pain response. That could be a big part of the puzzle for you. The next thing that we're going to talk about is this fear avoidance of movement. As your pain becomes associated with certain movements, you naturally become a little bit fearful of those. Add on to the fact that if you go to see some professional, whether it be your doctor or whomever else, they might demonize certain movements and be like, you should never do this because this is the reason why you're in pain. This is the reason why you got hurt. I think that there's a well-intention in that because people don't want to see their clients or patients get in more pain. It's extremely misinformed and extremely misguided, actually can do a lot more harm in the long run than the benefits that they're trying to give people. Here's what actually happens you now attach fear to the movement that you're avoiding. Then every time that you do anything that kind of represents that movement, you're gonna create a fear response. Again, because of what wires together, fires together, as you go to do that and you create fear around it, then you might be more likely to produce pain as a response. As you avoid that movement, you become less tolerant to the movement, which we'll talk more about tissue tolerance in the next one. Your nervous system doesn't exactly know how to fully coordinate it. It might like excessively use certain structures or just create this big like weird, faulty or dysfunctional movement pattern around it because it doesn't exactly know the best way to coordinate it because you literally never do it. It's like learning any other new movement or new skill. It just takes time to learn it. And all of that bundled together, when you go do this movement in life, such as that example I used before picking up picking the pen up off the floor, boom, there comes pain. There comes another big fear response because you're in pain, you don't know what's happening, you're a little bit confused. This is very much a positive feedback loop of a pain creating cycle, where just circles and circles and circles, unless you do something to intervene. So now we're gonna move on to the next one, which is which is tissue tolerance and tissue changes. Your tissues are adaptive structures, they adapt largely based on the stress that you provide onto them. Functionally, a lot of that stress is just manual loading. So most of the tissue in your body, when you apply physical stress and load into it, it will adapt by laying down more of the same tissue, by increasing motor unit recruitment so that way you can utilize the tissue better, increasing neuromuscular coordination, just overall increasing the total tolerance that it has for the load that you're applying onto it. As you remove load from tissues, there's a chance that it can atrophy. In bone, this is called osteopenia or osteoporosis. Uh, muscle atrophy is just something that we've all heard of, especially as you get into more of an aging environment or a lack of loading and training environment. Your tendons and ligaments also change too. Your tendons start to lose a little bit of stiffness. Ligaments can kind of weaken a little bit and have a less lesser ability to manage loads that are put upon them. Also, going back to that motor unit recruitment, you will be less efficient in how you engage and basically create the total amount of force that muscle could produce as you start to use it less. So your nervous system becomes less precise and less efficient in how it recruits those structures. On the flip side of that, you can also load tissues too much to where there is so much repetitive micro traumas that happen that, for example, tissues start to denature, you can get interstitial tearing and swelling in the tendon, which is when the tendon starts to get like large. It's one of the signs that you are probably going to be more at risk for tendinopathy, tendinosis, and potentially a tear. Both ends of the ends of the spectrum, it's kind of a double-edged sword. You can do too much movement and have tissue changes and tissue tolerance issues. Then you can go to the opposite side of the spectrum and underload everything and have tissue changes and then also tissue tolerance issues. In a chronic pain setting, technically both of these things can happen. In an example, such as tennis elbow, that is usually defined as repetitive micro traumas happening that then cause that interstitial tearing in the tendon, and an inflammatory cascade can come after that, and the tendon starts to denature. That's like kind of one of the examples of excessive load going into something. What also can happen when you're in a chronic pain setting, especially when you have the fear-avoidance nature of uh or fear avoidance of movement, you will start to offload tissue. You are going to decrease that tissue's capacity to manage load, whether it be at the like local level, such as muscles' ability to contract and to produce force and to stabilize joints, are going to be affected. You're also going to just have less motor unit recruitment and less neuromuscular coordination of how that muscle should be controlling and centrating the joints and stabilizing things as you're going through movement. You basically get a lower capacity for tissue to be loaded on a neurological level and on a local physiological level. If you couple in the fear avoidance of movement, which we talked about, central sensitization, also now your tolerance for the movements are going down because you're actively avoiding them and have this fear around them. Your nervous system is already sensitized to the movement to create pain. You can really paint the picture of how you have all these stacking things that are really working against you that are going to propagate this chronic pain experience even more. Again, going to the flip side, you can be chronically overloading a structure because something else in the kinetic chain isn't able to load as much. Then this other structure might start to take up a lot of the force and take up the brunt because there's some bigger issue somewhere else happening. Going back to that tennis elbow situation, a lot of tennis elbow cases are a response from some shoulder or scapular issue, of which the shoulder blade, the glenohumeral joint, or something around that area isn't able to put you through a large range of motion, isn't able to stabilize, produce force, etc. And then you go to the joint down below that can also make up for those ranges of motion. If my shoulder can't do this through movement, I can just overuse my wrist and elbow to be able to accommodate that movement. Then I get more pain at the lateral elbow, which is what tennis elbow is. As you do these loading patterns more and more, the nervous system is going to solidify that pattern more and more. It's going to become the default movement that you choose, then you stack on this neurological pattern that your body is going to rely on to do movement, which can also propagate this chronic pain experience. You can also have dysfunctional movement patterns. I like to think of function in two ways. There is like the function that you need to complete the tasks that you do in your day-to-day life. For example, if you're an athlete, such as a baseball player, let's get even more specific, you're a pitcher. There's a very specific demand that your body has to be able to achieve your sport. In a rehab process for somebody who's a pitcher, the definition of function gets a little bit more narrowed down to we need to make sure that this person can be able to lob 100 mile an hour balls. The interventions that you do along the way will get more and more specific to be functional to that individual adaptation that they're looking for. Another example is a grandmother might find it more functional to be able to get on the floor and play with her child grandchildren. Than it is to be able to throw a hundred mile an hour fastball. The definition of function changes, which is going to change how you intervene for this person. Now, the second definition, which both of these are very important. You can't throw one out just because you're focusing on the other. The other definition of function would be what is the just anatomical function that this structure does in relation to gate cycle and respiration? There are two things that define humans is that we're upright bipedal animals. We have a very unique gate. We have a very unique gate pattern that requires certain things to do certain things. A lot of the function of our anatomy is based upon movement subsystems that help to push you through space as you're going through gate cycle. Just overall, what these muscles do when you're either walking, running, or going in a full-on sprint. Basically, this just comes down to biomechanics. How does it work in a full system manner? And also locally at the joint, what is this thing supposed to be doing at the joint? Is it a power generator? Is it a stabilizer? Etc. When you're experiencing pain and injury, typically you are going to have some sort of intalgic response to it. In other words, you'll like an antalgic position is a position that you adapt, trying to avoid the pain that you're experiencing. A very easy example is typically when people have some sort of like shoulder pain or like major injury. A lot of the times they bias towards a little bit more protected, like adducted, internally rotated position, slightly flexed position like this, because it's generally protective to the shoulder joint. This would be considered an antalgic position. You're trying to avoid stressing the joint so much that it produces a pain response. That antalgic strategy might also become wired in to how you move, which could create some dysfunctional patterns. Also, chances are that you already have some dysfunctional movement before the pain or injury experience. That dysfunctional movement could also just get more and more solidified as you create that pain experience. Because you might not experience pain necessarily in the region that is dysfunctional. Some other thing might take it up, take up for it. Now that structure that you were overusing to be able to dissipate the force throughout your body can't take that force as much, and you further create dysfunctional patterns around that because the old strategy doesn't work. I still don't have full function in the thing that is the source of my issue. Uh so I'm just gonna find some other thing to load into. So being able to really understand what is the what what are the variety of different motor patterns that this person has? How what is this person's strategy for movement? Are there certain things that are doing way too much effort, way too much work that are throwing off other structures? Is there something that is just so over lengthened and holding on for dear life, trying to elicit as much control over the joint as possible, that it has no opportunity and chance to be able to have more force applied into the joint that it's trying to control to kind of even out what's happening? As you can get better at sussing out that whole situation, you can have some really solid strategies to redisperse load amongst a larger range of areas in the body. You can coordinate these tissues that are in this dysfunctional pattern to work a little bit more cohesively, which also could apply some better and more positive loading strategies into it to work on that tissue tolerance and tissue change issue as load is a really good way to improve tissue tolerance and to create positive changes in tissue. You can start to decrease the sensitization that you have. You can start to reprogram your fear around these movements because you can learn how to do it in a pain-free way and in a way that is more supportive to the anatomy. As your pain becomes chronic, all of these mechanisms, again, they kind of happen at once. Central sensitization can drive fear avoidance. You experience pain way more often than you did before. So you become fearful of moving. You become fearful of moving, so then you stop loading into that tissue and you stop doing that movement, or you excessively load into something else. This then can create some dysfunctional patterns and can create wear and tear in certain things, decrease the neurological and local physiological tolerance for load. You develop more dysfunctional movement patterns, and these movement patterns then perpetuate sensitization. Again, it's just pot this positive feedback loop where one feeds into the other and it feeds into the other, cyclically goes around and around and around. Which is why chronic pain cases can become so complex because there is so much history applied into something, and you start to stack on injuries that are either related or are completely unrelated to each other in terms of causation, life happens and you just get hurt doing something unexpectedly. Now there's this whole amalgamation of things that you have to consider in this person's case. You add on the top of on top of that that there's emotional stress. There could be financial stress associated with these different pains and injuries. There could be psychological damage from being told that you don't have a real issue or that your pain is being dismissed by some other provider because they haven't been able to figure it out, so it just must be in your head. You can have systemic inflammation issues that make you more sensitive to pain that also change the quality of the tissue as well, so on and so forth. Chronic pain often isn't a simple problem for a lot of people. It typically doesn't respond respond well to just generalized treatments. You oftentimes need to have a more specific approach for these people because there's so many things going into it. There is stuff that you can do for this, fortunately. The nervous system is extremely plastic, so it has the ability to change as you put more inputs into it that are different from the inputs that you were previously putting in. This is where I've created how I work with people in this population. The first step is always let's find a way to decrease the pain experience and improve either subjective or objective qualities of movement. Whether we're doing some form of manual therapy guided by neurokinetic therapy practices, breathing-based drills to help modulate the nervous system, also just to improve central loading, utilizing some strength-based movements to help teach somebody how to move a little bit better in their body, whatever it is. The goal is to bring that pain experience down and just improve their movement. From there, we usually start to learn more about how this person moves, these other things that might be feeding into their pain. We start to rebuild either those movement patterns or rebuild this person's confidence and relationship with movement and with load. This is all dependent on what are the major factors leading into certain people's pain. Certain people are have a very large mechanical issue that they just need to coordinate how they move, load structures a little bit better, things like that. Other people have a long psychological relationship with this pain. They need a little bit more attention on the teaching them that not all movement is dangerous. As we move through that phase, you we get into the third phase, which is starting to solidify things with more and more load and doing more strength-based activities. Usually these activities are specific to either the function of what the anatomy does or that is specific to the goals that the person has. If I have somebody that wants to be better at being able to pick up their pellets and fill their pellet stove during the winter, then we're probably going to be doing some form of like a sandbag carry, sandbag lift from the floor, sandbag deadlifts, stuff like that. If somebody doesn't have that goal, then I'm not going to waste my time doing a drill like that. I might just do a more standard RDL. This is where the definition of function of what is functional to this person's life also comes in. Unfortunately, all these things usually intertwine where like the function of the anatomy usually lines up with the function of the person's life. Of course, you can get more and more specific as you know what the person's goals are. All this is exactly why the acute phase matters so much. Intervene early. Addressing things early is always way easier than waiting years down the line. That whole list of things that we just talked about for the last 20 minutes are all things that have to be considered when you're working with somebody in chronic pain. There's no way around it. Typically, when something is more acute, it doesn't necessarily mean that this thing was a very randomized event. Usually there's been inklings along the line, something just pushed it over to create pain. There's way less of the psychological, sociological aspects that go into it, way less like moving around the pain. Now, the intensity of the pain might actually be quite high. Usually that isn't the hardest to get down. You'll find yourself being able to move through these that three-phase structure of rehab a little bit quicker if you intervene earlier. Now, of course, if there's like a severe damage to tissue, there's just some landmarks of tissue healing that you need to hit. Even then, if you do rehab during those landmarks, it is going to probably speed up the rate that you get to those landmarks, improve how the tissue heals. It's just going to be better overall. If you're somebody who's reading the blog associated with this podcast, or if you're just listening along, I really encourage you to handle stuff early. If you're somebody who is in chronic pain, handle your stuff now. It is still early in the relative time frame that you could be experiencing this pain. The best day to start is always now. If you, especially if you're in the chronic pain category of this, find somebody who is willing to spend a lot of time with you and investigate what is going on with you. A lot of places might be constrained by insurance to also chase the pain that you're experiencing. Like if you're going in with a primary complaint of knee pain, you also have a history of hip pain, a history of back pain. That knee pain might actually not be an issue at the knee. It might be something stemming downwards from the hip. If you go into an insurance-based practice complaining primarily of knee pain, they might be more constrained to doing stuff at the knee. They might not be able to get a full picture of the hip because they literally just can't bill for it. Obviously, case by case, this can change. You know, good clinicians will be able to figure their way through it and dose and stuff and just kind of probably be hush-hush about it. Don't go just chasing the symptom around. Try to get to the root of the issue. Oftentimes, you're going to probably just need more time with the person that you're working with. Quick 15-minute sessions probably aren't going to be the thing that's going to really work through this pain. 45 minutes to an hour, possibly up to 90-minute sessions for a lot of people is what's necessary because you just need to get a better understanding of what's happening and take the time to actually go through these things. The fortunate thing about all this is that no matter where you are in your pain journey, there's something that you can do for your pain. If you're somebody who lives in the Ulster County area or Dutchess County, Green County, Columbia County, surrounding counties of Ulster, I would love to help you. You can book a free intro call with me on my website. On that call, we're going to hear more about what you're dealing with. We'll be able to tell you about how we work and how we help people like yourself. And if we end up finding out that it's a good fit, we'll then schedule an eval with you. My evaluations are 90 minutes long. It allows us enough time to be able to do a lot of different movement screenings, orthopedic assessments, etc., to be able to determine what are the major contributors or potential root causes of what you're experiencing. Assuming it's something that I think that I could help you with, I'll recommend whatever I think would be best for you to work on this issue with me. As you're a listener of this podcast and most likely reading the blog along with it, you also get$100 off of the eval. Book your intro call, tell us where you came from on that call. We'll be more than happy to learn more about what's going on with you and book you up for that evil and get the process started.