Do you feel like you have tried everything to get rid of your pain, but it still persists? Have you ever heard of retraining the nervous system? In today's episode Dr. Alissa Wolfe helps us get a better understanding of the relationship between the nervous system and pain.

Listen Here:
Spotify | Apple | Google Play | Amazon Music

Show Notes:

1. Understanding chronic pain and the nervous system:

• Chronic pain is a result of the nervous system's overprotective response.

• The brain and spinal cord work together to create the sensation of pain.

• Miscommunication in the nervous system can lead to persistent pain.

2. The role of the somatosensory cortex in chronic pain:

• The somatosensory cortex maps the body and is responsible for sensory processing.

• In cases of chronic pain, the map can become distorted, leading to inaccurate pain signals.

• Brain-based drills can help rewire and retrain the somatosensory cortex.

3. The Biofeedback Loop and the importance of body awareness:

• The Biofeedback Loop is a communication process between the brain and body.

• Body awareness plays a crucial role in identifying and addressing pain triggers.

• Incorporating mindfulness and body scanning can help improve body awareness and pain management.

4. Progression of treatment: brain-based drills to real movement:

• Start with brain-based drills to retrain the nervous system.

• Gradually incorporate real movement into the treatment process.

• Eventually, brain-based drills can be used as a tool for flare-up management.

5. Flare-up toolkit for managing pain during flare-ups:

• Compile a combination of physical and non-physical resources to manage pain during flare-ups.

• Examples include heating pads, TENS units, meditation, breathing drills, and brain-based drills.

• Having a prepared toolkit allows for quick action during flare-ups, reducing severity and duration of pain.

Key Takeaways:

• Chronic pain is a result of miscommunication within the nervous system, and retraining the somatosensory cortex can help alleviate this issue.

• Incorporating mindfulness and body awareness practices can improve pain management and overall well-being.

• Dr. Alyssa Wolf's treatment approach progresses from brain-based drills to incorporating real movement, eventually using the drills as a flare-up management tool.

• A flare-up toolkit can be an effective resource for managing pain during flare-ups and speeding up recovery.

• For more information on Dr. Alyssa Wolf's work and to access the free flare-up toolkit, visit alyssawolf.com or follow her on Instagram at paincrusator.

Transcript:

Hello, everyone, and welcome back to Better Than a Pill. Today I am so excited to have Dr. Alissa Wolfe as a guest, and she is a chronic pain specialist and physical therapist. So welcome, Alyssa, and thank you so much for being here today. Hi, everybody. Hi. Thank you for having me. This is going to be a really good chat today. And also, can I just mention how cool is the name Better Than a Pill? That is so fun and awesome. Great name choice. Thank you, Alyssa. I have to say, I like it too. It's pretty cool.

Well, I am so excited to learn more about your work with helping people with chronic pain and the approach that you use using the nervous system. So let's start off just tell us a little bit more. First off, what is a chronic pain specialist and how did you get involved in this work? Yeah, well, I always like to say chronic pain. I did not choose chronic pain. It chose me. I didn't get into this field through having the experience of chronic pain personally, but just things in my path along the way. I started out as a physical therapist. I've had really great mentors and had a really great education in my PT program where I was exposed to chronic pain science and neuroscience.

And in my practice, when I got out into the physical therapy, like, real world outside of school, it was like, wow, there's this group of people that don't seem to get better with your traditional PT exercises and manual therapies. As much as we tried, we'd get to a point where you'd hit a plateau, and so it kind of kept pulling me back to what I had learned about neuroscience. This is something we're missing. We need to address this part of the puzzle. So I was so intrigued, just fascinated with it. I did a lot of my own, just, like, independent reading of research articles and journals, which is not what somebody would normally read, but it was like, this is fascinating, and I'd find an article about something about the brain, and I'd be like, go down a whole rabbit hole of different research studies.

But eventually, thank goodness, a program was created that would allow healthcare providers to specialize in chronic pain. And then so I completed that program. Back then. It was through the International Spine and Pain Institute. And it's not that anyone could do it, but you had to be some kind of health care provider. So they taught it to nurses and physical therapists and occupational therapists. Doctors could take it, but basically you could specialize in chronic pain. And their program taught a lot about basically that concept of the nervous system and what does the nervous system have to do with our pain and how can we address that side of the problem?

So that is kind of what a chronic pain specialist is. But to me, in my role. I see it as something almost bigger than that because chronic pain specialist means that I work with people with chronic pain and I address the nervous system. But to me, I am like this. I don't know how to define myself. Like, am I a coach? Am I a provider? Am I a physical therapist? Am I a psychologist? I feel like I'm a blend of all of those things because chronic pain really is it needs that kind of holistic approach. And so really, when you become a chronic pain specialist, you have to take on all of those things in order to really serve this population, the people with chronic pain.

Yeah, no, thank you. That's great. That helps. And as a pain free movement coach again, I'm not always sure what to call myself either.  I get it. I've had a lot of success helping people with pain. Not always chronic pain, but just pain in general and with movement. But I know there's a lot more. I know that not everybody can be helped just by movement. And so it seems like there's a lot of power in the nervous system, and I'm excited to learn a little bit more about that, especially when movement is not enough.

And so I'm just wondering if you could give us a basic breakdown of how the nervous system influenced pain. Yeah, it's so challenging to give a basic breakdown because this is a concept that I think culturally and in society, we're not really taught to see things from the side of the perspective side of the coin. I guess we're taught to kind of look for the structural and mechanical types of issues. Like if you have a disc bulge or you have arthritis or you have tendonitis or tendinopathy, we're taught to look for those things, or like, your alignment is off or whatever, but we don't see really past that and that there's an underlying we have a nervous system.

And so our nervous system innervates all of those structures in our body. We wouldn't be able to feel pain if we didn't have a nervous system. And so just like, you can have things kind of go wrong in the structures in your body. So, like, you can sprain a ligament, right? You can tear a ligament. That kind of thing can happen, and that would affect your pain. But then you can also have changes that happen in the activity in the nervous system. We can't see that with X rays or MRIs or a blood test, but we know that they happen, these changes happen, and then they can contribute to the pain problem.

So it's almost as if you can have at the same time, you can have two variables in the same experience of pain. Let's say you have a disc bulge and you have, like, sciatica or something like that. You can have the mechanical aspects of, like, yes, the disc is pressing on the nerve. It's putting mechanical pressure on that nerve, and you're going to feel pain because of that. But at the same time, changes happen in the nervous system, in the nerve, the peripheral nerve, the sciatic nerve becomes more sensitive. Changes happen in the spinal cord that allow more messages, more danger messages, and non danger messages to come up the spinal cord and get to the brain. And then the brain can change and basically start interpreting. It's not that it interprets everything as danger, but it loses some of its ability to correctly interpret the messages.

So the brain might be getting this message from the body saying, hey, you're wearing pants. And the brain gets this message of like, okay, you're wearing pants. But it doesn't hear that. It just says, okay, I'm getting this message, but I don't know what it's saying. And because I can't tell if we're just wearing pants or maybe we just got stabbed in the back, but I can't tell. I can't really figure out what's going on here.

And so it's safe for the brain to assume that you got stabbed in the back, and we're going to act as if we just got stabbed in the back. So you're going to feel pain. I'm going to make pain because of it. And I'm also going to activate those fight or flight responses to assume that it's either an injury or an infection, something we need to protect you from. So I'm going to activate my fight or flight responses. So I'm going to tense up muscles in that area. I'm going to add, like, that super guarded muscle tension. It's going to pull resources from your gut and your digestive system, from your reproductive system. It's going to ramp up your inflammation in your body because, again, we're trying to either heal from an injury or fight an infection. We just don't know what's going on. But it's going to try to protect you. And so all of these things start happening, and all of that makes the whole pain problem worse.

So when we're looking at pain from a nervous system perspective, we have to see that there are both elements at play. There are absolutely the structural and mechanical elements, but then there's also that element of the nervous system almost all the time. Like anytime we have pain, whether it's acute or chronic, we have a nervous system. The problem is, in an acute injury, those changes in the nervous system are supposed to reverse themselves and go back to normal. But in one in four or five, either one in four to one in five individuals, it doesn't do that. It stays. The changes in the nervous system stay, and that becomes problematic.

So we believe that when pain transitions from acute to chronic, it always involves this nervous system element. And so when it comes to the treatment, we kind of look at it like at some point, you plateau with the physical therapy, with the movement based types of things and it's challenging to get much further. Obviously those things, the movement based, the physical therapy stuff is going to be beneficial for you hands down. But to maintain your strength, maintain your coordination, maintain your functional ability, range of motion, but to really get pain down further, you have to take on that additional address, that additional part of the problem at the same time.

Thank you. Thank you so much. In my experience, just again, basic, basic I can feel my nervous system calming and encourage people a lot of times to use their breathing. I mean, that's all I do is slow down, focus on our breathing and I can feel how that is related to the muscles and just how tension can be released through focus. And that's just one example that I know there's that correlation and then I just want to share an experience I had that really made me aware that there's more going on is I had a series of two car wrecks, so I had a cervical strain twice back to back. And I was doing a lot of things on my own, even breath work, calming the nervous system, movement stuff. But I saw a cranial sacral therapist at the time and she did some work around the skull area and I was lying flat and it just was amazing to me, I'll never forget this, is that my arm just began flailing around, just uncontrollably. And she said that's the trauma, your nervous system was holding and it's releasing and it was like, wow. And I was so fatigued afterwards.

So I just wanted to kind of share that and get your thoughts on that. And I know it's probably related to what you do and everything. I don't know. Actually, this is an area where I still don't know enough about. My main mentor, the guy who got me really into chronic pain actually did craniosacral therapy. At least I believe that's what he was doing because he never actually defined it. But I got to watch those kinds of sessions where he would just sit and I don't want to say lay hands, but basically he would just sit and touch people, like touch their shoulders or touch the back of their head and crazy things started happening. Their bodies would start moving uncontrollably, they'd start weeping.

And when this was all happening, he would just kind of look at me with some side eye like, yeah, isn't this cool and crazy? And I'm like, I don't know what is happening here. And in that time, that was during one of my internships, I said to me, I am so curious. I said to him, I was like, I'm fascinated about what's going on here. I need to know more. And he was like, I'm not going to tell you because you are here to learn your Orthopedic skills and otherwise you will get too distracted by this because this is like advanced and you need to start with step one. And so he never explained it to me in depth of what the heck was going on.

And I know craniosacral. I know that they're doing something with the flow and the ebb of the craniosacral fluid and that it has its own pulse or it has its own rhythm and they're doing something with that. But I can tell you right now, I don't fully understand it. I don't fully understand it. I know that I would almost put the craniosacral, it's such a challenging category of treatment because it feels like it's in the mind body category to me. But it also has this physiologic component, so I don't know how to classify it. And I wonder if it also has some energy healing type of thing going on.

Those are places that to me I don't fully understand. And yet at the same time, when I don't fully understand something, that doesn't mean that I don't believe in it. There's plenty of energy healers out there and energy workers and people who do all of this stuff. And I've seen it work exactly what you're describing in the clinic. And I've seen these people come in and they leave and they're like they'll be one time a year they do that treatment and they're like, that's it. That's all I needed. It was better. So it works even though I don't fully understand it.

But what I will say is with work like that there is that nervous system component from what I can tell you in my own perspective whether it's mind, body work, craniosacral, learning to practice your breathing, calming the body down, working on those stress responses and stuff like that. If it's emotional work, whether it's unlocking trauma or working on emotional stuff, all of that stuff plays a role in this pain puzzle. Like earlier, I was just talking about movement as an element, the nervous system, and is an element, our mental, our stress levels, our emotions, all of that stuff plays a role. And I think that is touching a different sort of part of the puzzle.

But we need to remember that all of those little pieces are connected, right? So like, the nervous system overlaps with the mind-body elements and the mental and emotional and the trauma, that all is overlapping. So when you kind of calm down or you release some trauma or you unlock some energy, I don't know how to correctly use the correct terminology there, but I know but you experience a release that also kind of affects the nervous system that can calm it down.

Because really from my perspective, because I'm like laser focused, I do nervous system. That's about it. When you can calm that nervous system down, you're giving it that piece of safety of like, okay, so constantly if the nervous system is kind of constantly in that state of like can I say a bad word? Sure. If your nervous system is constantly in that state of like, holy shit, I don't know what's going on here, but I know I need to protect you. I'm like, I don't know. I don't know what's going on, but I know we need to be safe.

If you provide it with an element of calmness, of a sense of security, of a sense of safety, if you can make it feel safer because of some kind of trauma that happened to you and you can release that, all of that will affect the nervous system and kind of can have its impact in pain. Right. Breathing wise, breathing is a really good strategy because out of all of the autonomic functions that our body has, like breathing, heart rate, blood pressure, those kinds of things, the only one of those that we have cognitive control over is breathing.

I can't tell my heart rate to slow down. I can't tell my muscles to not be tense. I mean, there is probably some strategies that you can use to work on that, but really, breathing is the element that you can use to really control your physiology and help you shift out of fight or flight and sort of into that state of rest and digest. And so if you can control your breathing, you can control your heart rate, you can control your blood pressure, you can probably control some cortisol levels, stress levels. You can control your muscle tone. That's all wonderful stuff. And so then again, kind of that ties back into that nervous system piece.

So momentarily you're going to be in a calmer state, your body's going to feel better. Your nervous system is going to kind of go like, okay, we're in that restful state. We're in that restorative state. Let's work on our healing, like healing our injuries, healing our fighting infections and stuff like that. Let's get some sleep. Right? That's a big piece. Breathing is a really good strategy for that. The problem I see it's not that it's a problem, but really, those are really great management techniques. Like, that kind of stuff can really pull you out of that if you need to get out of pain without taking a pill, right? If you need to kind of see if I can manage this on my own without going to that step of taking the medication.

And that's an amazing skill to have, to have those strategies and have those techniques on board. But the way I see it, when we're talking about nervous system, we have to go one step deeper and actually address that piece. That where the nervous system is saying, hey, I need to be in fight or flight because I don't know what's going on. If we can kind of address that piece and change that nervous system and strengthen it up so that the brain can actually interpret the messages and say, oh, she's wearing pants. And we don't need to respond as if we just got stabbed in the back. That's what we need, our nervous system. Otherwise, it's just going to keep kind of putting you into that fight or flight response. You might be able to manage that in a moment notice and be like, okay, I'm going to do my breathing drill and kind of calm that down, but it will probably just come right back if you don't address that component of it.

But yes, cranial sacral still a mystery to me. I want to know more. If anyone can tell me what the heck is going on there, I want to know. And to be honest, I had a class in PT school, alternative Medicine, kind of where we learned that. We had a cranialsickral therapist come in, and she taught us to feel these rhythms of the cranialsickral fluid. And I felt it. It was there. I felt it. So I still can't explain it, but I know that it's a component.

But this is what is so challenging, I think, because sorry, I'm rambling, but I think a lot of people I was actually just having a conversation not that long ago with this guy. He's like, I have this knee pain, and it's been there for a long time. I've been told I need to have surgery, but I don't want to have surgery because I'm too young. I don't want to have a joint replacement, right? What do I do? What's the one thing that I should do? And he's like, Should I get injections? I'm like, Friend, the answer is not one thing because your problem is multifaceted. There's multiple things going on.

Yes, you need the movement and physical peace. Yes, you probably need some nervous system components. Maybe you need an anti-inflammatory thing. Maybe that's like anti-inflammatory diet. Maybe that's injections, maybe that's taking an anti-inflammatory medication. I don't know. But we have to be able to see that pain is multifaceted and it has these different components. You have to address all of those different components. And it was so hard for him to hear that. He's like, yeah, but I want the magic pill. I want the like, what's the thing? So we need to have multiple factors.

And so for some people, craniosacral may be a really good thing or like, addressing some of that trauma, because I know there's so many people who come into chronic pain having a history of trauma, got to deal with that stuff. All of that kind of ties together because I've actually worked with some people, working with their nervous system, and we've gotten them as far as we could with the nervous system and then still kind of gone, like, okay, it seems like there's some trauma stuff actually getting in our way here. So that is something I need you to go work with a trauma therapist because I am not that person.

So you have to build your team. You have to build your own pain care plan that suits all of your unique components of your pain. I think that it does help because it is multifaceted. It isn't just one thing. And yes, it is fascinating. And what you just said about trauma makes sense to me. Like, the trauma I had was from a car wreck. It could be trauma from all kinds of things. And so knowing that, it seems like it's not just the nervous system at play, but there's also fluid that they're working with, and it's a method in and of itself that was helpful.

Getting back to the work that you do, which involves retraining the nervous system. Right, okay, a couple of things on that. What signs or symptoms or how do you know that somebody needs to retrain the nervous system? How do you know? I know this is going to sound like very vague, and honestly, if you have chronic pain, meaning you've had pain lasting longer than six months, you probably could benefit from a nervous system retraining approach. Just because I would say and you've tried some of the traditional methods, like physical therapy, you probably tried some of those traditional things and you've ruled out big medical stuff. Of course you don't want to not address anything big medical. If you need a surgery, go get a surgery.

But really? I know that sounds super vague, but if pain has persisted for longer than we want it to six months, then you're in that chronic state, and it's very likely it's so common to have these changes in the nervous system that we can address that now. Signs and symptoms that you might have, like, a nervous system problem.

Aside from the length of time that you've had the pain, if it doesn't respond to traditional therapies, usually the longer it exists, it shows more of these signs. But basically, like, pain can spread, pain can become more and more widespread, like from head to toe or in more than one area. Pain that travels or starts in your back, but then you treat the back and now it's in your knee and then now it's also in my shoulder, but now I have headaches.

The traveling pain, the spreading pain, pain that doesn't seem to present with your really mechanical signs and symptoms. So it will still probably have the mechanical elements. A lot of times it does. Like if you bend a whole bunch, if you just spend 6 hours gardening and your back hurts. Yeah, okay, so that makes sense. But also you might have periods where the pain just kind of shows up spontaneously and you're like, I don't know what I did. I didn't seem to do anything physical to cause this. It just seems to flare up.

So that's when we start to see people who are sensitive to changes in weather, changes in stress, they might be sensitive to food, like certain foods and causing an inflammatory response in their body. Those kinds of things decrease really big decreased tolerance in sitting or staying in one position for a long period of time. And that has to do with sensitivity to changes in oxygen, like blood and oxygen. So when you sit or you're not moving for a long time, you're not getting as much blood moving around. So your nerves are very sensitive to that. Like, oh, we're not getting enough oxygen. I'm going to let you know brain, we need more oxygen. Move.

Those are some signs. If you really get further and further into it, you have issues with sleep, we have issues with brain fog start to come up. Sometimes it leads to having an impact on the digestive system. So a lot of people were present with gut dysfunction that can present in a lot of different ways reproductive system dysfunction, whether it's something as simple as having really low libido to something as complex as endometriosis and uterine fibroids and stuff like that, sometimes that shows up immune system imbalances.

We always see that having widespread inflammation or even having an autoimmune condition, sometimes that shows up brain fog, fatigue. I might have already mentioned fatigue, but it kind of presents as this syndrome. The worse and worse it gets, kind of like the further down you go into having that whole chronic pain syndrome sort of thing. But it can start as something as simple as a really bad sprained ankle that you spent whatever too long, let's just say in a boot. And maybe there were some predisposing factors that didn't go like that just were not in your favor. So maybe you had a really bad car accident, there was a lot of stress. Maybe there was some litigation going on that adds to the stress. Maybe your doctors weren't really paying attention. They seemed like they were discounting you, they were taking it seriously. You didn't feel like you were getting the right kind of care. And then genetics can be a predisposing factor.

But all of that imperfectly, imperfect concoction of predisposing factors can start off as can take a simple ankle sprain injury and take you into that chronic condition years down the road. So really important to kind of recognize some of those signs and say, okay, you know what? Maybe I do actually have this nervous system component going on. So yeah, there's lots of things that I'm looking for when I talk to people, like different variables and different factors to identify that. But usually by the time somebody gets on a call with me, I can almost guarantee that they're in that boat because usually anyone who's coming to me at this point is like, I've had pain for ten years. I've done 18 rounds of physical therapy I've done 300 injections. So at that point, I can almost say, like, yeah, your nervous system is a part of this. It's definitely a piece of the puzzle, so let's address that. But, yeah, even if your pain is somewhat new, you can still kind of benefit from some of these ideas, these techniques, and try to prevent it from becoming chronic, really?

Sure, that's very helpful. What is involved in retraining the nervous system? What are the important pieces? Gosh, I wish. So the solution is not a quick tip strategy or like, here, do this drill. This is the thing. It's this whole system. So nervous system retraining, in order to really be successful with it, you kind of have to have all the pieces together because if you take one piece, you might get a little bit of benefit, but you're not going to see the really big improvements in your pain that you want.

So the big pieces, top three things are going to be neuroscience education. I'll say them and then I'll dive into them. So neuroscience education, bottom up nervous system retraining, these are terms that I use. You probably can't google them and be like, what's my google? Yeah, so you won't be able to google them and find exactly what I'm talking about because these are just the terms that I use. But you need a bottom up nervous system retraining, and then you need top down nervous system retraining.

Okay, so education. So education about the nervous system. Like I said when we first started chatting, people know a lot about the anatomy, the physiology of their injuries. Like, I get on the phone with people and they're like, my c six, c, seven facet joint on the left. They're like using very clinical terminology. You guys know your anatomy or physiology. You know the structural components very well. But when it comes to the neuroscience piece, when I ask people like, what do you know about the nervous system? They're like, well, I think stress is a part of it. Is it my mood? I'm like, yes, it is. But also there's more going on. There is a physiologic thing happening in your nervous system.

When we understand what that is, it is greatly transformational. I have had in my program people always want to come in. They're like, what are the drills? Right? Tell me the drills. What do I do? I'll do it right now. Just tell me where they are. I'll skip all the rest. No, you're going to get the education because people get better with doing just the education and not getting any of the drills. It's such a big component. And I know that sounds like we were really mind, body, it's all in my head kind of thing, but really? Because when you know what is going on in your body and some of that mystery and that unknown of like, I don't know what is wrong here, I know I have a disc bulge. I have a facet joint with arthritis. I know I have that.

But when you have that other piece of like, okay, I know that my nerves are sensitive. They're reacting to changes in temperature and not necessarily movement, right? Of course there is that movement piece, right? But maybe the pain I feel is because it's cold weather outside today, or maybe that's why. And so my body is not trying to tell me I overdid it yesterday. Maybe it's just trying to tell me that it's cold outside and it's kind of over having an overreactive response to a couple of degrees of cold weather. The educational piece. When you know what's going on in your body, it relieves some of that stress of like, I don't know what's wrong. I don't know what I can do to help me. I don't know what I shouldn't do. Everything seems bad and scary.

Having that neuroscience education piece is crucial. And then bottom up techniques. So I call it bottom up because you can retrain your nervous system from the bottom up, meaning peripheral nervous system upwards. So peripheral nerves are any nerve that exists outside of the brain and spinal cord. So basically, sciatic nerve, for example, your median nerve, your ulnar nerve, like all the nerves outside of this. So those nerves can become sensitive, basically. They change their physiology, they change their sensors, they become more easily able to be stimulated. And that's when you start to get those nerves firing.

When a couple of degrees change in weather happens or stress happens, they shouldn't be firing when that happens, but they are. So when they become sensitive, we can use bottom up retraining techniques to calm them down. One of the ones that I teach is a nerve mobility drill. So a lot of people use them. You might have heard of them. Some people listening might have heard of them or tried them before. But when we do them correctly, we don't want to just do a generic like here, do three sets of ten and this is what it looks like, and do that like six times a day. No, we want to do them in a way that's not going to provoke pain or symptoms at all. So we don't want more pain. We don't want no more burning or pulling or stretching or numbness or tingling, anything like that.

When we do that, we can get those nerves to kind of quiet down and be less responsive to changes in movement and changes in blood supply. When we bring the sensitivity of those nerves down to those two variables, the nerves are going to be less reactive to any kind of stimuli because it's going to take a larger stimulus to get that nerve to reach threshold. I'm going way too far into it, but hanging in there with me. But as we bring down the baseline reactivity level of our nerves, they become less reactive to any kind of stimuli. So that's beautiful.

So we can do bottom up and then we have top down. So top down means retraining from the top down or from the brain and spinal cord downward. So we address some of the specific changes that happen in the brain. One of those is, like I said, the brain loses some of its ability to correctly interpret those messages from the body. So if we can strengthen that part of the brain up, it should be able to get a message and accurately decide, okay, that's you wearing pants, we don't need to respond versus, yes, she just dubbed the heck out of her toe. We need to get the ice pack or whatever, I don't know.

So top down Techniques I teach a series of four top down techniques that follow kind of a progression from easiest to most likely to provoke pain, more likely to provoke pain. The goal is never to provoke pain. The goal is never to push into pain. But rather we follow that progression because we start with the easiest one and work our way up following certain criteria and meeting certain criteria so that you don't provoke pain. So that it's safe. You never start with the hardest one and then work your way backwards, right? So we follow that progression and those drills, they work by activating our neuro neurons in our brain. And what that means is they basically get your brain to experience doing the activity or the movement or the position or the exercise or whatever your pain provoking thing is without provoking pain at the same time.

So that's one element that it does. So it gives your brain the opportunity to experience that thing without the pain. So a couple of things happen. It kind of decreases the strength of those synapses where one pathway is like, let's say doing the dishes, and the other pathway is pain. And if every time you've done the dishes for the past five years, this pattern of doing the dishes pain, doing the dishes pain, doing the dishes pain has just kind of existed and your nervous system is like, oh, we're doing the dishes. Oh, I know what to do. We always do this. We're going to just respond the same way we always do, regardless of if there's actually the physical thing going on or not. The brain is just automatically going to jump ahead, skip the steps and just be like, dishes, pain.

And so it forms this automatic response. And so doing those brain based strokes can help to kind of allow the brain to experience that doing the dishes without the pain and thus can kind of tear down that connection. And then the brain will also kind of feel a little bit safer and be like, okay, we can safely do the dishes. Like, wow, I didn't think that was possible, but here we are. So that's really good.

The other piece is it helps to strengthen up our, like I said, the processing ability so we can provide various different sensory stimuli to the body and basically get the brain to correctly interpret them. So this is going to sound, I don't know, this might sound weird or whatever, but basically if you can touch a paintbrush versus the back end of a pen cap or something on your skin, your brain should be able to tell there's a difference, right? Like that's the paintbrush, that's the pen cap. But people with chronic pain tend to struggle with that kind of activity to be able to interpret different sensory stimuli. And it doesn't have to be just a paintbrush and a PENCAP. We can experiment with lots and lots of different sensory stimuli. But just to give you an idea.

So basically we do drills to strengthen up that sensory processing ability so that the brain is actually tuning into that area and getting in there and going like, okay, yes, that's a paintbrush or that's a pair of pants, or that's a paperclip, or whatever it is. I know that sounds like hard to explain what this is exactly, but when it's correctly interpreting that and it's getting feedback about when it's correct and when it's not correct, it's going to strengthen up that sensory cortex so that messages it gets from the body won't be all just like this holy shit moment of like, we need to protect you.

So we have top down drills, neuroscience education, bottom up, top down. We also need to have pacing on board. So when it comes to movement and activities, everybody comes into chronic pain. They learn that coping strategy of just push through the pain. Got to get stuff done, so I'm going to just push through. It either that or you avoid altogether. You just say like, oh, bending hurt, squatting hurts. So I just don't squat anymore. I just move around with a stiff back and never bend.

So we have to include that element of pacing, which is kind of the happy medium between avoidance and pushing through. It allows the brain and your body to develop strength physically so you're not avoiding. But also you can perform that activity without pushing into pain. So that you're also tearing down those synapses and those connections of like, okay, I can do the dishes and not push myself into pain every single time.

So pacing is a big component, other little smaller, but big things are included in that whole nervous system retraining. You have to have sleep on board. So we need to work on your sleep because your nervous system does most of its pruning and cleaning up. If you want to retrain your nervous system, you have to sleep. So we work on that.

I do teach breathing drills. Having some breathing, having the ability to kind of I like to say breathing drills are like our control alchemy reset of the nervous system so you can get yourself into that state of rest and digest.

Even if it's like a moment, in a moment, it can be really helpful to get you there because then when you do those other drills, your body's in more of a restorative state so they can be more effective. So we do breathing drills. We have to work on flare up prevention and management. So not just managing flare ups and how do I get out of pain once I've put myself in pain or I've done too much, now I'm in pain, I'm paying for it. How do we prevent the flare ups from happening? You have to have a game plan for how to operate during your good times and when it sucks, so all of that comes into it.

Then there's the mindset piece of not necessarily, you know, having the, like, overly positive, like, toxic, positivity mindset of, like, telling yourself you're not in pain or like, you know, kind of gaslighting yourself in a sense of like, oh, it's all in my head, so just suck it up, ignore it, that kind of thing. We don't want that. But mindset, in terms of there's a lot of fear. There's a lot of fear of movement, of fear of pain, of fear of like, will this ever get better? Maybe this won't work for me, working through that kind of fear.

A lot of people I work with struggle with the all or nothing mindset or like, the perfectionist mindset, where it's like, well, I was just talking to somebody on a coaching call the other day, and she was like, I'm able to do 50 minutes on my stationary bike now, which is amazing. She hadn't been able to do that, but she was like, but now I need to get out and ride the real bike. And I'm scared to do that, but I think I'm just going to do it this week. And I said, okay, what if you just start with five minutes on that regular bike? And she's like, yeah, but that's not a workout. That's that all or nothing mindset of like, yes, but you're not ready for that yet. What if we just do five minutes and you get home, you're like, wow, that was great. It didn't suck. I didn't have a flare up. And then the next day you do ten minutes or whatever.

It is, like giving yourself that you don't have to have that all or nothing mindset that that can really get in the way of recovery. So working on all of those pieces at the same time is really what works, I think, and what I found that works the best. So, yeah, it's a process, it's a system.

Yeah, no, that's great. And yes, 100%, I understand the mindset component with the people I'm working with as well and get it. It's like, yes, in stages, right? Progress, not perfect. That is one of my biggest people ask me all the time, when am I going to see the progress? And it's not one of these things that you do it one week and you're like it's all better. Yay. I work with people who've had pain over 35 years and it's like, yeah, of course it's not going to go quickly, it's going to take time.

No, that's 100%. And I was just thinking about, even with from movement, my goal for people is it becomes more of a lifestyle. It's not just an exercise program. And I'm just wondering, as I'm listening to you talk, it seems like with the nervous system, there's some crossover. This becomes almost a lifestyle as well for people. Yes and no. I think with pacing, yes, pacing definitely becomes like a lifestyle skill that you just learn and you just start to do. You get better at it as you practice it. Of course, at first it's probably hard to tell to practice pacing, but some of the strategies so like the brain based drills, for example, the brain based drills may not be something you have to include all the time for the rest of your life in every day. Because you should get to a point. Like I said, the brain based drills follow progression from easiest to harder.

The next step up from a brain based drill would be actually performing the movement in real life and starting to get moving. So my goal is to progress people through those brain based drills and then get into the moving elements a little by little in the beginning. So like very beginning, it's just brain based drills. And then you move up to mixing some brain based drills with real movement. And then at some point you should be able to just get to the phase of like, I'm going to the gym, I'm riding my bike, I go swimming, I go on hikes. And you're just doing the movement bit. And then really, when you get to that point, the brain based drills become a tool in your toolbox for flare up management.

So when you have that flare up and you're like, I can't do my movement like I normally would, I'm in bed, I'm going to go back to my brain based drills. Because it's not a big moving thing. You can do them in bed. You can use that as a flare up management tool to kind of get yourself out of those flare ups faster. So, yes, to some extent it is a lifestyle. It's learning the skills really and how to put them all together. But it may not be one of those things that you have to include in your life every single day for the rest of your life. Because if you can change the activity in your nervous system, it should have a long term effect.

It's not like a breathing drill where it's like, if I do it the days I do my breathing drills, I feel better. It should have that longer term effect. So it's kind of figuring out where you're at and how long you have to kind of follow that progression, because everybody's a little bit different. Some people start off and they're already in the movement phases, so it just depends on the person and that progression. But yes, it is a little bit of lifestyle skill.

Yeah, thank you. That makes sense. So that some things people are not going to need to be doing all the time. There's a certain point where they can stop or they can use them, like you said, in a flare up situation, because I know you see this all the time. I know it can be individualized, but once somebody goes through the drill, I'm just curious how long typically just an idea to see improvement in somebody, how long does that take?

So, like I said, it can vary, it varies. And I wish I had specific data on this. I do have specific data on when people because when people start working with me and when they finish after 16 weeks, they take an assessment. So I actually have data points on that. So I know that improvements are happening prior to 16 weeks because they're finishing with improvement. So 16 weeks or less. Now, within that time frame, it's hard to say what week it is, but I have people who I've worked with for one month, like four weeks, three, four weeks, and they're, like I said before, even starting and doing a brain based drill before ever touching one of those drills, they're already seeing huge improvements. I had one client who came to me, and he started out, could not sit in a chair, could not put on a pair of shoes. Just like ten out of ten back pain every day. And then in a matter of three or four weeks, he jumped on the call with me. And he's sitting on the floor when we started our call, and he's like, I'm doing this because I needed you to see it. I'm sitting on the floor right now.

And he's like, in the following weeks, he went back to, of all things, he did, like, martial arts. He's like, I'm doing martial arts again.  nd so, like, transformations can start happening relatively early. Like, when you look at the grand scheme of, like, how long have you been in pain, three or four weeks is pretty quick, I think. It's not instantaneous, but it is pretty quick. I've had other clients, like, I had somebody who had pain her entire life, so probably 40 or 50 years really didn't start to see improvements until ten or eleven weeks in. Took a little bit more time, a lot of patience and a lot of commitment on her part. She's a rock star because she's stuck with it. And even though it was like, I don't see it happening yet, but then it did, and then it worked it varies, but yeah, less than 16 weeks for sure. Within that time frame of like, when can you actually see it happening? It's hard to say, but it does work at some point. Yeah.

Well, you are extremely knowledgeable and I know there's probably a lot more to all of this and we may have to have you on here again. I love it. But I just want to thank you so much for coming on today and just sharing all this valuable information with us. Absolutely. I know I learned a lot about the nervous system and everybody else here as well. Chronic pain. And if you want to learn more about Dr. Alyssa Wolf's work, you can visit her website@alyssawolf.com and you can also follow her on Instagram at paincrusator and she also has a flare up toolkit, which is a free download. And I'm going to be including the link in the description of this episode.

And if you want to just maybe describe a little bit about what that is, that would be great. Yeah, my flare up toolkit, so it's just a matter of looking at it teaches you to look for things that you can identify that help you with your pain. It has you kind of compile all of those things in one space so you can actually have a physical kit for the physical pieces. Some of those things are not actually physical things. So like, yes, you have your heating pad, you got your water bottle, you've got your tens unit, you've got those things. But then some of those things are not the physical things you put into a kit. So you can actually have a list of meditations, breathing drills, brain based drills, some of those other things. Prayer or books that you like, podcasts that you want to listen to. If you do audiobooks, that's me, I'm audiobooks all the way.

But having that list of things that you can start to that really help you with your pain, everybody's a little different. Like taking a bubble bath would not be on my list, but for a lot of people it is. So everybody's a little different, but it gives you some ideas of what should go into your flare up toolkit and what do you do with that. Because honestly, when a flare up hits, some of your executive function starts to go. Your ability to make decisions is much more on the feeling side than the logic side when you're in a flare up. And so if you take out some of the having to make decisions by having this kit ahead of time, you're able to pull out that list and go, what can I do right now? Versus scrolling on TikTok, because that probably happens. But what can I do right now that will be good for me, to help me get out of this faster so you don't have to think as much and make as many decisions. You have that ready to go, because the goal is not to sit around and wait for that flare up to get worse and worse and worse and sit here and go. Maybe it'll go away on its own right away. As soon as it starts, you've got to have that toolkit on board to get rid of it as fast as you can. So that's kind of where the flare up toolkit comes in. It's really getting you to focus on what can you do the moment that flare up starts to get rid of it faster. I'd love to give that to you guys. Thank you. And again, that will be in the link of the description. And thank you again, Alyssa. You're welcome. Thank you for having me.

Remember, we do new episodes every week on Wednesday, and I look forward to having you join me then.