What is pain? with Rachel Zoffness

0:00Pessimism. It's never going to improve a disconnected healthcare system. Next! So what will? At Optum, we're working every day to connect primary, specialty, and pharmacy care, and help lower prescription costs. Will we fix it all overnight? No. But we'll wake up trying, again and again, until healthcare works as one for everyone.

0:24Rachel Zoffness: That's healthy optimism. Learn more at Optum.com. Optum. Hey, this is Elise Hugh, host of TED Talks Daily. This episode is supported in part by Choiceology, an original podcast from Charles Schwab. Hosted by Katie Milkman, an award-winning behavioral scientist and author of the best-selling book, How to Change, Choiceology is a show about the psychology and economics behind our decisions. Hear true stories from Nobel laureates, authors, athletes, and everyday people about why we do the things we do. Listen to Choiceology at schwab.com slash podcast or wherever you listen.

1:28impossible. Gifts from people like you make these kinds of advances possible. Flexible support gives MSK's researchers the freedom to pursue new ideas and turn them into real treatments for people facing breast cancer. And right now, every donation to MSK is tripled. Give before October 31st, and your gift goes three times as far. Give now at msk.org slash TEDHealth.

1:56This is TED Health, a podcast from TED. I'm Dr. Shoshana Ungerleiter. I'm a board-certified practicing internal medicine physician, and I'm your host for today's show. Pain is one of the most universal experiences. Almost all of us will deal with it at some point. Maybe it's a bad back that never quite heals, or a migraine that just keeps coming back. joint pain, nerve pain, or pelvic pain, or pain that started with an injury but somehow lingered long after the tissue itself recovered. And when pain becomes chronic, many people begin a frustrating search for answers. We get scans, we try medications, we look for the one thing that's broken and hope that someone can fix it.

2:40But what if pain isn't quite that simple? What if pain isn't just happening in our bodies, but is being shaped by our brains and our emotions too. How do our stress levels, our relationships, sleep, and even the stories we tell ourselves about what's happening shape the physical sensation of pain? Today's guest has spent her career helping people understand exactly that. Dr. Rachel Zofnitz is a pain psychologist, a medical educator and assistant clinical professor at the UCSF School of Medicine. She lectures internationally on pain science and is the author of several books, including the Pain Management Workbook and Tell Me Where It Hurts.

3:21Rachel's work centers on a powerful idea. Pain is real, but it's also far more complex than many of us have been taught, including doctors. Rather than viewing pain as simply a signal from injured tissue, she helps people understand pain through a biopsychosocial lens, one that includes the body, the brain, and the environment around us. In our conversation, Rachel explains why two people can experience the exact same injury very differently, how stress and fear can amplify pain, and why chronic pain is not a life sentence. We also explore practical tools that can help retrain the nervous system, reduce suffering, and restore a sense of agency.

4:04So if you've ever lived with pain or cared for someone who has, or just wondered why it can be so persistent and mysterious, this conversation unpacks the science behind pain and offers a new way of thinking about it.

4:20Dr. Rachel Zofniss, welcome to TED Health.

4:24Rachel Zoffness: Thank you so much for having me. I really love the work you're doing and I really appreciate it. So starting at the beginning here, when most people think about pain, they think about an injury or a body part, but it can be hard to describe beyond the physical sensation. So as somebody who works on this subject, how do you define pain? You just hit the one thing that I think is most frustrating about pain. And I have been studying the science of pain now for over 30 years. But still, when we talk about pain, we focus just on the body part that hurts. And that is a mistake. That is an error. What science tells us is that the part of our body that ultimately constructs pain is our brain.

5:04Rachel Zoffness: And one of the reasons we know this is because of a condition called phantom limb pain. And phantom limb pain is when someone loses a limb, an arm or a leg, and they continue to have pain in the missing body part. Now, if you can have terrible leg pain in a leg that is no longer attached to your body. That is definitive evidence that pain cannot be constructed in the body part alone. It's ultimately constructed by the brain, of course, with input from our body, from our emotions, and from our environment. Yeah, it's so fascinating because it immediately shows that pain is more than just a symptom or a sensation.

5:42And I think that leads perfectly into something that you talk about often, the idea that pain is biopsychosocial. So in plain English, what does biopsychosocial mean and how does that change the way that we understand pain and think about treatment?

5:59Rachel Zoffness: I think that's actually the most important word when it comes to pain. Pain is biopsychosocial, which means if you imagine three overlapping circles in a Venn diagram, we have biological factors that contribute to pain. Those are the things we've heard the most about. tissue damage, system dysfunction, genetics, inflammation, diet, exercise, sleep. But what I want us to notice is that if we're only focusing on the bio domain of pain, we are missing two thirds of the pain problem. So the other two domains of pain, those other two circles, are the psychological domain of pain, which I will pause to say is fraught with stigma and misunderstanding and so often doesn't get the attention it deserves.

6:47Rachel Zoffness: And it also turns people away understandably. Women in particular are often told pain is all in their heads. That is not what is being said here. But here's the interesting thing about the psychological domain of pain. In the psych domain of pain, we have emotions, we have coping behaviors, we have predictions. The brain is a prediction machine. And the coolest thing that I learned when I started studying pain is that the parts of our brain that make emotions also make pain. Your listeners will have heard of the limbic system, our amygdala. Those are critical parts, not just of our emotion machinery, but also the pain machinery.

7:30Rachel Zoffness: And then we have this third domain of pain. It's the sociological domain of pain. And that's like everything else. It's access to care, socioeconomic status, race and ethnicity. It's loneliness. We know that loneliness actually can amplify pain volume. And it's also trauma. The body keeps the score. And we have known that for a real long time. But of course, everyone will notice that when we go to the doctor for chronic pain, let's just say, it is very rare that we will be asked about all of these different ingredients. We will be asked about the body part that hurts, but rarely about history of trauma or even diet and sleep.

8:09Rachel Zoffness: So I think this word biopsychosocial is so fundamental to understanding the true science of pain. I think that's so helpful as an explanation because it makes pain feel a little less mysterious, a little less one-dimensional because it's certainly not. I think nobody wants to feel like their pain is being dismissed or minimized. And you use this metaphor of a pain recipe, that a painful experience is the sum of many different factors. I love that because it's so relatable. What are some of the ingredients that commonly show up in people's pain recipe? I want to say what a pain recipe is. So do you like to bake?

8:47Rachel Zoffness: My husband is the baker in the family and not me. I try. I'm terrible at following a recipe though. Do you have a favorite thing you like to bake? Oh my gosh, chocolate chip cookies. Great. So just as there's a recipe for cookies, like certain ingredients in a certain order and in certain amounts, placed on a tray of a certain size, baked at a certain temperature, like environment matters too, so too is there always a recipe for pain. Always. And a pain recipe is just the biopsychosocial ingredients that go into creating what I'm going to call a bad pain day or a high pain day. And when my patients come to my office, I can usually ask them, hey, what are some ingredients that go into a high pain day for you?

9:35Rachel Zoffness: And they can usually tell me, and it sounds something like this, and I'm sure this will sound familiar. Sitting at my screen for too many hours without moving my body. Not protecting time to exercise. Periods of high stress where there's a lot of demands on my time. Poor sleep. I know that when I sleep poorly, my body's going to feel worse the next day. Eating a crap diet. So what we'll notice as we start listing out the ingredients is that some are biological, some are emotional, some are cognitive, some are social, some are environmental. And that is our pain recipe. And what I love about this concept of a pain recipe is that just as there is a high pain recipe, there is also a low pain recipe.

10:24Rachel Zoffness: And the low pain recipe is usually the opposite of our high pain recipe. And once we have mapped out our high pain recipe and we've written out the ingredients, which I highly recommend, we can look at these separate ingredients and we can figure out what we need to do to transform a high pain ingredient into a low pain ingredient. So for example, I noted that poor sleep is an ingredient in my high pain recipe. And what that means is in order to target that ingredient and transform it, I need to implement a strategy, for example, a sleep hygiene protocol. And I literally put an entire sleep hygiene protocol for pain in Tell Me Where It Hurts.

11:08Rachel Zoffness: And I have to say, the only reason I wrote that book is because, yeah, it's great that I've been studying pain for 107 years, but there isn't a lot of power in that. People need to know the science of how pain works in order to lower pain volume. And I want everyone to have that power and it is eminently doable. And it's a fantastic book. And what you're saying makes so much sense. Because when you start seeing pain as a mix of ingredients, you can also see, as you said, why it changes from day to day. And one ingredient so many of us recognize immediately is stress. I think many listeners have probably had the experience of pain feeling worse during the high stress times.

11:51What do we know about the relationship between stress, the nervous system and pain perception? Oh my gosh, yeah.

11:58Rachel Zoffness: And at the front of this, it's very important to me that people not think I'm saying like, oh, it's just in your head, or it's just emotional. The way I like to think about this is another metaphor or analogy. If you imagine you have a pain dial that lives in your central nervous system, your brain or your spinal cord. And this pain dial operates much like the volume knob on your car stereo. Like there's many factors that turn pain volume up. There's many factors that turn pain volume down. And what science now knows is that stress and anxiety are pain amplifiers that turn up pain volume in the brain.

12:35Rachel Zoffness: And there's a lot of data around this. Like if you go into Google scholar and look for papers on how stress is a pain amplifier, or even if you just type in stress and pain, thousands and thousands of articles will come up. So the science is complex, but it's also pretty straightforward. Like stress does a lot of things to our nervous system. And one of those things is it triggers our fight or flight system. And what happens when our body is in fight or flight is that cortisol spikes in our bloodstream. Cortisol is a stress hormone that over time suppresses our immune system. Stress is physiological.

13:15Rachel Zoffness: And of course, a suppressed immune system makes us more prone to illness. It makes us more prone to illnesses getting worse. Also, when we have periods of high stress, muscle tension spikes. And the relationship between pain and muscle tension is also well-known and well-established. We know that the more tense our muscles are, the worse pain is going to feel. In fact, there is a reason doctors will often prescribe muscle relaxants for pain. High levels of cortisol, high muscle tension, high stress, high pain volume in the brain is a recipe for higher pain. I can think of a million times during my own life where that when I'm stressed, my back pain or my hip pain feels a lot worse.

14:03And I'm more hyper vigilant about it. You know, it's sort of that that cycle that self reinforces. And I think this is really interesting, because it gives people something practical to picture this knob. And not that they're controlling pain perfectly, but that there are things that can influence that diet.

14:19Rachel Zoffness: I actually I want to address that thing you just said about when you think about pain and focus on it, it hurts more. And there's a science to that that's so fascinating to me. One of the parts of the brain that processes pain is our prefrontal cortex, the foremost part of our brain. And the prefrontal cortex, among other things, regulates attention. And it acts sort of like a magnifier. So if I say to you right now, Shoshana, I want you to focus on your right foot and think about your right foot and feel it on the floor and notice the temperature of your foot and maybe the sock or shoe on your foot, all of a sudden your brain, that magnifier in your prefrontal cortex, zooms in to examine that body part the second you attend to it.

15:04Rachel Zoffness: And the reason that magnifier is important for us to know about is because when we think about pain, talk about pain, and focus on pain, the magnifier is going to zoom in and amplify those physical sensations. and this isn't a suggestion that we should never talk about our pain. Of course we should. That's very important for processing pain. However, it is also important to have periods where we're distracting from pain and we're aware that we're hyper-focusing on it and maybe thinking about it too much, which is so normal with pain. Pain demands our attention. But ironically, focusing on pain and thinking about pain will only amplify the sensations and make pain feel worse.

15:48Rachel Zoffness: It's the reason why, like if you want to give a child an injection or a vaccine, you distract them with a screen, you know, a funny show, and sometimes the shot doesn't even hurt. It's pretty miraculous, this attention. So I'm curious if there's an example, I'm sure you have a million of them from your work that made this idea of turning down the volume and the stress connection really, really clear for you and in a powerful way. There are so many examples, and every patient who comes into my office has a recipe of ingredients. And usually we find a couple that we can focus on right away. But this conversation is making me think of a patient in particular who had kidney stones.

16:29Rachel Zoffness: And kidney stones are notoriously painful. And anyone who has had them will tell you that passing a kidney stone is not a lot of fun. She was dealing with these chronic kidney stones and came to me because she wanted to manage the pain better. and her father had recently died of cancer but her history with kidney stones was pretty straightforward she would get a kidney stone she would have some abdominal cramping and symptoms and then the pain usually was about a six out of ten and the stone would pass so as she was telling me this story she was telling me she was co-working with her husband in the office and she was continuing to have this persistent abdominal pain that she was attributing to her kidney stones and she was wincing with pain.

17:14Rachel Zoffness: And her husband said, wait, are you still in pain? The stone didn't pass. And she was like, yeah, no, I'm still in pain. And he said, well, it's been like six to eight weeks. Are you sure it's not something else? And she had this image, this immediate visceral image of her father dying of cancer. And she could see the cancer that she had been shown on his MRI scan. And she could see his face pulled tight with pain. And she could see him losing weight. And she had this thought in her head, oh my God, this isn't a kidney stone. This is the same stomach cancer my father had. And she said her pain spiked to an 11 out of 10.

17:54Rachel Zoffness: She was in such terrible pain that she cried out and fell to the floor. Her husband called 911. She was rushed to the emergency room. And the doctors, of course, did a scan to see what was going on with her. And she says, the second she saw the kidney stone and the doctor said, nope, I can see the kidney stone. It's still in there. That is most likely the source of the pain. Her pain dropped down to a three out of 10 and she went home with her husband. So pain is this phenomenon that is influenced by so many different factors. So the kidney stone stayed in place, But her pain changed from a 6 to an 11 to a 2 or a 3 within a span of a day.

18:39More of my conversation with Dr. Zofniss after a quick break.

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19:50Hey, this is Elise Hu, host of TED Talks Daily. This episode is supported in part by Choiceology, an original podcast from Charles Schwab. Hosted by Katie Milkman, an award-winning behavioral scientist and author of the best-selling book, How to Change, Choiceology is a show about the psychology and economics behind our decisions. Hear true stories from Nobel laureates, authors, athletes, and everyday people about why we do the things we do. Listen to Choiceology at schwab.com slash podcast or wherever you listen.

20:40I want to bring this down to a personal experience for a moment. For me, I had a preventative mastectomy several years ago, and I made the decision not to take opiates following surgery. And part of what helped me was reframing the pain in my own mind. So instead of seeing it as a sign that something was wrong, even though you could make the argument that maybe that's a helpful framing, I understood it as a signal that my body had been through a major surgery and was healing. And that shift seemed to, I would say, lessen my fear and maybe change my relationship to the pain itself. So what does pain science tell us about the role of interpretation?

21:26You've touched on this a little bit, but how can the meaning that we assign to pain influence the experience of pain without diminishing the reality of what we're feeling.

21:37Rachel Zoffness: I love that story so much. And I hear stories like this all day long, all the time. So pain is our body's warning system. It's our danger detection system. And what science tells us is that credible evidence of danger will amplify the alarm. Credible evidence of safety will lower the brain's pain alarm. And these messages of safety can come in many forms. They can come in the form of a message from a doctor. They can come in the form of an image on a scan. They can come in the form of a suggestion of a loved one. And they can come in the form of our own thoughts and our own predictions. I recently had a patient say to me, she came into my office, she has chronic knee pain.

22:23Rachel Zoffness: And she came and she said, she was a little sheepish. And she said, I have a story to tell you. She said, I think I've had a placebo effect. And I was like, well, tell me what you mean by that. She said, I've had chronic knee pain for many years. I'm a longtime athlete. She's a woman in her late 50s. She said, I'm a lifelong athlete. I've had knee pain for forever. And the doctor told me my meniscus was flapping around in there, and it was really dangerous, and I needed knee surgery. She said, so of course, I signed up for knee surgery and I was trying to get my insurance to reimburse it. They wouldn't reimburse it and I was fighting with them.

23:01Rachel Zoffness: And this fight took many months, months and months of fighting with insurance to get them to reimburse and cover this knee surgery that she needed so desperately. And she said, during that time where she was fighting, her pain volume was going higher and higher and higher. Finally, she checked her email. She got an email from the insurance company. they were going to finally reimburse her knee surgery. And that was going to help her pain. And the second she read that email, she told me her pain went down to a two. Just reading the email. Why? And she was so sheepish telling me that she was like, but you know, it's real.

23:40Rachel Zoffness: Like, I really have damage in there. And of course you do, because pain and tissue damage are not the same thing. They are separate things. You know, as we said with a story with the kidney stone, The kidney stone was real, but the pain was fluctuating based on all of these different factors. So if pain is our body's danger alarm, credible evidence of danger will amplify it. Credible evidence of safety will lower it. So that email was credible evidence of safety. She was going to get the surgery she needed to help the physical damage. So her pain alarm temporarily quieted. And she said her pain volume went down for like three weeks.

24:15Rachel Zoffness: She was like, I was able to move and exercise in a way that she hadn't been able to in years. These stories come in all the time. It's really wild. So that is the science behind why our predictions matter, our thoughts matter, and the messages we even get from healthcare providers matter too. So I want to talk a bit about chronic pain. And it is something that is such a huge issue for so many people. For somebody living with chronic pain, what are the most common misconceptions that actually make recovery harder? Two we've touched on. One is that pain is just physical, like it's only to do with the body part that hurts.

24:58Rachel Zoffness: The other, of course, is that pain is just emotional, like it's all in your head. It's just emotional, or you can think your way out of pain. Huge error. Pain is biopsychosocial always. We all have a recipe. And I would say the third thing that I think is under-discussed is the relationship between fear and pain. Pain by definition is an aversive human experience. We are literally designed to be afraid of pain because pain often saves our life, right? So you put your hand on a hot stove, it's painful, it's terrible. After that, maybe you're a little afraid of the hot stove and that's a good thing.

25:33Rachel Zoffness: It teaches you to not do it again. However, when we have chronic pain, we can be afraid of our pain in perpetuity because some people with chronic pain have pain for a few months. Some people have pain for many years. And we talked before about this pain dial that lives in our central nervous system. We know that fear will amplify pain volume. So I think the most important antidote, in my opinion, is understanding the true science of how pain works. That is the way we turn pain volume down. That is the way we reduce our fear of pain. That's true for me. I started studying pain because I was scared of it.

26:14Rachel Zoffness: And I discovered that the better I understood pain, the less scared I was. And it's certainly not something that we learn about much in medical school. It may be in fellowship if you if you're focused on pain management or anesthesia. But I think we have a long way to go in terms of thinking more broadly about what this is, especially in relationship to the sheer number of people dealing with us on a daily basis. I'm so glad you said that. I hear this from doctor colleagues all the time. I regularly give grand rounds at hospitals, and afterwards I have doctors contacting me like, why didn't we learn this in med school?

26:52Rachel Zoffness: We just aren't having enough conversations about pain. So there's 100 million Americans living with chronic pain, 1.9 billion around the globe. And a crazy statistic for you and the other MDs who are listening, just to validate it, 96 % of medical schools in the United States have zero dedicated compulsory pain education. And that is not fair to our physicians. Like physicians go into medicine to help and to heal. Why are we not teaching biopsychosocial pain science to every single doctor at the med school level? Like it shouldn't be reserved for residency or fellowship. And by the way, even when physicians do get pain education, it's usually a biomedical focus.

27:35Rachel Zoffness: It's on bones and body parts, anatomy, physiology, surgery, and medication. And we know that that is not the answer. We have an opioid epidemic. We're all sick of hearing about it. Chronic pain is not going down. It is on the rise. And I think at the core of it is the lack of pain education. And then on the patient side, of course, not everyone has the same access to the kind of care or certainly education or support that helps people move forward. and we know pain doesn't affect everyone equally. What would it take to make effective pain care more accessible across different communities and ages and backgrounds?

28:15So if I had all the money in the world,

28:17Rachel Zoffness: I would absolutely revolutionize our education system. Unfortunately, pharma has a multi-billion dollar budget to sell to all of us this myth that chronic pain is something to be cured just with a pill. And I'm obviously not saying that medications can't help. Thank God for pain medications. We don't have to bite on wooden spoons anymore during surgery. Pain medications are a gift. However, when it comes to chronic pain, they are not the best solution. They are not the only solution. And education starts, I believe, with us. But back to that thing where our health care providers are not receiving sufficient pain education.

28:56Rachel Zoffness: If our health care providers aren't learning the science of pain, how is anyone else supposed to understand the science of pain. By pain patient, by the way, and I'm using air quotes for people who are listening, I mean every single one of us. Pain is coming for all of us one day if it hasn't already, whether it's a bad back or childbirth or living in an aging body. Not a single one of us is going to escape. Don't we all need to understand the science of pain? yes this education has to be reachable and relevant for many different lives that is actually my motivation in life i am by nature a library mouse i do not enjoy public speaking i sweat through my clothes however i think the science of pain is so important for people to know that i do important podcasts like yours to disseminate this information because people are listening to podcasts and they're interested in science.

29:52Rachel Zoffness: So I think for people who are interested in the science of pain, and you know someone living with pain, you can share this podcast with them. I also write books for this reason, because books are like$20 resources that contain entire pain protocols. And that's why I wrote Tell Me Where It Hurts. There are a lot of resources that are either zero cost or low cost that we can use to change the way we talk about pain and to change the way we treat it. And your work is such a gift, you know, in that way, making it accessible. And one of the most hopeful parts of your work is the idea is that pain is plastic, and it's trainable.

30:30What have we learned about the nervous system's ability to change?

30:33Rachel Zoffness: So most of your listeners have probably heard the term neuroplasticity. And neuroplasticity is the brain's ability to change with time and experience and exposure. And I've had people say to me, oh, but aren't your brains only plastic when you're a child? But that's not true. Like there are periods where our brains are extremely plastic, right? Like when we're a kid, we can learn languages more quickly and a lot of sports and skills. However, the brain is plastic until the day we die. So if you've learned a new route to work or learned a new language in your adulthood, you know your brain is plastic.

31:16Rachel Zoffness: It is changing. And this actually leads us straight to the science of chronic pain and how we can change it, harnessing the power of neuroplasticity. If you said to me, Rachel Zofnitz, I want big, strong biceps, I would say to you, of course you do, Shoshana. Who doesn't want big, strong biceps? Go to the gym and lift lots of weights and over time your biceps will get big and strong. Here's the cool science. The pathways in the brain are like the muscles in our body. The more we use them, the bigger and stronger they get. So the more you lift weights, the bigger and stronger your arms get. The more you play tennis, the bigger and stronger the tennis pathway in your brain gets.

31:58Rachel Zoffness: The more I practiced piano as a kid because my mom would make me sit down and practice. The bigger and stronger the piano pathway in my brain got until I could just sit down at the piano without even looking at sheet music and my fingers just magically knew what to do. And anyone who plays an instrument and has practiced a song over time will tell you they can even hear the music in their head without playing a note. That is neuroplasticity. When we inadvertently practice pain over weeks and months and years, the pain pathway in our brain gets really big and strong. And when that happens, we say that our brain and our nervous system have become sensitive to pain.

32:42Rachel Zoffness: And I want to say what that word means. Now, a brain with a highly sensitive pain system picks up small bits of sensory data from your body and amplifies it to bring it to your attention to tell you something might be wrong. Because again, that is pain's job. It exists to protect us and save our lives. However, when our nervous system has become highly sensitive, it is now warning us, even in the absence of danger. It's like, you know, if you look out your window at that car and the car alarm is going off and you can see very clearly like a cyclist has ridden by, but the glass isn't broken. No one is breaking into the car, but the lights are flashing and the alarm is screaming.

33:27Rachel Zoffness: That's sort of like a brain on chronic pain. And it even has a word in neuroscience. It's called central sensitization. And central sensitization, it is believed, underlies all chronic pain to some degree. And the reason this is so hopeful goes back to a mantra that I like to use. If the brain can change, pain can change.

33:52we'll be right back with more of my interview after this quick break

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36:22since you also teach tools like cognitive behavioral therapy and mindfulness-based approaches i'd love to make this practical for people listening are there one or two tools maybe it's that mantra that consistently help people feel more in control of their symptoms we talked

36:39Rachel Zoffness: a while back about the pain recipe and how everyone has one. What we're saying here today isn't that you need to go to therapy necessarily to lower pain volume, although for many people, science says that can certainly help. It can help us adjust pain volume via cognitive and emotional processes. But what we do want to do is look at these ingredients that are changeable. And you'll notice many of the ingredients in the recipe are absolutely in our power to change. We can change nutrition. We can change sleep. We can actually regulate our stress. Like I usually put people on a social media diet.

37:15Rachel Zoffness: We are no longer doom scrolling at night. We are no longer watching the news at night. We're putting blue light filters on all of our screens. Actually, where I like to start with most of my patients, believe it or not, is with movement. Because what pain does is it scares us into not moving our bodies, right? Like you break your ankle. your body tells you, gives you a pain message. It says, stop moving. Something might be wrong. So oftentimes with acute pain, which is short-term pain, pain is a signal of danger that something bad is happening. But the problem is with chronic pain, it's not distinct enough for us to know, oh, this is my nervous system on high alert.

37:54Rachel Zoffness: My nervous system has become highly sensitive. It is feeding me data and amplifying it, and it is probably not dangerous. There's no way to really know that unless you know the science. So you feel the pain, you're scared, motionless. And I understand why that makes a lot of sense. And for a lot of conditions, we do need to reduce or restrict movement. However, one of the most important treatments for chronic pain is getting back to life. It's reclaiming real estate from pain. It's getting back to beloved hobbies and activities and rolling on the floor with our kids and our grandkids. And it's fudge making in the kitchen or whatever our favorite hobbies are.

38:32Rachel Zoffness: And one of the best ways to do this is via a strategy called pacing. And pacing for pain is much like pacing for a marathon. Like if you want to run a marathon tomorrow, you are not going to roll out of bed and run 26 miles. That would be a very bad idea. To pace for a marathon, you're going to slowly and gradually increase your activity so your brain and your body can adapt and adjust over time. The same is true for pacing for pain. And the protocol essentially is picking an activity you love and miss that pain has taken from you and figuring out your baseline. By your baseline, I mean, how much activity can you do on a bad pain day?

39:14Rachel Zoffness: How much can you do on a good day? And you take the average and you start engaging in small bits of activity and gradually increase the amount of activity over time. And there's so much science that supports this strategy for increasing our ability to move when we have pain. Reclaiming real estate from pain. I love that. I want to zoom out and imagine what might change if more of us understood pain through this bigger lens. So let's imagine every listener woke up tomorrow, understanding pain the way that you understand it today, what decisions might they make differently about their bodies or their health, even their recovery?

40:00Rachel Zoffness: What a dream that is. I think if we all understood pain better, and I think we're getting there just via this conversation, I think we would look at the entire recipe of ingredients. We would wake up in the morning and we would write down the ingredients in our pain recipe, like what has been going on for me lately? What are stressors that are within my ability to control? What toxic relationships are amplifying pain volume? Because there's so much research around that. Things like estrangement, which is rampant and not talked about enough, is a pain amplifier. Ostracization is a pain amplifier.

40:34Rachel Zoffness: Abuse, history of abuse, trauma, those are pain amplifiers. So we will look at all these hidden ingredients that just don't get talked about. and we would focus on those just as much as the biological drivers. So we would start treating pain from a biopsychosocial perspective because what we now know is that pain is a whole person problem that requires a whole person solution. And we would all feel so much more power over our bodies and we would feel so much less scared and paralyzed and we would feel so much more hopeful about the things that we can change starting today. This is such a powerful place to end, Dr.

41:13Rachel Zofnus. Thank you so much for helping me understand pain in a way that feels more hopeful and much more empowering. I just so appreciate the work that you're doing and the way that you make this conversation more accessible for people.

41:26Rachel Zoffness: The conversation about pain is just not happening in the places it needs to happen most. So thank you for bringing it out into the open.

41:37and that's it for today's episode thank you so much for listening ted health is a podcast from ted and i'd love to hear your thoughts about this episode send me a message on instagram at shoshana md this episode was produced by me shoshana ungerleiter and jess shane edited by alejandra salazar and fact-checked by vanessa garcia woodworth special thanks to maria Alagis, Farah Degrange, Daniela Balarezo, Constanza Gallardo, Tansika Sangmarniwang, and Roxanne Highlash.

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