Rethinking Pain: A Fresh Perspective on the Biopsychosocial Model and the Future of Biological Treatments

What is going on everybody? Welcome back for another episode, episode number 114 of the Modern Pain Podcast, and this week we have Asaf Weisman, a clinician and researcher, over in Israel, had an interesting conversation. Asaf's been on social media and Twitter And I'm, as you know, a very big proponent of person-centered care, biopsychosocial model, and he's had some commentary that made me scratch my head and like really kind of maybe challenged it, and you'll hear in the podcast the discussions on the biopsychosocial model and his struggles with it. So the discussion was interesting to me. I think we were able to talk about a lot of different things around the biopsychosocial model and his concerns over it. Some of the terms around psychogenic pain and that pain can strictly materialize in the mind. Asaf has a very big push towards focusing on the biology of the situation, not losing sight of the psychology and the sociology around conditions. But in the end it all comes down to the nociceptive apparatus And I'd be curious to hear what you all think and what your agreements or disagreements are. It was a great episode, great discussion. I hope you enjoy it. This is the Modern Pain Podcast with Mark Kargela. Welcome to the podcast, asaf.

Hi, thanks for having me.

Yeah, it's good to have you on the podcast. I've followed you on Twitter. For those of you, we'll make sure we put his Twitter handle in the show notes and things. But a good follow always has an interesting perspective and some good critical thoughts on some of the things we see out there, especially around pain and some of the tweets that folks are making. So I'm looking forward to our discussion today. But, asaf, for those who don't know you, if you can just kind of introduce yourself, let folks know where you're at and what you're up to.

Well, first and foremost, i'm a physio. I've been a physio for two decades now, not so much lately. I used to work full time until two years ago, so that's about 18 years of full time clinical practice. In the last two years I'm only doing half the time and putting more time into my PhD and managing the spinal research laboratory at Tel Aviv University.

Yeah, i know. I'm just curious what in your career because you're a very well-spoken and voice here in the pain space I know you've gotten to write with Milton Cohen, John Quintner and some things. I know you guys just released a paper on that. I'm just curious maybe what in your journey got you so interested in pain? I know you and your colleagues have written some great papers that kind of criticize current and we're going to get into that especially term psychogenic pain today. But I'm just curious what kind of in your journey really got you on that track?

My first encounter with pain was probably my passion for skateboarding. Skateboarding is a very dangerous sport and I've been doing it for years now, since I was like 13 years old. I'm 44 now, so people who skateboard know well, they know pain. So that's where it started from And I think also my hobby of skateboarding also led me into physical therapy. And I don't usually advertise this, but I suffer from chronic pain myself. For many years, since I was 13, i've been having very bad migraines and irritable bowel syndrome. Today some people would say that it can be considered a phenotype of fibromyalgia Ever since I was 13, i remember like I'm having like at least every month. I have like a whole week of horrible headaches and every once in a while I get like crazy bowel pain, a lot of fatigue that goes around with it. I sleep a lot. I don't advertise this a lot and I try to, and I somehow tend to like when I ride as a scientific investigator, i kind of detach myself from that. But yeah, i'm also a chronic pain patient for many years now. Besides all the besides all dealing with pain you know from injuries of skateboarding and stuff like that.

Yeah, it sounds like you have a pretty good first person perspective on the issue. As far as yeah, i would agree I've treated my share of skateboards. My foray in a skateboarding as a child was quickly vanquished when I was beaten up pretty good and I never decided to get back on Just never, never something I got any skill at which probably my body thanks me for it.

I don't think I have skills now after close to 30 years of skateboarding. It's a very difficult sport. It's really it's a 30 years. I think I suck. I love it. It's a very difficult sport.

Yeah, i see Greg Laman on social media trying to, you know, sharpen his skills at his age I'm not that you're old, greg, but you know he's. it cracks me up and I know he's probably banged himself up a little bit.

I adore people who begin skateboarding at the 40s and 50s, Like that's amazing. I think that's pretty remarkable.

Yeah, that's a brave pursuit, for sure, for sure. Well, let's get into the discussion because I know, as we were kind of leading up to the episode, i was reaching out to you to see what kind of topics we could chat about and immediately kind of psychogenic pain and the discussion that we saw. I saw a little bit of that around social media. but I'm just curious if you can give kind of your background of kind of what you're, where you think we're at with that term in the pain literature, because I think sometimes it gets thrown out. I'd argue sometimes it gets thrown out just in a convenient way to kind of brush aside you know it's a patient's pain and saying this is you know the all in your head thing. And I don't think maybe physicians are hopefully at least not just trying to like brush it aside and just, you know, invalidate this experience. but it can be invalidating to a patient, to, you know, have this you know very challenging journey that they've had very, you know, difficult, you know situation with pain, and then it gets brushed off as psychogenic pain. I'm just curious like your perspective on that term and kind of where your recent frustrations have kind of came from with that.

I'm very frustrated with the term and I think it's if I would were to sum it down it's bullshit. There's a lot of bullshit around it. First of all, we have to understand what is this term and where it comes from and why people tend to think it is what it is and why it's not what people think. It's a complicated topic. I get very upset with it because, as I said, i'm a chronic pain patient. I don't think that, you know, there's anything in my pain that can be attributed to like pain coming out of the mind. So let's try. Let's try and first of all define what is psychogenic pain. Apparently, the term is very ambiguous. If you read the literature then you get a lot of different perspectives about what it means. One common stream of thought of psychogenic pain can I think we can attribute it to John Sarno, the late doctor. He said that our psyche, our mind, can evoke pain in our bodies due to like psychological, previous psychological trauma, like it tends to nest in the body. That is one train of thought that people have. This is and I think John Sarno's trail of thought is very problematic and a dangerous one, and the other one is psychological events may underpin some circumstances that contribute to the development of pain, and I don't have much problem with this view, but it needs a bit like it needs a lot of fine tuning and a lot of nuances for us to understand why it can happen and how it's different from what John Sarno or other populist, populistic views of psychogenic aspects of pain differ. Where does it come from? First, we have to understand where is this idea coming from. If you look at the literature, then I think we can trace it to a lot of experiments of pain that were done in the lab on healthy subjects. That is where this conception I think can be traced to This guy named Timothy Bayer. He's a I think he's a psychologist if I might be mistaken, but I think he's a psychologist and he conducted a lot of well-known experiments on healthy subjects, like in the 90s. Laurie Mermosly always mentions his study about the helmet, you know, like the, where they get people like just this sham helmet and they had radio gauges and like buttons and stuff like that And they told people that this helmet does A and B and C and stuff like that And people reported headache without any, not just stimuli. And this study gets thrown a lot as a reference for how we can have like pain without any not just stimuli or without any noceception. And then, after that's after those Bayer studies and some other group started doing a lot of experiments on healthy subjects and those healthy subjects reported pain. Now those studies are highly problematic. They're highly problematic and they're always they always are presented as the ultimate evidence that you can have pain without any nociception. But the problem is they're always presented like that and they're hardly ever criticized. If I were to try and concentrate into the one problematic point is that A it's done on people that are healthy and B it's done in a pain laboratory. So you get people coming into a pain experiment and they already know that they're in a pain lab And they already know that they're somehow expected to report pain, whether you like it or not. We started our conversation and I told you that my name, my full name you see on social media, is Asaf Klav Weisman. Now, klav in Hebrew means cards and it's a stage name I was given when I was a magician, like, i used to do a lot of magic and like someone, just like one time like, oh, i said like Asaf Klav, and that nickname stuck to me And so as a magician I know that you can get people to report almost anything you want, like all those magic shows that you go to, like mentalisms. You know, like all those mentalists, they use a lot of psychological suggestions in their shows and they can basically like, basically they kind of like well, it's not really pure manipulation, but it's like suggesting the person. Suggestion is suggesting the person that you want him to say, something that you want him to say, and the pitfall of all those experiments is that the researchers haven't realized that they were suggesting people to say exactly what they wanted them to say. That's a problem. So I don't buy the conclusions of those studies. Laurie Mermosly also has this study which I read again yesterday. I read again the paper after after we chatted. I read the paper like he has this study where they give a thermal noxious stimuli and they sometimes use blue light and sometimes they use red light. Okay, and when the blue light turns on, the subjects reported apparently less pain. But if you read the paper it's really like it's explicitly said over there that patients were told it's an experiment about their pain reactions. So you're already kind of like pre-programming the people to say what you want them to say These are not convincing studies about pain without no seception. They're just not convincing studies. And the other problem with those with many of those studies is that also the Bayer studies, the Timothy Bayer studies and a lot of new studies that came out lately about this kind of construct The problem is that they use electrical stimuli. Now, electricity is a very dirty stimulus. It's what happens after all the synapse processes, like we got the nerves and we got the synapses and once you know like there's a transduction, we get an electrical signal. So it's basically everything that happens after the synapse. You're using it as a stimuli and overpasses all those processes and it's very dirty And often electricity is noxious. It's just unpleasant by its very nature. So most of those studies they use electrical stimuli and if they don't calibrate it correctly and it's very easy to not calibrate it correctly like you get a noxious stimuli. So of course the person is going to tell you yeah, that was like. Oh, wow, that's painful. So there are many methodological problems around those studies that are used as evidence in support of pain without nociception.

So, hearing you and I definitely interested in the argument Because there's a lot of discussion, you know, i remember you'll see the memes and I probably even share these myself of like nociceptions neither sufficient nor required for pain. But you're really saying, hey, we need to look at that. To look at that this is all based on the nociceptive apparatus in the human And that the studies that have really been pushed and it's been a very interesting argument to hear you make that really isn't convincing to say that this stuff can be just materialized from psychological phenomenon outside of the nociceptive apparatus. Now would it be okay to say in your mind to say, hey, you know, it's a nociceptive phenomenon Again, maybe those studies I could definitely see. You know, with the thoughts of like hypnotism and different things, can we be so suggestive to get people to say what we want? And I definitely would agree there's probably some contextual impacts of the results of those studies versus just the true. You know what they thought was the mechanisms of how those pain responses occurred. But so again, going back, would you say it's would be safe to say, or okay to say that you know, psychological phenomenon probably influenced the nociceptive apparatus? Maybe I always tell students or like it affects the gain setting on it whether, hey, that nociceptive apparatus is going to be more I guess I don't know sensitive or more, you know, apt to have, you know, action potentials and things moving forward. And then maybe you know there's certain psychological phenomenon, you know, and we need things that are more resilience factors. I guess you could say that might push, that might help the nociceptive apparatus be less sensitive, and you can feel free to tear me up here on this too. I'd be interested in your perspective on that.

Okay, what I said in the beginning is like I can accept that psychological Occurrences or, let's say, events, might be culprits of some pain states, but I Prefer to treat them as I called it. I prefer to call them as perceived threats. Let's say, for example, right now, like someone comes in and startles you, like very, like We don't very loud clap and you get startled and yeah, you won't get any pain, of course, right, because that's not sufficient to evoke an activation of all our Evolutionary systems of survival. It's not enough. But let's say, if you were to be put like in a freezing cell and they would wake you up, be like with a very loud sound every every two minutes, eventually, yeah, we know that, like we do it to animals, like all kind of startling Experiments on mice and stuff like that, we see that repetitive threats or noxious events, eventually they cause an upregulation of our nociceptive apparatus. So once we get like to a state where We are constantly in a state of being the threatened by perception, by perceptual events, then yeah, then what we'll get is like an activation of our stress system, like, for example, the HPA axis. What the HPA axis is, part of it sits in our brain and Once we get like all those received threats, it will get activated and we'll start release hormones now those hormones like cortisol and like it roams around our system and starts, starts connecting to all kinds of neurons, start sensitizing them and Upregulate some, down regulate some and this will eventually lead to a continued nociceptive state. But it's not like. It's not like we can't. We can't enter a pain state out of the ether, out of the pure mind. It just doesn't work like that. If it and if it would work like that, i think we'd be in trouble. We won't be able to function Okay, like if every little clap Startle dust and we'll get like pain all around our body. I'm not sure we'd be able to to function correctly. So we have to, we have to understand that, yes, we psychological threats are a thing, but we have to treat them as a continuous stimuli across Time. For example, why do some people get PTSD and some people don't? you can have like a platoon of soldiers in a battle. Only one of them will get PTSD after seeing like these friends get killed and you know stuff like that. Like, let's say, a platoon of 30 soldiers and out of them maybe two will get PTSD. Most of them will not, because we know that some people have a genetic predisposition to get to develop PTSD And it's it's already known like some of the genes have been identified, some brain, different brain differences have been identified for PTSD. So there are some people that have a tendency to develop PTSD and not everyone will develop PTSD. But again, it's a biological tendency to react to Psychological events in a certain way. It's not like, oh, the event itself causes it, caused in pain. It's a constitution, it's his genetic constitution and his predisposition which allows this one very, very dramatic Occurrence and event to Later develop pain. Now, most PTSD They don't develop pain straight away after the Trauma. It takes time because, as I said, you need like it needs, like the biological systems need to be upregulated over time and usually a long time. So I I Just like I just get really riled up from hearing people think that, oh, you can just think yourself into pain. It just doesn't, it just doesn't happen and it doesn't make sense. Okay, if it were true, i think we'd all be, we were all like human race would be in trouble if I would just like be able to think myself into pain. Fortunately, yeah, isn't so.

Yeah, no, you make your points out. Now This puts clinicians in an interesting you know conundrum, i guess, with with this term psychogenic pain and You know and you hear stories. Of course you know and I've probably been guilty of sometimes. You know, i know, before I understood pain It was much easier just to label people and then say that's a them problem. It's not me being, you know, grossly misunderstanding the complexity of what goes on in the pain experience, but I'm just curious, like your thoughts on what that challenges that clinicians face with this term Psychogenic pain or pain that can arise from the mind. I mean, obviously The temptations are there to start, have clinicians label this and then again, i would argue, kind of invalidates a lot of patients who are like I'm not just bringing this out of my mind. I know I've had patients come to me with this like Very frustrated with this. You know, belief that these clinicians and physicians that they've seen have all just kind of tab this like This is psychogenic. And I always cringe when I've chatted with some psychology colleagues in the past. Where is this somatic or Nonsomatic pain, you know, and just the different things where it's like, is this the real pain in the body or is this the pain in the mind that we're dealing with? That's false delineation Just just Everything is somatic. Yes, I would agree like pain.

What is pain? pain is an unpleasant somatic experience. It is experienced in the soma. But then again we get like this psycho, the psychosomatic. That's a very Unpleasant turn for a lot of people because it dismisses their experience. Now clinicians are in a very, as you said, are in a very big problem. And I would take it further. I would say okay, let's say we accept that, we accept the construct of Psychogenic pain and some other mental constructs of pain, like a pain memory. Okay, like this is also going around, like from all those fMRI Studies and brain studies and stuff like that, some researchers, they believe that you can have a pain memory. Like that, your pain is a memory of pain and not pain itself. And we accept another construct where we say your pain is a conditioned response. Okay, it's like you've been conditioned whenever you hear your wife speaking to get pain in your back. We accept those three constructs, we accept them as truth. How would we diagnose the difference between them? Because, as far as I can understand, like memory circuits are very different, are in very different places They're like in hippocampal and stuff like that Whereas perceptual, psychological stuff is more in the cortex. So I would I would say, wait, like. These are totally different mechanisms we should be able to to differentiate between them. How would a clinician would even you know approach this endeavor? Like how? how would we do it? It's like, how would we differentiate between a conditioned response Because again I would imagine that I would treat it differently than, let's say, a pain memory And then you get into a problem. How do you differentiate those brain constructs? And then it all becomes illogical And one stuff becomes illogical. That's where you have to lift your hands and say I give up, it just doesn't make any sense. We can't dwell on those illogical constructs. The only thing that eventually makes sense is that we always need no seception for a person to say that he experiences an unpleasant sensation in his body and he uses the word pain to describe it. If someone is using the word pain to describe something in his finger that he doesn't like, then we know that we should be able to to say that, yeah, there's something no seceptive going on there. It doesn't make sense to try and go, like into all those mental constructs, because, like mental and mind constructs because what is the mind anyway? we like, we don't even know how to define it and all those consciousness researchers. They still don't even agree on what consciousness is. So, in the meanwhile, the best construct that we have we have is biological, physical, biological, no seception. These are the best constructs that we currently have And we have come a long way, especially in the last 20 years. We've come a great deal, a great deal of understanding that no seception is not the way we defined it. Until now, no seception is defined if you look at the ISP website, defined as the activation of peripheral no seceptors. But in the last 20 years we discovered so many other mechanisms that involve activation of cells and immune neurons and immune cells across the pathways of no, no seceptors. They don't fit this classical definition of the ISP of no seception, but they are no seceptive in nature. Okay, so like we can have glial cell activation in our brain in the areas of second and third order neurons. If those glial cells get activated, they change the thresholds and they can upregulate or dysregulate or downregulate some neurons in our brain And this can be translated into like a pain state. Now it's and again, it's not a mind thing, it's a bio thing, it's a biological mechanism that is going in the brain that affects the no seceptive pathways, the no seceptive apparatus. Our colleagues and myself we prefer to call it an apparatus because some people say it's the no seceptive system. But we disagree because then again, like we get too many systems, we got the nervous system with the no seceptive system inside it. It's then you get a system in a system. It's more accurate to use an apparatus which is a part, which is a complex part, of a system. So we have within our nervous system, we have a specialized apparatus of no seception And it's always involved in pain states. When someone, again when a patient, says I have pain in my knee, you should be able to say, yeah, you have got a no seceptive process over there and it's not because someone bullied you in high school and now it manifests in your knee. It doesn't make any sense. Which brings me to another point. Like if we accept the construct of psychogenic pain or psychological pain or pain memories, then we have to ask ourselves why do they usually manifest in the same places and in the same order? Like, if you look at the epidemiology of musculoskeletal pain, it's always low back pain, the number one, then you get neck pain, shoulder pain and thoracic pain. In this order, it's always in this order. We have to ask ourselves why there, why, why is it specifically in those areas? And I don't think there is a good psychological answer other than good biological answers for that. That's my argument around this problem.

No, it's interesting. I like what you discussed there of the. I asked the definitions looking at pain, no, seceptive, peripherally only, where you bring up the neuroimmune interface And I think that whole topic area of the immune systems role and I think we've obviously greatly misunderstood the role of glial cells and some of those other cells within the immune system and their ability to modulate some of these apparatus.

Up until 40 years ago, we were so adamant that glial cells are nothing but glue. Up until 40 years ago they thought, oh, they're just glue cells. Now, now we know like they're not. First of all, they're more abundant than neurons. It's like, i think it's like, for every neuron, there's like four glial cells in the nervous system. Okay, so it's very condescending to think that they're doing nothing. We discovered so many things that they do. It's like they're like super important for processes.

Yeah, And I think, as you see, folks with complex pain states, oftentimes autoimmunity and immune system impacts are a big part of what they're dealing with. So I think we're starting to see now that we really give those conditions a little bit more of a critical view and bringing those into the picture. You can see a lot of that. So I think that's a fascinating topic area. With that, you know, with the big push for biopsychosocial care, i'm just curious where your perspectives are on that. You know, talking to you and you've made good sense of your thoughts on you know this all comes down to the nociceptive apparatus within the human of how these pain states can occur and, you know, emerge from a person. I'm just curious, with the push for biopsychosocial care, do you have any concerns on? I'm guessing, with the concerns of like, okay, we're going to start just becoming the next person to say this is psychological pain, not real biologic pain, and we're going to cordon people off to these three separate categories where I think and correct me if I'm hearing you wrong where it all comes down to biology but it can have impacts from our you know our psychosocial. You know experiences. Like you said, some of the psychosocial experiences of PTSD can start priming a biology to start, you know, over time developing some sensitivities and some different things to where you know. The nociceptive apparatus can then start becoming much more easily activated and in a more of a pain state. I'm just curious what your thoughts are on this whole biopsychosocial. What do you think there are some good things, some bad things. What are your thoughts?

I'm going to be blunt and I'm going to say that the biopsychosocial model is probably the largest red herring in medicine that we have ever had. Okay, It's like I think it like totally swayed us sideways, like really far away from off-target. Hopefully the revelations of neuroimmunology from the last two decades will bring us back to the path, because especially for pain I mean like the biopsychosocial pain has been a red herring for pain research. It's like just detracted us A lot of distraction and stuff like that. Because I don't know if you've noticed, but like in our lab, like we're a spine laboratory, but every low back pain or non-specific low back pain paper that comes out, it's got the same structure and they're always talking about the same things, like low back pain is the most common, like it starts, low back pain is the most common, blah, blah, blah, blah. And then like then they go and tell you about the epidemiology and then this stuff hasn't worked, blah, blah, blah. And then they get like oh, the biopsychosocial model of pain tells us this and tells us that, And it's all the same. Like 30 years it's like all the papers are basically the same, They're just regurgitation of the previous paper and they all say nothing because, let's face it, we've researched and we studied the biopsychosocial model for pain thoroughly for 30 years and it's not doing any good in clinical studies. Come on, let's put it out there. Like, really it hasn't really changed anything for researchers and for patients. It changed nothing really. Like take a look at all those systematic reviews of CBT, mindfulness, ACT, all those stuff. It's very marginal. It doesn't do any better than any other stuff that people out there use, like dry needling, massage. It's all got the same effect in. Eventually, if you look at the effects in clinical studies, it's all the same marginal, very insignificant effects. I'm blind. I said the biopsychosocial model has failed. It's time to recognize it. The only future is in biology. That's the only remaining path. And also, like the biopsychosocial model also makes another fallacy. You know what? it's not a fallacy? Maybe it's a valid conclusion. But we already can say that it doesn't, It doesn't work, Which the valid conclusion is. If psychological events or psychological occurrences lead to pain, then psychological treatment can redeem it. It's valid argument and conclusion. But then again, our studies, our clinical studies, show that it just doesn't work like that. And so we have to ask ourselves and be honest with ourselves, to ask why doesn't it work? And I say it doesn't work because biology is the barrier, not psychology. Okay, Well, maybe pain in a given patient has started because of psychology, Let's say, okay, we can accept it. But why does it persist in that patient is because of biology, not because of psychology. And we have a lot of evidence showing that the psychological treatments are not good, They're not doing as much as we would have wanted them to do. And so I think that the future of pain relief is going to be in biological treatments. And when I say biological treatments I'm saying yeah, like the stuff that they use now for cancer and for autoimmune diseases, like biological diseases are utilizing the immune system to do what she wanted to do and what it doesn't do by itself. The problem is that currently, like we're in the Stone Age of neuroimmunology we just say neuroimmunology is like a relatively new area in science. I would say no more than 20, 30 years. It's like it's nothing, it's like in science, it's considered like today's news. So it's going to take a few more years, a few more decades, a few more generations for those treatments to ripe and reach to a level where we'll be able to provide substantial relief or maybe even reverse conditions like fibromyalgia, complex regional pain syndrome, For example. I don't know if you've seen those studies of the passive transfer technique. Do you know what I'm talking about? that they've taken this German guy, Andreas Gubbel. He's made some really, really interesting studies where he has taken immunoglobulins from fibromyalgia patients. Okay, He isolated, like he took their blood and put it in a centrifuge and isolated, like this layer of immunoglobulins And what he did is a very ingenious thing. He did it backwards, he felt like backwards. He said, like we always experiment on animals, okay, we use them for our models. What he did was different. It took these blood tests from human beings with fibromyalgia and injected them into the mice and the control mice went about their business and the ones who got the infusion from the fibromyalgia patients developed illness behavior and only the mice that got the infusion from the fibromyalgia patients And they already know, like he discovered it like a decade ago. In the last 10 years he and his group and another group from, I think, the Karolinska Institute in Sweden, they've done like already 13 such experiments where they passively transfer immunoglobulins from humans to mice. They've done it on complex regional pain syndrome and they've done it also on patients with rheumatoid arthritis. There's this phenomenon rheumatoid arthritis where patients still complain of pain in their joints but they don't have the cardinal signs of inflammation, They don't have the redness and they don't have the swelling, but they still say, hey, my joints are hurting and you can't see the objective signs of rheumatoid arthritis. That's like when they're diseases, like in remission, they still complain about it. And they took those patients and they transferred their IgGs. They transferred them into mice and BAM again those mice developed illness behavior And on complex regional pain syndrome, they found something way more interesting. Like first they injected those immunoglobulins into mice and nothing happened. Like nothing. And then they thought, wait a minute, maybe we need an injury, maybe we need to create a lesion in those mice, like it happens, like in humans, like there's a lesion and then the response will get the response like complex regional pain syndrome. And that's what they did. They fractured bones of mice and when they injected those immunoglobulins then the mice developed symptoms like CRPS. What they discovered is that what they say is that there is a certain group of auto-antibodies of immunoglobulins that are impervious to proteomics and CPR testing and they were unable to locate them And for the first time. It's like it actually gives hope to all those chronic pain patients like fibromyalgia, who are dismissed on regular basis, that their pain is psychogenic And they finally probably have found the biological culprits of this condition which we were unable to see in our usual testing. It's condescending to think that we know everything. Just because we can't find something or a biological cause doesn't mean that there isn't one, And we've been presumptuous in thinking that just because we can't find something, it's not there. There's nothing there to find. And I think these studies, if they keep on replicating them, I think that this guy, Andreas Gouble, will get the Nobel Prize for this discovery In 2022, they had a review of all their experiments that they did on the passive transfer technique, like 13 studies altogether. It's quite fascinating And I say it was presumptuous of us to think that there's nothing there. The more we find and I say we have a lot of nocissive knowledge for a lot of different pain states And the more we find, the less likely it is that psychogenic pain actually exists.

So I'm hearing you. I definitely stimulated some thoughts because I'm getting your thoughts on that. In the end, it all comes down to biology with things. I'm curious because working with patients and it's where I just have told patients your biology doesn't live on an island. It's going to be influenced by the world you live in, the world you inhabit. Some of the analogies I'll often talk about. You can hear the studies on war-torn areas where kids in Serbia growing up or now, i'm sure, in Ukraine, unfortunately, where the world they live in is not very safe, there's a lot of threat perceptions to be perceived around them. And, of course, humans in general. We tend to find We all have psychosocial issues.

Yeah, but most of us prevail. Most of us, we're very adaptive, we're very resilient creatures and we adapt. And then again, that's where we have to ask why does it happen to certain individuals? When you ask these questions, you can start finding the genetic reasons, and we're getting very good at finding those genetic prints of people And we know a lot of those pain states. Chronic pain states are genetically determined.

Yeah, i know I've just was reading a study. It might have been actually just a report on one, it may not have been the exact study per se, but maternal stress, like when folks are in prenatal stress, and things can influence the genetics of the kiddo who then comes out. So I just think some of this stuff we're so scratched in the surface, i would agree with you, like this neuroimmune interface. I think we're way in the early stages of understanding it And I agree that we can't just assume things don't exist just because we haven't found them yet. There's a lot of things out there that are probably yet to be discovered, yet to be found. It just still my thoughts and this could be my stubborn clinician is, like I just still wonder, like the value of understanding the unique story of the person of? obviously we're not going to try to resolve this. Well, yeah, it's all because of this. Your biology is dysregulated, this nociceptive apparatus is not functioning. It's functioning at a very hypersensitive whatever again, level you want to say. But would you still say that there's value of maybe helping people connect the dots of what might be? I know we don't necessarily. Well, why did the other person who had a similar traumatic experience, not develop this thing, but maybe helping people see that their biology is influenced by much more than just things.

I think there's a room here for a clinical message, because when I talk about these things, my clinicians always tell me oh wait, wait, by what you say we don't have a lot, of, a lot of room to influence. And I say that's not true. And I want to get this clinical message across because we can do certain things. We do know that certain aspects they keep repeating in all our studies about pain and it's stuff that we can influence. And, for example, being overweight, okay, High body mass index is highly correlated with chronic pain states. And I just tweeted today an amazing study, today, right now, like a few hours ago, a study that was done in China on 40,000 people, a prospective study in China, okay, And 40,000 people that have and some of them have been taking Ozenpik, the GLP1 antagonist, and they compare them to people who haven't taken Ozenpik and they discovered that like it decreased their cartilage loss in the knee, decreased their cartilage loss, and they had less surgeries, they took less pain medications. Again, like they took less pain medications, less surgeries, and also the rate of their cartilage loss decreased. That's quite amazing, okay, So there's a very, there's a very great messenger and it's like talk about weight with your patients, you know, Like, try to get them to lose weight, because most chronic pain patients that I see are overweight Not all of them, but many of them are. Another thing that we should talk about is smoking. Smoking is also has also been found to be highly correlated with chronic pain states. Also alcohol consumption and lack of physical activity. People who are more active, they have less chronic pain. So these are all things that we can influence. We can influence right now, For example, aerobic exercising for people who are totally sedentary and don't do any aerobic exercise. They should engage in aerobic exercise. Not necessarily weightlifting Weightlifting might not be for everyone, but aerobic exercise can be recommended to everyone. Like, hey, just go outside and walk, Walk, you know, like, in a good pace, get your heart rate elevated a bit. You don't have to run, but you have to at least exert yourself a bit when you walk. These are all simple things that we can talk to our chronic patients with. And we can influence Also sleep. You know, Sleep is also poor. Sleep health is related to this, but that's more problematic because there's a bi-directional relationship, because when you have pain you don't sleep good, you know. So that's a problem. But like, we can talk about sleep hygiene with our patients. These are all factors that we can influence. So at the end we need to know that we won't be able to cure fibromyalgia, but we might be able to help them to get like a bit better, which is which might be significant for them, Even if we just get them, let's say, 15% better. That's for them, that's significant. You know, In the meanwhile that's what we can do, but I'm sure that I think that in 30 years from now you'll go to the doctor. The doctor will have like a swab. We'll do a swab test on you, we'll put it in a machine in his office and we'll order drugs tailored specifically for you from the company. They will see your epigenetic switching functions and stuff like that. They will see your inflammatory enzymes profile and all this stuff, and you will get drugs designed specifically for you, not for anyone else, specifically for you. That's the future. In the meanwhile we can do that much, which is not a lot but, we can influence that physical activity, also eating. There is some evidence for fibromyalgia, for example, that some foods are not good for them. It's very low quality evidence And I believe that in the next few years we'll get a much better understanding of how diets affect these sort of things. Like all the microbiome, research is really flourishing right now. It's really booming And I think we'll get better evidence for us for diet because there is good grounds to believe that some stuff that some people eat is not good for them and might be inflammatory and biological not incompatible with them. This would grounds to think that maybe it's not the direction, but there are some evidence right now low quality evidence that there is something to it.

Yeah, it's interesting to see the links of the gut and the nervous system and all these different things that we're starting to see.

And it's all neuro, immunological, it's all related.

It will be interesting to see where we go in the 30 years. I do tend to share the same kind of thoughts as far as what medications are gonna look like, what these different things, as we start being able to really understand the unique profiles of.

Biological treatments are already revolutionizing the treatment of some diseases, like I don't know if you saw that it was in the New England Journal of Medicine, but they were able to cure rectal cancer with biological treatments, like in 12 out of 12 patients. That's amazing. That was like a few months ago. I was in the New England Journal of Medicine and I don't know if physios have noticed that, but I haven't seen rheumatoid arthritis patients for close to a decade now because the biological treatments they manage their disease quite good so they don't need to come to us. We're already in the beginning of the revolution. It's already happening now. Like biological treatments are Tailored, individually tailored biological treatments are going to be the future. Today they're still kind of like global biological therapies. They're still not specifically tailored. I've seen some case studies where they took some cancer patients and tried and tapered with the bio component to fit their profile and some of them which worked, some of them which didn't. but we're getting there. So someone with fibromyalgia like a very certain phenotype of fibromyalgia will be able to go to a doctor, a rheumatologist, and he will be able to taper the biotreatment specifically for his phenotype and genotype. I think we'll get there. That's, it's bound to happen, it's already happening.

Yeah, no, it's exciting times to see kind of the possibilities in the future of what we can do hopefully to help some of these folks to get things better managed, because I definitely think we haven't obviously had the success and maybe that hopefully will be the missing piece that we've been lacking. But I wanna respect your time. We've been chat for a while. I've really enjoyed the conversation.

You've made me ponder, thanks for having me.

Yeah, absolutely. Thanks for your time today. I really appreciate it And for those of you listening, don't forget to subscribe to the podcast. For those of you watching on YouTube, we'd love to see you subscribe to the channel, just so we can help spread the message to more people. But until next time, we'll talk to you next week. Music playing.