Voyage into the World of Chronic Pain Management with Dr. Andrea Furlan

Hello and welcome back to another episode of the Modern Pain Podcast. This week we have an interview with Dr Andrea Furlan, a physiatrist and YouTuber from Toronto Canada. She attends patients with chronic pain at the Toronto Academic Pain Medicine Institute. She recently published a book for people with chronic pain called the Eight Steps to Conquer Chronic Pain. She has a YouTube channel let's Talk About Pain, with more than 550,000 subscribers and 45 million views. In this episode we're going to talk about her work and journey in helping people with chronic pain, opioids and opioid-induced hyperalgesia. Some of the issues with healthcare professional education are around pain and how she uses her YouTube channel to educate patients. It was great to get to know Dr Furlan's approach and she is someone we can all learn from as she aims to help clinicians and patients better understand and manage pain. I hope you enjoy the episode. This is the Modern Pain Podcast with Mark Karjula. Andrea, welcome to the podcast.

Thank you so much, Mark, for inviting me today.

Yeah, it's great to have you. We love having physicians on the podcast. It's predominantly, I think, physiotherapists or the audience. But you mentioned that you subscribe, which we're grateful to have subscribers like yourself. We have other physicians who occasionally tune into the podcast. It's great to have a physician voice. I think it's all a team effort. Especially with persistent pain issues. There's not going to be one profession that's going to be able to do it all. I think having a good interdisciplinary group of folks like yourself and PTs, ots and speech and many others can really make a big difference. In that, before we get into things today, I'd love, if you don't mind, introducing yourself to the audience and let them know a little bit about your background.

Yes, I am a physiatrist. I'm very close to physiotherapy. I did physical medicine rehabilitation residency in Brazil. I graduated from medical school and did my residency there. I'm, 25 years ago, immigrated to Canada. Now I am a physiatrist at Toronto Rehabilitation Institute in Canada. I'm a professor of medicine at the University of Toronto. I'm also a scientist. I do published papers and meta-analysis and Cochrane reviews on a variety of topics. More recently, I became a YouTube creator and have been writing a book. I do a little bit of everything.

You're not just a little YouTube. You have 560,000 subscribers and that's impressive and awesome to have folks like yourself. It is a lot of people and a lot of people to impact with your message, which we really appreciate. I've talked before the podcast and I think we share similar philosophy. It's good because, as we all know, there are some other messages out there that can be a little bit more challenging and things Before we get into a little bit more we'll talk about definitely a little bit more about YouTube and your book, because I think it's a great resource for folks. I'd love to hear, with your education background and your obviously teaching, I was at the International Association for Study of Pain probably six or so years ago now in Boston. I remember some of the presentations and being done by physicians about how, in general primary care I don't know how you have to tell me how it is in Canada but that the physician population is grossly underprepared to deal with complexities of pain. I'm curious what your thoughts are on that thought process and where you think we are maybe now and where you'd like to see things go as far as better physician education. This is an issue in physiotherapy that we're battling as well, so it's not unique to physicians. I'm wondering where your thoughts are on that.

Yeah, it is. There is a huge need for primary care providers because they are the ones who see most of these patients with persistent pain, chronic pain, ongoing pain. I am a specialist but my weight list is huge and I cannot see everyone but the primary care providers, including nurse practitioners, physician assistants and pharmacists, also in the community. They require urgent knowledge and education about this. I'm happy to say that I'm using Project ECHO. I don't know if you heard about Project ECHO in the United States. It was invented 20 years ago in Albuquerque, new Mexico, not far from where you are. I went there 10 years ago and this is a program that was created to educate primary care GPs in rural New Mexico to treat hepatitis C, because 20 years ago there were 30,000 people infected by hepatitis C in the state of New Mexico and only one specialist in the University of New Mexico that knew how to treat this. He invented Project ECHO to disseminate the knowledge that is in the heads of the specialists to primary care providers who are in underserved areas, rural areas. We went there to learn how to do this for chronic pain, so I brought this to Canada. It was the first one to implement this in Canada. Now we have eight ECHOs in Canada for chronic pain only, and this is a you create a community of practice. Basically, we meet every week via Zoom. I have my team of specialists, not only physicians, we have physios, ots, we have nurses, pharmacists, psychologists, we in a Zoom meeting, but then we invite primary care providers to join and present their cases. So once they present their cases, we discuss and everybody learn. I can tell you, mark, I learn more than I teach Every week, every session with patients that are discussed. The discussion is so rich because it's a truly interprofessional discussion and everybody contributes a little bit with their profession, what they know. The patient is not present, the patient is anonymous, but it could be like a family doctor in a rural area presenting a complex case and then we discuss this for about an hour. So I think we need to do more of this because the need is huge.

Yeah, no, definitely couldn't agree with you more. I'm jealous. I would love to be in, you know, to hear those discussions. I've had the opportunities and past to be in some interdisciplinary discussions and it's always, like you said, every opportunity is a learning opportunity to kind of see some of these conditions through the lens of a different professional, and I think we're seeing that some of these professional lines are blurring so much as far as really trying to incorporate psychologically informed care into all of our practices, whether you're a physician, a physio, an OT. So, yeah, it's great to have those interdisciplinary teams. There's not enough of them, of course, but we're working and I think the more folks like yourself get the message out and we get more exposure. I think it's great that you're reaching out to some physicians to help them, guide them, especially in rural settings where they might not have the greatest amount of resources available to them. I'd love to hear kind of the treatment philosophy that you have. Again, I'm a bit familiar with it, having looked at your YouTube channel and a few things in the past, but I'd love to hear if you can share with the audience kind of your overall kind of treatment philosophy when it comes to pain.

Yeah, and that's because I am a rehabilitation specialist. I think I bring that rehabilitation lens to see the person has a hole. I think you and I in our professions, when we rehabilitate anyone with a disability, you have to see the person where they are. You meet where they are and then you help them to recover and be the best that they can be with what they have. So I remember when I was in my residency years that you get a patient, admit a patient with quadriplegia spinal cord injury. Okay, let's see what is left. Where can we go from here? And rehabilitation is amazing because you can make that person sometimes better than they were before the injury. I am amazed at the Paralympics games that you see athletes amputated, blind, quadriplegic parapalyptics competing much better than I am able body person can do. So that's my approach that I use with chronic pain. I will say let's see what is left here. If there is an injury, what's going on? But you are a person and we will work with the person your mind, your body, your nutrition, your sleep, medications if needed. But I cannot just treat a body part where it hurts. Let's just look at the knee. I think that's too narrow to see.

Yeah, yeah, there's definitely much more to it than just the location of pain and coming off that a little bit. There's and I've had these discussions you may have heard them on the podcast of like our healthcare systems are so full of like tree specialists. If we're looking at the forest of a human being, especially a human being who's dealing with pain, I'm just I think there's strength in that system. Obviously, we know that pain disrupts immunology and necronology, all these different things. Rheumatologists have a role to play. I mean there's a lot of differentologists that can participate in somebody's journey. I'm just sometimes, though, that comes with a lot of fragmented labeling of different things and a lot of confusion with patients. I'm just wondering where you think that can be. I mean, there's strengths to it, there's weaknesses to it. I'm just curious what your viewpoint is on the whole specialization and kind of compartmentalized healthcare. I know that it is up and up and above the border here, but I'm curious what your thoughts are.

Yeah, it's good and bad, as you say, right, because it is good to have the super specialist that knows that disease. Even within, for example, rheumatology, there are people who only specialize in psoriatic arthritis and others only in kilosospondylitis, and it's amazing. I would say that the healthcare system, this fragmentation of specialties, is really good. To make a diagnosis, a very precise diagnosis, if something is wrong, to give an opinion, and especially for acute problems. Our healthcare system is geared towards fixing acute problems. Okay, here it is, here is where it's broken, I'll fix it and bye-bye. Our healthcare system is not designed and it's not adequate to handle chronic problems and when I say chronic problems, not just chronic pain, it's any chronic disease, because those are recurrent problems. They become complex, they involve then mental health in addition to that, and then the complexities of patients. These patients are stigmatized, they are labeled has complex patients and they have even difficulty to find healthcare professionals and they go from one to one to another one and, as you said, they get different labels, different diagnosis, because now it becomes a chronic problem. And I would say what is most frustrating is that the communication between these professionals is very poor. We don't talk to each other so well, even in an interprofessional team, that you are working the same clinic and you see each other like, let's say, every day. Even there the communication is not ideal because I think we should be more like a team, really a team. Let's see this person. That's why I like ECHO, because you bring the person at the center and everybody has a chance to think together. But unfortunately the patient is not there physically. But they do get this consult, this virtual consult. But when you put a lot of people together to discuss a problem it's interesting that you see the other person's perspective and when you hear their thought process you kind of understand where they're coming from, why they're recommending what they're recommending. But this doesn't happen in clinical practice, because a patient of mine can go and see a neurologist. I'll get the report, a written report, but I don't know what was the thought process of my colleague when was examining, talking to the patient. I don't even know what the patient told that physician, that they don't tell me. So it is really fragmented. I hope that with virtual care and with things like communities or practice, for example ECHO, Project, echo we could improve this. But again, not every patient would have access to this. That's the problem and they will continue seeing this fragmented care. And it's even more sad when the only care that they can receive is in the emergency department. A lot of people don't even have a family doctor and all that they have is a walking clinic or emergency, which is even worse because at that time they're only. How do I get you out of here? I'm not here to diagnose you or treat your chronic condition. I just need to see is this urgent, life-threatening, if not, bye-bye? Yeah, unfortunately we have that problem. It's not only in the United States. Here in Canada as well.

Yeah, I have a patient right now who, gosh, it seems like every other week she had been in the EDs. So we're trying to give her some skills and working kind of multidisciplinary. But yeah, it's a tough situation and it's tough when you're trying to co-create a narrative and a coherent narrative, when the narrative that might be a lot of team members are trying to create and then somebody goes to a different practitioner who really try not obviously this isn't with malice or any negative intentions. I think sometimes I know, before I understood pain, I just know how to talk about my little tree and I'd have a lot of labels under my tree that were very much reducing a very complex situation to the way I could best understand it, which was very limited at the time. And we're still figuring out a lot of things about pain, of course. But yeah, it's great to have those multidisciplinary programs. As you mentioned, the access issues are there. We don't have enough people who can get access to those things.

I'm more optimistic. I have been really passionate about teaching and coaching lay people to become coaches, I think, because chronic pain affects so many people 20% of the adult population have some sort of chronic pain I think we do need to start thinking about getting people who have conquered their chronic pain, who have managed well, who have done well, and see if they want to be coaches for other people. We do this in the spinal cord injury field, at least here in Canada. If a person becomes a new diagnosis of spinal cord injury quadriplegic, paraplegic they pair that person with. They have a database here in Canada of people with spinal cord injuries and then what they do is they will pair okay, are you a 25-year-old male? They will find another 25-year-old male that had the same kind of lesion and similar to be the coach of this person. And then they will meet with them regularly, telephone or video conference and check on them how you're doing. Are you doing what the doctor recommended? Why not? Why? Yes? I think that model works so well. I would love to do this for chronic pain because I think the best coach for a person with chronic pain is another person with chronic pain who had traveled that road.

Yeah.

So I am optimistic on that side.

No, that's. That's a great point. I mean we have we've been fortunate to interview some patients. Tom Bowen was on recently. He's doing some great things with his website. We have Keith Meldrum. We've had Joletta Belden who's doing some amazing things yeah. I mean some great people who've been there walk the walk and I agree, I think it's hard for patients to you know, to connect with somebody who may not, they can't see, as somebody who walked in the shoes and has been, you know, in some of those challenging, dark places that pain can get you. And so I agree, and I think it would be a scalable thing too and I think if we can get some of these things with some of our pain programs, when we're seeing people kind of come out the other end and really feel like they're successful, I know just talking to some people like they really do want to give back because they think there's so much opportunity for folks to make a big jump in their lives. But some of that coaching would be huge for sure. Let's talk a little bit, you know, selfishly to. I have a patient right now who's struggling with opioids and it's always a delicate discussion as far as you know. That's obviously as physios we're not there to prescribe or do things. But you know, sometimes when I'm seeing folks who are even struggling to maintain attention, they're really struggling with level of consciousness, literally it's you're on pretty high doses of things and it's, you know, limiting their cognitive function and you know husbands and things are very concerned. I'm wondering you know your your approach and how you can approach that discussion with patients and how you approach it overall with patients and maybe some tips you would have for clinicians to maybe start seeing if patients can can maybe work on some things in the opioid department. We've talked a little bit beforehand about opioid induced hyperalgesia and different things and how maybe that might be something as clinicians we can recognize and maybe help patients educate on. But I'd love to hear your perspective on that.

Yeah, so I am the leader of the 2010 Canadian opioid guideline, which was the first guideline in Canada published. That, would you know, put some rules on how physicians could prescribe opioids, and that was that was published in 2010. And just two months ago, I published a paper in JAMA on opioid tapering. It was a randomized trial that we randomized people in the United Kingdom to be randomized opioid, to be randomized to taper their opioids, and another group that was not, and the results were great because those who were randomized to taper their opioids, they received education, like a coaching by a person with lived experiences of tapering opioids and chronic pain, and 29% of people in the group the intervention group, the education group they tapered completely zero, they stopped their opioids, and only 7% in the nursing group without making pain worse. So actually they were saying why I was an opioid? Because I don't. I have my pains about the same, but now I'm not taking them, so so that's the the world. The discussion around opioids is very, very polarized. There are people who hate them and people who love them can swear that they work. That's the only thing that works. And people who hate because they probably you know, people who hate opioids are usually those who lost someone close, because that person got a prescription of opioids for pain and then ended up with an overdose and dying. So I know a lot of people like that parents who lost their children or spouses or children who lost their parents. So it's really, it's really polarized. Now, opioids I can guarantee to you opioids have a role in the management of chronic pain. There are some conditions that if it was not for opioids, those people will not have a decent quality of life. Now I think it's over prescribed and I think that's because of ignorance of physicians who are well intentioned, they want to help their patients. Because it's so sad when you see someone in front of you in pain, suffering pain scores really high, and you here have the power to give that prescription. Okay, I'll give this to you. So it's easy to say yes and it's hard to say no, because if you don't, that person will keep suffering and keep coming and you have to find alternatives and sometimes alternatives are hard. We know that not all chronic pains are the same, you know. We know that there are three types of pain nociceptive, neuropathic, nociplastic. I hope your audience is familiar with those classifications. So for nociceptive pain, opioids if it's nociceptive, chronic pain. Like the person has that problem constant, it's something that is constantly broken and there are situations that they have a chronic nociceptive pain. Then opioids work, but I would say that's rare. I think the most common type of pain, chronic pain, is nociplastic. For neuropathic pain, which is also hard to treat because you have that constant nerve damage and sometimes it's a progressive disease that gets worse and worse, you need to treat with antidepressants, anticonvulsants and sometimes opioids in the mix. But for nociplastic pain, which is a malfunctioning of the pain system, it's not a hardware problem, it's a software problem. I compare I say nociplastic pain is similar to your computer is not working. Let's say your computer stopped working. It may be because something is broken and you dropped the computer on the floor and then the motherboard or the hard drive broke or the wires are disconnected. So that's nociceptive and neuropathic pain. Now maybe everything is working, okay, nothing is broken. But it's a software problem. You need to check the antivirus, close all the windows. You need to close all windows and start all over again or reinstall the software or update the software. So this is nociplastic pain and in this case opioids can make it worse because of opioid induced hyperalgesia because of central sensation. So that's a real problem. So how do you know if opioids are now making it worse? You probably know it's because the pain starts spreading. Let's say that they started with a knee pain and you started treating the knee. Pain was very nociceptive. You could see the inflammation, the pain was localized in the area around the knee. Now, years later, the person has knee pain, thigh pain, back pain, shoulder pain. So the pain started spreading and they have some sensitivities. You go with a pink brick, with a toothpick, and you see that they are more sensitive. So that's hypersensitivity, hyperalgesia. So that is central sensation or opioid induced hyperalgesia. So if you give opioids to someone with nociplastic pain, it's the same thing that putting gasoline on the fire.

Yeah, and that's where do you think the general? We've already kind of spoke to this a little bit but in the general day to day primary care practice, you know I, just having talked to a lot of physicians, it sounds like that ability to discriminate, this nociceptive versus, you know, neuropathic versus you know nocoplastic, is not necessarily there in the education. I can't remember the latest statistics Hopefully it's changed but I can't remember it was something like 12 hours or something of pain education in med school or it might even be.

Mostly for acute pain. When you say pain education, they're being educated on acute. They don't need. They may have one hour of chronic pain.

Yeah, which is such a shame is as far as talk about a complex topic, chronic pain being probably one of the more complex topics out there because it takes in so much systemic change throughout the whole ecosystem of a human being. I mean GI, endocrine, humanology, all these different, you know body systems that again, we kind of tend to want to break apart for for good reasons, to better understand them in a very depth, expert way. But sometimes that has this cordon off people into pieces and doesn't allow for that broad, forced understanding instead of that focus on the tree. But what do you think would be some things we could change? And again, this isn't just physician education. I think what would be your ideal if you were able to reign over all the physician training and we create this mythical role where you could do it? How would you flip that a little bit? Or what would you institute in programs? I know we in physical therapy I'm a clinical professor so I see more patients than do teaching. But there's a lot of challenges, administrative challenges and things you have to change that we have to teach to a board exam and all these things. So there's structural challenges. But I'm just curious what you would look to do if you had the ability, minus some of these structural challenges that are out there, what would you be looking at doing in the physician education?

Yeah, and it's not just knowledge, because they may have just the knowledge like a lecture or know, be aware that this problem is this. I think every physician understands that chronic pain. I need to learn about chronic pain, I think. But I think the most difficult thing is how do you impart that skills on them, and especially the skills that they can feel confident and they can be competent, that they know how to assess a patient with chronic pain. I see this a lot in echo, because they come to us because they identified some problems or they were told to get more education, because they got into trouble with their colleges or there was a lawsuit, some patients. So it's an open call, right, but I would say you can give them the knowledge and they can go to a conference, they can attend an online course, but do they feel confident that they can examine a patient, they can make the diagnosis? This is not susceptible, this is not C-plastic or this is a mixed. I have patients that they have all three kinds of pain and even myself I only do this and even myself some days I'm scratching my head and say, oh my God, I don't even know where to go with this patient. So I think chronic pain is very complex. It needs a team. So you do need a team to at least do the assessments and come up with a plan. That's what that would be my dream that everybody would have a team of interprofessions. So, you know, let's hear what everybody has to say, opinion about this patient. Okay, so now let's devise a plan and then a coach that could be a layperson guided by a professional, so the professional would check on, you know the coach. How is it going? Do you have any questions? Is it going well? But the coach would be the layperson that already conquered the pain and that is the person that would meet with this patient on an ongoing basis until they feel. And when do you discharge a patient with chronic pain? That's another thing, because chronic pain would be chronic and many of my patients they think that once I admit them to my clinic they will be there forever. And I say no, we have a plan, we have this. And the plan is when they feel the patients get the knowledge about their condition, they're educated, but also they know how to take care of themselves. That's self-management. They know all the tools available to them, they know how to use, they know how to navigate the system and they understand all the comorbidities, the sleep problems, the mental problems. It's not news to them that, okay, I'm anxious and anxiety makes my pain worse. Now they know. Okay, I know anxiety makes my pain worse, so I do need to go back to my you know managing my emotions to take care of this. And then you can discharge the patient and say, okay, we don't need to see you anymore. You know how to do this. Go, you know, move on with your life. If you need us in the future, come back. And that's so rewarding. I got a lot of patients that they come back to me and they say, dr Furlan, I don't need you anymore. I'm discharging you because they know what to do, they know their tools, they understand the system, they know where are the resources.

Yeah, no, that's one of the more rewarding moments is when people say I don't need you anymore. And I mean that's you know. Which is you know you early. You feel like you always want to be needed. As a health guy, I know, earlier in my career I was like I want to be the hero, the savior, but when you get somebody who says I got this, I don't need you anymore, it's such a rewarding experience for sure. You know, we had Peter O'Sullivan and Peter Cantona. I don't know if you read their trial, the restore back pain trial that was in Lancet, but basically looked at cognitive functional therapy showed some interesting results, some promising results as far as really carrying over a treatment effect for a pretty significant period of time, which is kind of not a common thing, obviously in the low back pain world, chronic low back pain world. I'm wondering what your thoughts are on the whole booster session thing, because that was one of the things in that study, that and they had found in their kind of work in with this cognitive functional therapy approach, which is just a, you know, comprehensive, bio, psychosocial peak at a human and I'm probably reducing it a little bit but because you think about some patients who leave and then they have to navigate a world where there's such cultural messages around pain and folks looking to fix and pull people back into passive care and different things. And I'm curious what your? Do you have any concerns of folks when, when they leave, like, are they going to be able to maintain those skills? They're going to have relapses? I mean, obviously folks relapse. It's just part of you know, it's human.

Yeah, it's part of life and I talk about this in the book. I tell them I in my book I talk about the analogy of conquering the mountain, and so the steps are basic, the steps going up the mountain. And I use this because when they are at the top of the mountain, they conquered this mountain. So the pain that they had is still there. The mountain just didn't disappear. The mountain is still there. But they are the top of the mountain and now they are seeing the other mountains, because you rarely have only one mountain in a in an area. And so I tell them at the end of the book, I say now you're ready to tackle the next mountain because you learn how to tackle this one and you can practice the things. And when they tackle one mountain of chronic pain, they get more resilience, they get resourceful, they get more knowledge, more skills, self-efficacy, they are more confident and that works for a lot of things helps them to tackle in the future if they have cancer, if they have a stroke, if they have a mental problem, depression, because the resources will be the same. You know it is lifestyle, it is how you communicate with your healthcare professionals. I teach them, I have videos on my channel and in my book I talk a lot about this how you communicate your pain, how do you talk to your doctor, how do you talk to your friends, your family, your coworkers? Because I find that people they are so overwhelmed, pain takes a lot of space in their head and sometimes they either close and they don't talk about anything, they pretend that they don't have pain, they hide from everybody or every person that they see in front of them, they tell bluh everything. So I tell them you know, there are situations that you need to have these details and I teach them how you explain pain to your doctor. How do you approach your doctor if you want to talk about opioids without looking like you are a drug addict and you are, you know, after the drugs? Because communication is super special and it's a skill that a lot of patients don't learn about this, and I think it is sometimes it's our fault, because we ask questions and we need the answers. We're taking history and I need this questionnaire, but why don't we teach our patients? Okay, this is what I need to know next time you come and you need to bring me this information about your pain and that will help me to diagnose this. This is not a seceptic neuropathic, not seplastic, and I need to know what the treatments are doing for you and tell me about your sleep, your emotions. I want to know what you're eating because nutrition I am passionate about nutrition, especially for chronic pain, and we don't usually ask what our patients are eating, so I don't know we are getting. Yeah, I think our healthcare system is so focused on you know. Let me look at the MRI report. That's a piece of paper that doesn't tell me a lot. I need to understand who the person in front of me is, the whole person.

I definitely agree with you. I think We'll talk about your book, but before we do that, you mentioned some of the virtual work you do with, obviously, when you're kind of bringing in training and doing some of your interdisciplinary work, your ECHO program where you have, you know, rural physicians and things that can present cases. I'm curious what your thoughts are on the virtual medium. You're obviously probably ahead of the curve for most physicians. I mean, there's not a lot of folks in the physician population who have YouTube channels. It's getting much more common. But it's where you're using digital mediums to distribute a message and using it to educate your patients. It sounds like you have multiple videos you could point patients to to say, hey, here's some things to keep up with. What an amazing resource for patients where they can just go flip up their phone and say Dr Firlan had mentioned X, y and Z video and there they are they have education at their fingertips. I definitely something that I'm hoping to do on the physiotherapy front as well. I'm curious what your thoughts are on maybe not just the virtual front but also other mediums to help folks kind of get better education around pain.

Yeah, when I opened the channel I was thinking about writing a book at that time, but then my son is a teenager. He said to me Mom, don't write a book. Open a YouTube channel. And so I did and he helps me. He's my editor and I. I find that that kind of media like a video and audio and text, is better than a book. I have no doubt is better than the book, because the amount of information that I can pack in a short video eight minutes, 12 minutes, sometimes 30 minutes my longest videos are not 30, but most of them are anywhere between eight and 17 minutes is because I prepare that is so concise. I write the script and I put the figures that I want. It compliments my, my consult, like yesterday. Yesterday I was seeing many patients and I sat with them at the end of my consult. I sat with this gentleman and I said open YouTube here on your, on your, on your cell phone. He opened and I said I want you to go home and watch this video, this video, this video. I gave him the numbers because this will compliment what I diagnose you today. I. He has neuropathic pain, he had cervical spinal stenosis, lumbar spinal stenosis, so I have videos for that, the medication that I prescribed to him. I have a video about that medication that talks about the side effects, what does it do, what you can expect. So and then they go home and he was so thankful because he told me well, if this is great, because I can go home, show this to my wife, we can watch. You know, relax. If I don't understand something can go back rewind, instead of me trying to push to him a lot of education at the end of the consult, because at the end of an hour and a half I was tired, he was tired. It was not the best time for him to learn and grasp all of that information. So I find that you can have like an app, you can have a video, you can have a brochure, a pamphlet, a chapter, a blog, whatever a website, but patients can go home and compliment and absorb that message and that's so fun. I have patients that come to me and they say I already know what you're going to say, dr Furun, because I watched your videos. I'm just here to confirm if what I think you're going to say is actually what you're going to say. They kind of try to diagnose themselves and they want my confirmation and most of the times they are right.

Yeah, that's the beauty of the information I mean, and it's the beauty of what you're creating as far as you're giving patients such amazing resources, Some people who might be lost that come across your channel, that might be a huge. I'm sure you've already probably had episodes of people who've reached out and have mentioned, the comments are amazing.

You know, I read all the comments and people from Africa, philippines, asia, south America, so because all my videos have closed captions in 56 languages. So then they tell me, dr Furun, we have nobody here where we are and you are the only resource that we have to help us with chronic pain. And I feel sorry for them really, because that is not the best way to diagnose and treat someone with chronic pain. But they say they have zero resources where they are.

Yeah, I mean it's I've looked at and then we had this discussion with a couple guests of like I get the necessity of the research journal environment and if we're going to change health care, we need to produce studies and if we're going to but I think also we can change that grassroots ability to educate people and get information where it does not have to filter through a journal than through education. I mean, that's a process. Not I'm definitely it's a necessary one. I'm not by any means saying we should throw a journal articles and everybody just open a YouTube channel. But having physicians like yourself and other folks who are putting good information out there to help reach people because I mean you're reaching across the globe it's an amazing impact you can have with that and that's something that we shall be grateful for. I'd love to hear a little bit about your book. I know you've, you've, I've, I've saw it on your channel and I know it's relatively been published not too long ago. But I'd love if you can kind of share a little bit of a book. We'll link it in the show notes here so folks can take a look at that and have it as a great resource for them. But if you could just let us know what is, what kind of the books all about?

Yeah. So basically, when I, when I had a lot of videos on my channel I, the videos are disorganized. Although all the information is there, they don't follow an order. And if someone now that I have so many people don't know the order of the videos and they don't know what comes from, what should I do first? So I thought the need to organize all the content of the channel into a book. So that's basically how the book was, the idea of the book and then I organize the steps into what makes more sense, what should come first. If someone really wants to conquer this mountain of chronic pain, what they should do first. So then, before even the first step is about learn about what is pain, what is chronic pain, the three types of pain and how people diagnose the pain. And then, once you get this, let's start climbing the mountain. So the first step is retraining the pain system, is trying to get rid of noceplastic pain, because noceplastic pain is neuroplasticity, so it was formed with neuroplasticity, so you learn with neuroplasticity. So the first step is if we can eliminate noceplastic pain with neuroplasticity, great, because a lot of the problems will be eliminated. And then we talk about emotions, because we know our emotions that's the second step are a big driver of the maintenance of chronic pain, the stress that we carry in our body, the anger, the frustrations, the guilt. If you don't get rid of those emotions or if you don't manage them and sometimes you can't get rid, but sometimes you need to acknowledge and acknowledge that they influence your pain. That's the, you know, the goal of the second step. And then I talk about sleep, nutrition. I talk about talking to other people, the context that you have around you, because we know there is a lot of science about this that the context, your social context, who is around you, what's happening around you, influence a lot how you perceive that pain. I can give you an example. There is a, you know there are many research studies done but when a person gives a pain score, you ask them zero to 10, zero, no pain. 10 is the most unbearable pain that you have. And they say, oh, it's eight, nine, 10. We're talking about chronic pain. That's usually that eight, nine, 10 is in their head is how much they're suffering from that chronic pain. Okay. So if they say it's nine, it's because they're suffering a lot, they're tired of that pain, it's annoying, it's constant, it's loud Okay, even though they may not show anything like, they may not have behaviors that show that they're in pain, but it is nine because they're tired of that pain. Now, if you change the context, the social context around them and they did this in laboratory they showed these people like videos of happy people telling jokes and laughing, then the pain gets lower. Or they show videos and pictures of angry people, sad people or people that are being nasty to each other. They report higher pain. So you can change that suffering, perceived suffering by the context around you. So that is the step that I talk about. You know, talk to others and see how you can enlist help, because loneliness is. When a person feel lonely, they may not be alone, they may be a lot of people around them, but if they feel abandoned and lonely, their pain scores are higher. So we can help them with this. Then we talk. Of course, the other step is about medications. I teach them what are the medications we use for chronic pain, know your medications, ask questions why you are taking these medications. And then the other one is exercises, modalities, massage, manual therapies. And the last step is, once you get to the top of the mountain, what are your goals? How is your life? Did you achieve your goals? What changes you're going to make and who are you going to help now? So that's basically how I make the analogy of a mountain here. That is, climbing a mountain and again, when they get to the top of the mountain, the mountain is still there, their pain is still there, but they feel that they conquered, they feel that they I got the diagnosis. I don't have questions about my diagnosis. I got a good diagnosis. I know what to do, I know what to expect. I know that social context makes me feel more pain. I know that my emotions make me suffer more. So they know, and that knowledge is power.

Yeah, yeah. No, it sounds like a great resource and, like I said, we'll link it in the show notes so folks can can have that. I think having those kind of resources you can hand the patients to help them on their journey can be something that could accompany folks in a rehab space to help patients kind of navigate that journey. Have it as some things. I've had books similar to where handing it to patients and kind of working through it with them as you're doing some things in clinic. I think those can be huge resources.

The book has QR codes that connect that they can watch my videos if I'm talking about a topic.

Perfect, perfect. So, yeah, definitely those of you who listen, make sure you check it out. It's a great resource and obviously, dr Furlin is doing some amazing things with what you're doing. I want to respect your time tonight. I appreciate you joining the podcast and having a chat with me. It's been great and, like I said, I'm just really impressed with everything you're doing and grateful for folks like you. So keep up all your amazing work and we'll definitely be seeing you on YouTube.

Yeah, and you too. I really love the show. You're doing an amazing job also disseminating all this knowledge to everybody who is listening.

All right. Well, thank you very much for that. I appreciate that you're a subscriber, and those of you who aren't subscribed to the podcast, please do so. We'd love to have you as a subscriber so we can get more of this information to folks who are in need of it. And then also, if you're on YouTube, we'd love to hear you. I got to get to where. I'm at least getting somewhere. I want to at least get to 10,000. I'm not going to get to 100,000, like Dr Furlin for a while, but let's start bumping up the subscriber account so we can start getting more exposure to this information. We're going to leave it there this week. I really appreciate you all listening and we'll talk to you next episode. Please consult a licensed professional for your specific medical needs.