Understanding How Pain Works and Exploring Chronic Pain Treatment - Dr Kal Fried

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Today, I have Dr Kal Fried. Now, he is in Melbourne. Dr Kal is a specialist in pain management. He is also an experienced sport and exercise medicine physician. He’s worked with a lot of elite-level teams in the AFL, in Indian soccer, in netball, etcetera. He’s done a really deep dive into the world of pain. He’s part of something called the Pain Revolution. He educates people around dealing with chronic and persistent pain and what you can do outside of just taking painkillers, what you can actually do to help yourself, and to help you retrain your brain to understand how your brain affects your body and vice versa. So, a really interesting episode with Dr Kal, and I do hope you enjoy it. 

Before I get on over to the show, just a reminder to check out our longevity and anti-aging supplement: NMN. You can head over to any nmnbio.nz. NMN. It’s hard to say that three times in a row. nmnbio.nz and check out the supplement by Dr Elena Seranova there, a molecular biologist, which activates the sirtuin genes, which are the longevity genes in your body, and increases the pool of NAD. If that all didn’t make sense to you, head on over to the site, read a lot more about NMN and how powerful it is for turning back the clock and slowing down the hands of time, so to speak. Right. Over to the show, now, with Dr Kal Fried. 

Well, Hi everyone and welcome back to Pushing the Limits. Today, I have Dr Kal Fried with me, sitting in Melbourne, I believe. Is that right? 

Dr Kal Fried: That’s correct. Sunny Melbourne, it’s sunny at the moment. 

Lisa: Sunny Melbourne and we’ve just been commiserating over lockdowns because we’re in level four. Dr Kal, so you’ve been in and out of one sort of last year. You guys have had it rougher than we have. That’s for sure. How are you doing over there at the moment? 

Dr Kal: I’m personally doing okay. I’m fully vaccinated. I’m okay with work and things like that. But there are people really struggling, so I’m mindful of them. 

Lisa: Yes, absolutely. It’s a hard time for many, many people. Now, today, we’re going to be diving into the topic of pain. You might think, ‘Oh, it doesn’t feel like a very fun topic.’ But it’s a very important topic, and I wanted to learn from you today because you’re an expert in pain. You’ve got an exercise, and you’re a medical practitioner. But you have had a focus on exercise science and all that stuff. You’ve gone really deep into the world of understanding pain. Can you just give us a little bit of a synopsis on your career and what you’ve done today? 

Dr Kal: Yeah, just a brief idea of my background. I’m what we call a sports and exercise physician. In fact, the college spans across Australia and New Zealand. Some terrific practitioners down in your part of the world as well. I was very much involved in looking after the medical needs of athletes. Then, in my clinic, I just see regular people who played sport and people who didn’t play sport, just who got injured and had pain. I look at... That was fantastic. I enjoyed that immensely, but I suppose there was always this nagging question that I struggled with. It was really the injury that really predicted the outcome. You could get very minor injuries with really terrible outcomes, and you get really amazingly terrible injuries with good outcomes. I couldn’t quite figure that out. And I didn’t feel comfortable with a lot of that. 

Fortunately, I was exposed to an area of science, which wasn’t really taught when I was in medical school. If it was, I was asleep in that lecture. But then if I was asleep, a lot of other people were asleep too because it seems that very few people of my vintage figured that out as well. That’s the science of pain itself and how it all works. Once you delve into that, it really starts answering a lot of these questions. It’s like a rabbit hole. You keep going and the more you go, the more fascinating it becomes. We’ve got a lot more to learn. But some of the fundamentals of that science really start to explain the things that I couldn’t understand, and that was good. That led me on the journey. I’m involved with this group there called the Pain Revolution. I’ve got a, it’s behind me—the emblem. I urge people to have a look at that website because it pretty much encapsulates where I am these days. 

Lisa: Fantastic. So, that’s it. I’ll put that in the show notes. painrevolution.com.au, I’m presuming?

Dr Kal: No, no. painrevolution.org.

Lisa: Okay, we’ll put that, make sure that the team can get it right. So, let’s dive into this a little bit. A lot of people have an injury, for a bit of example, like they get a sore back or they have injured themselves while lifting something or playing sport. Why is it just not a mechanical thing? We think that pain is caused by a structural damage in which, and it isn’t in many cases, but why is it a bit of a simplistic look at pain? Why is it a bit more complicated than that?

Dr Kal: Look, it’s complicated. It’s certainly very complex, but it’s also, the fundamentals are actually quite simple. But they’re hard to get your head around because we don’t grow up thinking this way. We grew up thinking exactly the way that you just mentioned, that pain is a mechanical thing. It’s created by injuries and damage to our bodies, things we see on scans, but that’s not actually the case. The fundamentals are quite simple: Our bodies do not produce pain, ever. I’m not just talking about injuries. I’m talking about headaches, stomach pain, all sorts of things. The body only ever produces electrical signals. These signals get picked up by sensory nerves. And these signals get transmitted through the spinal cord to the brain. Then, the brain lights up in all sorts of different interesting ways because of a lot of preconceived ideas, and contextual influences, and sociological influences. 

You get a pain response depending essentially on how much danger your brain thinks you’re in. This is a protective system. This is designed to protect us. It can be quite proportional to the injury you have, but it’s not always proportionate. Sometimes, it’s very disproportionate, and we can all think of examples like that. Anyone that’s involving with football teams or sporting teams will know that, anyone who watches a Tour de France, will know that people have these horrendous injuries. At that level, they probably don’t get enough pain for their protective needs because they keep going. Then, on the other end of the spectrum, there’s the situation where you just have a minor lifting injury—can be just a bending event. And that sets you up for pain for the rest of your life. We know people like that. They’re quite common, unfortunately. And there’s everything in between. It’s a spectrum. 

I like to think of pain in terms of, not causes, but the contributors. The physical side is important. It’s not that it’s not important. It’s only one contribution of many. That applies equally for acute pain, like when you break a leg, or for chronic pain. Acute pain, if you’ve broken your leg, but a car’s about to run you over, you get up and probably walk away without feeling that leg for a little while. There’s some examples of that. There’s two people I’ve had to... You can look these people up on the internet. One of them turned into a movie, a book and a movie, for people who’ve cut their arms off to save their life. 

Lisa: Yes, I know the story. 

Dr Kal: Yeah. There’s another one actually. He was in a cellar of his house, and he couldn’t get help. Both of them say exactly the same thing and that’s that they were amazed how little pain they got. Think of this, they’re cutting through muscles, nerves, bones. Because they’re in a survival context, their brains essentially shut out that large amount of that pain because it wasn’t in their survival interest. That’s essentially how pain works. There are these extreme examples that we can learn from. But really, if you then apply them to the everyday examples that we see all the time, it starts to make sense. Things start to fit into place. 

Lisa: This is really fascinating. Richard Little, he’s the founder of a company called exsurgo.com. He’s an engineer, but the company is working on computer-brain interfaces, if you’d like. They help with pain modulation. So this is a really cool piece of technology that’s not yet on the market, but he’s bringing it to market in the next year or so. It’s looking at training your brain to not feel the pain anymore. I’m probably butchering his description of it. But basically, you’re playing a video game. It’s reinforcing all the things that do to stop the pain. It’s reinforcing all these neural pathways in your brain to actually stop you experiencing it. And it’s rewarding, the behaviours that lessen the pain, from what I understand. 

In other words, it’s not just, it is very much about how we understand it. I also heard a story of a man who was at a construction site, fell off a floor or something, hit the ground and a nail went up right through his boot. Do you know that story? I bet you do. 

Dr Kal: Yeah, that’s a story that was written up in a medical journal quite a long time ago. There’s a photo from that actual event of the nail in the boot. I use it in talks. It does the rounds quite a lot. Essentially, this... Do you want to tell the story? 

Lisa: No, you tell the story. You’d be better at it. 

Dr Kal: Essentially, what happened was when this fellow fell, the nail went through his boot, and he was howling in agony and had to be given... He was taken to the emergency department. He had to be given all sorts of really strong medication just to take the boot off. When they took the boot off, they found that the nail hadn’t, in fact, gone through his foot. It just gone in between his toes. The visual sort of contribution, in that case, was huge, and this person was in extraordinary pain. But once, obviously, that he realised that the danger wasn’t what he thought it was, everything settled down quite quickly. 

There’s actually another article at the tale of two nails. There’s another interesting nail story that was written up in a magazine somewhere. It was a fellow who was operating a nail gun. Nail gun went off suddenly, and he got a bit of a fright, but he looked around. He couldn’t see anything wrong, so he just kept going. He kept going for a week, he kept working. He went to his dentist because he had a bit of a toothache. When they took an X-ray, the nail that he thought had just gone off somewhere had gone up through his palate into the front of his face.

Lisa: And he hadn’t felt it because he wasn’t aware of it. 

Dr Kal: Exactly. Because there wasn’t that awareness, he didn’t get enough pain for his situation, I suppose. 

Lisa: Wow. These are two opposite sides of the spectrum here. People are probably thinking, ‘Oh. Well, that guy was just a tough ass, and the other guy was probably a wimp.’ But it’s not. It’s a bit more complicated than that, isn’t it? 

Dr Kal: I don’t like that conversation of pain thresholds and people being soft or weak. I’ve seen some situations involving people who were elite athletes, but the circumstances of their lives changed. I suppose it’s a bit like cricket. Sometimes, you just have to get the timing right, and the ball sails over the fence. You can just have a few things going on in your life that are perhaps affecting that you’re not aware of, even—some stresses, some fatigue. Now, with COVID times, I suspect this is going to probably result in some serious persistent pain contribution over the next period of time because everyone’s under so much stress. 

Yeah, I think it’s contextual. It’s got very much to do with our beliefs and our expectations. I think it’s just important to understand this stuff. You mentioned before about some of the technological advances. There’s some fantastic things going on, but what we found is, by just getting people to conceptualise their pain properly, we can make a difference. 

Lisa: Yep, and to be able to understand where it’s coming from and taking control of some of those pathways. Because my background is an ultramarathon runner, so doing extreme endurance races for 25 years. People seem to think that you have a really high pain threshold. While that may be true in some aspects, in other aspects, I’m a complete like... I can’t handle it, can’t handle the pain. There’s different types. And I think you’re right on the money when you say... The times when I’ve been in even more pain than I could cope with have also been times when I’ve been under a hell of a lot of stress and will have a lot less resilience for whatever reason because I’m dealing with a whole lot of stuff going on or something’s happening. 

Your perception, women will know this. At different times in the cycle, they’re more likely to feel a bit more vulnerable, and a bit weaker, and a bit more teary, and a bit more prone to feeling more pain than at other times of the month. Is that a thing? Are we very much susceptible to all the inputs in our environment and not just the actual, the nail going through the boat in this case? 

Dr Kal: That’s definitely a thing. I think the best model exists for understanding pain is that anytime we feel pain, or for that matter, all the sensations we feel, which are essentially produced by our brain. There are a lot of things going on at the same time. Some are recognisable, and some are not recognisable. There’s a hell of a lot that are under the surface that we really can’t even perhaps recognise or acknowledge. I think you can make it so complex that it’s almost a bit scary. But I think just accepting that there are lots of things involved, I think helps a lot. I know personal experiences, it’s helped me. 

If I can get my patients to come along this road and understand that, then they start to change. Their responses change. They’re less likely to get that terrible persistent pain problem where the neurological system just creates pain for you for very little contribution from your body tissues. We call that sensitisation. When pain persists, it takes a lot less contribution from the physical component to produce the same pain. Sometimes, no contribution at all and people remain in pain. The injury could have healed years ago, and the pain sticks around. I think it’s really important to understand that this is a multi-factorial situation all the time, not only in the acute phase and also in the chronic phase. 

Lisa: Well, so that’s in other words, say you hurt your back, and you’ve got a mechanical problem there, and you have been a chronic, after a while that develops into a chronic pain pathway. So your body’s sending these signals even though now the back has actually healed, but you’re still receiving the signals. Is it almost a habit that the body’s got into? Just like with habits that you do, the first time you do it, it takes quite a high threshold to actually do the action that you’re wanting to take. And then, you do it everyday and it gets easier and easier and easier. Is it the same sort of thing that’s going on with pain pathways? That it becomes just very easy to trigger that pain if you’ve had that very often or persistently? 

Dr Kal: Yeah, absolutely. But not only is that the case, but it’s inevitable. There’s some really interesting work done where we looked at the way that the nerve pathways behave. Desensitisation is quite a real thing. We know what happens at the neurotransmitter level. But essentially, for us to understand, your brain just develops a direct channel to that area. Any tiny contribution starts to get amplified. It’s like having a little noise next to a big amplifier, and this just gets stuck. There are certain medications we can use to help people to, as a circuit breaker for that, but medications are not really the treatment. The treatments are to develop other habits and other practices that help you change that pathway and desensitise it. It becomes sensitised. You need to aim to desensitise it, and there are ways of achieving that. 

Lisa: Wow. I’ll give you an example. I recently went through shingles. Bloody awful thing. I recommend anyone, don’t get that. During the day, I would have pain, but I could handle the pain. At night time, I was just beside myself. Sometimes, the pain was just so bad. I would be unable to sleep and unable to do anything. I was in such a bad state. I would get up in the night, often, and go and have a nice cold shower on the affected area. That gave temporary relief for about 10, 15 minutes. 

My thinking was, and I don’t know if this is right, this is just me being a biohacker who’s always testing things out. Broke the circuit of that pain because then I was focusing on the freezing cold, and it seemed to stop the pain for a little while. And then, it would come back after a half an hour. But I’d get sort of a half an hour reprieve. It could be because of the cortisol response that I’ve just caused and the adrenaline response from the cold water. I’m not sure what’s going on there, but it was effective. And it did help me, at least temporarily, get on top of it. My thinking was because I didn’t want to have painkiller, after painkiller, after painkiller, and they weren’t working anyway with this sort of nerve pain. Was it a good intuitive thing to be doing? 

Dr Kal: Absolutely. Look, you’ve touched on a few things there. I hope I remember them. The first one was the concept of the role of distraction. That’s a real thing. One of the problems at nighttime is that we lack distraction. So, there’s often a higher pain experience at night that’s quite common. That also leads to sleep disturbance. And we know that the more fatigued we get, that’s also a negative contribution to our pain condition. There’s a whole lot of things. The system of pain itself will fuel itself because the more it sticks around, the more worried we get and the more concerned. It’s just such a horrible experience, as people who’ve had it know. It’s sort of a vicious cycle that just keeps going round and round. 

So, yeah, distraction is important. We use that in treatment processes as well. There’s a whole lot of probably chemical and hormonal things that are going on, and you correctly mentioned that. At the end of the day, I think a lot of people will develop a lot of intuitive strategies just like you had. That’s absolutely right, what you said—very, very important part of treatment. You can only really explain that by understanding the pain science the way we discussed it before.

Lisa: You mentioned the neurotransmitters. And I talked briefly there about cortisol and adrenaline. Can you, by manipulating the neurotransmitters in play, actually manipulate the pain experience? Like, the example that you gave of the person who’s gonna get run over by a car. Even though they’ve got a broken limb, they’ll get up and go, and they won’t feel it. Because the danger and the adrenaline is running so high, they will take action before they’ll actually feel that pain. Is there a way to use that knowledge to help people who are experiencing chronic pain? Like manipulating neurotransmitters in that way? 

Dr Kal: I’m not sure what you mean by that. When we change people’s behaviours and their conceptualisations and get them to do what I call a re-adaptive programme, then those neurotransmitters will change. That’s, I suppose, a natural way of doing it because the neurotransmitters are very responsive to our thoughts, our actions in that way. In terms of external manipulations, by giving people medications and drugs...

Lisa: Yeah, not so much there, but behaviours like the ice-cold showers are behavioural things that we can do to help. Because things like adrenaline do dampen the pain response or endorphins. I can know from running that if I’ve got pain, usually... Say I’ve got a sore leg, and I go running. The first few minutes will be excruciating, so I’ve got blisters. That’s a really good example because I’ve had a ton of blisters in my life, right? When you had a break, you’d have the blisters. It’ll be painful. You’d start running again, the blisters were excruciating. After 10 minutes, you stop feeling them. Then, I thought that that must be the endorphins or something kicking out that are actually dampening that pain response because of the mechanical damages there. It’s no different. 

Dr Kal: That’s exactly right. We’ve got what we call a drug cabinet in our brains. All the medications that we give, I mean got a big problem with prescribing morphine-containing medications. But our brains contain morphine- type chemicals: endorphins and others. If we can harness these processes and get our own brains to produce the right chemicals for us, then that’s absolutely achievable. 

One of the problems with that condition called pain sensitisation that I mentioned before, and that’s when your pain becomes really easily provoked, and it’s there all the time and that it becomes, also, quite resistant to medication. I’ve seen people on absurd doses of medication and all sorts of different medication, and their pain goes from whatever it is. They might say 10 on 10 to 7 on 10. Well, that, to me, is not what you’d expect from that type of medication. That pain is resistant, and that’s quite common. 

One of the problems in that situation, if you go and see the people who just keep giving you different medications all the time, and they’re not tweaking on to the fact that your pain’s actually resistant, then that takes you down a road that’s not helpful for you for quite a while. It’s hard to come back. 

Lisa: Yeah, and it’s very bad for your... We know the consequences of the opioid addictions. We hear what’s happened, especially in America with the over-prescription of opioid medications. They all have knock-on effects. Even the anti-inflammatories that you buy over the counter are going to impact your liver, and your health or your body in general over time, your gut health. That’s not a path we want to be staying on for very long. Anything that we can do, but having been through this recent experience with the shingles, makes me very compassionate for people that are going through chronic pain for years on end. It’s just like ‘Buh’. It’s hardly worth living when you’re in that much pain, and you can see people must be struggling to cope and function. 

When it goes on for a long time as well, then the people in your environment become numb to you moaning about it. There’s another aspect, as well, because hearing about you and your pain everyday, then people are just gonna stop responding. That makes the whole world even worse because then you’ve got no outlet to voice your discomfort that you’re going through. Is that a real thing too? Do you see that?

Dr Kal: Absolutely.

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Dr Kal: Look, as I said before, there’s so many vicious cycles in pain, and that’s one of them. I think one of the problems with pain is that, please don’t take this wrong, but it’s not sexy. That’s how I would describe it. If you’ve got something else, like diabetes or some other chronic disorder, then I think the compassion you get, the empathy you get from people is pretty endless. But if you’ve got pain, it’s very limited. You get a lot of social breakdown. Marriages, families break down, regularly. Your community starts to judge you. You feel judged. Your workplace becomes a very toxic relationship, often. All these things just feed back into the monster.

Lisa: You’re less able to cope too. When you’re in pain, you’re irritable, shitty, and you’re not a nice person to be around. You know, I’m not. When I’m in pain, it’s like I’m a bear with a sore tooth, literally. Then, other people suffer. Your family members suffer. Your colleagues suffer because you’re not on your A-game. You’re taking it out on them if you’re not handling it well. 

These are all conversations that I think the fact that it’s not a sexy topic, as it should be, because it’s one that hits so many people and. In fact, it will hit us all at some point in their lives. We’re all going to have some sort of a pain to deal with. If there are ways that we can learn to cope with it better that aren’t medications because we’ve got that to fall back on, but it really should be a fallback option, not a thing that you want to do for long and not the only option. 

What’s your take, then, on things like meditation, and things that are going to calm the nervous system, and stimulating the pain in its parasympathetic nervous system state, and all of that good stuff? Do you think this has a role to play in this programme of dealing with the things that you can do that are in your toolbox to deal with pain? 

Dr Kal: These things are pivotal. The great thing is that they’re quite mainstream now. I’m at least pleased that the medical professionals here in Australia have taken these things on as mainstream interventions. They’re absolutely pivotal in what I call re-adaptive programmes to get people back, I, even though as an orthopedic surgeon in Melbourne, who gets all his patients to do mindfulness before he operates on them, which I think is terrific. 

Lisa: Wonderful. 

Dr Kal: It’s starting to become quite mainstream. Look, again, if we just keep conceptualising pain as being related to physical injury and damage, then none of this makes sense. But if we understand pain is a protective mechanism, and we have to get people to readapt, both in terms of calming down the nervous system with these techniques. There’s a lot of different aspects. There’s cognitive behavioural therapy, acceptance therapy. What I find is that people relate to different things. For some people, one modality will be super beneficial. In others, it won’t. You have to find, I think, an individualised programme for people, which makes it a little bit hard because the medical system doesn’t like that individualisation yet. But I hope that’ll change. Yes, I think things like that are really important then. 

I come back to my roots as a sports and exercise physician because exercise rehabilitation is really important. You got to get people to understand that the pain they’re feeling doesn’t equal harm. They need to progress through it. If the exercises hurt them, then that’s a problem, and we need to think about that and know how to address that. We tend to have this programme called a graded exposure programme. But you can’t sit around doing nothing. You can’t keep protecting yourself from pain because that won’t work. That’ll just make you worse. 

To me, the answer is a programme where you educate people, get them to understand how this all works, and that’s not easy because everyone learns differently. But if you can achieve that, then that’s the foundation. Then, the next is to use some of these psychological techniques, talk therapies, I suppose we call them, to help give people practices to do, like meditation, mindfulness, yoga, all sorts of things, CBT, etcetera. 

Then, I think the next really important phase is to get them to do exercise in a way that’s individualised for them. Respect pain flares but get people to understand how to manage them. Then, gradually get people back to normal. The mantra of the Pain Revolution is to rethink, reengage, and recover. Recovery is very much back on the table. One thing that happens in chronic pain, persistent pain, is that people very commonly get told based upon all the things we’ve been doing in the past, which really haven’t been aligned with this type of science, they get told that you have to learn to live with your pain. 

If you’ve got chronic pain and someone tells you have to learn to live in pain, that can help a lot of people, don’t get me wrong because that’s an acceptance thing, and it might actually help them. But for a lot of people, I think that that message is not optimal. Because through things like these programmes, through neuroplasticity, bioplasticity, which is that wonderful adaptability of the human body and brain, we can get a lot of these people back. I don’t like people believing that if it’s not necessary. 

Lisa: Yeah, and I totally agree with that. I think they have, in general, in the medical world, my background, which you don’t know but my listeners know, I have a mum with a massive brain injury from an aneurysm. We were told she’d never do anything. She was in a not much over a vegetative state, age of 74. Massive brain damage. Put her in a home. Make her comfortable. For a start, I don’t do comfortable because I think comfortable is the way down, and that life, we need goals; we need to push through struggles; we need to go through a certain amount of pain in order to come out the other side is my premise as an athlete, if you like. I understand the benefits of going through physical pain as far as training pain goes in order to get stronger, right? I understand that principle in biology. For me, it was no different. 

So with Mum, being told that she couldn’t, just accept that. I didn’t. And it took me two and a half years and thousands of hours of research, and retraining her brain, and hyperbaric oxygen therapy, and everything else that everyone’s heard me preach about on this show many times. But it took me two and a half years to get her back to full health again—complete full health. I don’t accept when someone says, ‘You can’t do something.’ Or ‘You just have to accept that this is your lot, and that’s the end of the road. This is all we can do.’ 

No. That just means that doctor or that person doesn’t know what else they can do. They don’t know, and that’s fine. Go find someone else because someone else may have a different perspective on it. Go and research, find other ways around the obstacles, rather than just going, ‘Oh, that’s just me. Damn, that’s all I’ve got.’ Because I think, very often, we’re written off as that’s the end of the road. 

When you go to a doctor, and they are the ones that went to medical school, they’re the ones with the big brain, they’re the ones with the education, you tend to go, ‘Okay, they know what they’re talking about.’ And to accept that. Whereas, my thing is that maybe that person just doesn’t know all of the things that are out there. Maybe that person’s super busy, and they got 10 minutes to spend with you, and they haven’t got time to take you through a rehabilitation process. As you said with what you do, it’s education. It’s rehab. It’s all these things that are extremely time-intensive. Now, most people in the standard medical care don’t have time for that thing or the resources. 

Therefore, it’s up to us as individuals to start taking control, and doing the research, finding people, and doing this all ourselves to the best of our ability if we want to come out the other side. It’s the premise of the show and why I get to interview amazing people like yourself that have pieces of the solution for pain for people. So that they can, ‘Oh, that’s interesting. I might go and research what Dr Kal said there, and go and visit his website, and maybe that will help me.’ That’s, I think, a very empowering standpoint to come from, rather than, ‘It’s all over. There’s no chance.’ Then, you’ve got this. But do you agree with it? 

Dr Kal: Largely, absolutely. Look, science is about questioning. It’s not about accepting. I think science is wonderful. That’s really where I looked to for answers—that questioning, not accepting. I think one of the problems that’s happened in mainstream medicine, and perhaps the health industry, to a large extent, is that we’ve started to accept too much. We’re not questioning enough. For example, if you go and see someone, they’ll give you diagnostic comments and prognostic, which are predictions of the future comments based upon things that were done previously. Okay. 

Now, I can tell you that in this field of medicine, and there’s a lot of crossovers to other areas of medicine, too, this area that the biopsychosocial model of care we call it, and that fundamental role of the of the brain in the nervous system in our biological processes hasn’t been addressed anywhere near adequately in the last 10, 20, 30 years. The opinions that we offer and the predictions we offer are based upon a whole period of time where we haven’t been recognising this incredibly important part of health. 

I think people do have to question and look for other possibilities. Now, you’ve got to be a little bit careful with that too because there are so many snake oil salesmen out here. I think the answer has to still be in science. Then, you also have to know how to interpret the science because there’s a lot of things in the research that are not optimal. There’s conflict of interest and all sorts of things. You have to be a little bit careful how you interpret that stuff. 

Look, this isn’t easy, to be honest. But I think the key thing is to not give up hope, keep questioning, and understand that there are things that can be achieved by harnessing this plasticity concept that we’re talking about. I think, quite often, and I say this with a heavy heart, the people who do well in things like pain or recovery from injuries are often the people who have elected not to listen to the things they have been told. They’ve just fired ahead regardless. We have lots of examples like that. Your mother seems to be one as well. 

Lisa: Yeah, she is. And it’s not a factor of ignoring medical advice. It’s not what I’m saying here. It’s just going, go and give it a second, third, fourth opinion, go and do some research, go and listen to some top podcasts and professors, go to PubMed. It isn’t easy. It isn’t easy, like in this journey with Mum and on other journeys because what I do now is help other people on their difficult health journeys and stuff and connecting people and so on. It isn’t an easy thing, and I’ve run up a number of dead ends. I’ve wasted money. I’ve gone down paths that lead nowhere. 

But by the same token, there were a number that did lead to places that are not being fully recognised. Things like hyperbaric oxygen therapy, for me, my opinion, is a totally underrated, undervalued therapy that can be doing a heck of a lot more, but there’s no money in it. No one’s going to be promoting it hugely as far as... There’s no pharmaceutical company behind it. They can’t do anything with it, in that sense. It’s always going to have a limited. So all I can do is bang my drum about it, teach about it, and point to the doctors, and the resources, and the books, and stuff, people that have had success with it. 

I think it’s the same with pain. We’re starting to understand that neuroplasticity, that the brain and the body and the connection between the brain and the body is just an area that we need a lot more science in. It’s not always a physical thing. We’re going back to what we were talking about at the beginning. If someone comes to me, and they’ve got a sore back, you may be looking at the back situation, or you may be looking at what their inflammation markers are doing in their body? What’s their gut health like? Is it the fact that they’ve got a sore back a signal that maybe the nerves are not turned on? Can we activate...? In other words, there’s other directions to be looking, and it might not be a mechanical back issue. It could be something on the front end, or the gut, or the digestion, or whatever the case may be in that situation. 

Sometimes, it’s looking outside what you normally would think is for the problem area. It’s also a really good holistic viewpoint. Let’s not just look at the back pain. This is another thing with the standard sort of medical system where the body is broken up into areas of specialties. Rightly so, in a lot of ways because you can’t be an expert in lungs, and heart, and gut, and so on. But there needs to be more connection between... Somebody is looking at the whole picture, piecing this all together for the person. The lungs and the heart, that’s a really good example. They’re very interconnected, but they’re completely separate disciplines that don’t really talk to each other. I think more integratedness in their approach would be good, if that’s a proper word. 

Dr Kal: I think it’s integration, isn’t it? I think there’s a lot in that as well. I think the key thing is to try and avoid being too passive in your own health because reliance on external fixes can be a problem. A lot can be achieved by energy, by lifestyle changes. Now, these days, unfortunately, I think there’s this trend towards outsourcing your problems, rather than... I talked to my patients about the long game versus the short game, and it’s the long game that wins. Yes, try and be more active in your own health. Question and ask. 

But I think we do need to put a little disclaimer here. There is need for caution here, as well, like I said before because there are a lot of... Now, some of those treatments, I think, fall into what is commonly called the placebo category, which to me, that’s a fascinating area of neurobiology. Just the whole, the way that the placebo constructs, operates. If people don’t understand, it’s like when you get the sugar tablets, got nothing, no properties on it, yet you still get the same response as if you had the real tablet. But it’s the expectation and the belief that dictates that response, which again, comes right back to the neurobiology and the role of the brain. It’s not the tethered sugar tablet that does that. I think some of these things operate through a placebo construct. 

Now, I have no problem with the placebo. I think it’s fantastic. In fact, there’s some fascinating work being done in that area about how we should harness that in a constructive way. But there are safety issues with the placebo construct approach. For example, if you keep resorting to that approach, then the benefits wane with repetition and time. Then, what happens is you tend to go to a more aggressive type of intervention and perhaps more dangerous. So, that can be a problem in that direction. 

There’s some fascinating research in the last 10 or 15 years, which is showing us at some of the very common surgeries that we’ve been using and we have been thinking are incredibly effective, when they’ve been looked at against a fake surgery comparison, and these things are done, then, the results were exactly the same. Knee arthroscopy is one, and there’s others as well. Even surgery can fit into this placebo construct. And I don’t think anyone would think that surgery is entirely safe. We’ve got to be careful with that type of approach. I think, again, we do need to apply really, really good quality scientific approaches to this, and get the data out, and understand what works directly, and what works indirectly, and the benefits, and the safety problems, etcetera. This means that the patient or the person with the problem has to really be quite active in their own management. 

Lisa: Yeah, and I think that it’s probably the biggest takeaway from all this is... I think we grow up with this mentality: When you’re sick, you go to the doctor, you get a pill, and you get, become alright. That mentality is just very flawed in the fact that it often takes work. It often takes lifestyle interventions, which, to quote you, is a very unsexy thing, for me to tell you to go and do some more exercise and to eat less fish and chips. You’re like, ‘I don’t want to do that. Just give me the pill to fix it,’ is often the answer and it’s not. No amount of just taking a pill... It’s not getting to the core of the problem depending on what the situation is, obviously. But lifestyle interventions and behavioural changes are things that we should be grabbing to, first, before we resort to medications and things, where appropriate. 

That’s a conversation that needs to be had. It isn’t just about going to the doctor because people sort of, I think, expect to get a prescription when they come away from the doctor. “If I didn’t get a prescription, then it was a waste of time.” “I went to the doctor, I paid him x amount of dollars, and I didn’t get a prescription. I got told to do some more exercise and lose some weight, eat better, go to sleep earlier.” It’s like, ‘Where’s my pill?’ approach. I think if people understood biology a little bit, and understanding why that may help your back pain or your whatever the case is, there’ll be a bit of conversation. 

If I can just flip and just say, what do you do, then, at the Pain Revolution? If someone dealing with chronic long-term pain is listening to this, how can they come to you, get support, get help around this education process? What exactly is it that you do there? 

Dr Kal: That’s obviously the pivotal question. The Pain Revolution approach is pretty much along the lines of what I was talking about before. The first thing is to really understand how this all works. That is a major challenge because one of the biggest things that we’ve looked at is how people learn because everyone learns differently. That is actually a really big conversation: the whole conversation about education and health literacy, pain literacy. But unless you can achieve that to a certain extent, the risk becomes very difficult. That’s important. The rethink part of the mantra of rethink, reengage, recover is really, really important. Now, to do that, the person who started the Pain Revolution’s a fellow called Lorimer Moseley, Professor Lorimer Moseley. Have you heard of him? You should get him on your podcast one day. 

Lisa: Do you know them? Can you hook me up? 

Dr Kal: I can inquire, but he’s a lot more entertaining than I am and a lot better at this, at explaining it. But he wrote a book called Explain Pain with another fellow called Dave Butler, also an excellent person and answered. Lorimer just wanted to do something practical to create a programme that people could harness. He came up with the idea of the Pain Revolution. I got on board very early. It started as we do an annual outreach event, which is a cycling tour. We go and give presentations in all different country towns along the way. This year, of course, we couldn’t do it because of COVID. We’re doing an online thing, which is starting in October. It’s all about raising funds for this programme which is to... 

There’s a course, a two-year course for what we call Local Pain Educators, where we take over all sorts of disciplines. Doctors, physios, psychologists, occupational therapists, pharmacists, there’s probably a few more that I haven’t mentioned, anyone who’s interested gets on this programme, goes through the programme with mentors and comes out the other end. Then, the next wave is what we call a local pain collective where those people start to talk to the other people in their communities, health professionals, people with pain. We’re hoping to grow a room full of... 

We’re only about four or five years into this. It’s got a long way to run but it really is starting to gain ground. I’m very proud of it. It’s very much focused on non-interventional techniques. It’s not to say that pharmacies and interventions don’t have a role, but I think that higher reliance on those things to create an outcome isn’t working for us. In fact, it’s creating a whole lot of other issues, so this is very much focused on a neuroplasticity-type approach, a re-adaptive programme to get people back to normal as much as possible. 

Now, the structure of that, I think, as I said before, can vary from person to person. I encourage people to explore all the different resources, website resources. There are certain programmes that have come out of the Pain Revolution. I’m involved with a few of them. I’m involved with one called Brain Changer, which has a website as well, which is a programme put together by a lady called Tina McIntosh who is a recovered persistent pain, chronic pain person herself. She’s put together an app and a computerised programme to help people, practical. Again, there’s some pain coaches in that. I have only been involved with it in a sort of advisory capacity called Permission to Move by a fellow called Dave Moen, who’s also got some terrific approaches and some website resources. 

I’ve just noticed, this is exploding, which is really encouraging. Because when I started doing this, I felt like a lone voice in the wilderness. But now, there are so many terrific programmes coming out all over the world along this direction. It’s all about empowering people and getting people to start mapping out their own recoveries. 

Lisa: This is just marvellous, and I just love this approach. I think pharmaceutical interventions when they’re required but not just relying on that. Let’s re-educate, and retrain, and help with other things. That’s fantastic, so I hope that lots of people will go and visit. I’ll get all of the links from you to all of those that you’ve mentioned perhaps, and we can put those in the show notes to help further this conversation, and o give people because there’s so many people suffering various levels of persistent chronic pain with different disabilities. It wrecks your life. It does. It just takes away your joy from living. If we can help people with this conversation, today, I think get people interested. Perhaps, this is something for me that could help me with my journey. Also, in the education space and this is what I’m passionate about: educating people about the different areas. 

It’s been marvellous to have you on the show, Kal. I’m really, really grateful for our mutual friend, Craig Harper, for introducing us. Shout out to Craig. Just really grateful for your time and your passion that you’re bringing to this because there’s lots of people suffering out there. If we can help them in any way, that’s really, really important. Any last words before we wrap up here, Kal, that you want people to think about or to do?

Dr Kal: Last words, these are supposed to be really wise words, aren’t they? 

Lisa: You’re always being put on the spot in the end. It’s like, ‘Oh, I just told you a whole hour of stuff.’ 

Dr Kal: I think just reiterating that there’s real potential for recovery now. Now, certainly, there are some conditions, which are exceptions and we have to respect that. But to the great majority of people in chronic pain, from musculoskeletal issues, bad backs, bad necks, various injuries, they’ve had this enormous potential for recovery. Of all these things that we see on scans were painful, I’ve got to tell you, we’ve all been in agony. The reality is that most of them are well adapted. There wouldn’t be things like sport. If there was a linear relationship between body damage and pain, we wouldn’t have things like sport because we’d all be in too much agony. 

The reality is that the vast majority of these things are well adapted, and that’s what you should aim for. If you’ve got an injury, if you’ve got a problem, you just need to create that adaptation pathway for yourself, which doesn’t just involve the injury. The injury can do that. We know it can do that. But it also involves the neurological system, the brain. That is where all these types of aspects come into play. 

Lisa: That’s absolutely wonderful. Dr Kal Fried, you have been amazing today. Thank you so much for your time, and I really, really appreciate the work. 

Dr Kal: Thank you for having me. I appreciate you asking me to come on. 

That’s it this week for Pushing the Limits. Be sure to rate, review, and share with your friends, and head over and visit Lisa and her team at lisatamati.com.