Is Chronic Pain A Disease? 3 Types & Causes Of Chronic Pain with guest Rafi Salazar

On this episode of the St. Louis Pain Expert Podcast, Dr. Dave Candy, PT and Rafi Salazar, OT discuss the disease process of chronic pain. They'll explore 3 different types of chronic pain plus tips to help.

Table of Contents

Episode Transcript

Dave Candy: Welcome to the Saint Louis Pain. Expert podcast. I'm your host Dr. Dave Candy. I have with me here today Rafi Salazar.  He’s an occupational therapist. And we're going to be talking about the topic of chronic pain. So thank you for joining me today. Rafi, can you please tell me a little bit about yourself and just how you got into the field of chronic pain?

Rafi Salazar: Sure. Yeah, thanks for having me. I'm an occupational therapist by trade and early on. In my career, I began working in an outpatient upper extremity specialty rehab clinic at the Department of Veterans Affairs. And that, that's really just fancy for saying anybody who had an issue from their neck, to their fingertips that was not solved in primary care came to our clinic. And one thing that became very apparent. Treating all of these patients that were being referred to us for non-descript chronic shoulder pain, for example, and being into it. We really realized that a lot of the issues that they were having a lot of the pain that they were having really stem from other disorders, right?

We had a lot of veterans. So post-traumatic stress disorder. PTSD, depression, psychosocial factors were all affecting their lives in a way that manifested in real experienced, physical pain. And that kind of led me on the path as a clinician working in that department to kind of explore different methods and modes for treating chronic pain. We ended up doing a big interdisciplinary pain management program at the VA that I worked at which was Charlie, Nord VA Medical Center in Augusta and we had like psychology, psychiatry Physical physiotherapy, kinesiotherapy, aquatic therapy occupational therapy we had like 10 different specialties involved, VOC rehab was involved and it's just a great learning experience for one interdisciplinary, pain management. But then also just kind of learning about individuals who are experiencing longstanding and persistent pain and just following in through their journey of trying to gain back some semblance of normalcy in their life. From a, from a function standpoint,

Chronic Pan vs Acute Pain

Dave Candy:  And for people who may not be as familiar with chronic pain, how would you describe the difference between chronic pain and the more familiar kind of acute pain that people are used to dealing with?

Rafi Salazar:  Sure. Yeah, I think it helps to define pain too. So pain itself as described by the International Association of For the Study of Pain (IASP) is an unpleasant sensory and emotional experience that's associated with either a real, or perceived tissue threat or damage. So if you think about it, that's what pain is, it's your body responding to a threat that might be real. It might be perceived as tissue damage. So, chronic pain or acute pain. Let's start with acute. It is something that's very sudden, it's sudden and onset and it's related to a specific event. So you fall and twist your ankle. You throw a baseball and hurt your shoulder, you twist funny and hurt your back. Like those are a cute

Rafi Salazar:  Pain in that, it's very, it's a sudden onset. You feel it immediately and it's related to something very specific. I was throwing the baseball with my shoulder hurt, or, you know, I felt the pop or I stepped off the curb. When I felt, my ankle twins, or whatever it is.

Rafi Salazar:  Chronic pain, on the other hand, really relates to something that maybe started out as acute pain. Maybe it started when you threw that baseball and with your shoulder and thought that pop. But it is that pain. Now it has lasted longer than the typical time frame for healing of normal tissue. So the research varies about what qualifies, like acute versus chronic pain. The most of the breakdown though is pretty consistent that it's generally somewhere in, in the three, to six month rain. So, if you're having pain, maybe from an acute injury and now it's three to six months afterwards. That's outside of that normal time frame for tissue healing. And that's what we would consider chronic pain.

Is Chronic Pain A Disease?

Dave Candy: So is chronic pain a disease itself then.

Rafi Salazar: At, you know, there's been a big move in the literature to kind of define it as such. Because again, we've been thinking about pain as like, you know, the fifth vital sign or it's a symptom of something else. However, in instances of true chronic pain, that’s not always the case. There are three different types we can talk about here. That pain may happen regardless of whether or not there's a real biological or physiological process going on. So when you know, when I think about pain, or when you think about paying a lot of times, you know, we're thinking, Okay, I cut my finger and that damage to the tissues with signals that they send the pain signals left my brain and then I have pain and my finger right with chronic pain. And there are specific types of chronic pain that happen regardless of whether or not you actually experienced a damage to your tissue and issue with your tissues if you would, to quote, Adrian Lowe. 


Rafi Salazar:  You think about that original definition of pain, it's that physical and emotional response in response to a threat. Whether that threat is real or perceived. So yeah, there is an argument for discussing chronic pain in particular as a disease process because it is one of those things that doesn't necessarily need to involve an injury for you to experience real pain. I mean, this pain is real, it's not something that's just made up or that and maybe that, you know, it's all in your head. For example, like these are, this is a real sensation. And we need to figure out how to deal with it on its own as an experiential impact, if you would, rather than just the symptom of another injury or something like that.

Dave Candy: Yeah, that is a common stereotype and what we'll probably dig into that.

Rafi Salazar:  Yeah. Sure.

3 Types Of Chronic Pain

Dave Candy: A little bit deeper here in a bit but you mentioned three different types of chronic pain. Can you just kind of expand on that a little bit about the three different types of pain and what makes each of them different and how a person who might be suffering with pain that's gone on longer than it should know which one they might be suffering with and how to treat it.

Rafi Salazar: So the literature defines three different types of chronic pain or classifications if you would have chronic pain.

Neuropathic Pain

The first one would be called like a neuropathic pain, so neuropathic, and this results in some it's either a lesion or a disease process in the this a big words somatosensory system but that the nerves and the tissues and all that and what this means is that maybe there wasn't an acute injury, maybe there wasn't a real, an injury to the to the muscles or the tissues themselves, but this is actually a disease process happening with the sensory system. So maybe it's a lesion or a disease to point on a peripheral nerve or spinal cord nerve that's sending those signals of pain right and that is one type. So this neuropathic pain which would be something is actually there's a lesion going on there's something physiologically wrong with the somatosensory system itself.

Nociplastic Pain

 And then you've got nociplastic pain which is also kind of referred to as like nociceptive pain, but it's the type of chronic pain and it's, this is again defined by the nIternational Association of for the Study of Pain as it's pain, that arises from the altered perception of the signals that we're getting basically. So in order for this to class or for someone to classify qualifies like having quote unquote, nociplastic pain. It would have to be pain that's been going on for around three months into duration. It's regional rather than discrete. So instead of it being like my index finger has pain, it would be like, Oh my whole hand or maybe my forearm. Maybe it kind of moves up into my form of my album, back down to my hand and then the the report of pain, the third qualifying factories, the report of pain can't

Rafi Salazar:  The entirely explained by either a no susceptive or neuropathic mechanism so it's regional. It's distributed, it's been going on for three months and we can't point to a lesion in your wrist, like a carpal tunnel. For example, we can't point to an entrapment of that nerve as being the reason for this pain.

Rafi Salazar:  And then the final kind of qualifying characteristic is that this person experiences hypersensitivity, which is really just really hypersensitive or light touches can cause pain that are at least present in the region of the pain. So maybe just going with the hand. Again since we're here, it's been going on for three months. It's kind of regional, it's not just the specific area, it's not a lesion in the nerve, maybe we did a study and there's nothing going on. It doesn't look like carpal tunnel, but if you touch or rub your hand, very lightly, you're getting a lot of sharp shooting pains. It's really sending the signals off. That would really qualify. As what we call nociplastic pain, that's really just altered perception of the input that we're getting, right?

Central Sensitization

Rafi Salazar:  And then the final type of chronic pain, if you would or classification of chronic pain is called central sensitization and that's really just what we call an amplification of the neural signaling of the nervous system. So again this is like if you think about the threshold for most people or for the typical developing person might be right here before they get pain so you can step on the floor for example and maybe that the nerve signals are right here and they don't get high enough just to send the alert signals to the brain to trigger a pain response. It's with central sensitization. What we see is that that threshold gets lower and lower and lower so that even you know, normal or typical input that we would get from walking around, for example, or from putting your hands in your pockets is eliciting that response. It's sending those dangerous signals so there are the three different types and then the types of treatment you know, varies depending on the type.


Rafi Salazar:  Right? If it's a neuropathic pain I mean there's a disease process there which probably requires that. You go see a physician and speak with some specialists about. Okay, where is this? You know, this lesion occurring in the nerves and then What are the treatment options? You know, Maybe it's something like steroid injections, maybe it's sometimes surgery for things like neuroplastic pain or that perception type pain. Then you're talking about, okay? The types of the types of things we need to do to address that type of pain, really involve.

Rafi Salazar:  Re-altering our perception of the inputs that we're getting, right? So maybe this involves something like mindfulness, deep breathing, bodywork, yoga stuff like that. There's a lot of research and there's a great book called The Way Out and I can't remember who wrote it, but he talks about Neuroplastic pain. The word he uses is neuropathic pain which is the same type of thing and he the the author of the book describes something called somatic tracking which is basically it's mindfulness pointed to the parts of your body that are in pain.

Rafi Salazar:  And what you're trying to do is, you're acknowledging the pain, you're seeing the pain, you're observing the pain, and then you're reassuring yourself and your nervous system that these are normal sensations. And they shouldn't cause pain and there's actually pretty good research. Using somatic tracking to decrease that altered perception of pain. And then with things like central sensitization, where you have that threshold, that's gotten lower and lower. Well, the goal obviously, then it's to increase that threshold. And how do we do that? Usually, with some sort of sensory, retraining, and things like that. So it's pretty complicated. I mean, when you're talking about things like central sensitization and nociplastic pain and neuropathic pain, they’re  big words, a lot of things you've thrown around and it is fairly complicated. It's hard to tease out on a podcast but those are some general guidelines that can kind of help you figure out. Okay, if this is the type of pain that I'm experiencing, you know what, what kind of treatment should I be considering?

Dave Candy: Yeah, it is a lot to jam in a podcast…

Rafi Salazar:  Yeah, books have been written about this subject.

Dave Candy: Absolutely. And for people listening in the audio only version and Rafi was using an example that I use about a threshold and it made some hand gestures. But you can check out the video version of this podcast on YouTube and, or just picture a cup filled up with water, almost to the brim, and you just put that little last bit in to top off the cup and spill it over. But those were great examples. So you've got basically on one hand, your acute tissue-based nociceptive pain. And then on the other hand, chronic pain and those sort of subcategories underneath of those.

Rafi Salazar: Yeah.

Psychosocial Factors In Chronic Pain

Dave Candy: So how do the psychosocial factors work into this? You mentioned at the beginning that you dealt with a lot of psychosocial factors at the VA and how does that affect chronic pain?

Rafi Salazar: Yeah, I think for a long time, you know, if you think about our understanding in general, in healthcare, about mental health or cognition and its role in Our perception and experience of the physical world around us. I mean, PTSD is a diagnosis. Really only came about in the late 60s. I think it was finally codified in 1968. So if you think about the long history of medicine that we have going back, literally to,…

Rafi Salazar: You know, thousands of years to just from 1968 or 1970 to. Now, you're talking just 50 years, that's such a small time frame that there's, there was a lot that was going on and it's still going on that we really just don't understand. Because we didn't know where to look, right? One thing that became very apparent though.

Rafi Salazar:  In stunning primarily veterans with PTSD, coming back from wartime and having experienced some sort of battlefield trauma or service-related trauma was that. One of two things can happen and they both generally happen simultaneously. Like, If you are involved in some sort of traumatic event, right? And that leaves an impression on you, what we know from the literature now, after having studied it, for the last couple decades, is that


Rafi Salazar: Traumatic events in particular alter the chemical makeup and even sometimes the structure of the brain making a person at risk for higher or what they call negative affective states. Maybe maybe it's depression, maybe it's something like a mood type disorder. However, also when it relates and when it comes to the pain piece of it, this is the part of the brain. So your limbic system, which involves your amygdala, which is responsible for fight or flight. For example, the same is involved in both the pain response and these emotional responses, right? So, if you think back again about pain, the definition is that it's both a physical and an emotional experience. If you experience something that's emotionally traumatic, it would stand to reason that it is being processed through the same part of that brain. That amygdala is setting that fight or flight response that there's going to be some kind of bleed over a carry over into the other. 

Rafi Salazar: Part right. That other experience whether it be the physical or the or the emotional side and what we know from the literature that there are people and I've experienced this myself, Treating people in the Department of Veterans Affairs, they have chronic pain, maybe they have shoulder pain, they're at a, maybe they're rating, their pain at a scale of one or…

Rafi Salazar: out of 10 when they leave the clinic. And this was not uncommon and they would go over the weekend. It was like the Fourth of July or something like that. And maybe fireworks are going off in this bedroom, would have a flashback or what we know from the literature is a flashback is like really living of that traumatic experience. Your brain doesn't recognize it as a flashback or not. It's all real to the brain and they would come back and they would rate their pain at a scale of nine or ten out of 10. Well, look at this veteran, like they didn't fall, they didn't reinjure themselves, they didn't pull a muscle, they experienced a psychosocial stressor, that resulted in a real and experienced change in a level of pain.

Rafi Salazar:  Well, that happens that way, right? Like something in the psychosocial effects, the physical when and it also works the other way. So let's say you're in chronic pain or you're experiencing pain, a lot. Again those pathways are very similar neurons that fire together wire together and it's not uncommon for people to experience that. Chronic pain or experiencing a crane of pain over a long period of time to begin developing some emotional problems, right? Maybe it is depression. Maybe it is anxiety. We talked a little bit about the clinic that I work at. Like, kinesiophobia people being scared of movement because they're afraid that they're gonna experience pain. Maybe they're backing away from social activities, they're not going out because they know they're gonna experience pain and it's very much a two-way street. So it is weird, incredibly complex. As people we're not just joints and tissues and muscles, we have a brain, we have emotions and in order to really address chronic pain, effectively, we need to look at those. Not just what is going on with the joints and not just what's going on with the brain. And with the emotional side of things, we need  to look at a treatment path, that kind of blends, all of them together and addresses each component for each person.

Dave Candy: Absolutely. An example we gave like the fireworks or the car backfiring is sort of the traditional example of PTSD, but that can happen from other things too, like adverse childhood experiences. You know, a peace during, you know, teenage years or in adulthood other traumas like deaths of the family, all kinds of things can bring it about.

Rafi Salazar:  Yeah, there's a great book, Bessel Vander Coke wrote it. It's called The Body The Keeps Score. I think it came out like 2014-2015, but he runs the Boston Trauma Center, and it's based on his research with veterans and then he's also done a lot of research with children who grew up with, really severe emotional and physical abuse and the whole book is he outlines in. Painstaking detail. The limbic system and the fight-or-flight response and how that translates to ill, chronic pain development later in life and it's a good read. It's not for the faint of heart because it's pretty intense. I mean, trauma is trauma. So his explanation of, of the, the link between what is going on Psychosocially and the effects that we're seeing in the clinic physically is really, really good.

Is Chronic Pain Real?

Dave Candy: And we'll get the links to both of those books that you mentioned and put them in the show notes as well. For people who may be interested in learning a little bit more. Now, you mentioned the brain, kind of producing this sensation of danger or fear or threat or however, you want to label it, but that doesn't necessarily make the experience any less harmful in the person's memory. It doesn't make their suffering unreal like they're not making it up. Can you explain a little bit more going back into that?


Dave Candy: Stereotype of people saying it's all in your head and how that's not really quite true.

Rafi Salazar:  Yeah, yeah I get this a lot in the clinic and I would get it a lot when I was at the VA. Like someone would come in and they'd say something along lines of Well X-rays were negative MRI, Maybe they went and had an MRI. Maybe they had a CT scan where they did a nerve study. And, you know, they were very distraught because the X-rays were negative, right? No, no, unusual findings. So, one of two things happens, right? That the painting, the, the patient, then, either believes themselves that they're just, maybe I'm just making this up or the worst effect would be like the clinician that they're treated that treated them said. Well, there's no reason for you to be in pain because your X-rays are normal.

Rafi Salazar:  Um, both of those are bad. The reality is because of pain again, going back to this definition, we're gonna, we're gonna go back to it a lot because it's so fundamental. That pain is an emotional and physical experience that is in response to  a tissue threat, whether that threat is real or not. So, regardless of whether there is real tissue damage happening or that threat of tissue damage is real, or not, the pain that you were experiencing is real. And they've done functional MRIs or they can see that the parts of your brain that light up when you hit your finger with a hammer are the same parts of your brain. That light up when you're experiencing nociplastic pain, for example. So 

Rafi Salazar:  It is a real experience and I think people get discouraged when they see a negative X-ray or a negative MRI because then they start to feel themselves. Like, Okay, maybe I'm just making this up. Maybe this is all in my head and the reality is like, well, your head is involved, your brain is involved, but that doesn't mean that what you're experiencing isn't real. What it means is that physically that we can't find anything in your, in your joints, or your tissues to point to, why experiencing that pain. So that just means we need to go level deeper. You know, it's not just something as simple as, okay, you pulled this muscle, this is something that requires a little bit more, specialized skill, a bit, a little bit more specialized treatment and in-depth. Look at what's going on with you. In particular, you're in a different situation. so that we can tailor a treatment plan that's really addressing. The fundamental root of your pain, which is going to be that perception of that pain, or that perception of that threat. And maybe it is something like your threshold is lower or maybe it's something like a real nociceptive or nociplastic pain that we need to address either way. We want to be able to, to get past this idea that just because an x-ray doesn't show a broken bone or just because an MRI doesn't show some kind of tear and a ligament, or a tissue does not mean that you're not experiencing real pain. Because again pain is an alarm signal. It's your It's like your body's check engine light if you would and you need to, you need to explore that. Even if the easy reason that you might be experiencing that check engine light isn't the reason for it being on, right? So it's the same type of thing that just because you can't point to something very not superficial that sounds bad, but something like an X-ray and say, That's why I'm having pain doesn't mean that your pain isn't real. In fact, it is very real.

Dave Candy: Yeah, it's interesting…

Rafi Salazar: We just need to address why it's happening. Why are you experiencing that pain?

Dave Candy: how visually we are to just want to have something to point out and…

Rafi Salazar:  Yeah.

Dave Candy: That's it. That's what’s causing my pain.

Rafi Salazar:  Yeah.

Dave Candy: You know the car analogy is great like your check engine, like goes on and you want it to be a flat tire or a belt or something like that. You can just replace it and move on. But, you know, sometimes it's the problem in the electrical signal where you are in the system, where you look at it and everything is connected, but the electricity isn't moving through.

Rafi Salazar:  Exactly. Well I think there's some aspect too of like the stigma around chronic pain because it kind of blends into if this isn't a real biological issue than is it a mental health issue? And there's a big stigma about mental health and there I think there's a part of patients that I treat for sure. Don't want to be labeled like that, right? They want to be able to go to their family, their friends and say I went and saw somebody and it is a disk in my back that's causing all this problem. Because everybody kind of understands that, right? If you go to your friends and say I've got, you know, nociplastic pain and this is, you know, it's a perception in my brain and we have to try to figure it out like it automatically moves you from this, okay? It's socially acceptable to pull your back, or have a bulging disc for some reason. It's not so acceptable or just kind of out of the norm to have something going on with your somatic sensory system that we need to address. So, there is this idea of like the stigma around pain and mental health, and the psycho social factors, or health it over time.

Rafi Salazar:  Been breaking down but not quickly enough in my opinion.


Dave Candy: Absolutely, you know it's perfectly acceptable to say. Oh man. My back is really hurting today but yeah,…

Rafi Salazar:  Yeah.

Dave Candy: If you say man, I'm feeling really depressed, I'm sad. Everything is going wrong, people look at you like, you're like, I don't want to hear that. 

Rafi Salazar:  Exactly. Yeah.

Dave Candy: But that stigma is certainly still around. 

Relationships And Chronic Pain

Dave Candy:  So, we've talked about the psychological components of pain. What about the social components? What about the relationships that pain causes between people? For example, when you can't participate in activities you like, sports you want to do, you can't go do things with your family with your friends. You can't take care of your kids. Can't go to work. How does that affect people?

Rafi Salazar:  Yeah. Yeah, I think it's one of those things that can kind of lead into a tailspin, right? Like a kind of a self-feeding downward spiral. Particularly with people that are used to being active or out and about doing things, there's an emotional component about missing, you know, maybe missing social events that you wanted to participate in or not being able to do things that you were able to do previously. Perfect example, The day after Christmas, I was trimming my dog. We've got this golden doodle my wife wanted for the kids. So I'm in there trimming it and I stood up and got this like sharp shooting pain in my back. I mean, I almost fell to my knees. I was in so much pain.

Rafi Salazar:  And this pain lasted. All right, four or five weeks. Like last week, I was the first week that I was like, Oh man, I can kind of move and it's not hurting and I'm a pretty active dude, I run, you know, several miles every week. I do push-ups. I exercise and try to stay fit mainly because I've got kids and I want to be able to play with them and just those few few weeks of, like, not being able to get down on the ground and, you know, roll around and play with my children like emotionally myself. I was like, Oh man, I'm a bad dad, look at me. I'm just one of those people that's like sitting on the couch and I'm watching my kids play instead of doing things and I don't even have chronic pain. You know, I'm young and healthy. Yeah, I'm gonna get back to doing things eventually for some people though, just the fact that you're being removed from, maybe it's an activity that you really enjoy doing a hobby or a sport or maybe it's your social connection, maybe you play. Pick up a ball with your college friends, and you've done it every, you know, every week.

Rafi Salazar:  Months and now you're not doing that that has a real emotional toll so that's one aspect of it. Like there is an emotional, an emotional threat if you would when you are removed from doing things that are meaningful to you and that can open you up to what the research calls negative effective negative affect. So mood, disorders, depression, anxiety, all of that.

Rafi Salazar:  The other thing that it can do and the other aspect of this interpersonal relationship and how it can affect pain, is, we mentioned the stigma thing. So again, what if you're used to being physical? Maybe you work a manual job like roofing or construction or something. And now you're limited because of that, and you're the, maybe you're the breadwinner and now you have to face your spouse who's expecting you, you know, there's these expectations that you're gonna go out and work and be hard and generate the income. And now you can't, or you're limited in doing that, that also has an emotional toll and all of those emotional stressors as we've outlined earlier, have a real impact on the experience of pain right there. That limbic system is working both ways and it can definitely affect the level of pain that you're experiencing today. And then there's the whole piece of how interpersonal relationships can actually help improve your pain right? If you feel emotionally connected supported by

Rafi Salazar:  Those around you, those important relationships, whether it be a spouse to significant other family, or a group of friends or even the clinician. There's good research showing that they are called therapeutic alliances, but the relationship that forms between a treating clinician and a patient that's experiencing. Chronic pain can actually improve clinical outcomes in the long run so the same way that being pulled away from relationships and pool being pulled away from social interactions can damage us, emotionally being pulled in or welcomed into strong. Supportive relationships can help increase our ability to cope with the pain that we're experiencing now but then having hope for the future of recovering and becoming again a fully a full participant in the life that we want to live.


How Does Pain Become Chronic?

Dave Candy: Yeah, that's a great example. And the example, you mentioned about the golden Doodle that you had or injuring yourself, playing basketball. Yeah, that's a great transition really into the connection between chronic pain because we sort of talked about it at the beginning,…

Rafi Salazar: Yeah.

Dave Candy: Well there's acute pain that's tissue based and then there's this really kind of strange complex thing known as chronic pain over here but in most cases a chronic pain, it doesn't start out. It's just being created in your brain or psychosomatic. It's usually the case of acute pain…

Rafi Salazar:  Yeah.

Dave Candy: where there was a tissue based injury and it just never went away. Even though the tissues may have long since healed up. So how does that work?

Rafi Salazar: Exactly. Yeah, usually it can be again. So you injure yourself. There's a real, it's specific. You know what it is? I pull my back, you know, trimming my dog or whatever, sometimes and it's the research because everybody's very different in our, our somatosensory systems processing things differently. It's very hard to get standardized. We can't be like, well, if you do xyz, you're gonna end up with chronic pain. But we do know, for example, that movement immediately after in the time frame after an acute injury is very very beneficial in preventing the development of chronic pain later. So for example, they did a study and I don't know, I can't remember what journal it was in but it was a study about people that experience an acute low back injury and this is a they kind of look looked at

Rafi Salazar: Looked at medical charts to kind of gather their data. So this wasn't like they injured people and then had them lay down in bed. But what they did was they looked at the people that the medical records that they studied and they divided them into two groups.

Rafi Salazar: And the first group of charts that they said, were people that experienced an acute low back injury, for example, and then tried their best to return to normal activities as soon as possible. And then the other group of people were a group of people that experienced some kind of acute low back injury.

Rafi Salazar: Some kind of strain pool or whatever and then they had bed rest for two to five days and what just looking through their, their clinical charts and their outcomes, What the researchers found was that people that laid in bed for two days or more after a back injury, where something like 75%, more likely to end up with a chronic pain or still be experiencing low back pain, six to eight months after the initial injury. So you know what that tells us as clinicians is that people in general that might be experiencing some kind of pain is the worst thing we can do. 

Rafi Salazar:  If we have some kind of acute pain, just totally not move that area. Again, you want to do this under the guidance of a clinician that can make sure that okay, it's safe to move this because there are some instances like, if you fracture your back, you don't want to be doing things, right? If you fracture your arm, you need to make sure you're splinting it appropriately, but assuming that there's no pathophysiological, real damage going on, that's gonna require some sort of higher, intensity care. It's just a musculoskeletal injury of some kind of strain or sprain. We want to make sure that we're moving.

Rafi Salazar: For two reasons, one movement keeps you active keeps, you limber, keeps you from stiffening up prevents you from losing range of motion but the probably the more important thing is that again…

Rafi Salazar: If you think about this threshold that we have, the worst thing that you can do is not move because that threshold's gonna get lower and lower. And if you're scared of injuring yourself again, scared of injuring that back, again, you're going to become more hypersensitive to the normal kind of stimuli that you get from sitting and moving around and doing normal activities. So again, this is not something like you falling off a ladder. I don't want you to go run five miles. The next day, we do need to be cognizant of this correlation between immobilization and not moving and the development of chronic pain later. And I think that's a, that's a big one is movement to our knowledge right now is the best pain medication that we have both for chronic pain and even for some of you injury, that's that

Rafi Salazar:  Requirements like surgery or splinting or casting, so we need to make sure that we're continuing to be active. Despite some of the pain, we may be feeling because ultimately, it's, it's gonna be good for us to do that and not to sit and develop some kind of nosy plastic pain later in life, right?

Dave Candy: Right. Yeah, to respect pain, but not to fear it.


Chronic Pain And Movement

Rafi Salazar: Yeah. Exactly.

Dave Candy: kinesiophobia like you mentioned earlier.

Rafi Salazar: Yeah, and if you think about that pain, being again, it's an emotional and a sensory response, or physical response in response to that threat, whether that threat is real or perceived, we want to do everything that we can, so that our somatosensory system or nervous system doesn't perceive normal movement as potentially threatening, right?

Dave Candy: Absolutely.

Can Chronic Pain Be Cured?

Dave Candy: So what are the expectations with chronic pain? Say someone suffered with pain for three or six months or longer and yeah they've gone through kind of the traditional route of getting tests and X-rays. And you know, is there an expectation that they can improve from that or sometimes people get frustrated? And they just think, Man. Am I gonna have to deal with this forever?  Is this just the way it's going to be?

Rafi Salazar: I think that's totally. It's a valid concern and because I don't know about you, but I felt this way when I had this back pain going back. This example from a month ago, you almost when you're in it and you're feeling pain, you can almost not perceive or not visualize what not feeling in pain will look like right or somebody. That's like a cold, for example, like I can't ever, like, I'll always feel this post nasal drip, or this sore throat, or this headache or whatever. It is like we as humans just kind of freak out about, maybe this is my personality

Rafi Salazar:  But it's very hard for us to kind of visualize. It'll look like we're experiencing the here and now pain, right? So while I can't tell everybody that you're gonna get healed and you're gonna not experience pain, few in the future. I think we can provide hope and obviously it depends on the type of pain that you're experiencing. Whether it's that like if it's a neuropathic pain, maybe that's gonna require some type of real intervention for you to kind of overcome

Rafi Salazar: Whatever the issue is and experience, some pain relief. If there's nociplastic or central sensitization, there's some things we can do to kind of self manage to kind of increase our threshold for for activity, but there is a chance that there. There's gonna be some ongoing self management. If you would in perpetuity that doesn't necessarily go away. So I'm thinking primarily, if somebody who's got neuroplastic pain or something like that and maybe they do some somatic tracking, maybe they do some mindfulness and that gets them, you know, they're able to do some things. Again, if you live an active life, you're probably gonna bend that wrong way. Again, you're probably gonna do something else that kind of triggers a pain response. And what we can do is build resiliency so that even if you experience pain and I tell this to patients all the time in the clinic, listen just because you're not feeling pain. Now at the time of discharge, or after this point, like doesn't mean you're not going to experience pain.

Rafi Salazar:  In this same spot ever again but hopefully what we've done is we've given you the tools and the ability to kind of manage it on your own to give you the resiliency to be able to overcome that. When you have a relapse in the future, right? One of the things that gives me a lot of hope from just reading the literature and the research is that, you know, our brains because of neuroplasticity which is just the ability of the brain to, to change or rewire.

Rafi Salazar:  Like our brains are constantly changing from the moment we're born until the moment we die. So to me, that gives me a lot of hope that just because we're I'm experiencing, or you might be experiencing this, chronic pain. That's from a somatosensory issue. Now does not mean that you're going to be experiencing it forever. Your brain is constantly changing. It's constantly adapting. It's constantly wiring and rewiring new neural pathways. So that means there's always hope that we can kind of retrain that nervous system. So with the chronic pain, maybe we feel a little bit of stiffness, maybe a little bit of pain, maybe we relapse again, but it's going to go on balance because I'm better over time, right? And it's going to look different for every person. But there those are what some of the things that give me hope about working with and really talking to people who are experiencing chronic pain,

Dave Candy: Absolutely. And even if you, the pain doesn't completely go away. If you can bring it down from Aurora to a whisper, and not being able to do the things that bring you happiness,…

Rafi Salazar: Yeah.

Dave Candy: and joy to be able to do those then for most people, that's enough.

Rafi Salazar: Exactly. Yeah I had so I host a podcast called The Better Outcomes Show and I had Bronnie Thompson on. She runs the The Interdisciplinary Pain Management Program and Otago University in New Zealand. She's like a big big name in the pain science realm and…

Dave Candy: Yeah, Bronnie was actually on this podcast about a year so ago…


Treating Chronic Pain

Rafi Salazar: She and I were talking about treating chronic pain and she talked about in the people that she saw on her clinic were all bikers and they would run out and they would you know ride their bike on the weekend and being a lot of pain or whatever afterwards and she'd say You know like was it worth it and they would these these patients would light up absolutely is worth it. She's like okay well then that's what we're trying to do. We're trying to not try to totally take away your pain so that you never feel it again. We're trying to let you do the things that that light you up to get you excited and then if you have pain, we're gonna give you the tools to manage that after the

Rafi Salazar:  Act. But we should never think about it as because I have pain, I can't do these things that I love to do. I think that's the biggest takeaway. We, we want to in as much as possible engage in what what gives us purpose and meaning and what's meaningful to us and then obviously work on strategies and techniques to to kind of manage the pain that we we know might come from doing those activities, but we don't we, we don't allow ourselves to be crippled by the the fact that we're that we have pain, right?

Dave Candy: Absolutely. Yeah, it's all just about bringing value to your life and being able to do the things you want. And yeah again pains just a warning signal and…

Rafi Salazar: Exactly.

Dave Candy: Sometimes it's worth it to go through that. Brief period of discomfort or suffering to allow you to do something that you really really enjoy and would regret not doing. So, kind of wrapping up…

Rafi Salazar:  Yeah.

Dave Candy: If people want to find you or get more information from you, how can they access some of your information or if they happen to be in your area of the country? How can they get treatment from you?

Rafi Salazar:  Sure, yeah, so the best way is probably the clinic website, which is the clinic I run called proactive, rehabilitation and Wellness. And the website is and we have a lot of videos and articles specifically about pain and chronic pain and treating that type of pain. So you can go there, follow us on, you know, Facebook, Instagram, YouTube. All those places? And we are in Augusta Georgia. So, if you are experiencing pain and you're within the region of us, you can call the office or just go to the website and reach out to us there.

Dave Candy: And not for people who may want to access your podcast as well. How would they access that?

Rafi Salazar: Okay, that's the better outcome show and you can find that at

Dave Candy:  Wonderful. Any closing thoughts that you'd want to leave people with today Rafi?

Rafi Salazar: I think the biggest thing that I would want somebody to know and walk away from this episode is that if you are in chronic pain or you're experiencing pain, persistent pain, I don't let discouragement get you down. I like to say that we're all one or two decisions away from a radically different life and that's true. Both of our health and of the pain we experience as well. Like it doesn't need to be life-shattering decisions either like small baby steps. You know, like choosing to move would be a big one but two one or…

Dave Candy: If that's a wonderful message to close on and…

Rafi Salazar: two small decisions every day can help put you on a path towards long-term healing and recovery. And it's just a matter of not becoming discouraged in that pain that you're feeling now.

Dave Candy: thank you so much for your time and your knowledge and your information and thanks to everyone at home. Who's listening, if you found this episode helpful, subscribe to the podcast so you can get notified of our future episodes.

Want To Learn More?

Check out Rafi's Book Better Outcomes: A Guide to Humanizing Healthcare

And Dr. Candy's Book Chronic Pain: You're Not Just Getting Older, You're Not Crazy, And It's Not All In Your Head

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