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Podcast, Provider Interviews

“Climbing the Mountain of Chronic Pain” with Physiatrist Dr. Andrea Furlan

August 25, 2023
52 min read
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Summary:

On Episode 101 of the Arthritis Life Podcast, host Cheryl Crow, OT and Dr. Andrea Furlan, MD discuss the latest in pain  science and help you understand how lifestyle factors like sleep and exercise can reduce chronic pain. They reflect on how the words we use about pain can make a difference, and Dr Furlan explains what “conquering” means in the context of her new book: “8 Steps to Conquer Chronic Pain a Doctor’s Guide to Lifelong Relief.” 

Dr. Furlan reminds listeners that while some people might question the severity of your pain, what you say is pain IS pain. She also shares her best advice for newly diagnosed patients: as you navigate the winding road of autoimmune arthritis, find support from those who’ve traveled it before – they can be your guide. 

Video

Episode at a glance:

  • Relation to autoimmune arthritis: Dr. Furlan is a physician at a pain clinic, a scientist at the rehab institute, and assistant faculty at the University of Toronto. She is a physiatrist who specializes in pain. 
  • Understanding Pain: Dr. Furlan explains how pain science is continually advancing and more information about how the brain processes pain is being discovered. There are different types of pain, and multiple systems in the body involved with the sensation/perception of pain.
  • Your pain is valid: Some people might not see your pain, and you may be stigmatized, but what you say is pain, IS pain. If other people say you’re not in pain, it’s because they don’t understand the pain system. 
  • Language around pain: The words we use about pain can make a difference too. Cheryl and Dr. Furlan discusses different ways of approaching words like “conquer” or “defeat” in the context of living with a painful autoimmune condition.  
  • 8 steps for living better with pain: Dr Furlan explains strategies for exercise, sleep and more. For example, she recommends breaking up exercise into smaller “snacks” or movement breaks. She also shares the importance of quality sleep is important too, since it gives you energy for other lifestyle factors. Investigate if you have a treatable sleep condition (like sleep apnea), and then address your sleep hygiene/routines – including making sure you’re not sleeping too little or too much. Lifestyle factors are often interconnected, and taking care of your mental health and nutrition can also support sleep and exercise. 
  • Dr. Furlan’s best advice for newly diagnosed: Doing it alone is HARD. Find support, someone knowledgeable who’s climbed their mountain or helped others do it, who’ve traveled this road before – they can be your guide.

Medical disclaimer: 

All content found on Arthritis Life public channels was created for generalized informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Episode Sponsors

Rheum to THRIVE, an online course and support program Cheryl created to help people with rheumatic disease go from overwhelmed, confused and alone to confident, supported and connected. See all the details and join the program or waitlist now! 

Speaker Bios:

Dr. Andrea Furlan 

Dr. Furlan is a physician specialized in Physical medicine and rehabilitation. She works as a physician at the pain clinic in Toronto, she is a professor of medicine at the University of Toronto and a Senior Scientist at the Toronto Rehabilitation Institute. 

Cheryl Crow

Cheryl is an occupational therapist who has lived with rheumatoid arthritis for nineteen years. Her life passion is helping others with rheumatoid arthritis figure out how to live a full life despite arthritis, by developing tools to navigate physical, emotional and social challenges. She formed the educational company Arthritis Life in 2019 after seeing a huge need for more engaging, accessible, and (dare I say) FUN patient education and self-management resources.

Episode links:

Cheryl’s Arthritis Life Pages:

Full Episode Transcript:

Cheryl:  00:00

I’m so excited today to have Dr. Furlan, who I consider, like, a YouTube pain science star. And she’s going to help us understand pain and what people with inflammatory arthritis maybe need to know about pain science. So, welcome. Thank you so much.

Dr. Andrea Furlan:  00:15

Thanks, Cheryl, for inviting me to be here today. 

Cheryl:  00:18

Yeah, and we’re also gonna talk about your new book, of course. But can you just give a quick introduction, like where do you live, and what is your relationship to arthritis?

Dr. Andrea Furlan:  00:29

Yeah. So, I live in Toronto, Canada. I am originally from Brazil. That’s where I did my medical school and medical residency in physiatry. And I emigrated to Canada 25 years ago. And here, I did my PhD. I built my family here, had my kids in Canada. And then, I am a physician here in Toronto in the pain clinic at the Toronto Academic Pain Medicine Institute. And I am a scientist at the Toronto Rehabilitation Institute and the Institute for Work and Health. And I’m also professor, associate professor of medicine, in the Department of Medicine at the University of Toronto. And on my spare time, I have a channel for people on YouTube, people with chronic pain, where I talk about causes of chronic pain, including arthritis, and many types of arthritis may cause chronic pain. And I talk about fibromyalgia and other things related to chronic pain.

Cheryl:  01:32

Yeah, it’s really, you’ve done a wonderful job of being able to distil the complexity of pain science into, like, understandable nuggets of wisdom. But you did, you mention, before we go further, I do want to take a minute to define, like, what is a physiatrist? She didn’t say ‘psychiatrist’, she said ‘physiatrist’. What kind of doctor is that?

Dr. Andrea Furlan:  01:54

Yeah, so that’s a specialty of medicine. It’s one of the oldest specialties because it started after the First World War, when people came from war with a lot of disabilities, amputations, and trauma, and nerve injuries. So, physiatry is the specialty of the person with physical disabilities. We work with a team of physiotherapists, occupational therapists, like people like yourself. And we work with a team to rehabilitate the individual. So, this could be people with spinal cord injury, paraplegics, tetraplegics, amputations, stroke, brain injuries. And in my case, I chose to subspecialize in rehabilitation of people with chronic pain because I consider this being an invisible disability. And the person may still have disabilities, but they look normal. And then, they need rehabilitation.

Cheryl:  02:51

Yeah, and it’s really, you know, it’s almost a oxymoron in some ways, because in rehabilitation, it’s usually meant to say, you had a skill, you lost it — like, because of an injury — and then you’re gonna gain back. But with a chronic condition, the idea is this is something you’re going to have the rest of your life, but can you rehabilitate, can you gain some of those skills back, do you know what I mean? Like, to a certain point while knowing that you might not be able to get a hundred percent back to where you were before your —

Dr. Andrea Furlan:  03:24

But no, you know what, I tell my patients, rehabilitation can make you better than you were before.

Cheryl:  03:31

Oh, that’s a great point. I didn’t even think of that. Yeah. I should have thought that, as an OT. 

Dr. Andrea Furlan:  03:36

Yeah, we can make them better because we use neuroplasticity a lot. We use bioplasticity, not just neuroplasticity. So, if you remember those paraathletes that compete in the Paralympics, you know, they can be paraplegic, but they if you interview them, they’re wonderful, because they will tell you their life is much better now after rehabilitation because now they’re travelling the whole world. They’re making a lot of money, they can compete, they have sponsors, things that they would never achieve in their life if it was not for the rehabilitation.

Cheryl:  04:14

You know, yeah, you’re reminding me of another Canadian person or person who lives in Canada, Chronic Eileen, Eileen Davidson, she has spoken on that. She’s had rheumatoid arthritis for, I think, a little less than 10 years now. She’s been on the podcast before, so I feel comfortable sharing her, she talks about her experience all the time. And she said the same thing, that she was, you know, her relationship to her health, prior to her diagnosis, she wasn’t really engaging in a lot of like healthy lifestyle behaviors as opposed to now. So, that’s a really great point. Yeah, and I love, I think, I’m always telling people about the different specialists they might not have heard of, in addition to, you know, their rheumatologist or their primary care. So, there’s, like, podiatrists for your feet. There’s physiatrist for that physical medicine and rehab. And then, there’s also, of course, there’s OT’s and hand specialists, there’s just so many. Social workers, counselors, it’s a shame that most people are just kind of, like, sent to only one or two doc — you know what I mean? A team approach is so much more comprehensive. But anyway, let’s get to pain science. Because, you know, we, the lay person, tends to think of pain as a very straightforward thing, right? Something hurts me, there’s tissue damage, and then I feel pain. But it’s actually much more complicated than that. Can you help us understand some Pain Science 101?

Dr. Andrea Furlan:  05:40

Yeah, let me see if I can summarize this in the little time that we have. 

Cheryl:  05:44

Yeah. 

Dr. Andrea Furlan:  05:45

Yeah, the field of pain science has advanced a lot. A lot. I can’t keep up. Even though I am a specialist, that’s what I do full time, I can’t keep up with all the science. I try. That is because I think in the last 60, 70 years, that’s when people started thinking about pain as a pain system in our body. We are, we knew that for 300 years, 400 years, we know that there is a cardiovascular system, there is a respiratory system, there is an immunological system, there is a reproductive system. Our kids learned this in middle school in biology class. My kids had classes of, you know, they had a project to do in group, choose a system of the body and describe and explain to the class. Now, I asked my kids when they were in this biology classes, where is the pain system in this list? Because the pain system is exactly the same as like any other system of the body. It has a function. It’s a group of organs, different organs, different cells, and they have a function. So, the discovery — outside the discovery, or the interest of the scientific community in the pain system started in the 1960’s when you probably heard about the gate control theory by two Canadians, Melzack and Wall, who published the first paper on the gate control theory that says, well, pain is not just a electrical impulse that goes from your toes to your brain. If you put your toe in the fire, you’re going to feel pain, and pain is felt in the brain. That’s it. Pain is just a, you know, something is wrong. And it’s just an electrical impulse. No. 

Well, the importance of the gate control theory was that they discovered that in the spinal cord, there are cells that modify those impulses. So, by the time that that electrical impulse travels to the brain, a lot of things happen in the spinal cord. We call this modulation. So, that opened up, a lot of scientists started to say, okay, what’s going on in the spinal cord? Can we block pain? Can we increase pain? Can we stop pain at the spinal cord? Guess what, we can. So, they discovered a lot of things that happen there, but not only that. So, then people started going up, because the spinal cord is easy to study, but the brain was difficult. So, they did not have tools to study the brain. Now, we have with a lot of imaging, functional MRI’s, and many other types of imaging of the brain. Now, they’re opening the box. They said, oh, my God, it’s a lot of things happening that at the brain level, you can increase pain, you can decrease pain, you can create pain from nothing; even you don’t need an electrical impulse coming from the periphery, your brain can create pain on itself, without any stimulus. So, it is fascinating, because we need to tap into those resources to make people feel normal, to feel better. So, that’s basically where the science is now, trying to understand the pain system and where we can tap into the pain system to help people who have pain. Not only acute pain, but chronic pain, because those are two different things.

Cheryl:  09:18

Yeah, that was gonna be my next question. So, you perfectly lead into it, you know, can you describe a little bit the difference between acute and chronic pain?

Dr. Andrea Furlan:  09:26

Yeah, they are two different things. And you know what, many doctors, physicians, healthcare professionals, don’t know the difference, and they treat chronic pain as if it was an acute pain. So, the explanation, let me see, let me show the analogy of an alarm system of a house, okay. So, if you install — the pain is our alarm system of our body. It’s installed in our body. The function of this pain system is to alert that something is wrong, damaged, broken, injured, diseased, right. We all know this. So, if you have, if you installed an alarm system of your house, in your house, you installed sensors for smoke detectors, burglar detector, break ins in the windows, et cetera, we have those sensors in our body, too, we have sensors for pain all over. Skin is very innovative, your tongue, your hands are very innovative with tons of sensors for pain. The organs, internal organs, the joints, when we talk about arthritis, the joints, the bones, the tendons, they don’t have that many sensors for pain than the skin has. But that’s acute pain. Acute pain is similar to having a fire in the house. So, this smoke detector is making, detecting the smoke, sending this information to the box on the wall. The box on the wall sends a signal to the office in the central office of the alarm company. And the alarm company will receive that signal and send the fire truck through your house to put up the fire. That’s acute pain. So, if you have any inflammation and joint inflamed, and you can see that joint is red, swollen, painful, cannot move, so you can see there is an inflammation there. You treat that inflammation and the pain gets better. Okay, now, chronic pain, there is no more fire. So, when we talk about chronic pain, primary chronic pain, is because the problem is in the pain system itself. It is the pain system that is malfunctioning. So, if your house alarm is making a lot of noise, is going off all the time constantly, the sound is very loud, you call the ambulance. The fire truck, they come, and they say there’s nothing wrong, there’s no fire here, you call the alarm company. And they come, and they fix the alarm. And that’s what chronic pain is, it’s a lot of noise. It’s a lot of constant, very loud. But the interesting thing is that it’s not the person is imagining this; they are feeling this pain. I’m not saying that this is in your mind, in your psyche, you’re crazy. No, the pain is very real. But now, the pain is originating in the pain system itself because the pain system has been sensitized when the injury that started that pain is already healed.

Cheryl:  12:36

Yeah, and I think something that — that’s a really, that’s a very helpful analogy. And the idea that, I think, it gets confusing when you have an ongoing inflammatory disease like rheumatoid arthritis to understand, if I’m feeling a worsening of my symptoms, is it maybe that I’m experiencing the central sensitization, which is the faulty alarm? Or is it my body’s perceiving an actual flare up? Do you know what I mean? 

Dr. Andrea Furlan:  13:06

I know. I know exactly. And that is the — that’s why they come to me sometimes and they say, “Okay, help me. How do I treat this?” So, the diagnosis — and there are names for this. The three types of pain, they’re nociceptive pain, neuropathic, and nociplastic pain; those are the three names. Nociceptive means the pain is coming. The origin of the pain is the inflammation in the joint. Neuropathic means the wires, the myelin, the axons, the neurons are damaged somewhere, so you have neuropathic pain. So, how do we know if this is an inflammatory pain or neuropathic pain? The characteristics of the pains are different. The — you tap in the nerve and the person feels an electrical shock, that’s neuropathic pain. You do an EMG nerve conduction study and you can detect that the nerve is being compressed, it could be a carpal tunnel. So, a person with rheumatoid arthritis, they do have more carpal tunnel syndrome because of all the swelling that goes in the hands, the bone structure, so they may have both. They may have the inflammation in the joint and the carpal tunnel syndrome that is compressing the median nerve here, so that they have those electrical shocks going to the hand, which is from the neuropathic pain, and then they have the joint pain which is the nociceptive pain. Now, the third type of pain, nociplastic, which comes from neuroplasticity changes in the pain system, can be superimposed to those two, that they may have the three types of pain. So, how do you know if the pain is nociceptive, neuropathic, nociplastic? Nociplastic thing is when the pain starts spreading outside of those boundaries. So, if they, if you can see the joint pains are here in the joints, you see the redness is here, but now the pain is spreading outside. So, if they come to me and they say, “I have pain all over here, and it’s spreading here,” that I cannot explain that by the joint that is inflamed here. So, then, I say, “Oh, I think there is some spreading, there is some central sensitization.” And when we do a physical exam, you can see hypersensitivity to touch. So, touching the skin may hurt, putting a little bit of pressure should not hurt, but in their case it starts hurting. So, that’s when the person starts developing fibromyalgia, because fibromyalgia is central sensitization that has spread all over the body.

Cheryl:  15:33

That was — I was just gonna say is that is really what leads to fibromyalgia. So, that really helps. I know, some of the people listening might have to pause and listen again, because that was a lot of really helpful information at once. And I think the more that you can, as a patient, understand the different kinds of pain, you can be a better, like, reporter to your healthcare teams. I think it can be hard, right? They just, you present as an appointment. And then, they say, just write your pain on a scale of 1 to 10. Now, I know, as a physiatrist, you probably have the more, the more detailed pain scales, where it’s like the different kinds of pain, — burning, tingling, numbness — but sometimes, the other providers don’t offer that. And so, it’s just this one kind of amalgamation of just pain. And I think, yeah, it’s so helpful to have language around the different types. And yeah, and you’ve mentioned in the kind of, the blurb about the book, that part of what you discuss in the book. And I was, by the way, the ‘Eight Steps to Conquer Chronic Pain’, I was able to get an advanced copy, which was really exciting. And I think it’s super helpful. And you mentioned that one of the ideas of the book is to teach people how to rewire their brain to control their emotions and therefore control the pain. How is that possible? That is too good to be true. No. [Laughs]

Dr. Andrea Furlan:  16:58

Yeah, it is possible. I’ve seen this happening. So, I know it is possible. And there are a lot of studies now published, randomized trials, high quality trials, in Australia, United States, Europe, showing that this is possible. It is rewiring. It’s similar to calling the alarm company to come and fix the pain system, the alarm system. So, I call myself the doctor of the alarm system. You know, when the fire truck, the ambulance, they already took care of there. So, if they have a rheumatoid arthritis, or carpal tunnel syndrome, go take care of that. Take your medications. But now, if your alarm system is too, you know, showing and telling you that you have this pain, which is a real pain, it’s coming. It’s just the origin of the pain is different. So, how do we fix this pain system? How do we normalize this pain system? Because these, you know, this pain system has buttons. We can modulate up and down. And it is possible. And one of the things that modulate up, that make the pain of nociplastic pain worse, we know what it is. It’s already well established. There are many things that make it worse, like increasing the volume of pain. Like, this alarm of your house. Imagine, it’s 24 hours making noise. And now, the noise is louder. One of the things — one, there are many — one of the things that turn the volume up is the stress, is when your brain thinks that you are in danger. So, if you are in this house, the alarm is going off all the time, and you are going overstressed, you are, “Where’s the fire? Where’s the fire? I can’t live in this house.” It’s almost like the volume of this noise is going up and up and up and up, to the point that is so intolerable. They will do anything to stop that noise. 


So, just by the fact that you decrease the influence of stress in your life, let’s say, if you just say, “Okay, I know I’m living in this house and I can’t live in another house. This is my body. I can’t move to another house. I can’t do a body transplant. I have to live in this body. I know this pain doesn’t mean that there is a fire in my house. There is no smoke. The doctors guarantee to me that I’m taking the right medication. My rheumatoid arthritis is under control. They guarantee to me that I am okay. I’m not going to break. I can move; I can do anything I want. But I’m afraid of moving because I’m so afraid that I’m going to break myself or make this arthritis worse,” if you keep with that fear, your body will move less and less and less. And the less you move, the more pain you will feel. So, we need to break that cycle. So, that’s basically controlling your emotions. When I use that word ‘controlling your emotions’, ‘controlling your stress’, it’s basically understanding what’s going on in your body and understanding that if you move, if you go to a party, it may hurt. Yes, it may hurt. I’m not saying that it’s not going to hurt. But you’re not broke — you are not breaking your body. You’re just using your body and using your body is healthy. And the more you use, the more you live a normal life, then those dangerous signals will get lower in your mind. And then, you will perceive less pain. So, that is basically what controlling their emotions and the pain system mean.

Cheryl:  20:37

Yeah, yeah. And I think it’s, you know, I mentioned to you before this interview that my own therapists from an anxiety standpoint have taught me how to let go of control at times and how that’s useful. But in this case, it’s kind of empower — I think of it as empowering yourself to understand that you can still make choices, too, that are not determined by your perception of your pain. So, for example, I’m in pain, and I’m going to still try to take a walk, see how I feel after five minutes, maybe I won’t be able to make my goal of walking 20 minutes, maybe my fatigue or my pain will get in the way. But it’s almost unlearning this idea that’s a very primitive idea that I think we all grow up with, which is if you’re in pain, rest. Don’t move something if it’s in pain. And that’s true, like, an acute injury, like a, you know, my brother twisted his ankle last week, I’m thinking what — I’m walking on, or doing a hike on uneven ground. And it’s like, of course, in that case, you need to. So, I think it’s, you need to rest. So, I think it’s hard for — it’s, again, a whole new language, a whole new science people need to learn, how to live with pain, that it’s you can’t just go with your gut instinct. Sometimes your body might be saying — same with, I’ll just say, one of the things, we didn’t really talk about, because this is more about pain and fatigue, but they’re all interrelated. And I thought the research on the effect of exercise, the positive benefits of cardiovascular exercise on fatigue is so fascinating to me. And I’ve felt it in my own body where I’m like, oh, my gosh, I feel like I kind of want to take a nap. But let me see if I can do my exercise bike for 15 minutes, see if I still feel that need. And it’s actually, my fatigue is improved, short-term and long-term with exercise. But isn’t that unintuitive, right? You think, I’m tired, shouldn’t I save my energy, not expend energy? So.

Dr. Andrea Furlan:  22:32

Yeah. That’s why, the person, they need — each person is an individual. They need, you know, a coach. I would say they need a coach that will help them to see these possibilities. Because sometimes the patient is stuck in their mindset, and they only see one thing. And the doctors, you know, the healthcare professionals, unfortunately, they don’t know these concepts, and they are really not helping the patient the way they should. And sometimes, they keep trying to find where is the fire, where’s the fire. They keep ordering more MRI’s, more lab tests, more X-rays, more injections, that lead to more surgeries. Sometimes they have to stop. The problem is not there. The origin of the pain is not coming from there, the origin of the pain is coming from a malfunctioning pain system. And then, the person spends, you know, 5 years 10, 15, 20 years trying to find where is the fire, where actually the problem was it’s just a malfunctioning alarm system.

Cheryl:  23:35

Yeah. And that’s, it’s hard because it’s almost a strange experience to have. I mean, I actually use that exact analogy in the analogy of feeling like you’re your body’s on fire, and the fire department saying there’s no fire, I use that as an example of the experience of being kind of accused as being a hypochondriac. So, on this — obviously, context is everything. This was prior to my diagnosis. And they kept saying, “You’re not sick, you’re just anxious.” And like, in this case, it’s saying you — so, in the case of chronic pain that’s not resulting from tissue damage, you’re saying that your perception of your pain is real, your subjective experience is real. But the problem is not in the building. The problem is in the system. And so, I think it’s hard, it’s a hard pill for some patients to swallow because MRI’s and stuff and the idea of surgery, it culturally, at least in the US, it’s like this idea of you’re going to fix the problem. And it’s hard to get your mind around the problem isn’t in my knee or it’s not in my hand, it’s in my brain. But obviously, as all your experience shows, that once you can understand the root of the problem is in your perception, then you can do all these helpful things to change that. Yeah. 

Dr. Andrea Furlan:  24:58

And one thing that you mentioned, it’s not just in the brain. We know that the pain system can be malfunctioning, but think people think it’s only the brain. We have the pain system constitutes of the brain, the brainstem, the spinal cord, all the nerves, the receptors, and plus the hormones, and the immunological system, and the gut bacteria. So, they’re all connected. So, this dysfunction of the pain system can affect any of those areas. And so, it’s fascinating. You need a, really, a doctor that understands the pain system, and will look at you as a whole because, again, I’m not saying that the pain is only the pain system that is malfunctioning, it might be a joint that needs a joint replacement, okay. So, it might be two types of pain, or three types of pain. But if there is this malfunctioning of the pain system that is making this noise all over, it’s going to confuse the diagnosis of that knee that needs replacement. That’s what I try to explain to my patients. If we can eliminate all of these other sensitization, the sooner we get rid of that, it will be easier for us to help you with that nociceptive pain in your knee that needs a joint replacement. Because right now, we can’t see that. It’s in the middle of all this noise.

Cheryl:  26:27

Mm-hmm. I love that example. I think that’s super poignant. And thank you for that clarification when you say it’s not just — I misspoke when I said it’s in the brain. Yeah, it’s in the whole nervous system and the — I am glad you mentioned hormones, that’s something I’m starting to learn a little bit more about. And certainly, gut bacteria. I’ve experienced that as somebody with chronic gut issues along with rheumatoid arthritis. But I want to, I’m going to go a little bit skip ahead in my notes, if that’s okay, and go on to the, you know, in your book, you really delve into the lifestyle and mindset changes that help people who are living with pain, you know, reduce their pain, live well with it, decrease the negative impact of pain on, you know, on their lives. And you have eight steps, which is so helpful. Because all this is very overwhelming. So, being able to distil it into individual steps is super helpful. And, you know, you mentioned in the book things like retraining your brain, lifestyle factors like sleep, nutrition, social connectedness, which I love, you include that in emotional regulation. That’s so — anyway, very consistent with my experience personally and running my Rheum to THRIVE support groups, that that social connectedness is just crucial, in addition to medications, goal setting. So, we could have like, eight different episodes on each. But I did want to, I wanted to isolate sleep just for a little bit, because it seems like it’s the little, it’s like the ugly stepsister of lifestyle medicine. Almost everyone’s like, diet, nutrition, diet, nutrition, and mindfulness, mindset. It’s like, hello, sleep’s over here! Like, I haven’t even had a full episode on sleep. So, I’m including myself in that. Like, what do you think people — what would you want people who are living with chronic pain to know about sleep, and how it affects pain?

Dr. Andrea Furlan:  28:23

So, first of all, a lot of people with chronic have sleep problems. They tell me they don’t sleep well. They are awake during the night. They can’t go back to sleep because pain wakes them up. And then, during the daytime, they’re tired. That’s very common for us to hear. My approach to sleep in this situation is first of all, let’s investigate to see if you don’t have a disease of the sleep that could be treated. So, sleep apnea, restless leg syndromes, et cetera. Those can be treated and they should be treated and diagnosed early. But if you don’t have any sleep disorder, and you’re just having a bad sleep, I tell them, let’s work on this. Let’s try to fix this. Because you need to have your energy to fight this thing, to do all the other steps that I will ask you to do. That’s why I put the sleep at the bottom of the mountain, conquering the mountain. And the sleep is right at the bottom because if you can help with your sleep quality, then you will have the energy to do everything else that I’ll ask you to do, including exercises, including go grocery shopping, and cooking for yourself, et cetera. So, sleep is important because it is during sleep that your pain system, that the whole pain system is going to take a rest, and will create the neurotransmitters that you need for the day. So, going back to the pain system. In the brain stem. Here’s the brain. I know people who are listening this podcast, I will try not to do a lot of visuals because they will not be able to see this. But the brain is on the top of a brainstem. It’s like a tree and the stem or the trunk of the tree. In this brainstem behind have an inner pharmacy. We produce our own medications. I have a video of this on my YouTube channel. And you produce your own medication. You produce your own opioids. They’re called beta-endorphins. enkephalins, dynorphins. You produce your own cannabinoids, similar to cannabis. 


And they are called endocannabinoids. They go all over your body. So, you don’t need THC. You don’t need to smoke pot; you can produce your own. It’s in their pharmacy. You have also dopamine. You can produce dopamine, which is the motivation neurotransmitter. You have serotonin, which is the antidepressant neurotransmitter. So, how do you open that pharmacy is another story. It’s with meditation, exercises, doing things that are healthy, lifestyle, but you need to have those medications inside of the pharmacy, otherwise, you’re not going to have them. So, when do you produce those neurotransmitters? It’s when you are sleeping. And you also need to eat well, so they’re linked. Like, in order for you to make those neurotransmitters, you need to feed your body with the nutrients to make them. So, if you feed your body with junk food, processed food, you’re not giving the pharmacy the nutrients, the chemicals, for them to produce those neurotransmitters. So, that’s one thing. So, when a person tells me that they are not sleeping well because pain wakes them up, I usually ask them, well, did you think about the opposite? Maybe your sleep is not good quality, because you are taking long naps in the afternoon, you’ve been drinking a lot of coffee, you’re abusing the blue light from computers and electronics, you are putting a lot of stress in your mind before you go to bed, like watching the news before you go to bed. So, now, your sleep is very superficial. And anything will wake you up because your sleep is so poor quality. So, even a little bit of pain will wake you up. And then, you think you are waking up because of the pain. So, did you think the opposite? If you had a deep sleep, high quality sleep, then any pain would not wake you up in the middle of the night and you will be able to sleep the whole night. So, there is a lot of conversations that we have in the — we have sleep classes in our hospital that we send our patients to learn how to do sleep hygiene and change some of their habits. Sometimes it’s just cut the caffeine, you’re drinking too much. How can you expect to have a good night of sleep if you’re drinking too much caffeine during the day?

Cheryl:  33:03

Yeah, there’s so many little things that it’s such a negative — it can be a very vicious cycle, because then you’re feeling sleepy in the day and then you’re drinking more caffeine, but you kind of have to have to be willing to go through a short-term period of like, with, you know, withdrawing from the habits that haven’t been helpful like taking long naps and such in order to reset everything. So, I think that’s really helpful. And I remember there’s a great study, I’ll link to it in the show notes, on rheumatoid arthritis that it was actually a condition where they induced lack of sleep in a randomized control trial. They induced four hours asleep only in half the participants and the other half got to sleep their typical amount. And the people who were in the sleep deprivation condition, not surprisingly, reported much worse pain, worse emotional regulation. And it’s not like — it’s intuitive, but it’s also having those studies helps us, right, be able to give that scientific heft to the recommendation of hey, you know, start to really prioritize your sleep if you can. I don’t know if — I don’t know if this resonates with you, but I’ve literally recommended to people or maybe just encouraged people to be, I call it being a Sleep Diva. Like, and my husband will completely validate that I do this. I’m like, no, I am like, you will not interrupt my sleep. Like, I will sleep in a separate bedroom if I need to, you know. I feel like I’m a diva, right, where I’m I’ll say, like, I need — like a diva, like, you know, in music, musicians where they’re like, “I only want red M&M’s,” or whatever, like you have to advocate because people, if you told people, “Oh, I’ve been starving for five days, but it’s fine. I’ll just push through,” they’d be like, “What? You need food.” Like, and the same, but with sleep, they’re like, “Oh, it’s just sleep. Like, just push through. You’re young,” or, you know, so do you find that in all your clients, like that there’s a social pressure to kind of, like, not prioritize sleep?

Dr. Andrea Furlan:  35:06

Yeah, it is. Humans are the only animals that sleep — they are able to deprive themselves from sleep. All the other animals they sleep whenever they have to, they don’t — the other point of sleep, too, is some people over indulge in sleep. And we know from research that people who sleep more than they actually need they develop symptoms very similar to fibromyalgia. So, you need, yeah, so the ideal, now what we recommend, and that’s what I talk in my book and in my video, find your normal. What do you need? Between seven and nine hours. So, less than seven is too little, more than nine is too much. And so, you do need to also to be vigilant not to spend too much time sleeping because that is not good. It has the studies show they developed symptoms very similar to fibromyalgia, pain all over the body.

Cheryl:  36:07

Yeah, and I think another, you know, and you have a lot of great sleep hygiene tips in the book. And I think one of the things, again, I briefly mentioned this in relation to rheumatoid arthritis earlier, but it really is true that not only does exercise and movement reduce fatigue, but it improves sleep quality, which is so great, right. Because then you’re like, I feel like with rheumatoid arthritis, oftentimes, people are like, you need to exercise to support your joints. Which is true, muscles support your joints. But that’s like the very tip of the iceberg, right? Exercise also positively affects your mood, it positively affects your sleep, it reduces fatigue. So, anyway, just one more, you know, and I know people get annoyed at hearing that you need to exercise, or hearing the exercise is helpful, but it’s not just about muscle.

Dr. Andrea Furlan:  37:00

It’s one, it’s one pill. If I could prescribe one pill that would do all of this, and prevent cancer, and prevent heart attack, and prevent stroke, and prevent so many other problems, Alzheimer’s, that is exercise. So, we were meant to move. That’s basically, humans were meant to move, not to be sedentary. 

Cheryl:  37:25

You know, and it’s funny, I don’t, I hope this is not going to sound, like, not appropriate. But when I got a dog in it, it actually kind of struck me. I’m like, wow, we really recognize how important movement is to dogs, right. You’re like, well, of course I need to walk my dog every day. But why don’t we think about that for ourselves, right? You know your dog becomes restless, agitated, if they don’t get their exercise. Now, I do have a couch potato dog, so that’s not really related to my dog personally, he’s totally happy to sleep. He’s a Cavalier King Charles which is genetically the least similar to a wolf of any dog. There just like little floof balls. But most of the time, yeah, dogs, it’s like we recognize that exercise is important. So, yeah, I think that it’s getting started small, you know, just do five steps more than you did yesterday each day, you know, if you can. It doesn’t have to be some gigantic, you know, five hours a day at the gym.

Dr. Andrea Furlan:  38:22

Did you hear about exercise as snacks?

Cheryl:  38:25

I actually heard about it, probably the same conference I met you at. But yeah, tell everyone what exercise snacks are.

Dr. Andrea Furlan:  38:31

Yeah, there are a lot of research now showing that, you know, you don’t need to do, get all your exercise in one big chunk, like one big meal. You can get all your nutrients if you take small snacks, healthy snacks. So, the same thing with exercise, you know, in Canada here they recommend that it’s good that you get 150 minutes a week of moderate intensity exercise every week. But you don’t need to get that in like three sessions of 50 minutes. You know, straight, or 30 minutes. You can break down this into snacks of two minutes, five minutes, but it has to be intense. It has to be not just walking around your house, it has to be, if you have stairs at home, just go up and down stairs for five minutes. You got your five minutes of snack.

Cheryl:  39:24

Yeah, I love it. Actually, stairs are one of my favorite workouts because you get a really good cardio impact, like you get your heart rate up so quickly. And you get your, you know, you can feel your burn in your quads. And I have stairs in my house so you can — also, if you have stairs in your house or apartment, you know, you can do it on on your own time. Also, I live in the Pacific Northwest of the US where there’s a lot of like, a lot of hills, and there’s a lot of like little miniature — they’re not really parks but they’re part of our, I guess, they are public property that have stairs. I don’t know if you’ve seen that. Yeah, they’re a little bit a little bit of a tripping hazard when it’s been raining, because it has lots of moss on them, but it’s good.

Dr. Andrea Furlan:  40:05

Some people who work, if you work in a place that has an office, then instead of taking the elevator, take the stairs. Once a day, a couple of times a day, don’t need to go all the way up, go to the fifth floor. And then, from there, get the elevator. But use the stairs everywhere you can find one because they’re great.

Cheryl:  40:24

Yeah. And we mentioned, so so far, we’ve covered — I knew we wouldn’t have time in 60 minutes to cover everything. But we’ve covered a little bit of the rewiring the brain, the sleep, and exercise. Is there anything else you wanted to highlight from the ‘Eight Steps to Conquering Pain’ from your book?

Dr. Andrea Furlan:  40:44

Well, I think that there are a lot of important steps there. And but yeah, I talk about exercises — [coughs] excuse me — I talk about exercise, of course, because exercise is a whole, you know, modality in itself. One of the steps is learning to use medication. So, of course medication is part of the steps to conquer chronic pain. So, I do teach people when and how you can use medications, what do they do for you, why some people use antidepressants, anticonvulsants, why people need opioids, why they don’t need opioids. And I also teach in the book and in my videos about how you communicate with your healthcare professionals about medications, specific about opioids. Use the pharmacists. Pharmacists are great team members of a pain team. So, you know, learn a lot from your pharmacist, talk to your pharmacist about your medications, ask questions. Why am I taking this medication? Why do I need this medication for pain? For how long do I need this medication? Because sometimes, they are put on medications for pain by one doctor, but then nobody questions them if they still need it, right. So, medication is a big important, it’s a very important step. And the socialization is extremely important, because now, with a lot of science, there are a lot of studies showing that the context where pain happens, who is around you, what are the kinds of support you have, if you feel lonely, you feel more pain. If you don’t have emotional support from people around you, you suffer more from pain. So, actually, when people give that number 8, 9, 10 in a pain scale, actually that number, what it really means is how much they’re suffering from pain. It’s not just how much is the pain sensation. Because you probably know, people may have been even in the absence of an organ, like amputation. Post-amputation pain, a person may have an amputated foot, an amputated breast, an amputated tooth, and then they now have been in that foot, breast, or tooth. It’s a phantom pain. So, even in the absence of an organ, your brain can create pain.

Cheryl:  43:10

Yeah. No, I love that you mentioned context, too. And I think one thing that I’ve noticed in my support groups is that a lot of people feel like they’re doing it wrong, like they’re missing something. And it’s true that there are things we can learn, right. Sometimes you don’t, you don’t have all the tools in your toolbox and you need to learn more. But other times, it’s a matter of, like, understanding that some things might be out of your control at a certain point and learning how to, you know, move forward along with it, and have self-compassion towards yourself. And, you know, and say that it’s not always my fault. It’s just what I’m dealing with right now. And that can be really unburdening, personally, in my experience,

Dr. Andrea Furlan:  43:55

it’s okay to have good days and bad days. But what I really don’t, what really makes me sad, I don’t want to see, is when a person stops living because of the pain. And you probably have seen that too. They just give up, you know, they don’t want to do anything. They don’t want to meet people. They don’t want to work. They don’t want to study. They don’t want to learn. They just give up anything. And they stop living. That’s so sad, because I know there’s a lot of things they can do for themselves to have a very good quality of life. 

Cheryl:  44:28

Yeah. Well, I mean, and yeah, giving people hope through all of your steps is, I mean, just a beautiful, it’s a beautiful legacy you’re creating, not just on YouTube, but now with the book. And I just, I wanted to, before we get to the rapid-fire questions, I just wanted to briefly talk about language a little bit because I’m very — I think it’s because I took a linguistic anthropology class in undergrad, I went to a very liberal arts college. I find the language we use around chronic illness really interesting. I’ve had conversations with people, and you might have seen this, too, some people, for example, who have rheumatoid arthritis like to think of themselves as like a warrior. Like, I’m fighting this, and I want to conquer this. And other people don’t like that imagery. And so, I know that, like, in the case of, you know, a book, you put a lot of thought into the title, and it’s ‘Eight Steps to Conquer Chronic Pain’. Do you, like — I don’t know, I was just going to ask, like, are there some cases in which, maybe— or what actually, what does ‘conquering’ mean to you? Because you do define it in the very beginning of the book. So, maybe take a second to explain, in your opinion, what does ‘conquering’ mean?

Dr. Andrea Furlan:  45:41

Yeah, when I had to choose the word, I imagine, you know, it could be so many things. And I was talking to people. And for me, the analogy of climbing a mountain came. That’s why the cover of the book are mountains, and I use the eight steps climbing the mountain. Because when a person climbs a mountain, and they conquer the mountain, when they get to the top of the mountain, the mountain is still there. So, that’s what conquering chronic pain may mean for a lot of people. You are climbing this mountain of chronic pain. Maybe the chronic pain will be there for the rest of your life. But you are on the top of the chronic pain now, and I’m teaching you. I’m your guide. And you have — I’m not going with you. So, the other thing is, I will tell you how to get to the top. And you have to go, like the mountaineer. That’s what they do. The coach will tell them, okay, you go. And when they get to the top of the mountain, for each person, it’s a different definition. But then, they can look at the next mountain. And they say, okay, I conquered this one. And I’m going to conquer the next one. So, they build on there. They are increasing their resilience. They are increasing their resources; they’re more resourceful. They know what worked for that flare up, and I’m going to use for this flare up. And I will not, I will not be at the base of the mountain looking at this mountain and cry, “Oh, I have chronic pain.” No, I’m going to start climbing this and I’m going to conquer it. That’s what it means.

Cheryl:  47:12

I love that. So, I love that idea that the mountain is still there. And it’s not like you then hop off the mountain and there’s no mountains ever again. And I think, yeah, I know that, you know, it’s interesting. I feel like sometimes my therapist who uses Acceptance and Commitment Therapy, I joke, I’m like, you’ve created a monster because so, you know, he kind of encouraged me to not — I think from the anxiety standpoint, too — to not make my goal to conquer my pain or conquer my condition in the sense of if that means to me that I will reach some endpoint where it’s no longer in my life. That’s not a realistic goal, right. But to say, okay, I’m going to be able to feel the sense of resilience and empowerment and understand that if I look at the next flare up, like you mentioned, I have the tools to get up this mountain again, and accept that this disease is not one mountain that I just conquer and then succeed, you know, check off my box, never have to worry about it again. But it’s a series. It’s a much more, for me, mentally healthy standpoint. 

Dr. Andrea Furlan:  48:22

I want them to feel empowered, that they know they know their diagnosis. Their emotions are not interfering with it making this pain worse. They took care of that. They took care of their sleep, their nutrition, their medication. So, they’re doing everything right. If they still have pain, they know that they are doing everything they can do for themselves. But the horrible thing is you look at this mountain, and they’re not sure, am I doing everything? Am I getting the right treatment? I don’t even know where to start. That’s where they’re, I think, they stop living and they feel so frightened. When they look at this mountain and they feel overwhelmed. I want them to take one step at a time and let’s, you can climb it. You can get to the top.

Cheryl:  49:07

I love that. Yeah, it is, I’m thinking for some reason I was thinking about Cheryl Strayed, her book ‘Wild’. Did you ever read that one? 

Dr. Andrea Furlan:  49:16

No, I did not. 


Cheryl:  49:17

She went from never having hiked before to hiking the entire Pacific Crest Trail, so like Mexico to Canada. And I was just thinking, anyway, she has a great — and this is being too literal — she has a great description of her putting everything in her backpack for the first time and putting her backpack on, and then just immediately following that, being like, “Oh, no, I can’t even take one step in this, with this backpack.” But then, you know, you take one step, and then another, and then, yeah, it’s a great book. They turned it into a movie too. But yeah, so we are now in just the wrapping up, a couple of rapid-fire questions there. They can be long or short, but let’s make — we can make them short. Do you have any words of wisdom for somebody who might be newly diagnosed, specifically, let’s say with an inflammatory arthritis condition? What would you say to them?

Dr. Andrea Furlan:  50:10

Oh, yes. So, I would say find a support. Someone who is knowledgeable, who had conquer, you know their mountain. And this could be your healthcare professional who has helped other people. But sometimes, if they’re busy, they don’t have a lot of time for you, find other people who had travelled this road before. They can be your guide. Because being alone and trying to navigate the system, find the resources, is hard. And getting a new diagnosis, sometimes it’s frightening. You don’t know what it is, and it will paralyze you. So, don’t let this happen. Get help. You don’t need to do this alone.

Cheryl:  50:52

Oh man. I so resonate with that. I was so stubborn initially. Like, I want to figure this out on my own. Not the easy road to take. Not the more fun road to take. And then, do you have a favorite mantra or inspirational saying that either helps you in tough times or your clients?

Dr. Andrea Furlan:  51:12

Yeah. So, what helps me because I also have pain. And I don’t have chronic pain, but I do have — I just came from a surgery on my foot. 


Cheryl:  51:20

Oh, my gosh.

Dr. Andrea Furlan:  51:21

I’m just recovering from surgery. And yeah, so the mantra, what I like to say is, especially related to pain, pain is very subjective. So, your experience is your experience. And even though some people may not see your pain, and you may be, you know, stigmatized, like a drug seeker, you just want your opioids, you just want drugs, or being gaslighted that people really ignore what you’re saying, and they don’t want to give you credit. I’d say, you are — what you say is pain, is pain. And the number that you give is the number that you give. Don’t be judged by other people that cannot see your pain. They’re not, you know, if other physicians, other people say, “Oh, but you’re not in pain, you’re normal,” it’s because they don’t know much about this pain system. Give them, you know, some space and but try to find someone who understand what you’re going through and that you can communicate. And don’t do this alone, because doing this alone is very sad and will make your pain worse. So, basically, trust your instincts and what you’re having is what you’re having. Your number is your pain.

Cheryl:  52:49

I love that. That’s so — I’m sure people listening right now are feeling so validated. And just one last one, what is something that’s bringing you joy right now?

Dr. Andrea Furlan:  53:00

Well, I’d say my life. Teaching other people, helping other people is what brings me joy. And the reason that I decided to open the channel was because I wanted to help more people with this knowledge. And in my clinic, I can only see one person. I spend an hour and a half with each patient. And during that one hour and a half is what I could be doing — I could be spreading this knowledge a lot. So, right now, my channel is like, this hour that we spent talking here, there are between 1000 and 2000 people watching me on YouTube. So, it is amplifying a lot of the message that I want people to hear and to be helped. So, I really, my intention, my goal in life, my mission is to help as many people that I can with chronic pain because this message needs to go out. We have a pain system. You can regulate this pain system. You can, you know, do things that will bring your pain system, calming down. There are a lot of treatments for chronic pain. Controlling your, you know, emotions, even though you don’t like that word, but I still use that word. But managing your emotions, knowing your emotions, and journaling. A lot of things are very helpful. So, the more people that hear this, the best.

Cheryl:  54:22

Well, I think with control, I might have overcorrected what my therapist, you know, meant. Probably it’s more just that not everything, it’s not a tool that — it’s not something that you should approach every problem with a control mindset, more that understand that control what you can, you know, and learn to let go of what you can’t, I think, that’s been a lesson for me. But yeah, it doesn’t mean that all control is bad. We do have some control. Life is not a hundred percent random. It’s just somewhat random. So, thank you so much. I know people can find you on Dr. Andrea Furlan, that’s F-U-R-L-A-N, on YouTube. I’m gonna have all your — and also your website, Dr. Furlan, drandreafurlan.com. And your Twitter is @ADFurlan. And then, your Instagram is @Dr.Andrea.Furlan. So, those are all on the show notes. I just wanted to say them out loud in case someone’s like, oh, I want to follow her right this second. And your website, or your website and your, you know, all your channels are super, super helpful. So, I appreciate that you took an hour, especially when you’re doing lots of interviews today, I appreciate you taking the time. And I hope everyone checks out your book, ‘Eight Steps to Conquer Chronic Pain: A Doctor’s Guide to Lifelong Relief’. If you see my eyes going like left and right if you’re watching the video, it’s just because I’ve been looking at my notes and my copy of the book to make sure I didn’t misspeak. But yeah, thank you so much, and I’ll look forward to seeing you virtually online.

Dr. Andrea Furlan:  55:51

Yeah, thank you. Thank you for inviting me and your show is great. I love it and I recommend to a lot of people who have rheumatoid arthritis.

Cheryl:  55:58

Oh, thank you so much. All right. Bye-bye for now. 

Dr. Andrea Furlan:  56:01

Thank you, bye.