Podcast Episode #29: Dealing With Burnout


Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston.

Eric Purves 0:17
And I’m Eric Purves. This is a podcast by massage therapists for massage therapists.

Jamie Johnston 0:22
Our objective is to simplify how to be a more evidence informed practitioner. Let’s dig into this episode. Well, it seems as though the pandemic is over, I’m sure there’s still repercussions of going on in different places. But one big repercussion of it in the last year for both of us was how it affected our mental health and some other aspects of life. So we thought what we would do with this podcast is talk about some of those things, because we’re pretty sure we’re not the only ones who went through some major stuff, either pandemic and post pandemic or just post pandemic, but we thought we’d have a conversation around that. So that those of you who are out there that listen to this, for one thing, hopefully you feel like you’re not alone, because we went through it as well.

Eric Purves 1:20
Yeah, it’s encouraging to have these conversations to know that you’re not alone. Because, I mean, I’m sure that I’m sure the I mean, there’s still lots of new cases of COVID. And there’s still, you know, I don’t know, I think the World Health Organization said that the pandemic was the worst. So it was over, they did release something recently about it, but there’s no more lock downs, you know, we’re kind of back, everything’s open. And, you know, everyone’s had COVID a few times, it seems, or at least once and, you know, and we’re having to live with, and we’re still unsure of what the long term consequences what that means. But, yeah, when this, this whole thing happened, you know, you’re, you’re kind of just living in the moment. And then now it’s been we’re into our, I guess, year, three, three years after we’ve in March of 2023. Depending on you’re listening to this, it’ll be three years, and you don’t realize how much the whole chaos of the world impacts us until it’s kind of behind you. And then you realize, oh, shit, like, this was? This was hard. Major. Yeah, there was a lot of things that we at the time we used to put your head down, you’re going through it, you’re just doing the things. And then you realize, yeah, there’s actually consequences too, for a lot of us in the isolation and the change in the world has been significant.

Jamie Johnston 2:35
Yeah. 100%. So we, the brief little chat that we had before we started recording here is the thing that both of us realized we went through, is both of us suffered from a lot of burnout. And the interesting thing to that is that we both dealt with it differently. You know, and, and I think, I think an important thing to mention, and I might get some hate for this is that as as guys, we generally don’t talk about this kind of stuff enough. And I think that’s one of the, towards the end of this episode is one thing that I’ll probably like to bring up a little bit more is that, you know, if you need help, then, you know, talk to somebody. But when we look at the way that we both managed or burnout, you managed to turn it into, like, hyper focus on on business things and online things. Whereas for me, it kind of just shut me down. And I had, I had little to no focus. And we’ll get into some of the reasons for that for me later. But it just really interesting how it sort of affected us differently.

Eric Purves 3:42
Yeah, and we’ve talked about this a lot. It’s, it’s tough, because, you know, you don’t realize, like I said, you don’t realize you’re you’re burnt out until you’re burnt out until you’re out

Jamie Johnston 3:51
of it. And especially if you don’t know what it is or why it’s happening. Yeah. And

Eric Purves 3:55
so I’ve spent a lot of time in the last six months to six to eight months really reflecting on on it. And you know, there I should have, this is very unresearched episode. But I there’s like, there’s like, there’s like 10 or 12, like, steps of like burnout. And I know, from presentations that we’ve seen at St. in San Diego, they’ve talked about this, and I ticked off all of those boxes, right with, you know, the anxiety and the depression and unhelpful coping mechanisms and all these things. You you go through until you just are like, done, I can’t function effectively anymore. And I went through all that. And I think what happened for me was that initially with when, with the shutdown, I felt like this massive sense of loss because we were preparing for 2020 for both individually and collectively to be like, the biggest year we’d had from a business perspective. There was courses scheduled and sold out like all year. Yeah, as of like, as of February and we’re like, this is gonna be great. And then all of a sudden everyone From that, to nothing. Yeah. And then it was a panic of like, oh my god, like, how am I gonna pay the bills? How am I going to feed the family? What am I going to, you know, all these things are like there’s this huge sense of loss. That’s what I felt I felt there was a sense of loss. So I needed to somehow make up for that. And part of,

Jamie Johnston 5:20
in addition to like, clinics being shut down, and it was one of the things. So you know, it wasn’t just the loss of income from that it’s several sources of income, that it was all gone.

Eric Purves 5:29
Everything was gone, and you didn’t know and you’re like, how am I like, how are we going to pay the bills? How are we going to feed the family? Right? How are we like are is the clinic going to have to shut down because I was the owner of the clinic at the time. And luckily, we had good landlords, and that was, okay, we were able to make that work. But there was a lot of stuff that was really stressful, and at the time. Medium is stressful was,

Jamie Johnston 5:51
yeah, good. Because you put your head down and just dealt with it as I dealt

Eric Purves 5:55
with it as best you could. And, and for me, like you said, like, I had a hyper focus. So I became so like OCD, I’m like, I need to figure this out, I need to find a way. So that’s where I went to create, like, went to all this online stuff, I created all these online courses. And I just spent so much of my time learning and studying how to create and market online content, how to create online courses, and they weren’t great, but they just did. And I made them happen. And they became very, very, very successful, like way more successful than I ever could have imagined. And fortunately, you know, once things kind of came back and COVID became less of a restriction on our life, people were still wanting to stay at home for the next year or two. And so people were just really consuming this online content at like, crazy high levels. And so the more I put out there, the more success it had, the more people were buying, the more money that was being made, the more people that were coming into wine to learn from me, and it became almost this like, like, I look, now it almost became addictive. Where you’re like, Okay, if I just keep working hard, if I just keep putting out content, I keep interacting, people will keep doing all the stuff, I’m going to get rewarded for it. And it gets those dopamine pathways going. And so it just became this like terrible positive feedback loop. Where I did, the more you do, the more reward you get, and the more people and bla bla bla bla bla and just kept on cycling through. And it got to the point where I just was working nonstop, seven days a week, 1012 hours a day, a lot of the time, not sleeping. And when we got to the point where I was like, I just couldn’t function anymore, because it was so unhealthy. Yeah. And that’s how I dealt with my burnout was working.

Jamie Johnston 7:40
Yeah, yeah. Whereas for me, it went the other way. It kind of shut me down. You know, before that I’d had several productive years with the blog, and, you know, writing content and doing all that stuff. And I don’t remember the last time I put out a piece of content. And I think the I think the last time we recorded a podcast was in July. It’s been that long. Yeah. So February now for anyone listening. Right? So So yeah, my year just was not productive. And, and you talk about for you not being able to sleep, I actually got early last year, was diagnosed with insomnia and had to go through treatment with a psychologist in order to figure out just how to sleep. Because it’s, you know, I was maybe getting a few hours of sleep a night, even though I would go to bed at 930 and get up at six, in addition to already having sleep apnea. So sleep just enlightened. So that really, obviously took a toll on not only mental health, but physical health throughout that year. And fortunately, he was able to get some help and and figure it out, and figure out how to get back to sleeping again, but for a really long time. You know, there was no sleep, and you’re trying to function and you know, you’re you constantly have a total brain fog, because you’re not sleeping properly, which leads to not eating properly and not exercising enough and not being productive and all those other things. So the burnout was just, it was Mitch,

Eric Purves 9:11
how are you sleeping now?

Jamie Johnston 9:12
A lot better. Yeah. Yeah. That’s good. That was it’s very interesting, what he what the psychologist did and if anybody out there is dealing with insomnia right now, this is the approach that he took with me. And I encourage anybody if you if you are dealing with that to get some help, because it makes a big difference and it’s important to ask for help when you need it. But what he would do is probably have a piece of paper here he basically yes, there’s well. So he gave me a piece of paper that looked like this. And this is all like time throughout the day. And

Eric Purves 9:48
when people and for people that are listening,

Jamie Johnston 9:51
you can see basically a graph of each day with our our time slots in it. So what have you been do is like, Okay, if you’re gonna go to bed at 930 color in what time you go to sleep in the morning, and then for every, for all the times that you wake up in the night, leave a space empty and then color in when you go back to sleep. So you’d see these big white boxes where I was awake throughout the night. And then I go back sleep for half an hour, and then a bit another big white box where I’d wake up and over like a 10 hour span, he looked at it and he said, You’re really only getting like four to five hours sleep in that 10 hour span, but you feel like you should have gotten more sleep. So after a week or so that he looked at it and he goes, Okay, now what I want you to do is if you want to be up at six in the morning, I want you to stay up until like midnight, or one and then condense that sleep into that four or five hour span. And you’re gonna sleep like that for a few weeks. And then we’re going to start adding 15 minute increments into it, so that your body gets used to that again. And when he explained it to me, he said, so in the morning, when you get up, you need to expose yourself to light right away, because that resets your circadian rhythm. And he said, But what most people don’t understand is that a circadian rhythm actually runs on a 24 and a half hour cycle, not a 24 hour cycle. So he explained to me that in his treatments, that’s where they run into some difficulties with blind people who have insomnia, because they don’t get that light exposure in the morning. So that circadian rhythm automatically wants them wants to make them go to bed a half hour later every night. Because they don’t get that exposure. So really interesting thing there. But what he did is he just said, okay, so go to bed at midnight, get up at six, a week or so later, you’re gonna go to bed at 1145 a week or so later 1130 until, you know, up to about 10. And then I would start sleeping like a normal, relatively normal eight hours. But he really stressed to me and said, you know, people think that you’re supposed to sleep a solid eight hours and never wake up. He’s like, it’s totally normal to wake up, roll over and go back to sleep. He’s like, that should happen four or five times a night. So don’t think that that’s like your insomnia keeping Yeah.

Eric Purves 11:59
Oh, interesting. So it’s okay to wake up in the nighttime. Yeah,

Jamie Johnston 12:03
he’s like, it’s totally normal. And you’re supposed to, he’s like, nobody sleeps for. I mean, you’re very lucky if you do, but he was like, very few people just sleep a consistent eight hours and never ever wake up. But he’s like, just, you know, if you wake up in your roll over and you go back to sleep, that’s normal. So he’s like, but if you’re up for like an hour, that’s where the insomnia is the problem, but

Eric Purves 12:25
I find that happens to me sometimes is I will get up in the middle of the night, and then I can’t fall back asleep. Yeah, my brain starts going, it’s better now than it was months ago. But it I would usually I’ll get up sometimes, like three o’clock in the morning. And I’d be on and I gotta do this, I gotta do this, I start going through right, the the wheels start spinning. And then I, you know, I get up for a couple hours I’m trying to go to bed for and I’d sleep for an hour and then get up again and be like, got six o’clock yesterday. And then you’re just like, if like you said, you feel like garbage, right and just can’t function when you’re tired.

Jamie Johnston 13:00
And he even recommended that he’s like, if you wake up and you can’t get back to sleep, he’s like golden watch TV, go read a book, go to out of the bedroom, go do something else. Which was also super interesting. Because as we were having the appointments, he goes all that stuff that you’ve learned about. What’s the term now? sleep hygiene, where they’re like, you know, no, no light before bed and no TV for half hour before he’s like, it’s all BS. Don’t worry about it. Just if you want to watch TV till you go to bed, watch TV till you go to bed and go to bed just right.

Eric Purves 13:29
Yeah. Whenever that stuff comes from, I guess it might be one of those just things people say enough. Maybe and maybe

Jamie Johnston 13:35
there was some research that was done or something that that showed it was beneficial. But according to and this is just the psychologist that treated me you might go to another psychologist that says something different. But that was just the information that he gave me. But yeah, super interesting stuff.

Eric Purves 13:50
Yeah. But you’re feeling more productive now. From that?

Jamie Johnston 13:55
Not from that? Well, I mean, I feel better from that. But I mean, the other thing that we were talking about too, is in November, I got an ADHD diagnosis. So I, to be honest, and I say this with absolutely no offense to anybody out there who, who has ADHD. For years, I was like, that’s a scam. That’s not a real thing. And I know of course I get diagnosed with it and but it’s it’s really funny. The more that I read about it, the more that I’m like, Oh, this totally makes sense. Now. It totally like, like, if you look at the like the symptoms and things of ADHD, it’s like yeah, that one that one that one that one yeah, that’s me to a tee. So so super interesting with that is now I’m getting regular doctor appointments for medication prescription that’s supposed to help with to get the brain kind of working properly again, but one of the things that that I learned from it is that people who have ADHD they don’t really get the dopamine release from things so we look for that dopamine release from other things, and it’s one of the reasons we’re not productive is because we don’t get a dopamine release from being super productive. And so you sit on the couch and procrastinate about something because you get a dopamine release from like watching TV. Because it’s like a half hour thing that you enjoy. Meanwhile, your brain is going, but I need to get this other stuff done. But you continue to procrastinate about it.

Eric Purves 15:18
So interesting. Yeah. So it’s

Jamie Johnston 15:21
like, there’s all these things that I’ve been reading about and learning that I’m like, Oh, my goodness, yes. And there’s even I forget what it’s, I forget what the term is. But there’s a term associated with it, where it’s where you just assume that people don’t like you, which I’ve dealt with for years and have the imposter syndrome and all that kind of stuff. And now I find out, Oh, that’s a result of having ADHD, it’s like, it’s one of the symptoms of that. So

Eric Purves 15:49
it says, I’m assuming and October wrong, tell me if I’m wrong. The ADHD in adults presents My shuffling the dozen children,

Jamie Johnston 15:56
I think, but I from from the bit of reading I’ve done when it comes to kids is that they’re, they tend to be more hyperactive, and things like that when they’re in class, or when they’re at school, or they’re fidgeting and things like that, because they can’t focus on the thing that they’re doing. And so they need an outlet to write for that energy that they have where they can’t focus on something. Whereas I think, and I’m sure it’s different for everybody. Whereas I think with the the adult, it’s more like the procrastination and different things like that, that that occur, because things feel overwhelming, and you can’t just focus on one thing to get it done. You feel like you have to attend things on the go. But you also can’t properly multitask either. So

Eric Purves 16:40
it’s Is that is that? Is that working for you? Is it getting better now?

Jamie Johnston 16:45
It Well, I had a pretty productive day yesterday, I think the medication is starting to help a little bit. But like I said, I’m going to be having a meeting with somebody tomorrow, who’s a coach for ADHD, people who have ADHD with productivity and things like that. So I’m trying to put some things in place that make it so that, you know, every day is, you know, we at least get a few hours of productivity out of it. So that, you know, then I can have multiple online courses and all those things as well. But it’s been Yeah, it’s been a bit of a kick in the jump per se to look back and be like, you know, I should have had these things done a couple of years ago, but But now I understand why I just couldn’t focus enough to get it on properly. So, right. Yeah.

Eric Purves 17:28
Yeah, I think the adult age age or ADHD in general seems like one of those things, it was probably not probably under diagnosed. Or probably. Yeah, I know. Some, some people have to learn simply because people I talk to the as adults have been given that kind of diagnosis and just, like a lot of things, right, if you have some insight into it and a rationale, then you don’t feel crazy. Okay. It’s not I’m not, there’s nothing. There’s nothing really wrong with me. I’m not lazy or I’m not a I’m not. Not a loser. You know, it’s just like, oh, no, I’m like, why? Our brains all work differently.

Jamie Johnston 18:04
Yeah, yeah, there’s an actual reason for it. It’s not just that I’m lazy. Yeah, exactly. Because I, because that’s the, like, you hit the nail on the head there. Because I know for a fact I’m not lazy. I’ve worked hard my entire life, but it’s just a matter of, you know, figuring out now, how how to get the brain to work the way I want it to, or how me to work with it to.

Eric Purves 18:26
Yeah, yeah. So so interesting. One thing, I mean, it’s, it’s funny, because, like, you know, bring this back to the talking about kind of the burnout and the ADHD, which is probably contributed to it for you as well. And I know, for me, that when I was just like, basically a workaholic, I was probably a lot of different holics I was just doing a lot of that I was just doing a lot of things that were not, not healthy. But I feel like you know, in the last few months, I’ve kind of, I feel better, I feel like I did pre 2020 I feel more like my old self again, and which is great. It feels good. But I know one thing for me to manage my workload, because I do have a tendency to overwork and people often like Eric, how do you do so much? I’m like, I it’s not it’s like Don’t Don’t be like me, right? Like, it’s not healthy. But now I feel like I’m gonna go much healthier habits. And whereas like I’m I say no to things, right, put things off until I’m ready to deal with them. But the biggest thing that worked for me was, I learned that a strategy called time boxing, which is where I do every day I print out like a like a block schedule. And at the beginning and I get up in the morning and my coffee and usual plan the whole week ahead or a couple days ahead, and I just go in and I’ll write down between 10am and 11. Between 10 to noon or whatever it is I usually start my dad 10 Collect toward the gym if I can first after I take the kids to school and so and then I just write down what I’m gonna do that day and I have an end to my day where I won’t respond to emails. I won’t Text Message anybody has work related. I just leave the work stuff within a work time. And following this this time boxing schedule has worked really well, to manage my, my time. So if anyone’s listening and you’re and you feel like you’re can never say no or I don’t know how to how to manage your time totally works well.

Jamie Johnston 20:18
Yeah, yeah. Yeah. Cool. I’ll have to give it a whirl. What my ADHD coach says tomorrow,

Eric Purves 20:25
yeah, yeah, it works really well. It works really well for keeping you know, if you haven’t, like I’m, there’s probably you’re probably similar. You go on your computer, and you got 25 tabs open.

Jamie Johnston 20:37
You can see my other screen right now. There’s a small amount of,

Eric Purves 20:41
okay, I was just being I was just being nice. But if I opened up mine, right, I usually have like that many of so many. Open and it’s it’s like you’re sometimes you’re there and you respond to an email, you’re like, Oh, I gotta check this, and I gotta do this. And you’re kind of going all over the place. So let me post it on social media here. Let’s see, someone replied to my email. And you’re just like back and forth. Meanwhile, maybe you’re creating some, some slides for a course or you’re responding to something that people have commented on. And you’re like, it’s just like, Oh, my God, I’ve done nothing, except just spin in circles. So now with this, I just, I can block out my day. And it makes a big difference. So

Jamie Johnston 21:18
this keeps the brain calm. So my tabs open anymore. Yeah,

Eric Purves 21:24
I usually Yeah, you have a few open, but I’m like, they’re, I would I would have done actually is I rather than having an all in one, like browser window, I’ll have multiple browser windows, I’ll just, like minimize them and open up the one I need. Right. So that way, I’m not distracted by something shiny that says so and so replying to your message or whatever. Yeah.

Jamie Johnston 21:45
And it’s so easy to get distracted, and go down a different rabbit hole that you didn’t want to go down in the first place.

Eric Purves 21:50
Yeah. And I like labs. Me too, as I like to read a lot of like, research articles or things. So I will have like, 20 articles open. And then I’ll, like, want to read through them to see and then, you know, you read one, you’re like, Oh, what about this? And then you like, read or you’re like, Oh, I gotta find a reference for this. I opened up another one. And just next thing, you know, it’s just like, she just takes off, right? Yeah, yeah.

Jamie Johnston 22:16
Yeah. Yeah. So did you? Did you find the burnout affected you in in any other ways other than the ones that we talked about?

Eric Purves 22:26
Well, yeah, I mean, there was definitely I think, you know, the, it’s easy to say that the positive was it allowed me to, to create, because that was my way of managing. And but I would say they eventually got to a point where I just didn’t wanna do anything. Yeah. You know, like, I just became not like I did, you don’t want to do anything, you just kind of become you feel lazy because your body is, your mind is just like, we need to disapprove. So let’s just shut everything down. So there was a while there, like in the summer, I didn’t do her. I didn’t do any work. Really, I very little, I just did a couple things. But that was all I could handle. So my capacity to be able to deal with as many things as I had going on at one time became difficult. And also, yeah, burnout, like my physical health as well. Like I, I wasn’t exercising as much. You know, I was not eating as well, it was, you know, probably drinking too much. And, you know, just doing things that you’re just like, this isn’t healthy. Why am I doing this? I don’t know why I’m doing it. Yeah. When you start to form these kind of like, habits that are, you know, unhelpful. And so, yeah, I think for me, now, I’m doing a lot more like I’m trying to develop more purposeful time reading. Just for pleasure. Yeah, I might you know what, maybe I could just watch shows tonight rather than my computer. And like, you know, I’ve watched in the last few months, I’ve watched a lot of Netflix and prime and crave all the streaming networks, Disney Plus, we’ve got Paramount plus,

Jamie Johnston 23:54
that’s pretty good. I got a I don’t know if I should admit this out loud. But one of the guys that were programmed to a Google Chrome for me, I get everything on that thing, though. Oh, yeah. Yeah, no one’s listening. It’s fine. Yeah. But that’s interesting. Because they, because yeah, that’s what the last year has been. For me. It just didn’t feel like doing anything. And even like, when we went and taught the courses that we taught last year, I’d like I didn’t feel like myself in any of the courses and don’t even feel like I was teaching well, even though I know that I’m pretty good teacher. So you know what even affected a bunch of those things. So fortunately, it feels like things are starting to come around a little bit now.

Eric Purves 24:34
Yeah. Yeah. It’s funny because we the way it was before, it was the we had like the teaching seasons, there was like a spring and a fall and always the fall like before the end of the credit cycle was just crazy. cramped. Yeah, it’s crammed. And, you know, we could probably do a whole other episode on that. But that I think that’s one thing that, you know, we’re very fortunate that we were able to have successful, successful CE courses and courses that were are very well attended over the last number of years. Now, obviously, we talked about I think we talked about in a previous episode there, they’re changing the CEC thing. So there’s not going to be that mad drive for it. But I would find myself every single September October, particularly, like, so burnt out. Oh, yeah. Because even if you if you’re teaching, like every weekend, or every second weekend, there is just it wasn’t the teaching itself. Like the day the teaching itself was fine. Like, I really enjoyed that. But it was all of the constant admin background stuff. People asking questions and certificates now many credits is this and, you know, can you tell me more about this course? And, and we’re just stuff which I’m totally happy to answer, because you’re like, Yeah, I want to be fully transparent with anybody that wants to get a course. But what I did find was, once November hit, I was like, I don’t want to talk to anybody. Because I’m, like, I see like too much overload. Because it was just too much it was constant. And so I don’t want anyone to listen to think that I’m complaining because I’m totally thankful. But there is that, that when you’re constantly on, yeah, you never get a chance to kind of turn it off. And that’s, I felt, I feel that it was something that was very hard to manage.

Jamie Johnston 26:22
And I didn’t understand it for years. But with me, because I know, I’m an introvert, there was especially like, early in my massage therapy career, I would come home at the end of the day and be like, I don’t want to talk to anybody. I don’t want and I mean, I was I always lived alone. So it didn’t really matter. But, you know, people would call and be like, Oh, do you want to go out tonight, you want to do this, I’m like no, and I come to realize it was because I had to be on all day, talking to people, like you know, six patients a day, or however many I had, where you just had to be on all day. And so when when we were teaching courses and things like that, where even if I’m doing first aid courses, or some of my other stuff here, you gotta be on for that, you know, four hours, eight hours, two days, whatever it is. And at the end of the day, I’m just like, I just want to talk to anybody, I just want to be alone. I just want to chill out. Yeah, I don’t want to be on anymore.

Eric Purves 27:13
It is a thing, hey, that I don’t know, if people talk about it enough. It would be really interesting actually, to have like a like a focus group with a bunch of the seats or like people that teach as much as we have. And see, like, how do you guys feel about this, because I know when I’ve had some conversations with people, you know, you kind of feel high on the day, like it’s a good thing. Like I love the feeling of teaching, particularly a live course online is good, but not nearly the same. But I love the feeling of that in person course. We’re just like their their energy and you kind of feel high like you feel a rush and it’s really good. And then afterwards, you go in for dinner and having some social time haven’t drink. And you know, it’s really fun. But then by the time that weekend is over, you’re exhausted, exhausted. And it’s like it’s like a week recovery. And I think that you said is it for a lot of us that. You know, I think a lot of massage therapists probably are a little bit of introverts, because these mostly, a lot of us have similar personalities is that you? It’s hard, it is tiring. It’s very tiring. And I don’t know if that would say that led to any burnout. But it’s definitely something I’m more mindful of now is like, Oh, I feel really exhausted after these weekends. I need to make sure that I recover. So that way I can be on my best again for the next time.

Jamie Johnston 28:29
Yeah, give yourself the Monday off or something like that to just to have a day to get feel like you’re in your own skin again and get back to feeling normal. Yeah,

Eric Purves 28:39
I did that the second half, or this slot? 2022. I did that. But previous that I didn’t do that enough. Like I would be like, Oh, I gotta go back to work. I gotta go back to clinic, I got to do my things. And yeah. never recovered. You just and it was that constant, constant, constant constant. Go, go, go, go, go go. Yeah. Which probably leads to well, you know, it’s never one thing that leads to the burnout. I think it’s a combination of it. All right. So let’s teach a course on the weekend. And those come home. And then let’s not take any time off. And let’s go and start like promoting the next course. Or let’s, let’s let’s start responding to all the emails and saying there’s certificates like today because people want them because they need them. And, and let’s, let’s go and, you know, let’s go to podcast and let’s go record a podcast and let’s Yeah, you start doing all these things. You’re like, whoa, whoa. Yeah. doesn’t need to happen today. Don’t wait. It can wait a week, and the world’s not going to end. That was the hardest thing for me to do was to like, No, it’s okay. I’m good. I could just couldn’t wait. I need to look after me first. Because then I’ll be better for everybody else that is paying attention to me and my content, my courses and better for like, family and those around me too. When I’m like, give the time.

Jamie Johnston 29:50
Yeah. Yeah. And I think I think the takeaway that I’ve gotten from this past year, is that it’s okay to be kind to yourself because we’re I mean, I mean, you and I have spent a lot of time together over the last number of years. And I know that both of us are pretty hard on ourselves. And I know for me like, it’s, especially this year, last year where I haven’t felt like doing anything and I’ve been unproductive, then you’re even harder on yourself, because you’re like, well, I should be getting some content out, I shouldn’t be doing this stuff. But I’ve come to realize it’s okay to just take a step back and go, You know what, that stuff can wait, because I’ve got other stuff going on. That That should take precedence over this. So. So for, for those of you out there are that are listening, don’t be afraid to be kind to yourself, when you need to be kind to yourself, because that’s really what’s most important, and for, for all the reasons that you just mentioned, because then you’re more present with your family, you’re more present with all the other things that you have to do and, and while making money is great, and doing things to improve the profession is, is awesome and great. If you if you don’t have the capacity to do it, and you don’t take care of yourself, you’re never going to be able to do all that stuff.

Eric Purves 31:03
That’s very well said, Jamie. And that’s something that we should really a society and at least for us as individuals to be mindful of is that we are in this kind of buy field that we’re like almost in this success, obsessed profession or success obsessed, maybe a profession, lifestyle. In society, where we’re we tend to identify we I’m obviously generalizing a lot of us identify by our accomplishments. Now we’ll look at all the things we’ve done, look, look, look at look at how, you know, the success that we’re having, and or look at the person we look at the success they’re having, I want to have that success too. You know, why are they having that I’m not. And so we, I think it can create this very unhealthy mindset where we’re always looking to achieve, we’re always looking to, to make a big impact on the world. And, and I think sometimes if we do that, without looking after ourselves, first, we’re going to have less of an impact. Yeah, and that is, for me, something that I’ve been very mindful of is that you look after yourself, first. You maintain your own genuine who you are, and you start focusing on you. And then when you can look after you, then you can start being more productive or being better. And you know what, just because you’ve had success one year doesn’t mean the next year, you have to be as successful. And how you define success is totally different for everybody.

Jamie Johnston 32:34
Totally, it’s individual to each person, you know, my idea of success compared to, to another person’s idea of success, where maybe their idea is to just go to work every day and come home and really enjoy their family. Yeah, that that might be one person’s idea of success. And that is a complete success. For anybody who does that. But for somebody who doesn’t have a family, you know, my, my ideas of success are going to be different from that. So, in each case, let’s just make sure that no matter what we’re being kind to ourselves

Eric Purves 33:07
brilliant advice. It’s really, really important. Because if we, if for so for our people like you, and I teach courses and have online, a lot online presence, if the goal of that is just to make sales or is just to, you know, get people to follow you or if it’s any of those type of things, which are these kind of superficial things. It becomes that’s not like that’s, there’s there’s no is that a reason? It’s not the reason, right? And so I started looking at things, I might start to realize that, you know, I would rather have, I’d rather have more of an impact, because the stuff that I teach the stuff that I believe in is like, it’s it’s who I am. And, you know, for me, you know, I’m, you know, evidence based practice around the science of pain is so fundamentally important. Because if we don’t understand that, and we don’t apply that to our clinical situation, and people are suffering needlessly, potentially, right, we follow the evidence, because it helps make us less wrong. And so for me, you know, I’ve really had to take a step back and realize that, you know, I can’t push this onto people, but I can at least the people that are here that want to follow the one Listen, that want to take my stuff, they want to ask me questions, I’d rather help them really well. Yeah. And a whole bunch of people. A tiny little bit. Yeah.

Jamie Johnston 34:33
Yeah. And if you if you think about how that affects people who are working clinically, if you’re not taking care of yourself, how are you going to take really good care of the people who come to see you? 100% and we would constantly give them the advice, to be kind to themselves and go home and do some home care, do do things that are important to you do the things that you enjoy. But if we’re not taking that advice ourselves, then we’re not going to be able to help those people as much. No Yeah,

Unknown Speaker 35:01
yeah. Be kind be kind to each other because yourself.

Jamie Johnston 35:05
Yeah. So this might be a good spot to transition into the other thing that I want to share. Yeah, please, that I just dropped on you. My cousin, who was one of my lifelong friends took his own life on December 19. So, really, you know not to say that people are having those thoughts, and I’m sorry if this is triggering for anybody. But I think it’s just important thing to talk about, because it’s something I’ve seen lots in my life, just happened to my cousin happened to my brother, six years ago, happened to my uncle when I was a kid happened to one of my captains when I was at the fire hall in Campbell River. So I don’t know if I’m just a jinx on people or what it is. But for whatever reason, I’ve seen this lots in life. And I think the as much as we’ve been talking about being kind to ourselves, it’s also important to ask for help, like, critically important to ask for help, whether it’s that you’re dealing with burnout, or insomnia, or you’re having negative thoughts or whatever those things are. And like I touched on, earlier on, I think as guys, we don’t do it enough. We don’t ask for help enough. And we don’t, we don’t talk about our feelings and all those things enough. So it’s just, I think it’s a really important thing to bring up. That, in addition to being kind to yourself, ask for help when you need it, no matter what it is you need help with.

Eric Purves 36:37
I couldn’t agree more. Yeah, I mean, that’s, that’s awful to hear that you’ve had so many people close to you. I’m really sorry to hear that, that have committed suicide. That’s I can’t even imagine. I’m very fortunate that I don’t have that many people in my life that have that’s happened to so it’s hard. I know, one, one thing I didn’t want to share, because I don’t know how many of our how many of our listeners are men. I know men are the minority in our profession. One website that I found, which really helped me in kind of realizing my like what was going on in like, the burnout was a website called Heads up guys.org. And it says for men about men, and you can find therapists on there, they have articles, they got, it’s all about depression and stress, and they’ve got like, the self checks on there. It was really, really, I found it really, really useful to just kind of be like, okay, like, so this is how this kind of meant these mental health things appear in men that might be different in men and women. And this is, you know, and knowing that, okay, like, I’m not alone. And I think I believe this website actually is run from the UBC, University of British Columbia. Yeah, University of British Columbia. So it’s there. It’s kind of their website on anyway. Male mental health. So anyway, really useful if anyone Heads up guys.org. Really, really

Jamie Johnston 38:03
useful? Yeah. And just quickly buzzing through it, it looks like a great site, and it’s got some good resources on there as well.

Eric Purves 38:11
Hmm. Yeah, I couldn’t recommend it enough for men, the men’s out there, the men’s

Jamie Johnston 38:17
side. Yeah. Okay. So that’s probably a bit of a somber way to, to bring the podcast to an end. But, you know, it just I thought it was an important thing to bring up that, you know, if you need help, don’t, don’t be afraid to ask for it. I’m sure there’s lots of I know, there’s lots of phone numbers out there and, and things like that, that are, you know, free resources and things like that for people when they’re, they’re having, you know, depressive thoughts or negative thoughts or things like that. So, if you’ve been through that, as far as this pandemic and coming out of it, then, you know, reach out to maybe one of those programs or reach out to a friend or, or somebody and and talk about it, which I think is it wasn’t the sole reason we did this episode. But I think one of the things we want to get across is that, you know, if you’re going through something like that, we’ve, we’ve been through it, too, and still coming out of it. So don’t be afraid to ask for help.

Unknown Speaker 39:17
That’s all I have to say about that. Right.

Jamie Johnston 39:20
There. All right. We’ll see you next time on the pockets. We hope you enjoyed this podcast. These kinds of topics are what we’re all about. If you’d like to learn more, go to our websites, the mtdc.com or Ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.


Being Of Service, While Still Being Kind To Yourself

Several years ago, I started this blog, and the whole reason was to be of service to my community of like-minded Massage Therapists while trying to educate and lift up the profession. 

Well, the last year has been really tough to do that, and I feel like I’ve kind of let you down as a reader of this blog. 

So, I thought I would share why. 

Like it has been for most of us, this pandemic over the past couple of years hit hard, but I truly didn’t understand how hard it hit me and ended up going through some health issues if any of you were going through something similar, I’d love to hear back from you. 

There were a few big things I dealt with and what I learned about them along the way. 


I was dealing with major bouts of insomnia, and several things contributed to it; and fortunately for me, I live in a part of the world where I could get referred by a doctor and get help with this as part of our medical system. So I was referred to a psychologist who helped me start sleeping again. 

I didn’t know this, but there are two types of insomnia, one where you have a hard time getting to sleep and one where you have no problem getting to sleep; staying asleep is the issue (this is what I had). 

During our sessions, the doctor had me make a sleep log, and we determined that, on average, I was getting about five and a half hours of sleep a night. I’d go to bed around 9:30 and usually try to get up between six and seven in the morning. When I made my sleep logs, there were big gaps throughout the night where I was awake. So, the strategy we used was to “condense” my sleep. 

We picked a time I would like to get up in the morning, so I chose 6:30 am. The doctor counted back 5.5 hours and said okay, then I want you to start going to bed between 12-12:30 pm. Basically, getting myself to the point that I’m so tired around midnight would make sleeping easier to stay asleep. 

We continued to fill out the sleep log, and as the sleep became more condensed, we would start adding 15 minutes to my go-to bedtime. So instead of 12 pm, I’d go at 11:45 pm, and as that sleep got better, then 11.30 pm and so on, until I was going to bed around 10 pm and sleeping much better. 

He also recommended that when getting up in the morning, I immediately expose myself to light as this helps reset the circadian rhythm, which made going to bed that night more inducive to sleep. 

Interestingly he also told me that all the things we are told in the media etc about “sleep hygiene” doesn’t really matter. If you wanna watch TV right until bed, go ahead, and many of the other things we are taught don’t really matter either…except one. 

Alcohol. I enjoy my wine, and I know over the pandemic, probably enjoyed it a bit too much. Now, I was told there’s nothing wrong with having a glass of wine at night, just don’t have any alcohol three hours before bed because while we quite often think it helps our sleep, it actually messes it up pretty good. So avoiding it three hours before bed is a good rule if you’re trying to sleep better. 


I know I’m not alone on this one. 

But over the past year, burnout has played a big role in my life, and my mental health has taken a beating for it. I’m sure it contributed to insomnia as well. 

However, there were a few things to learn with this as well. 

Figuring out the things that are important to you and focusing on those things. 

For me, I know exercise does a lot to help my mental health. Especially if it’s sports like hockey, or golf where I get to hang out with the boys and enjoy camaraderie in conjunction with an activity. Going to the gym was helpful as well, but getting that social aspect helps a lot as well. 

It’s also really important to give yourself a break and be kind to yourself. 

If you’ve been dealing with the same and are wanting to become more productive, one thing that’s helped me is just setting small daily goals of accomplishment. Everything seems so overwhelming most of the time but it has helped to just break things up into small chunks and try to accomplish a little each day, even if it’s just a half hour to an hour of work, at least I’m getting something done.

While the outside pressure of careers etc will never go away, sometimes we just have to accept that we can’t do it all, all of the time. It’s okay to take a break, it’s okay to have downtime, and it’s okay to step away from some things if you don’t have the capacity to do it all without beating yourself up about it. 

A Break-Up and Mental Health In General

As I know probably happened to many, I also had a good relationship come to an end. 

So taking into account insomnia, burnout, and, more recently, the end of a relationship, my mental health over the past year, as I said, has taken a bit of a beating. 

BUT, I came to learn that it’s okay to ask for help. 

I think all too often in our career we don’t ask for help. We are considered the ones people come to for help, but how often are we asking for help ourselves?

Yeah, we see posts online about “self-care” which is usually followed by suggestions for yoga or some other thing (not that there’s anything wrong with these suggestions), but how often do we really ask for help regarding our mental health?

We have people come in every day, lay on the table and vent about what’s going on in life (yet it’s suggested we don’t influence mental health at all), and quite often, we take some of that on ourselves. But how often are we talking about it? 

I’d venture to guess not nearly as much as we should be. 

So I’ve started having regular counselling appointments so that while the gym and sports for me is beneficial, especially for my physical health, it’s time to really start making mental health just as much of a priority. 

Now, I didn’t write this article to gain sympathy or anything like that, I don’t want that. 

I did it to highlight the need that we as healthcare professionals need to recognize our health is just as important as the people we are helping. To show that it’s okay to talk about it and that yes, sometimes WE need help, and it’s okay to ask for it. 

As I mentioned at the beginning, I started this blog to be of service to my community, so if you’ve been dealing with anything similar, I hope you know you’re not alone, there are probably more of us dealing with this than we care to admit. 

And if there’s some way I can help you, please email me and know there’s someone on the other end who’s going through the same but still pushing forward.


Amazing Low Back Exercises to Try Right Now.

Sometimes coming up with exercises in your clinic room can be difficult. Even more difficult is finding some that you can recommend as good home care.

Last week we went over how to do a great exercise called the “Dead Bug”.

This week we’re basically going to flip that over and progress the exercise to something called the “Bird Dog”.

What I love about these, is you can do it right on your table, and they’re easy for a patient to do at home.

Once your patient is confident with doing this exercise on top of the swiss ball, we can make things more difficult by removing the swiss ball.

This can still be easily done on your table in your clinic room, but it’s just a bit more difficult and will build a bit more confidence than when you’re using the swiss ball.


Now we can ramp things up just a bit more after your patient is confident with these movements.

By using an exercise band we can make things just a little more difficult and still build more confidence in movement with our patients.

Give these a try.

Doing movements like these will reinforce everything you did with your hands on the table and bring about greater outcomes with your patients.

If you’d like to learn more on how to incorporate more things like this into your treatments, and generate greater outcomes, register for our newest online course “Clinical Applications Of Pain Management Using Therapeutic Movement” by clicking HERE

5 Ways to Prevent Professional Burnout

A reader who works with a chronic pain, military population recently asked if I had any tips to prevent burnout. Here are some of mine and also some I gathered from Social Media.


1) Take Different Con Ed Courses

  • Most of us gravitate toward con-ed courses we are familiar with, have a certain reputation, etc
  • A good way to prevent burnout is to expose yourself to a good seminar on a topic that is novel and challenging
  • To most I would recommend Explain Pain or Therapeutic Neuroscience Education
  • Getting new ways to interact with patients, especially a chronic pain caseload that does not respond rapidly helps
    • Changing your mindset as to how you view these patients prevents the “I feel powerless to help”


2) Hangout and interact with like minded professionals

  • join a group like PT: Practice, Education, and Networking on facebook started by my buddy Rick Daigle of Medical Minds in Motion
  • participate in a forum like Manual Therapists, ask questions and chime in on other people’s posts
  • try to start a local Clinician’s group where you can practice techniques, assessments and discuss cases semi regularly
  • avoid arguing on the internet or with colleagues who are stuck in a model that disagrees with your practice (to a point)


3) Consider taking part time cases in a different setting

  • if you’re in outpatient, try home care
  • even 2 different cases in a different setting once a week really helps prevent burnout
  • prior to all my different endeavors, I worked full time in a private clinic (as a manager), did Clinical Peer Review, and taught at 3 different PT schools, needless to say, I did not get bored!


4) Don’t take your work home with you

  • obsessing over a case you think you could have done better often prevents you from relaxing at home
  • if you need help, ask online in a facebook group, twitter, or a forum, but otherwise enjoy your time away from work
  • just like I tell my chronic pain patients, make sure you take time to listen to your favorite music, have a glass of wine, or watch your favorite movie

5) Strive to change and adapt regularly

  • part of stagnation or burnout is a lack of change, we all need variability
  • if you have not changed the way you assess, treat, or the framework at which you make your clinical decisions at least every 2-3 years, it is time for you to rethink things!
  • finding a mentor, whether it’s online or in person really helps with this as you watch them in their patient interactions

Starting Over


*While Laura Wrote this back in April, its applicable today as we look to the new year, especially as we see a second wave hitting several places, with new shutdowns in place. 


A couple of months ago, any one of us could have started a sentence with “When this is over,” and chances are, no one except your family or close friends might have known what personal problem you were referring to. Now, everyone knows what it refers to: COVID-19. For many of us, it’s personal on some level. We’ve had a friend or family member or acquaintance who was sick with it, or died from it, or maybe you’ve personally been sick with it.

At this point, no one knows when “it” will be over…” it” meaning the effects on society. There are millions of Americans out of work due to shutdowns of “non-essential” businesses. There are shortages in grocery stores…every day on my social media, I am still seeing people who can’t find a roll of toilet paper. This is Easter Sunday, and millions of Americans who would otherwise be at church are at home watching a service on television or streaming service on the Internet.  Some churches are holding parking lot services where the congregants remain in their cars.

I’ve had a lot of private messages from massage therapists asking my opinion on when we’ll be back to work. The short answer is, I don’t know. Nobody knows. I live in NC, and the governor ordered things shut down until April 30. I personally believe it will be extended beyond that, and even if it isn’t, I will probably wait several weeks beyond the date that it is lifted to go back to work. I’m the suspicious type, as well as one who errs on the side of caution, and I fear a “back to work” decision from the government that is based on economics instead of actual safety.

We tend to think in terms of ourselves and our own occupation and our own lives. There may be no intention of being selfish or self-centered, but that’s the way things are. In reality, there are going to be a lot of businesses, of every type, that do not survive this shutdown. Your favorite restaurant, coffeehouse, or bar may be forced out of business. Your neighborhood florist, art gallery, or gym that is privately owned and not part of a big chain may be gone. While some landlords are giving rent relief, others are not. Some business owners simply cannot pay rent for several months when they don’t have money flowing into the business to cover that cost. In fairness, some landlords count on their rent money to make ends meet themselves.

For many massage therapists (and others), once the shutdown is over, this will be like starting all over at square one. While many may have faithful clients that can’t wait to come back, we have to consider that many of our self-employed clients or those who work in businesses deemed non-essential, may be in the same boat we’re in: unemployment checks are not coming in yet, but the bills keep piling up.  A lot of people may have to choose between getting a massage or trying to catch up on their bills.

For those who are self-employed, and ICs (many of whom are misclassified, but that’s another story altogether), this situation may cause you to rethink your employment circumstances. Those who are employees have had a much easier time signing up for unemployment. While the federal government has announced the intention to extend unemployment payments to self-employed and ICs, most state unemployment websites have been waiting on instructions from the feds to get that started. NC’s website states that it is expected to be in place by April 25 for self-employed and ICs to file. If you don’t have a cash cushion, that’s a big financial strain for those who are waiting.

Anytime you choose to be self-employed, you’re taking personal risks. If you’re using independent contractors in your business, they (and you, if you have them misclassified) are also taking a personal risk. Ask yourself if you could live for 6 months without money coming in. If the answer is no, rethink your decision about your work circumstances. Go over your budget and see where you can cut expenses in order to save money. Maybe that means doing without stopping for coffee on the way to work every morning or doing without eating out. Or giving up your addiction to new shoes, or carefully tracking the mindless spending most of us do. I recently saw a meme pointing out that spending 27.35 per day adds up to $10,000 in one year. Using an app like EveryDollar can help you see where your money is actually going.

Many people are just one paycheck away from total disaster. I’ve been there myself in years gone by. This isn’t meant to be negative; it’s meant to be a reality check. We don’t know how long this is going to last, but it’s already evident that many people are in big trouble.  It’s a good idea, when the world returns to some semblance of normalcy, to treat this as an opportunity to start over with a plan to be better prepared, so the next emergency doesn’t knock you flat.

It’s also a fact that at the end of our lives, none of us are going to say “I wish I had worked more.” We’ll be wishing we had taken more time to stop and smell the roses, spent more time appreciating our families, had more quality time with our spouse, or learned to play the flute or paint or whatever you think you never have time for. If you have that time now, just do it. While you’re adding up your problems, don’t forget to add up your blessings.

In closing, I express my gratitude to all the medical personnel who are on the front lines, and the essential workers who are enabling us to still go to the grocery store, the gas station, and wherever else we NEED to go. I’ve found out in the past couple of months that I don’t need to go near as many places as I thought I did. Bless all who are sick and suffering and all those who have lost loved ones.  Bless you, all, and may you remain safe and well.

To Predict Chronic Pain, Look to the Brain

Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain –  the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability?  Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.


Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

Vachon-Presseau, E, M V Centeno, W Ren, S E Berger, P Tétreault, M Ghantous, A Baria, et al. 2016. “The Emotional Brain as a Predictor and Amplifier of Chronic Pain.” Journal of Dental Research 95 (6). International Association for Dental Research: 605–12. doi:10.1177/0022034516638027.

Baliki, Marwan N, and A Vania Apkarian. 2016. “Nociception, Pain, Negative Moods and Behavior Selection” 87 (3): 474–91. doi:10.1016/j.neuron.2015.06.005.Nociception.

Apkarian, A.V., Balik, M.N., Geha, P.Y. 2009. “Towards a Theory of Chronic Pain.” Progress in Neurobiology 87 (2): 81–97. doi:10.1016/j.pneurobio.2008.09.018.Towards.