“I was slowing down, and that bastard hit me so hard from behind that I broke the steering wheel with my head!” Said Sean.

You could tell Sean didn’t take this accident lightly. He was a construction worker, and was built like a truck. Not only because he always had his hands working on a job site, but because he spent a lot of time in the gym lifting heavy.

“Whoa. That’s a heck of an impact! What did you say you were driving?” I replied.

“A Chevy Silverado. I don’t know how much you know about trucks, but mine is a monster. They hit me so hard from behind that they broke the frame. My truck was written off! ”

I cheekily replied: “Kind of like you! You look like you spend a lot of time in the gym.”

While gesticulating with his hands, Sean said: “No way man. You have no idea. I’ve been working out since I was 15. I was in the gym 6 days a week, rain or shine. I haven’t been able to work out since this pain started.”

“That sounds like a huge loss to you.”

“A huge loss? That’s nothing. I haven’t been able to work since that a$$hole hit me. He was looking at his phone!”

Anger. Irreparable & severe loss. Blame.

These are all very important but often ill-identified signs of perceived injustice.

What is perceived injustice & how does it relate to pain?

Perceptions of injustice are defined as cognitions which typically arise when an injury results in unnecessary suffering resulting from another person’s actions, or the experience of irreparable loss.

But how do these thoughts, beliefs and cognitions relate to pain?

“Did you begin to experience pain immediately after the accident?” I asked.

“No. I was a bit woozy for a second. But I just got out and started screaming at the stupid guy who hit me. The ambulance came to take me to the hospital for a check-up, but I didn’t go because I was feeling fine. I had terrible pain in my entire upper body and head the next day, and ever since.”

I followed up by asking: “So tell me this: on a scale of 0-10, where 0/10 is no pain at all, and 10/10 is the worst pain you have ever had, how bad is the pain right now?”

“8/10.” Sean replied.

“How bad is the pain when you feel at your best?”

“8/10.” Sean replied.

“So you’re at your best, now?”

“Yes.”

“Man, that must be heavy. And how much when you’re at your worst?”

“11/10. It’s terrible.”

Perceived injustice is known to influence recovery, contributing to greater pain intensity, disability, and mental health problems (Trost, 2013).

So if we are not picking up on injustice perceptions, we are missing a crucial piece of the puzzle which may inform prognosis for recovery.

The ramifications of perceived injustice

“So just to summarize, the pain is always severe and intense, and there are never any times where the pain is less than an 8/10?”

“Yes! See what my life has been like since the accident?”

Sean wanted me to be seen and believed.

“Of course. I hear you. It sounds as if your life has completely changed.”

Sean was getting angrier the longer we spoke: “I just can’t do anything because of this pain!” He slapped his hands against his legs and said: “I can’t live like this. I haven’t been able to provide for my family. I can’t be me! This pain has to go away.”

Share

Subscribe now

How can clinicians identify perceived injustice?

We detect this largely through our clinical interview. Injustice beliefs are especially common in the context of compensation, traffic accidents, legal cases (Sullivan, 2008).

Sean already told us this in our interaction. He was in a car accident and a legal case was ongoing. But there was more.

I asked: “Did you ever get treatment for your pain?”

“Yeah. I saw a physio, and that guy told me I’d get better. I just got way worse for days after seeing him. He didn’t do anything.”

Injustice perceptions are also associated with promises of recovery without improvement or iatrogenic injury (Sullivan, 2008), and most often occur alongside attributions of blame, magnitude/severity of loss, unfairness, irreparability of loss and/or anger (Sullivan, 2008).

So how should clinicians identify these variables? Again, this goes back to our clinical interview (Sullivan 2008, Sullivan 2012, Lynch 2021).

“Sean, I’m going to ask you some questions that sound like they don’t have anything to do with your pain, but they really do. Is that ok? Remember, I’m not here to judge you, just to try and help you figure out a way forward. Is that cool?”

Sean consented: “Yeah man, shoot.”

“Ok. Do you feel as if you are suffering because of someone else?”

“Yeah! That a$$hole was looking at his phone!”

Blame & anger. Check.

“Do you think people know how much you’re suffering?”

“Kind of. My wife knows I’m in pain, but sometimes she wonders how we can pay the bills. My dad is old school, though. He just tells me to suck it up and get back to work. Most people don’t see how bad this pain is.”

High magnitude & severity of loss. Check.

I replied with: “I can imagine that feeling really unfair. The reality is, people aren’t in your body and they can’t feel what you feel.”

“It is really unfair! They don’t even know what I have to go through every day!”

Unfairness. Check

“So if the lawsuit finished tomorrow and you got a good settlement, would you be ok with that?”

“Hell no! That won’t make up for what I’m going through and the financial loss to my family.”

Irreparability of loss. Check.

These clinical indicators most often occur if injuries are directly in the context of another person’s perceived negligence or victimization, or indirectly as a consequence of injury (Sullivan, 2008).

Share

So what can we do?

Sean started therapy with me and members of our excellent psychology, naturopathy and massage therapy teams.

Sean’s hard work, along with our guidance and support, got him back into the gym: “I’ve been working out 5 days a week. I do the exercises you gave me before and after, so that’s amazing.”

“That’s great! How do you feel about that?”

“Good. I can’t lift heavy though. And sometimes, my pain is worse until the next day.”

I followed up with: “I’m still really happy that you’re working out! What about work? Think you could go back to work?”

“No way. Work is physical and can go all day. No way I’d last. It’s unsafe. We’ve lost so much money, it’s not even funny.”

“I hear you there. It makes sense that you wouldn’t go back if you don’t feel safe.”

Sean is confirming exactly what the research tells us: that a heightened sense of injustice is associated with less acceptance of pain, less likelihood of engaging in meaningful activity despite pain, reduced physical function and higher disability (Carriere, 2018).

Here’s the crummy and not-so-glorious summary about perceptions of injustice: the presence of these cognitions makes prognosis for improvement poor. To make matters worse, no specific intervention for injustice perception exists to date. Some psychological treatments such as CBT, forgiveness therapy, anger management, and acceptance & commitment therapy show promise, but the evidence is not Earth-shattering yet (Sullivan 2008, Evaniew, 2025).

However, it has been established that anger mediates the relationship between injustice and pain intensity, and partially explains the association with depressive symptoms (Scott, 2013). So, from a psychological perspective, anger may be a therapeutic target.

“How intense is your pain overall?” I asked.

“Still high. It can go as low as a 4/10 on a really good day, but that doesn’t last. Most days, I’m still often hovering around a 7-8/10. It’s still pretty awful.”

Is Sean’s lack of change all our fault?

The short answer to this is no: the fact that Sean didn’t get better wasn’t the fault of our team. Pain in the context of injustice perceptions is just a very difficult scenario. The circumstances just didn’t allow for things to improve. Personally, I think Sean is pretty justified in his feelings and cognitions. Problem is, they’re hard to change, and that’s not Sean’s fault either. It’s just reality.

Let me talk about our responsibility as clinicians, though: we should be screening for this stuff, and that can be done the easy way, or the hard way.

The hard way is the way I did it: slogging through the mud and asking questions. There are pros and cons to this. The pros are, I learned what Sean’s experience of pain was like in the context of his life, and understanding this is valuable because Sean felt heard. The con is that it took a lot of time, a luxury many clinicians do not have.

So what’s the easy way? Use of a questionnaire called the Injustice Experience Questionnaire (IEQ), where a score >30 is associated with high injustice perception. Problem is, it’s not very legally accessible, so you might have some hoops to jump through if you want to use it.

Overall, injustice perceptions make treating and prognosis for recovery from chronic pain that much harder.

How hard?

A recent study in a large Norwegian sample of people with chronic pain showed considerably higher levels of disability, pain intensity and bothersomeness, psychological distress, fatigue, insomnia, and pain catastrophizing in people with high IEQ scores compared to those with low IEQ scores. The study also showed that those with elevated IEQ scores presented with more painful body regions, poorer health-related quality of life, lower self-efficacy, more adverse health outcomes, and greater likelihood of ongoing litigation and application for permanent work disability (Reme, 2022).

So what’s your responsibility as a clinician?

Simple to say, hard to do: look for perceptions of injustice, and decide if this is someone you want on your patient roster. If you don’t, then refer on to a member of your team or another trusted clinician who has the skills.

If you feel comfortable, go ahead and treat!

Your responsibility is to know and to refer accordingly. And as GI Joe said: “Knowing is half the battle!”

Just 30 more seconds of your time: can you please complete the poll below? It really helps with future newsletters. Thanks!

Share

“Disarm you with a smile. And leave you like they left me here. To wither in denial. The bitterness of one who's left alone”

• Disarm - Smashing Pumpkins

“I was leaving work about 5 pm. It was winter and there was some fresh snow on the ground. That’s when it happened.” John described.

Outwardly, John was a tough, stocky 58-year-old insurance broker. But the persistent neck and diffuse back pain he’s suffered with since his motor vehicle accident 6-months prior had been interfering with his life, and that was stressing him out.

“Can you tell me a little bit about what happened?” I asked.

You wouldn’t notice if it you weren’t really looking, but this John was welling up through his tough exterior.

“I was leaving the plaza where my office is, and ‘BAM’ they hit me.”

I could tell John didn’t like talking about his accident.

I smiled and said “How did they hit you? What were the mechanics of it?”

“I was pulling out onto the road and it was slippery out. As I pulled out, someone skidded and hit me right on the driver’s side. The impact was so loud, and I remember the sound like it was yesterday. I hit my head on the door and the car skidded around. I opened my eyes and I was facing traffic. I thought I was going to die, because another car was going to hit me.”

“That sounds really scary.

“It was…”

The scary thought that you’re going to die signals that this may not only have been a major physical trauma, but also a major emotional trauma.

Combined physical and emotional trauma often goes unnoticed.

We moved forward with the conversation when I asked: “You mentioned that you hit your head. Did you lose consciousness?

“That’s the thing….I don’t think so. But I remember sitting in the car with my hands on the steering wheel kind of out of it. Like I was in a dream”

This part of the story is important to pay attention to: what John described here is called depersonalization or derealization, whereby someone feels detached from their own body or experience, and is a classic sign of trauma (Boyer, 2022). This kind of depersonalization is much different from psychiatric depersonalization/derealization disorders which can occur often as a product of trauma (especially in early childhood), and have their own diagnostic criteria.

John went on to say: “I kind of snapped out of it when someone knocked on the window, and I got out of the car. That’s when I clued into my neck pain.”

“Did you go to the hospital?”

“Yeah. The paramedics came, put me in me in a neck brace then took me to the hospital where I waited for a long time, only for them to tell me nothing was broken and send me home.” John said, with an angry look on his face.

“Being put in a neck brace, then transported to the hospital and having to wait there for hours sounds like a stressful scenario too! When did the pain start to get worse?” I asked.

“I went home with this intense pain in my neck. I couldn’t sleep because of the pain. I couldn’t believe it wasn't broken. I didn’t sleep, but I woke up and my whole neck and shoulders hurt all the way down to my low back. I felt like I was a brick.” John described.

Treatment of the physical problem is often unsuccessful

“So I started physiotherapy and chiropractic for the pain. They were nice people, but I felt terrible. I went there, and I’d be in more pain after I left, and I’d need to recover for a day afterward.” John volunteered.

“What was so terrible about it? Did you just hurt more?” I asked.

“Yeah. It felt like the pain was so much worse every time I had to move or any time I was touched.”

“Like things were just more sensitive?” I clarified.

“Yeah.” John confirmed.

“Tell me about sleep. Do you have difficulty either falling asleep or staying asleep?” I asked.

John laughed. “Yeah man. Terrible.”

“What makes it terrible? Does pain keep you up, or something else?”

“I hate going to sleep. My pain is so much worse, and I can’t find a comfortable position. I’ve started sleeping in my recliner in the living room.”

I then asked a burning question: “Any nightmares?”

John raised his eyebrow, seemingly surprised that I asked about that: “Yeah…”

“Nightmares about what?”

John clarified: “Nightmares about the accident. I see myself staring into the headlights of the oncoming traffic every night. There are other dreams, too. Like I’m scared and running away from something.”

“That sounds terrifying. Has anyone else asked you about this stuff? Like your lawyer, doctor, physio or chiro?” I asked

“No. I haven’t told anybody.”

Share

Subscribe now

When you find one symptom, dig for more

It was very clear that there was more to John’s pain than just his neck and back pain. So, naturally, I probed further.

“John, I’m going to ask you some questions that may seem unrelated to pain, but they really are. Is that ok?”

“Ok…”

I first asked about driving: “Have you been able to drive since the accident?”

“Yeah…”

“How do you feel while you’re driving? Do you feel worried or fearful?”

“I’m constantly checking my mirrors, and I get really amped up when cars get close to me.”

John was constantly scanning for danger.

“Have you returned to the site of the accident?”

John paused: “Yes. I started to panic and went home. I haven’t been to the office since the accident. I’ve been working from home and meeting clients online or in their homes since then. ”

John was avoiding the site of the accident.

“Do you find yourself thinking about the accident often day-to-day?”

“It’s often all I think about.”

John was having intrusive thoughts about the accident.

“John, do you find yourself feeling worried in your day-to-day life?”

“Funny you mention it. I’m so scared of my kids and wife driving. I call them all the time to make sure they’re ok, and they get mad at me. I worry about them getting into an accident. I also jump when I hear a loud bang. So if something falls, it scares the crap out of me.”

John was experiencing anxiety and hyperarousal.

“Last question: Do you ever find yourself reliving the accident, as if it’s happening all over again?”

“Oh man. I did! For the first few weeks, if I heard a loud bang, it would trigger that.”

John was previously having flashbacks.

John was showing symptoms of post-traumatic stress disorder.

What is PTSD?

PTSD is a psychiatric condition that may occur in people who have experienced or witnessed a traumatic event or series of traumatic events such as accidents, violence or war. The pooled PTSD prevalence in people with persistent pain is approximately 9.7%, but varies according to pain location (Siqveland et al, 2017) In general, there are 3 symptom clusters including, (i) hyperarousal, (ii) intrusions of memories from the traumatic event, and (iii) avoidance of situations and actions reminiscent of the event (DSM-5, 2013).

John was showing symptoms of all 3.

“It sounds like the accident has made you fearful a lot of the time.” I commented.

“Yeah, but I’m here for my neck and back pain. What does all that have to do with it?”

Educating your patient

“That’s an excellent question. The fact is you’re dealing with 2 things. The physical pain you feel in your body from the accident, and the psychological trauma. When both of these are present and showing symptoms, it makes both harder to treat.”

John then asked the expected question: “So you’re telling me that my pain is all in my head?”

“No, quite the contrary. Your pain is absolutely real. I don’t believe you’re crazy, or making this up or are out to lunch. You hit your head and suffered a whiplash as a result of the accident. No question.”

John nodded and encouraged me to continue.

“But the whole incident was both physically and emotionally traumatizing. Think about it - you thought you were going to die! I can’t even imagine how frightening that must have been. The reality is, the systems in our body that create our stress responses and the systems in our body that create pain responses from an injury talk to each other.”

John was confused: “What do you mean?”

I tried to explain: “You’ve had an injury, and you can think about that like fire on your bbq. And the other symptoms like the anxiety, avoidance, dreams, etc are like someone has come by and thrown gasoline on the fire. The original fire you started is still there, and it’s cooking the meat. It’s just been thrown out of control. The reality is, you can’t separate your mind and your body. What we perceive as ‘diseases of the mind’ have very real effects on our body, and what we classify as ‘diseases of our body’ like injuries have very real effects on our thoughts, behaviours and how we feel. It sounds like you’ve suffered a physical and emotional trauma at the same time, and they’re compounding each other.”

“But how does the anxiety and whatnot have an effect on my body?” John asked.

“That’s another great question. There are a lot of theories about how this works. What we know is that stress can activate the systems in our body that can cause a pain response to occur, and if stress is too intense it can kind of get locked in. The other thing that happens is that we become really sensitive. Your outdoor motion sensor light is a good example. Pretend for a second like when the light goes on, it represents a pain response. Generally, someone needs to walk by or wave to trip the sensor to make the light go on. The threshold to activate it is appropriate. We don’t want the light turning on for a fly going by. One thing that intense stress can do is make our sensor more sensitive than baseline. So instead of turning on when someone walks by, it turns on when someone walks around inside the house. Or it’s just always on and won’t turn off. It’s a very sensitive sensor that makes the light go on when it shouldn’t. So when certain sensors in your body are activated, they’re causing a pain response at a much lower threshold.”

In their recent publication, Weisman and Masharawi (2026) propose that the systems governing stress responses interface with nociceptive circuitry throughout the body. Further, they posit that exposure to severe or persistent stress can cause a sudden biological phase transition where the interconnected network of nervous, immune and endocrine systems rewire into a self-sustaining pathological state. Once locked in, the system recalibrates whereby the stress level required to maintain pain is much lower than the stress level required to initially activate it.

“So what do I have to do?” John rightly asked.

What next?

“Well, first of all I think you may need to see someone with the skills, knowledge and scope to diagnose this trauma properly. Once it’s diagnosed, there are many treatments that can help with the emotional trauma part. Especially from the standpoint of the anxiety, dreams and sleep.”

“So do you refer me to someone?”

“Yes and no. It depends on what you may want and need. I can refer you to a psychologist who can do talk therapy and help you with some parts of this. Some people may also need medications for a short time to help with symptoms. In that case, you may need to see a psychiatrist who can prescribe medications. Your family doctor can refer you. If you want, I can send your family doc a letter explaining all this and ask them to refer you. Does that work?”

John replied: “Yes, that works. But what about my pain?”

“There are 2 roads here. One road is where you get treatment for your psychological trauma first, and once that’s under control, you come back and see me for pain-related treatment. The other is that you get treatment on the psychological side and pain side at the same time. Either way, both need to be treated by a team who is all on the same page.”

“What would treatment from you look like?”

“Well, we can do the hands-on care which can help some people. We’d start by helping you understand what’s happening in your body and helping your body get back to doing the things you love to do. We can start you on a good exercise program that you can tolerate, and build from there.”

Moving forward

“Seeing the physio and chiro were agony. So if doing these other therapies will be helpful, I’m going to start there.”

I can’t fault John for that decision! He ended-up seeing a psychologist who confirmed the diagnosis of PTSD and started treatment. He was also started on some medication for his PTSD-related nightmares and anxiety. The combination of these 2 therapies improved his pain, sleep and emotional stress by a lot!

This is an example of where allied healthcare practitioners like chiropractors, physiotherapists and other professions fit generally into the healthcare system. Firstly, we need to determine if the patient is in the right office! Do they need the care that a chiro or a physio may provide? Do they require assistance from someone else? Or both? To answer this, we need to be familiar enough with diagnostic criteria to identify something that requires a workup from another healthcare provider. We don’t need degrees in psychotherapy. We just need to take our time, pay attention to the human being in front of us and be honest with them.

The point is, John was left alone to deal with his trauma. We had to disarm him with our compassion, time and with a smile.

10 more seconds of your time: can you please complete the poll below? It helps with future content!

“Everything started for me 5-years ago when I hit my head off my headboard. It was a bad concussion.” Sally said emphatically.

“Concussions can be really tough. How was your recovery?”

“It improved a lot over 5-months. But my symptoms all came back and worse after I tapped my head on a cupboard.”

Sally then gradually accumulated injuries and pains all over her body after what seemed to be fairly innocuous movements.

This led me to a question I ask all my patients with persistent pain: “How has pain changed your life? What has it stopped you from doing?” These questions are very important, because they give the person an opportunity to communicate what their life is like and their goals.

Sally began to cry.

“My arm pains stop me from holding and breastfeeding my baby!” Sally replied.

“I remember how much my wife bonded with our son while breastfeeding. I can’t even imagine how hard that must be for you.”

“Yeah…”

After waiting a few beats, I asked: “Can you tell me a little more about how pain has affected you?”

“It really stops me from doing anything. Carry my baby and doing yoga hurt my body for days. Something like camping would be awful.”

“Have you tried camping since all this started?” I asked.

“No! Walking down the street hurts. I can’t imagine camping.”

“It seems as if pain has stopped you from doing everything you love.”

“Yes…”

Like for many individuals, pain made Sally’s life small. What’s worse is that Sally began to predict that doing certain activities would be painful even though she hadn’t tried them.

It begs the question of why these pains would accumulate in the first place.

Chronic pain rarely happens in a vacuum

Clinicians must account for the context within which people live. This is why I often ask the question: “What else was going on in life when the pain started?”

Sally suffered from longstanding anxiety, for which she sought therapy. But her pains also began during a time of extreme change and uncertainty.

“I started to get all these injuries all over my body around the time COVID started. I was isolated at home with a young child, and my husband was a nurse. I was always worried about him being in the hospital.”

Over time, Sally started having panic attacks, which made life even more scary.

This narrative of anxiety almost acting as an accelerant for pain is not surprising, given the evidence. A novel study showed that higher anxiety, independent of depression, was linked to lower pain thresholds throughout the body in people with knee osteoarthritis and predicted new onset knee pain a year later in an initially pain free population (Burston et al 2019).

“The last several years have been hard,” Sally said.

“I can’t even imagine how hard they have been.” I replied.

“I’m just constantly worried about everything.”

“Does it stop you from sleeping?”

“Yes!”

Sally wasn’t exaggerating. Her experience is quite common, as approximately 40% of people with chronic pain describe significant symptoms of anxiety (Aaron et al, 2025), such as excessive worry that’s difficult to control, restlessness, fatigue, and sleep disturbance.

“Let’s talk about how we move forward. Is that ok?”

Try, try and try again

I opened one of our later sessions with: “I remember you mentioning that carrying your son and yoga were activities that you’d love to get back to. Can we talk a bit about why you can’t do them?”

“Sure. Most of all, they’re painful! I’ve tried them since this all started. Sometimes, I’m way worse and sometimes I’m the same. I can’t make heads or tails of it. So my old physio and I decided to avoid them until I built some more stability.”

This led me to ask: “What do you mean by ‘stability’?”

“Well, the best I can understand it is that my muscles need to be properly balanced, and to do that I needed to do some exercises to strengthen.”

When someone provides me with a potentially damaging narrative like this, I often ask thoughtful questions that make the person question the narrative.

“So how do we know when your muscles are balanced enough to start doing these activities?” I asked.

“Well, I suppose my pain would be better? I don’t know…”

“So to summarize, you’d do exercises to balance your muscles, which when balanced, your pain would improve and you’d be able to do the activities you want?”

“Yeah…” Sally rolled her eyes.

I then asked: “How’s that working?”

“Well, I’m still in pain…”

Once they begin to question the narrative, I’ll try to offer a different one.

“Can I offer another possibility? When a basketball player sprains an ankle, it can get pretty red and swollen right?”

“Yeah.” Sally replied.

“They might also use a brace and walk with crutches if it’s bad enough. Why do they do that?”

Sally thought for a second and offered: “Because it’s painful!”

“Yeah, exactly. And one of the reasons it’s painful is because of inflammation. But then the player starts seeing their athletic therapist and physio teams, who get them back to playing. Do you think that they just do a few things and poof, they’re back on the court?”

“Well, no. They might do some therapies and then slowly return to playing.” She replied.

“Exactly! They return slowly. So at first, they might just start with putting weight on their ankle and moving it around. Then they may go on their tippy toes. Then they may hop. Then they may start passing and shooting the ball at 50% effort. The moral of the story is, they don’t wait until it’s perfect before they go back to play. They slowly go back to the sport while doing therapy on the ankle so the athlete builds tolerance. Does that make sense?”

Sally thought for a little bit, and clarified: “So they won’t wait until it’s perfect before going back to playing?”

“Often, no. Gradually returning to playing even with some pain is part of the process. It’s not ‘heal, then play.’ Gradually building tolerance to playing by participating in the game is part of the healing.”

“Oh…really?” Sally then asked a brilliant question that most people with persistent pain ask when faced with the reality that gradual exposure is one potential way to return to the things they love: “How can I do things when they’re so painful?”

“Well, we have to accept that tolerating pain might be part of the process. We just have to set limits on how much is safe to tolerate and start there, while trusting that the pain will improve over time.”

From there, Sally and I dove into the Traffic Light Analogy created by Annie O'Connor. I did a whole newsletter on this topic (here). This is a tool that I use with nearly all chronic pain patients, so I urge you to go back and read that newsletter (because it's awesome).

Share

Our next session was magic

“So I’ve been thinking a lot about the Traffic Light. It occurred to me that many of the flare-ups I’ve had in the past have been green and yellow lights.” Sally offered.

“Ok. What does that mean to you?”

“I think it means safe but sore. It’s tissue sensitivity that can improve over time!”

“You’re right on the money. So where should we start?”

From there, Sally decided that she’d start with gradually returning to yoga, because it was her favourite social physical activity.

“Let’s do some slow neck and shoulder movements to start.” I offered.

We went into the gym and did a few.

“These are painful, and I’m scared. But the pain isn’t too bad.” She said, mid-exercise.

“Ok, let’s note that and see what happens afterward.”

We did about 5 minutes of movement, and returned to my treatment room.

Sally sat quietly for a minute, and finally said: "Ok. My arms and neck are buzzing a bit. But it’s improving the longer I sit here."

“And what does that mean?”

“Green light. Safe but sore.”

“Exactly!” And we celebrated that success with an epic high five!

Progressions

After a few sessions, I knew that Sally was ready to progress to more demanding movements. But I couldn’t push her into it. Remember that people suffering with symptoms of anxiety are stuck anticipating a bad future. Our job as clinicians is to ground them in now, hold their hand while they take a risk, and navigate what happens.

“So in yoga, what are your favourite 3-4 moves?” I asked.

"I used to love upward dog, downward dog, sun salutation and warrior pose.”

“Ok. How do you feel just doing one of each of those poses today? One, then rest. Do the other, then rest. etc.?”

“Ok. I can try.” Sally said bravely.

I will often try to disarm a person’s anticipatory anxiety by offering: “I’ll do them with you.”

I suck at yoga.

“How did that feel?” I asked after doing the movements.

“I feel good!”

As our sessions went on, we began to chain these movements together into a 10-15 minute yoga routine.

We then began to expose her to holding her baby for longer durations of time using a kettlebell Zercher carry, first using very low weights, and gradually increasing them.

Over time, Sally began to feel more confident holding her son for longer periods of time at home.

We just added movements. Brick by brick. Her pain and tolerance to movement gradually improved.

Life goes on

“So we decided to go camping in a few months!” Sally said.

“That’s amazing! I’m so happy for you!”

Sally then said my favourite thing…

“Can we do some exercises to improve my tolerance?”

We then started doing a myriad of different exercises that partially simulate some of the activities she might do while camping, such as carrying a tent, carrying a canoe with a partner, rowing a canoe, etc. All designed to give her confidence in doing the tasks she desired.

From an exercise selection perspective, you’re only limited by your imagination. It’s the narrative of building safety and tolerance that matters.

Eventually, Sally finished her maternity leave and decided to return to work. “I’m nervous but I think I can do it,” she said confidently.

After that, we worked on navigating perceived roadblocks such as how to structure exercise into her day while she was working full time and how to appropriately recover from a long day at work.

She even went on that camping trip. She helped pitch a tent and rowed a canoe! All without “muscle balancing.”

Final thoughts

It is not our responsibility to diagnose people with an anxiety disorder. Our role is to identify the signs and symptoms of anxiety, educate the person on why it’s important and to refer out to our network if needed.

If you want to dive deeper into the signs and symptoms of anxiety, you can download an amazing anxiety symptom checklist I created here. To screen for how intense anxiety-related symptoms are, you can download a version of the GAD-7 here. Note that a score of 10 or over on the GAD-7 is indicative of moderate anxiety and warrants consideration of a referral.

The reality is, most people with anxiety are not comfortable with uncertainty. Our responsibility as clinicians is to help people feel that whatever happens tomorrow is not as bad as their anxiety makes it out to be.

The combination of her bravery and our humanity allowed her to finally unlock the door and step outside.

Just 10-seconds more of your attention. Please kindly fill in the poll below. It helps me with future material! Thanks!

Share

Your assessment starts in the waiting room

I walked in and saw Greg sitting there. He had a strong and athletic build, but his eyes looked sad.

“Greg?” I called in the waiting room.

“Yessir.” he answered. He made eye contact and shook my hand, but immediately looked away.

“My name is Dr. Demetry. It’s nice to meet you. Do you mind following me?”

“You too. Sure. Thank you.”

Greg slowly stood up, and winced enough for me to notice that it was painful. And he had good reason.

The Trauma

After exchanging a few pleasantries, Greg told me his story.

“I was in a motorcycle accident in 2015. A cube van moved into my driving path, and I hit the broad side of it.”

The accident resulted in significant poly-trauma, including organ injuries, multiple fractures and ligament damage.

Greg added: “I’ve been left with pain in my body since the accident. The doctors just said to live with it.”

“That sounds so scary. I’m sorry you had to go through that. How was your recovery after the accident?” I asked.

“I got through…”

Short and sweet answers was Greg’s M.O. He was never rude, just efficient enough to say what he had to without saying much more. He also very rarely made eye contact and showed nearly no emotion on his face at all.

“That recovery must have been hard.”

“Yeah.” He simply stated.

Despite his recovery, Greg was left unable to do most things he loved like playing hockey, baseball and weightlifting.

“Do you want to be able to get back to doing those things?” I asked.

“For sure. I was strong. But, I’m getting old. Can’t do that stuff anymore.” He said matter of factly, while averting my eyes.

I wasn’t sure if Greg was stoic, or if he just had not hope of life improving.

Like with most patients, we needed to dig deeper.

Breaking through

Greg moved to the UK in 1998, and travelled all around the world working as an electrical engineer in the offshore oil industry, which he greatly enjoyed. He returned to Canada in 2022, following a divorce. His pain finally stopped him from doing the work he loved, so he transitioned into an operations manager role.

“Do you have any children?” I asked.

“Yup. 2 girls.” He responded.

“Do they live with you?”

“No, they stayed in the UK when I moved back to Canada.”

Greg immediately began to weep uncontrollably and said: “I’m sorry. I shouldn’t be crying like this.”

This is classic behaviour for people who feel shame. They express it by apologizing for “burdening” you their feelings.

“You’ve been through a lot. It’s completely ok for you to show your emotions. If you’re comfortable, can you tell me what made you feel this way?” I handed him the Kleenex box.

“My girls. I just miss my girls.”

This is the thing about chronic pain. We assume that people are only grieving lost time and lost abilities. Greg suffered a major traumatic life change from his accident, but he later lost contact with his children - a second trauma that weighed on him.

“I can’t even imagine how hard that must be.” I said.

“It is.”

He continued to cry

Share

Additional symptoms

“Greg, you mentioned that you used to take part in activities like weightlifting, hockey and baseball. What stops you from doing those things now?” I probed.

“Well, I’m old. And it hurts. And, I just can’t seem to find the energy.” Greg began to sob again. “I’m sorry, I really don’t walk around like this crying all the time.”

“It’s really alright, Greg. I won’t judge you for a second. You have the right to feel any emotion you want to feel.”

“I’m also just really tired a lot of the time. Pain stops me from sleeping, but I also wake up really early.”

“Does pain wake you?” I asked.

“No, I just think and worry about things.”

“Do you feel sad often?” I followed.

“Yeah, a lot of the time.”

Not only was Greg suffering physically, but he was suffering emotionally. It is not in my scope to formally diagnose someone with depression, but he certainly was showing many symptoms. Low mood. Fatigue. Sleep disturbance. Withdrawal from or loss of valued activities. These are signs for us to recognize, not a checklist for diagnosis.

The interesting thing about depressive symptoms and chronic pain is that many of the treatments that may be used for depression can also be used to help with pain.

When you think about it like that, so many different treatments that are within my scope are on the table. Behavioural activation. Graded activity. Manual therapy for pain.

To help a person in pain, we need to help them regain parts of their life. So that’s where we started.

Hearing what a person wants and giving them what they need

Greg and I did a few sessions going through some basic rehab and manual therapy to reduce pain. But after a while, our sessions transitioned into something different.

“So if I snapped my fingers and your pain was gone, what would you be doing?” I asked

“Well, I’d be playing ball [baseball] and hockey, and probably weightlifting.”

“What kind of weightlifting did you do?”

“Well, I was spoiled on many rigs. They would have a big gym with lots of free weights that no one would use but me. 4-5 days a week, I’d finish my shift and head to the gym.” He then dove into his philosophy about lifting, and how important consistency and going close to failure was to him.

“It’s pretty awesome that you did all that on a rig! Ok - how would you feel about starting that back up?” I asked

“I’d love to, but I don’t think I can.”

“Why not?” I asked

“I’m getting old and I shouldn’t do that stuff any more. I also just haven’t had the energy or motivation to do it. ” He replied.

“There’s no evidence that I know of that says people in their 50’s shouldn’t lift weights. In fact, as you get older, your muscle mass starts to progressively deteriorate. Weightlifting helps slow that loss and can help you a lot as you get older.”

“Is that right?” He emphasized.

“Yeah. When was the last time you bench pressed?”

“Not sure.” He replied.

I then stood up, opened the treatment room door and walked Greg into our gym. He became wide-eyed and had a big smile on his face. He then did 5-sets of bench press, followed by some incline dumbbell flies.

“How are you feeling now?” I asked

“No pain. I might just feel this tomorrow” he said while touching his chest muscles.

Greg did feel it, and it felt good to him. He came in for his next treatment with a smile on his face and said while laughing: “So I went out to the car and immediately called Donna [his partner]. I told her, ‘guess what I did today’? She said, ‘what?’ I said, ‘I bench pressed’. She said, ‘YOU DID WHAT?!’. I said ‘Don’t worry, it was with Demetry, he said it was ok’. Man, I was sore for 2-days!”

“That’s awesome! What do you want to do today?” I asked.

He replied: “Let’s do legs!”

So we marched into the gym and did 5 sets of squats, some seated leg extensions and leg curls. We ended the session with him saying: “I feel good.”

I had a feeling that Greg was feeling better in a lot more ways than just pain.

Hope for the future

Greg came in a few sessions later stating emphatically: “So I signed up for both ball and hockey this summer.”

“Dude, that’s amazing! What made you do that?”

“Well, I figured that if it’s safe to weight lift, it’s safe to move my body like that.”

Greg and I then pivoted the goals of his care pain management, toward improving his physical tolerance, confidence in playing sports and managing soreness from playing.

Several sessions later he said:“You should have seen it. Last game, I hit a single, a double and hit a home run!”

And a few weeks later: “So the guys told me I’m not allowed to miss games because they need me on 3rd.”

Greg would later come in and say things like: “I have this fear of doing new things in the gym. I haven’t done much pulling. Once you do it with me, I know I can do it.”

Over time, Greg’s confidence grew, and started taking leaps all on his own, like going on extremely long hikes while vacationing with his partner.

Overall, Greg got a lot more from our sessions than just pain relief. He turned into this person who was empowered, who was confident taking risks, and felt safe enough to ask for help when he needed it. It was a true transformation that it has been an honour to be part of.

He now lights up the room with his smile.

This is the power we have, just from listening to a person, identifying their needs and helping them achieve it. Baseball. Hockey. Lifting weights. Hiking long distances. Greg achieved those things through a lot of hard work, despite pain and depressive symptoms.

Final lessons from Greg

In preparation for writing this newsletter, I spoke to Greg and he said this: “Yeah, all that confidence stuff is important. But none of that would have worked without our rapport.”

Greg was right. Without investing in a trusting therapeutic relationship, the likelihood of him achieving these amazing things would be much lower. We had rich conversations. We built trust. We shared decisions after examining evidence in his daily life. We identified barriers and solutions to overcome them.

Treatment of chronic pain is about building trust and collaboration. That way, the ‘road is less hard.’

Greg's story leaves us with more than a case study, it leaves us with a few durable lessons.

What skills should we learn from this story?

The biggest lesson here is to understand that people are complex and layered. There are also many barriers, like the depressive symptoms in this case. The hard part about helping people manage chronic pain is that there is no simple way to do it. No one therapy is better than another. But this complexity it’s also part of the beauty of treating chronic pain. There are many solutions to solve a single problem, and we have to help people find which one works for them.

The most important skill to reflect on here is to be curious and listen to honest answers. This allows you to identify what person-specific success looks like when you achieve it. You can’t identify a person-specific problem without the person involved.

Finally, clinicians need to learn how to let go of therapies that have served their purpose and are no longer necessary during a treatment program. We did more focused rehab and manual therapy initially, but eventually stopped because they were no longer needed. So if a person plateaus while in your care, maybe their needs have changed. We need to dig for what that need is and try to fulfill it (or find a person that can help them fulfill it - that’s often as good).

When to refer to a mental health professional

Nearly 40% of people with chronic pain screen positive for clinically significant depressive symptoms (Aaron et al, 2025). So if you are helping people with chronic pain, co-morbid depression WILL walk into your office. The most important thing is to recognize the symptoms (without making a diagnosis which is outside of your scope).

You can find a helpful depression symptom checklist that I’ve created here.

If you see a few features of depression and you want to use a questionnaire to help you evaluate it more closely, the PHQ-9 can be found here. If your patient scores 10/27 or more, or endorses a high functional interference to their daily life, you may want to consider a referral.

Until next time. Be curious and listen, and new opportunities with your patients will present themselves to you.

Just 20 more seconds of your time: can you complete the quick poll below? It’ll help me with future content

“Hi Dr. Demetry. I’m feeling really good today” Hannah stated matter-of-factly.

Over the years, Hanna had seen me for a smattering of chronic neck, low back and foot issues, that we’d been managing through manual therapy and exercise.

“Ok. I’m very happy to hear that! What brings you in today?” I responded

“I don’t know. I was going to cancel, but I thought I’d keep our appointment just so we can check everything out.”

Hanna was genuinely a lovely person to be around. She always had a happy and positive attitude, which lit up every room she entered. But her life wasn’t without its fair share of challenges.

A few years prior, Hanna unfortunately lost her husband to cancer. She had also retired from a long career as an HR director and went through a major and prolonged condo renovation.

Hanna just wasn’t herself that day.

Trust Your Gut

When someone like Hanna shows me a completely different demeanour, that is cause for alarm. So, I didn’t beat around the bush.

I probed: “Is everything ok? You seem a bit low energy today.”

“I’ve been feeling off lately” Hanna replied woefully.

“Ok. Do you feel comfortable talking about it?”

“Oh, it’s nothing.” She responded.

Our patients will quickly brush their feelings aside when they feel vulnerable. Sometimes, patients will feel shame for feeling down, and don’t want to burden you.

I paused and nodded, encouraging her to proceed.

Spilling the tea

“I’ve joined my condo board, and it’s been really challenging. The people on it are weird and unprofessional. I just get so angry with them during our meetings” she described.

In this scenario, validation your patient’s feelings is the most important next step.

“Having to spend time with so many people you don’t like sounds like a rough place to be.”

“Yeah, it’s been rough.”

Like many, Hanna didn’t have hobbies. When work came to an end she felt kind of lost and this is a common occurrence in retirees (Yesuf, 2025). Retiring can be majorly stressful.

Picture this: you stop working. Like many, you begin to feel purposeless, leading to distress. And because you’re not up and about as much, you function starts to decline.

My theory was that Hanna was desperate to feel purpose. But I had to prove it, and most of all, prove it to her.

So I asked: “I know we’ve talked about you trying new things. We spoke about book clubs and dance classes. What made you want to join the condo board?”

“I like the idea of helping people in the building. But the people on the board are just terrible. They don’t really care about the people in the building. They just want the power of being on the board!”

I paused. Hannah had spent 30 years in HR helping people. Now retired, she'd tried to recreate a familiar role on the condo board, only without the parts she actually loved. She was chasing usefulness, not the work itself.

“Can’t you just quit?” I asked.

“Not yet. My term is almost up. But the people in the building need someone good on this board to help them.”

Asking the right questions

Studies have shown that retirees whose function declines and have weak social networks show a sharp and significant rise in psychological distress. Conversely, having high social support can neutralize this psychological impact (Yesuf, 2025).

I probed some more: “It’s great that you want to help people. You spent you life in HR doing that, and helping people is in your nature. But, why does that person on the board need to be you?”

“I don’t know….I thought I could be useful, but I just hate it.” Hanna responded.

I nodded, smiled and said: “Aren’t there ways to feel useful without hating it?”

“I guess so. I just don’t know what else to do and I’m having trouble figuring that out.”

There was my opening to ask her a very crucial question.

Share

Making a referral

“I hear that frustration. It’s not easy to start new things after major life changes happen. It’s kind of like learning who you are all over again. Have you ever thought about talking to someone about it?” I asked

“Like a psychologist!?” She said surprisingly.

“Yeah, like a psychologist. You don’t need to have major mental health problem to see one. You could go in with a specific problem like yours: figuring out life after retirement. And asking for guidance.”

“I don’t even know where to find one…” Hanna stated.

This reaction is very common. People feel unsure about how to respond, so they identify every possible barrier. What saved me in this scenario, was having a network of people to refer to.

“Oh I’d refer you to someone I trust here in our clinic. I’ll even send them a message explaining everything we’ve chatted about so they’re prepared. Do you think that would help?”

Hanna was pleased: “Yes! That would be so helpful. Thank you!”

What happened next?

Hanna and I spent our entire 30-minute session chatting. No manual therapy. Not because there was nothing to treat, but because what she needed most wasn't my hands. It was my ears. Sometimes, the most important thing a healthcare provider can offer is presence and attention

“You know, Dr. Demetry, I’m glad I didn’t cancel our appointment today. For some reason, I knew I needed to come in and this was why.”

“I am always happy to listen.

Hanna saw one of our amazing psychologists a few weeks later. After a few sessions, she decided to leave the condo board. Interestingly, Hanna decided to try something she had never done before: she got a retail job selling clothes to senior women. She truly “faced the strange.”

In a later session she said: “It’s kind of fun! I feel useful and I get to meet all kinds of people! " I thought being on the board would give me that sense of purpose. But all it did was make me miserable.”

She seemed happier and back to her delightful self.

Lessons learned

This appointment with Hanna confirmed one thing: our ears are the most important tool we have. Remember, our patients don’t just come in with aches and pains. People are layered and complex, which means their problems are layered and complex too. But here are a few simple rules to follow:

1. When a person’s demeanour is different, be curious. If they are letting you see behaviour change, chances are they want someone to talk to.

2. You are a healthcare provider first. Identifying a person’s needs and helping someone figure out how to fulfill them will provide you with much success.

3. Talk to your patients about their life, even while doing manual therapy. This gives you important context, so when something is off you’re ready to notice it. Be curious.

4. Validate your patient’s feelings, and ask thoughtful questions. People open up when they’re not being judged. When trust is established, big things can happen.

5. Ask people what their thoughts are on seeing a mental health professional. Don’t just recommend it. Let them mull it over and if they’re ready, make the referral.

6. Have a network of people you can refer to, if they’re not in your office. Your relationship with that healthcare provider should be so good that you can drop them a line and tell them about the person you are sending to them. This enables excellent continuity of care.

7. As my amazing friend and mentor Dr. Shawn Thistle wisely said: 'ears are > hands sometimes.' The next time a patient tells you something vulnerable, remember: listening is treatment. Being present is your most valuable tool.

One quick question: would you please take 10-seconds to complete the poll below? It will help me with future content!

Subscribe now

We all carry burdens. The weight of them can vary, but we all carry them. For some, the weight of burden is light, and carried through the world without care. For others, the burdens carried are crushing and anchor you to the ground.

The scary part of this is that we never truly know how heavy burdens are for the people we meet, and this is especially true for the patients we see.

Put yourself in this scenario: You are a patient with pain in your body that has been affecting you for a long time. The pain has upended your life. You have difficulty working, sleeping and doing the things you love. You then step into the office of someone you don’t know. They ask you a bunch of questions. They have to touch you where it hurts. And finally, they sit in front of you with all the confidence in the world and tell you what needs to be done to solve your problem.

Sounds scary, doesn’t it? But more than that, it sounds vulnerable and powerless.

Now see that scenario through the eyes of someone who carries the heavy weight of trauma. Abuse. Neglect. Stress. How can that person share trust and feel safe when their trust and sense of safety have been violated, sometimes by the people they trusted most?

It is our responsibility to handle these situations with care.

My interaction with Rachel taught me how to do just that.

How It Started

Rachel was a 26-year-old female with widespread body pain. When I called her name in the waiting room, she looked anxious. Shaking her right leg up and down, and biting her nails was a tell-tale sign of someone who is a bit nervous about our encounter.

Upon sitting down I asked her: “Is it ok if I give you a brief explanation for what to expect today?”

“Yes, please! I was really hoping you would.” She responded.

“Well, as I said in the waiting room, my name is Dr. Demetry. That’s my first name. My last name is Assimakopoulos. You’ll never remember it, so Demetry is fine.”

“Ok…” Rachel replied

"Well, first I am going to chat with you about what brings you in today. Then, if it’s ok with you, I’m going to do a gentle physical examination. Then, we will sit and chat about what might be going on, what you’re hoping to get from care and how we might be able to achieve that. Is that cool?”

“Sure, sounds good.” Rachel was a woman of few words.

I say this to every person that walks into my office. I want them to know what they’re getting into before we actually start so they can provide consent to proceed. I’ve also observed that this transparency sets the path for building trust.

Then I said what I say to every patient: “Tell me your story.”

Rachel had been suffering from widespread pain since age 11, which started seemingly out of nowhere. She had seen her family doctor who ruled out any health problems that might cause body pain, only to be told that she has fibromyalgia and that there’s nothing she could do about it. She had trialed seeing a physiotherpist, unfortunately without success.

“It must have been scary to experience such pain in your body while you were so young.” I said.

“Yeah.” Was her only response.

Her behaviours and one word answers made me feel that something was off…

The Pain of Toxic Stress During Childhood

Whenever a person tells me that their pain started during childhood, in their teens or “out of nowhere”, I always ask: “What was going on in life around that time? Any new physical or emotional stressors?”

I often ask this question because the unfortunate reality is that adverse childhood experiences (ACEs) are startlingly common, with 64% of Americans reporting at least one ACE, and over 1 billion children worldwide experiencing abuse and neglect annually (Baca, 2023).

“Yeah. My house growing up was a very stressful place. Lots of abuse. Why is that important for you to know?”

“I’m so sorry that you had to go through that, and I want to thank you for trusting me enough to tell me. The truth is, it’s now understood that when your stress response is constantly active as a child without adult support, the odds of having lifelong health issues like depression, anxiety, substance use and chronic pain as an adult significantly increase.”

Bussières et al (2023) actually did the math on this, and discovered a dose response relationship between ACEs and chronic pain, whereby one ACE increases the odds of chronic pain to 1.29, while 4 or more ACEs nearly doubles the odds (OR 1.95).

That’s exactly what Rachel was describing.

But the conversation became more interesting as we went on.

Share

Toxic Stress Over Time

“How does that happen?” Rachel asked.

"Well, when your body is in a very stressful and unsafe physical and/or emotional environment for a long period of time, your body might adapt in ways that help in the short term but have long-term consequences. Your stress systems get overloaded and become hypersensitive even to safe situations, and chronic inflammation causes nerve sensitivity. Some of those long-term adaptations lead to a person experiencing pain all the time.”

“Really?” She asked.

Rachel and I completed our history, and then progressed to the physical exam.

How We Respond Means Everything

I framed progressing to the physical exam using the 3C’s: Compassion, consideration and consent.

“Is it ok if I examine you? This might involve me asking you to move, and placing my hands in certain areas that may be painful. I will always tell you what I’m doing and will ask for consent. You have the absolute right to refuse, and I am ok with that.”

“Yeah, sure.” She said

Always compassion to your patients, not pity.

“If things get uncomfortable in any way, let me know.”

Always show your patients consideration. Make sure the person understands what is happening. Where you’re going to stand. Where you might place your hands. The next thing you’re doing in your examination.

“Is it ok if I stand behind you?”

Always ask for consent. Even when you don’t think you need to or should. Don’t assume consent. Avoid violating what they want to happen to their body, and give the person the opportunity to say no.

“I’d like to gently examine your neck muscles. Is that ok with you?”

Going Forward

Rachel’s examination was as you’d expect: neurologically and orthopedically normal, with tenderness everywhere I touched.

“So what does all this mean?” Rachel asked.

“Well, it seems as if your body has adapted as we discussed previously: it has become much more sensitive over time. So much so, that you have varying degrees of pain all the time.”

“Ok. What do I do from here?” She rightly asked.

“There are numerous ways a person can proceed from here. What do you think your body needs or what are you ready to start?” I asked.

“I don’t know…what are my options?” she requested.

We discussed the various forms of treatment I could provide. Education on how to feel safer in her body. Teaching her some simple self-regulation strategies. Gradual exposure to movements and exercise so she can do more of the things that bring her joy.

Rachel and I also discussed the notion of undergoing some form of therapy with a person specializing in mental health treatment. Rightly or wrongly, Rachel opted for this, because she felt as if this was the best place to start.

“I support that decision. I’m always here if or when you may need. Thanks for your trust today.”

The 4-R’s of Trauma Informed Care

Rachel taught me that whether we like it or not, we have huge influence over our clinical interactions with people. When people come into our offices, they trust us to help them heal in some way. If we aren’t cognizant of this power, we can cause more damage.

How do we accomplish this? Baca & Salsbury (2023) describe the 4-R’s for Trauma Informed Care.

The first R is to Realize how large of an impact trauma may have on a person’s health, behaviours and experiences. Rachel was obviously anxious, likely had some trepidation about seeing a healthcare provider. Making her feel safe was priority. I also provided her with some understanding of how trauma can negatively affect her lifelong health.

The second R is to Recognize the signs & symptoms of trauma. Remember, when someone sees a clinician for pain which started insidiously, without known provocation and/or during childhood, to ask more questions about stress and their environment. We also need to recognize how our postures, questions and examination may be potential triggers for a trauma response.

The third R is to Respond with empathy, build trust and have a referral network for additional support. The 3C’s are some good guidelines to follow here. We also provided Rachel with what her potential treatment options were and let her decide what happens to her body.

Finally, the fourth R is to Resist Re-traumatization - this is especially important for clinicians who touch their patients.

Above all, just treating each person you see with respect, decency and kindness will guide you.

Rachel never did come back. But she learned something crucial: hearing her narrative about her life and connecting her experiences to her present-day symptoms matters. She also had agency over what happened to her body that day. For someone whose trust has been shattered by trauma, that's everything. That's the real healing. And that's what we're here to do.

So think to yourself: what's one small thing you can change in your clinic today to make people feel safe enough to trust you with their vulnerability?

Quick question: can you take 10 seconds and take this poll? It will really help me with future content

Have you ever experienced grief?

I know I have. In 2013, I lost a lifelong friend who fell asleep on the subway after a night of opioids and alcohol. It was horrible. I had a lifetime of memories with this person, and from that day forward, there was no future with him in it.

Grief happens to all of us. Loss of a loved one. Losing a job. Selling a house full of memories. The list goes on.

Now imagine doing something that you love. Biking. Martial arts. Dancing. Sex.

Then, all of a sudden, that thing brings joy to your day is just…gone. Against your will, never to be done again.

I’d imagine it feeling like part of yourself is missing.

Now imagine that patient in your office with chronic pain. Their ability to do what they love? Gone. Their ability to socialize? Gone. Their ability to go through their days without feeling their body? Gone.

A person in this situation may present like their depressed. Instead, these people are grieving a life lost.

At least that’s what it was for Laura.

Laura’s Story

Laura is a perennial lover of life. Her character is bubbly, big and warm. Her lifelong profession suited her personality: she was a music theatre actor and professional dancer.

One day, Laura started to feel pain in her left groin. This pain eventually worsened, and stopped her from moving like she ordinarily would. Her jumps became less graceful. Her ‘a la seconde’ was not quite straight. Kicking overhead? Forget about it.

Laura was frustrated, scared and sad.

Things then took a turn for the worse.

The Importance of Identity and Sense of Self

Then one day, Laura had to make one of the biggest decisions of her life: she had to stop dancing, and shift her career into stage production. For a high performer like Laura, this was life ending.

As you can imagine, this kind of identity change is a focal point in the management of persistent pain, specifically because of a concept called self-concept clarity (SCC).

Importantly, SCC is rooted in how a person sees themself, the precision of those self-impressions and the level of self-assurance they have regarding that self-knowledge (Reed et al, 2021).

A high amount self-concept clarity is crucially important to one’s identity, and is protective against the psychological distress of existential threats (Reed et al, 2021).

Laura’s hip pain blurred her sense of self. Laura regarded herself as a mover, but she couldn’t move. Laura regarded herself as a dancer, but she couldn’t dance. Laura regarded herself as a performer, but she couldn’t perform.

In other words, chronic pain drastically reduced Laura’s SCC, and the cost of that was steep.

Subscribe now

Low Self-Concept Clarity

Reed and colleagues (2021) elegantly studied how SCC changes in the presence of chronic pain. They found that a lower SCC predicts higher pain catastrophizing and lower pain acceptance (Reed et al, 2021), which are known poor prognostic factors for recovery.

The relationship between SCC and prognosis is understandable. Laura’s life was upended. You can imagine how sad, angry and alone she must have felt. What else would be the case if pain is preventing a person from engaging in behaviours that literally define who they are?

I’d be grieving my life like I grieved the loss of my friend.

And that’s how Laura felt. A profound sense of grief for her previous life.

But as Christine Mason Miller said: “This is not how the story is going to end.”

A New Hope

“The MRI of my hip was normal! How could it be normal!? I can’t even roll in bed without pain!” were Laura’s words of frustration.

But my examination made me believe that she had an intra-articular hip injury that was missed by the MRI. After some deliberation, our team decided to order a magnetic resonance arthrography (MRA) examination at an academic hospital, and referred her for an intra-articular corticosteroid injection.

The injection instantly changed her life.

Laura said: “You don’t even understand. The pain isn’t gone, but I can move so much more freely!”

“How do you feel about moving around in the gym?” I asked.

With a little bit of fear and excitement, she replied: “Let’s do it.”

After a brief warm-up, I admitted to Laura: "I am not a dancer. I didn’t even dance at my own wedding.” True story.

“What!? I have to teach you!”

We stood in the mirror, having fun doing a few dance moves…well, she did. I mostly fell over.

Then I asked: “How about you try an ‘a la seconde’”

The glare and shade she threw me was hilarious, but she did it.

“…I haven’t done that in a year.” She instantly started crying.

I didn't say anything. Neither did Laura. We just stood there in front of the mirror. Her in tears, me watching her realize that her body remembered who she was.

Then the journey really began.

Movement, Movement and More Movement

Laura was still grieving her ability to move. But now, she had an experience that she could move again in some capacity, which made her feel open-minded toward setting goals.

Goal setting is important in the context of chronic pain management. But we can squeeze more out of goals by linking them to identity (Reed et al, 2021).

Here’s a generic example that you may have seen in your office: Grandpa Stavros is beginning to have some difficulty with mobility and walking long distances. He used to take his grandchildren to the park on Saturday mornings, and now has to rest half way. They smartly see you in your office, and you suggest a 20-minutes a day walking program to improve his overall health.

Think grandpa will follow through?

I bet your experiences will tell you they are unlikely to follow your instructions.

Where we fell short with grandpa was in asking determining why this exercise plan is important to his values, identity and self-concept clarity.

Your line of questioning in this regard may have yielded a response like: “I want to be able to walk my grandkids to the park.” By understanding their ‘why’, our interventions not only help the person to achieve their goals, but to accomplish something that brings their life meaning and overcome potential goal conflicts (Reed et al, 2021).

“So how do you want to start moving again?” I asked Laura.

“Well, I think that if we worked out in the gym, I can start to feel good in my body again.”

“Ok, I’m game for that. Anything else?”

“Well, my dogs need a lot of exercise, and I’d love to be able to walk them for 5 km.”

“Perfect. Let’s work with that!”

My sessions with Laura just became training sessions in the gym. We created a simple but challenging program, that built her sense of bodily safety performing movements she felt were necessary to make her feel good in her body. Core work, squatting, lunging, carrying, hinging, etc. Everything was on the table, just regressed to a tolerable load.

Like grandpa, Laura also started on a progressive walking program, and quickly made it up to 5 km.

But Laura wasn’t only just lifting and walking.

What Happened To Laura?

To my surprise one day, Laura tearfully said: “So I danced in the studio.” She got me so excited that I even did a little dance!

Over time, she started feeling confident choreographing dance numbers for the music theatre troupe she works with, which made her so very happy.

Remember the MRA we ordered? Well, it came back showing a significant labral tear that was not visualized on the first MRI. After seeing an orthopedic surgeon, she opted to delay surgery because she was managing so well.

In preparation for writing this article, Laura sent me this email: “I continue to thrive more and more every day. The journey back to myself hasn't been a straight line—it still has its peaks and valleys—but the difference now is that I'm genuinely excited about the future and all of its shades of light and dark. I'm looking forward to new opportunities and to not only meeting, but celebrating, the new parts of myself that I get to discover along the way. What a difference a year makes…”

The Pink Floyd lyrics at the beginning of this newsletter share an important life lesson. It tells us that there will be good times and bad times in our lives. Our lives are what we make it through all we touch and all we see.

We have an opportunity to help improve the patient's lives in such special ways. By helping them find meaning in the process, you help change all their life can ever be.

It sucks when patients flare-up. Some of us feel guilty. Some feel sad. Others frustrated.

I often wonder how much of this frustration it is actually directed at ourselves?Because when a patient flares up, somewhere in the back of our mind, a voice says: “I should have protected them from this.”

That feeling has a cost, and it changes how we show up in the room. So what do we do when a patient flares-up? What does good flare-up management actually look like, and what does it teach us about the patient in front of us?

“Tell me your story.”

Like many people living with persistent pain, Helen's life had been hard. She began living on her own early in life, and lived with addiction for many years before kicking it through AA.

Through lots of hard work, she earned everything she wanted: a very supportive husband, 2 beautiful children and a career as a teacher.

Until one day on the school yard changed her life.

Helen was struck in the head with a ball causing severe concussion symptoms. After weeks stuck in a dark room, the headache pain began to spread to the rest of her body.

But the thing that was most disabling was immense fear.

Fear of never returning to the life she loved.

Fear of forever lasting intense pain.

And above all, fear of flare-ups.

How did we prepare for this?

First, We Had A Conversation

In our first session, I told Helen something most patients aren’t prepared to hear:

“Pain and pain intensity are important because they’re the things that brought you here. But they’re a moving target. Sometimes they’re up, sometimes they’re down, and for no good reason.”

I paused…

“So in addition to pain intensity, we need some other things that give us an understanding of success. Is there anything that you LONG to get back to that if you do, you’d consider your treatment successful?”

Helen knew exactly what in life she wanted back. The ability to dance, sing, and run. But most importantly, being present with her kids. Not just physically in the room, but actually there. These were the things that mattered most to her. And every single one of them scared her, because every single one of them hurt.

“Having more pain during activity can be scary, and it will happen. It’s not always an indication of more or permanent damage, just sensitivity.”

Helen stared at me blankly, and for good reason.

The phrase “hurt doesn’t equal harm” probably came to mind.

We say this constantly. We put it into guidelines. We put it on handouts. We use it in every flare-up conversation.

But here’s the truth: most patients have no idea what it means. And neither do most clinicians. We need a framework to back it up.

That’s where the Traffic Light comes in.

The Traffic Light Analogy for Activity Safe Pain

The best tool I have to teach people the concept of hurt vs harm this is the Traffic Light Analogy. This gift to the pain community was originally developed by my colleague Annie O'Connor, whose book A World of Hurt: A Guide to Classifying Pain fundamentally changed how I think about pain assessment, treatment and patient communication. This framework is hers. I’ve simply applied it to the clinical context in my own way. You can buy the book here!

Here’s how I sold the Traffic Light to Helen:

I pulled the whiteboard down.

“To figure out whether you're hurting or harming yourself, we need a shared language to communicate what you’re feeling, so neither of us is guessing. I call it the ‘Traffic Light Analogy’. Can I show you?"

The Harm Check: Your Functional Baseline

We start by establishing something the person does all or most days unless their pain is so severe they are bedridden. This “harm check” can be anything: walking the dog for 20-minutes, making breakfast for their son for 10-minutes, putting on underwear. The harm check serves as a functional baseline that raises an eyebrow if it suddenly cannot be performed.

This simple measure becomes the anchor point for everything that follows.

The Three Lights: Understanding Safety in Pain

The magic happens when we teach the person about the three categories themselves.

Green Light (Safe but Sucks):
A mild increase in pain that resolves within twenty-four hours with no new symptoms and no change in the harm check. This is hurt, not harm. The person is safe.

Yellow Light (Safe but Sucks a Bit More):
A moderate increase in pain lasting up to forty-eight hours with no new symptoms and the harm check preserved. The person is safe here, but they’ve likely hit their psychological ceiling for pain tolerance. You may need to adjust frequency, intensity, or duration of the activity to help them manage their activity exposure dose. The goal of treatment is to make activities that cause a Yellow Light into a Green Light, and to turn Green Lights into no light at all.

Red Light (Stop and Reassess):
A severe increase in pain lasting more than three days to weeks, potentially accompanied by new symptoms such as swelling, tingling, leg pain, weakness, or reduced range of motion. Red Light is defined by a consistent reduction in functional ability: the harm check drops by 50% or more during the time of the flare-up. This warrants a proper re-evaluation for new injury or tissue damage. Act appropriately.

What Makes This Framework Work

What is essential to understand is that it’s not necessary to hit a Green or Yellow Light with activity. The real goal is for the person to understand that when they perform a desired activity and feel pain, they are safe because of specific, measurable reasons. This is a framework that allows them to practice moving away from an immediate emotional reaction to pain toward a way to identify safety.

The Traffic Light validates the person’s pain experience while confidently reassuring them that they are safe and that if they continue with exposures, they will improve.

It’s also important to understand that these aren’t distinct categories. The lights can “bleed into” each other. People have often described feeling a “high green” or “low yellow” before. The framework isn’t about rigid boxes. It’s about helping people recognize a spectrum of safety.

I then asked Helen: “Now tell me…when was the last time you were in a red…”

She replied with: “IDK, a handful maybe?”

“So every other time you’ve experienced more pain, it’s been a yellow or a green? Those are hurt, not harm. They are safe but sucks. You can habituate to them and over time, things that were once painful, can be less painful or not painful at all.”

The Traffic Light gives your patient a language to communicate with you, their loved ones and most importantly themselves, that they are hurting but safe.

(A great worksheet for this can be downloaded here).

Be Ready: It May Pay to Have a Flare-up Plan

During our time working together, Helen has experienced flare-ups with activity. Each time, we come back to the Traffic Light to remind her that hurt doesn’t equal harm.

But what else can we do?

For some people, having a flare-up plan in place is necessary. One patient of mine had a box that they’d crack open that had a hot compress, chocolate, and a favourite movie.

For many, the best thing to do is to ramp down their activity to a tolerable level, take Advil and slowly build back up. Different people have different needs at different times. Design something practical for your patient.

Helen used components of all of these, but also needed a lot of reassurance.

“How do you know I’m not making myself worse?” Helen would ask.

My response: “Well, let’s go through it. Which light do you think you’ve hit?”

“Like a high yellow…” she said.

“Has it improved over the last 48-72-hours?”

“Yes.”

“Can you still function?”

“Yes.”

“Overall, is your pain better than it was when we started?”

“Yes.”

“Then what’s the logical conclusion here?”

“This is sensitivity not injury.”

“Right on.”

Helen just needed to know that it was safe to keep going. But how she kept going wasn’t always the same.

Flexible Persistence

Repeatedly running into flare-ups can be frustrating. This is where the concept of flexible persistence comes in.

Flexible persistence is a lifelong process of having clarity about what is important in life, persisting with valued occupations, and being flexible when tackling challenges (Lennox-Thompson, 2020).

In the case of Helen, the goal was to feel confident in her body again. Some of these activities included dancing, running, exercising in the gym - all of which were things that were grounding and important to her.

Despite flare-ups, Helen remained persistent in her goals, but was flexible with how she achieved them. Some days that meant a shorter run. Some days it meant moving differently. Some days it meant sitting with the discomfort of doing less, and trusting that doing less wasn’t bad for her recovery.

The goal never changed. Only the path did.

So What is Reassurance Anyway?

Most of us think reassurance means saying the right thing.

It isn’t.

Reassurance is a set of both verbal and non-verbal behaviours that happen long before you open your mouth (Linton et al 2008). So how do we impart reassurance in practice? Some very smart people answered this question by describing the following 4 principles (Belton et al, 2022):

1. Effective Data Collection: Let patients tell their narrative and explore the impact of pain on their life. Elicit their emotions and beliefs so you understand the full picture of their experience. How can you reassure someone unless they’re given the opportunity to tell their story and feel safe enough to do so?

2. Relationship Building: Listen without interrupting and respond with genuine empathy to show you are truly attentive. Indicate through your presence and words that their story matters. How can you reassure someone unless they trust you to listen?

3. Explicit Validation: Recognize their suffering and distress, and indicate that you believe their entire narrative without judgment. Show that their emotional response to their condition is understandable and valid. How can you reassure someone unless they feel safe from judgment?

4. Effective Cognitive Reassurance: Describe possible causes when you can, discuss likely prognosis, and agree together on how treatment might interact with their body. This includes giving them the information they need to make informed decisions about their care. “How can you reassure someone unless they understand what’s happening, what comes next, and what to expect from treatment?”

Helen makes me proud every day. While she still asks for reassurance, she is presenting more calmly during and after flare-ups.

That’s it. That’s the whole goal.

Not zero pain. Not zero flare-ups.

Flare-ups aren’t failures. They’re the curriculum.

As Nelson Mandela said: “I never lose. I either win or I learn.”

In chronic pain care, so does your patient. They sometimes just need you to remind them which they are doing: winning or learning.

Want to deepen your biopsychosocial approach?

If this framework resonates with you and you’re interested in expanding how you integrate pain science, patient psychology, and clinical reasoning into your practice, my colleague Dr. Shawn Thistle and I created a comprehensive course together: Mastering the Biopsychosocial Approach: A Contemporary Lens for Chiropractors. It’s designed for clinicians who want to move beyond symptom management and truly transform how they think about complex pain cases.

You can purchase the course here.

Until next time!

Subscribe now

Imagine this: you start your day by learning that a new patient has scheduled an assessment. While receiving their history, you discover they’ve been living with pain for a long time, but they’re happy, goal-oriented, and pragmatic. Working with patients like this can be incredibly rewarding.

But many of us have had the opposite experience.

Imagine starting your day with another new patient assessment. This person arrives looking defeated, sad, flat, maybe even hopeless.

Many clinicians have shared with me that they feel frustrated treating patients with chronic pain who present with a negative affect. So how do we navigate those difficult emotions and help our patients?

“Tell Me Your Story…”

Monica had been living with widespread body pain (fibromyalgia) for 25 years when she started seeing our team at the Pain & Wellness Centre.

In short, Monica grew up in a country affected by civil war. She came to Canada alone at a young age and, through sheer determination, achieved her lifelong goal of becoming a healthcare provider herself. She got married and had 2 beautiful children, but her pain began in the context of significant and unrelenting family discord.

Monica tearfully recounted her story and told me what pain had taken from her: moments with her children, her career, and her ability to find joy in almost anything.

Her pain mattered, but what struck me most was everything wrapped around the pain: grief, loss, despair, and a fractured sense of self. That's suffering. And here's the thing most of us miss in clinic...

We often treat pain and pain-related suffering like they’re the same thing.

They aren’t.

What Is Pain-Related Suffering?

So what actually is suffering? And why does it matter clinically?
Stilwell (2022) identified the following four key attributes of pain-related suffering:

1. Pain and suffering are related, but distinct. You can experience pain and suffering together, pain without suffering, and suffering without pain.

2. Suffering is deeply personal. It is subjective, private, and lived from the inside.

3. Suffering comes with painful emotional states: sadness, grief, anger, frustration. (Yes, clinicians, patients feel these too. So if you’re feeling them in the room, they may be feeling them even more. Time to flex your empathy muscles!)

4. Suffering often disrupts one’s sense of self: identity loss, role change, loss of control, and difficulty pursuing meaningful goals.

Monica had a hard life, and she was suffering. But here's what I noticed: despite her pain, fatigue, and functional limitations, she genuinely wanted to find a path toward recovery. The question wasn't whether she had the will, it was whether I could match her willingness with the right approach. So we started with something simple.

Seek and You Will Find

I always warn people with persistent pain that it may take a few sessions to figure out a path forward.

That’s because I need to get to know them, and, just as importantly, they need to get to know me.

On our second visit, I asked Monica a difficult question:

“When was the last time you felt well?”

She paused.

“Maybe last week for an afternoon. It’s unpredictable.”

After some back-and-forth, I asked another question.

“Was there ever a time when you woke up feeling awful, and then for some reason spontaneously felt better?”

“Yes… when my nephew visited from California. It was such a surprise, and I was so happy to see him. It was like my pain melted away for the afternoon.”

I responded:

“Isn’t that interesting… why do you think that happened?”

“I have no idea.”

“It sounds like you experienced a large and intense feeling of joy.”

From there, we discussed the last time Monica consistently felt joy in her life.

She fondly recalled dancing on stage around the country as a youngster. This is where things clicked, and where I realized we weren't going to solve this with traditional rehab protocols. We needed to rebuild her sense of self, and the only way forward was to take a risk.

Subscribe now

Your Clinic Is Your Laboratory

I proposed putting on her favourite performance music and imagining herself dancing.

More than that, I asked her to imagine it in vivid detail: the smell in the air, the temperature in the room, the noise of the crowd.

After looking at me like I had three heads, she gave it a shot for about two minutes and…

…nothing changed.

For me, when nothing changes, it usually means one of two things: we either need to try something else, or we need to keep going.

As a clinical risk-taker, I chose to keep going.

I turned the music back on and asked her to simply perform the hand gestures she might use in a dance while sitting.

She did that for about two minutes.

Afterward, her pain was a bit better.

“Isn’t that interesting?” I said.

When I asked why, Monica replied:

“I feel happier, doc.”

“I feel happier, doc” is probably one of my favourite phrases a patient can say.

I then asked Monica to stand up and actually dance for another two minutes.

Afterward, she told me her pain had dropped from 8/10 to 4/10. We induced analgesia with movement that made her happy. Isn't that wonderful? So why did dancing work when traditional rehab hadn't? When meaningful goals are sufficiently rewarding, the brain can suppress nociceptive signalling through top-down processes (Garland, 2021).

Why Is Joy a Viable Treatment for Pain?

Three interventions may help facilitate this: savouring pleasant sensations, generating pleasant internal states despite pain, and cultivating meaning by connecting pain to a broader life purpose (Garland, 2021).

Monica wasn’t just exercising. She was savouring something pleasurable and reconnecting with something she deeply missed.

So when you ask your patients, “What do you want to get back to?” don’t stop at function.

Guide them toward activities they genuinely long for.

Activities that bring joy and restore their sense of self.

In cases like Monica’s, are we treating pain or treating suffering?

Who knows. All I know is that it worked.

So what happened next?

Joy Begets Joy?

Monica had an embodied experience that joyful movement could reduce her pain. That gave her hope, and a willingness to do more things that brought her joy.

From there, we gamified pickleball by playing keep-up with her racquet to reacclimatize her to wrist movements (yes, in my treatment room).

Then she started hitting against a wall at home by herself, which she found fun and pain relieving.

She started baking for her kids again because the smells brought her joy.

We even started walking outside together as part of treatment, which led to some meaningful and unforgettable conversations.

“Use dance like it’s an Advil. Take it when you need it. But there’s no ceiling dose. You can’t overdose on it.” That was my advice to her.

Recently, Monica told me she trained for and completed a 5 km charity walk. It brought her immense joy because she never thought she’d do something like that again.

These are the cases that bring you back to work every day. Helping Monica rediscover joy was as healing for me as it was for her.

So here's the question I want you to sit with:

But here’s what’s important to know: Monica’s journey wasn’t a straight line.

What Can Joy Teach Us?

Monica’s recovery had ups and downs. She had good days and bad days. Often, we had to pause and figure out how to support her through the bad days.

Sometimes that meant difficult conversations. Sometimes those conversations were about the past. Sometimes she was simply frustrated with pain.

That’s okay. Good and bad days will happen and recovery is never linear.

Time and consistency lead to growth, and that is the seed we need to plant in our patients.

I believe Mother Teresa’s quote above is right: Joy can be anything to anyone. Prayer. Strength (training?). Love. Through joy, we can help people reconnect with their sense of self, their identity, their humanity, or, if you prefer, their soul.

You just have to use your imagination.

Subscribe now

To help with future posts, please kindly complete the 10 second poll below!

Share

“Everyone you meet is fighting a battle you know nothing about. Be kind. Always.”

• Robin Williams

Have you ever said this about a patient?

“They’re just so depressed and they need help. What do I do?”

“I spend all our sessions talking about what’s wrong in their life.”

“I can’t seem to convince them that there isn’t something more wrong with them.”

I have, too.

I bet you also feel that when chronic pain, stress, and/or mental health challenges co-exist, treating MSK pain becomes more challenging (Foley et al., 2021; De La Rosa, 2024).

Me too.

So how should we deal with this combination of factors in clinical practice? And most importantly, how do we discuss these issues with our patients without damaging trust or implying the pain is “all in their head”?

Sophia Walks Into My Office

These questions were running through my mind when Sophia, a stressed 30-year-old, came in with six months of daily headaches. Like always, I started our session by saying:

“Tell me your story…”

Sophia reported that her headaches began “out of nowhere” and had remained at an unrelenting 8–10/10 ever since. Her pain gradually worsened as the day progressed, was aggravated by stress, and improved by performing HIIT workouts.

Sound familiar to your day-to-day?

It is not uncommon to stop receiving the history here and move on to the physical exam. However, to truly understand a person, their environment, and the context of their life, we must dig deeper.

So I asked:

“What was going on in your life when the pain started? Were there any new physical or emotional stressors?”

Sophia revealed that her headaches started about two months after starting her part-time MBA (which she hated). She was also working as a branch manager at a busy bank location (which she also hated). Finally, her twin brother revealed that he was moving to England for work (she couldn’t stand the thought of living without him nearby).

Suffice it to say, getting out of bed every day was hard for Sophia.

An experience we often see in patients, and perhaps in our own lives, too.

When Stress Becomes Relevant

The onset of symptoms after an unrelenting stressor is a common story people in pain tell, and it’s easy to miss. They may disclose work-related stress, difficulty sleeping, marital discord, or being a caregiver for a family member.

I know what you might be thinking:

“Come on, Demetry, we all have stress in our lives!”

But these stressors are different.

Stressors may be persistent or feel intense to the person, even if they seem minor to you. Patients may also feel they have little control over the stressor or have no idea when it will end.

That perceived lack of control matters.

There are other clues that may raise suspicion:

• Improved pain while on vacation that returns upon coming home (no, it’s not the nice weather)
• Pain throughout the week that improves on weekends
• Pain after talking to or being around a specific person or group of people
• Pain that is inconsistent (“It hurts while I’m driving some days, but not others.”)

While these factors aren’t the be-all-end-all, hearing them should trigger you to be curious and ask more questions.

When Stress Shows Up as Pain

When stress persists, systems involved in sleep, autonomic regulation, immune function, muscle tension, attention, and emotional regulation can become dysregulated (Chapman et al., 2008; Scarlatti et al., 2026).

Once that happens, pain, fatigue, anxiety, poor sleep, and rumination can feed into each other, amplifying suffering (Chapman et al., 2008).

Wait… what happened to Sophia?

The physical exam revealed significantly limited active cervical spine ROM and suboccipital tenderness. Interestingly, Sophia could rotate her neck nearly 90 degrees while speaking with me, which was far more than during formal testing.

Sophia was buzzing.

“What’s going on!?” she asked.

I asked for two more minutes to try something else: a body scan.

It went something like this:

Breathe in and gently tense your toes… then release.
Calves tense…then release.
Shoulders tense…then release.
Jaw tense…then release.
Brow tense…then release.

After two minutes, Sophia’s pain was 2/10, the lowest it had been in months.

I sent Sophia home with instructions to do the body scan twice daily and continue HIIT classes 2–3 times weekly.

She came back the next week with 0/10 pain and only one short-lived, low-intensity headache that resolved after doing the body scan.

Having the Conversation

Sophia and I then discussed how, when someone is under prolonged or intense stress, a pain response can occur. We don’t always know exactly how, why, or in whom, but it can happen.

I told her:

“It doesn’t mean you’re crazy.”

“It doesn’t mean your pain isn’t real.”

“It doesn’t mean the pain is all in your head.”

“It just means that human beings are complex and by extension, so is pain.”

Most patients don’t need a complicated explanation. They need a coherent one: human beings are complex.

More importantly, Sophia now had a tangible solution.

But that wasn’t where we stopped.

The stressors that were present when the pain started were still there.

So I asked:

“Can I make an observation and maybe a recommendation? All those stressors you told me about… they’re still present. Would you ever consider talking to someone about them? Maybe you can find ways to resolve them or cope better?”

Sophia excitedly said:

“Sure!”

In the end, Sophia never experienced another headache.

After working with a social worker, Sophia made some difficult but important decisions. She quit her job. She left her MBA program. Eventually, she moved to England with her brother.

That’s the kind of impact we can have when we give the right person the right intervention at the right time.

Sometimes, that intervention is simply education, a referral and the company of someone who truly hears them.

Things to Look For

Not all patients are like Sophia.

Some patients are depressed and/or anxious, and treating those conditions is outside the scope of many allied health providers.

But that doesn’t mean we can’t ask questions and guide the person accordingly.

In the context of depression, we may ask:

“Can I ask you some questions about life in general? Have you been feeling sad lately? Do you feel sad most days? Does it make it hard to do the things you need to do, like going to work?”

Here are some signs and symptoms of depression to look for:

• Flat affect
• Lack of desire to do things previously enjoyed (anhedonia)
• Feeling sad
• Slowed movement or thought processes
• Difficulty falling or staying asleep

In the context of anxiety, we may ask:

“Do you often feel worried? Is your worry hard to control? How often? Most days? Does worrying make it difficult to function day to day?”

Here are some symptoms of anxiety to look for:

• Nail biting or skin picking
• High heart rate or palpitations
• Nausea
• Sweaty palms
• Lightheadedness, dizziness, or fatigue
• Feeling jumpy
• Poor sleep

(Of course, rule out drugs 🙂)

You don’t need to collect all of this information on day one.

Ask over time, once rapport is established.

Ask while working on their neck or back.

Ask on the day they look stressed and can’t hide it.

Just ask.

People will tell you when they’re ready.

Subscribe now

What We Can Do in Practice

The fact is, stress and mental health challenges can affect your ability to help someone.

As healthcare providers, we must help the human being in front of us, and if we can’t, it is our responsibility to get them to someone who can.

In the end, play to your strengths:

• Ask questions. Give them the gift of your time. And. Just. Listen.
• Understand your patient, their worldview, and their environment
• Develop a strong therapeutic alliance
• Don’t judge—ask, reflect, and validate
• Refer out when necessary

Sometimes the most important thing we offer isn’t a manual therapy technique, an exercise, or even a diagnosis.

Sometimes it’s helping someone feel seen, understood, and safe enough to tell the truth about what is hurting.

And sometimes, that changes everything. As Robin Williams said:

I have linked some amazing resources to help you in clinical practice below. But before looking at those, I kindly ask that you fill in the brief poll below. It will help me with future posts!

Helpful Resources

If you want to explore this topic further, here are a few resources I recommend for both clinicians and patients (hyperlinked below):

• Centre for Addiction and Mental Health (CAMH) — excellent resources on depression and anxiety.

• Visit the Centres for Addition and Mental Health (CAMH) website where you can also find amazing mental health and addiction overviews, training programs and tips on how to interview someone about their mental health

• Screening questionnaires such as the PHQ-9 (depression) and GAD-7 (anxiety) can help identify depression and anxiety in practice

• Canadian Mental Health Association (CMHA) provides programs and supports across Canada. Visit CMHA for resources, access to Bounceback (an online resources in your Canadian region), and other national programs

• Pain Canada — a great resource for people in pain and clinicians wanting to learn more. Visit Pain Canada

Until next time.

Share

Leave a comment

Subscribe now

Going one more round when you don’t think you can. That’s what makes all the difference in your life.

• Rocky Balboa

How many times have you seen a patient with chronic pain and thought, “Man, they’re hopeless...”

I suspect most clinicians have felt this at some point. We may not use the word “hopeless,” but we often describe the same observation in other ways:

• “They won’t do their exercises.”
• “They’re depressed.”
• “They’re catastrophizing.”

Sound familiar? It does to me too, because I’ve definitely said all of them.

But what if we’re describing the wrong thing? What if what we’re observing isn’t hopelessness at all? What if it’s helplessness?

I believe what many of us are really describing is a patient’s deeply personal sense of helplessness about their ability to recover.

Helplessness is theorized to occur when repeated failures create a feeling of lost control, which reduces one’s motivation and effort toward achieving future goals (Scherer, 2022). Over time, that helplessness can spread into other areas of life. Someone who repeatedly fails to achieve one important goal may begin to doubt their ability to achieve others (Scherer, 2022, Boddez, 2022).

Chronic pain provides fertile ground for this process.

People living with pain often seek relief through rest, exercise, medication, injections, surgery, chiropractic care, and countless other approaches. When those attempts repeatedly fail, they may stop believing their actions can meaningfully influence their future. They may give up. They may feel helpless.

Research suggests that helplessness is associated with passive coping, avoidance behaviours, poorer mental health, and higher pain intensity (Samwell, 2003). To this end, person may arrive in your office wanting help, but with an empty gas tank for things like exercise, movement, and self-management. This can look like “non-compliance,” preference for passive care, depression, or catastrophic language.

Sounds pretty helpless, doesn’t it?

More importantly, it sounds understandable.

What if our role is not simply to treat pain, but to help people regain a sense of control despite pain?

A beloved patient named Maria comes to mind.

Maria came to our clinic with several musculoskeletal complaints, the most disabling being persistent pain in both lower legs. She was a lifelong athlete, but couldn’t squat, skate, run, or do many of the activities that made her feel like herself because of pain.

Her legs were investigated thoroughly, and nothing was found that could adequately explain the severity of her symptoms. Maria felt frustrated, scared, and most of all helpless. Her identity had been shaken.

Once our team was confident nothing sinister was occurring, we shifted our focus toward helping Maria safely reconnect with meaningful activities.

We talked about what she missed doing and how pain had affected her identity, confidence, and sense of self. More than anything, these conversations helped her feel heard, understood, and safe.

Over time, Maria began to view her pain differently. Rather than seeing it as evidence of damage, she began to understand it as sensitivity. We also identified movements and positions that could reliably reduce her symptoms, even if only temporarily. This showed her that pain was something she could influence.

That changed everything.

Together, we began setting small behavioural experiments designed to help her return to meaningful activities. To accomplish this, we followed a few simple rules:

• Goals were set collaboratively.
• Goals were meaningful to her.
• Mildly heightened but short-lived pain was acceptable.

We started with upper body training. Then we gradually introduced leg exercises that were mildly painful but tolerable. Eventually, she returned to movements that had once seemed impossible, such as squatting and lunging. There were setbacks along the way, but each success built confidence for the next challenge.

Maria was also fortunate to work with members of our psychology, naturopathy, massage therapy, and mindfulness teams. Through those experiences she improved her sleep, developed healthier boundaries, practiced self-compassion, and regained a greater sense of control over her life.

Small wins created bigger wins.

There is some evidence supporting this approach. A 2019 study found that people with chronic low back pain who set their own treatment goals achieved greater improvements in pain, disability, confidence, quality of life, and fear of movement than those receiving standard exercise advice. While the study had limitations, it highlights the potential value of collaborative goal setting (Gardner, 2019).

Reading that study made me ponder this issue of ‘non-compliance’ that clinicians have:

• Are we prescribing movement that is meaningful to the individual?
• Does our advice fit within the context of their life?
• Are goals being developed collaboratively or prescribed unilaterally?

If you think about patient care through this lens, are people truly non-compliant, depressed, or catastrophizing?

Or do they feel helpless?

To be clear, this is not an argument against effective treatments. Many patients improve with exercise, manual therapy, medication, injections, or surgery. Rather, it is a reminder that different people need different things at different times.

So what should we do? I always come back to the following:

• Talk to your patients & listen carefully. Understand their environment, their values, and their worldview.

• Make patients feel safe, seen and heard.

• Treat pain when you can.

• Help people return to meaningful life whenever possible.

To me, patient care is ultimately about collaboration, trust, and building resilience through helping people rediscover what they are capable of doing.

What a privilege…

Until next time…

I bet we are all scared of something. Some fears are very common, like ophidiophobia (fear of snakes). In the case of snakes, my mom comes to mind - she even dislikes my son playing with toys that look like snakes! My son is weirdly afraid of animatronic robots, so that part of the Chuck E Cheese birthday party where everyone dances with the big mouse is a bit difficult for him.

(He can be a bit creepy, no?)

Others, may have less common fears. Some of us may have anatidaephobia, which is a hilariously irrational fear that somewhere, somehow, a duck is watching you!

(Yeesh!)

The fact is, we are all scared of something. It’s a very human experience. Some of our patients have very particular fears, one of them being kinesiophobia.

Kinesiophobia is defined as “An excessive, irrational and debilitating fear of physical movement resulting from a feeling of vulnerability due to painful injury or re-injury (Vlaeyen et al 1995). A bit judgy if you ask me. Irrational? Anyway, some of our patients fear movement (kinesiophobia), pain itself (algophobia) and/or even losing out on parts of their life because of pain or injury (something-bad-happening-o-phobia).

Helping people through this part of their journey can be extremely challenging, but not impossible. Let me tell you a story about a lovely 38-year-old female with constant low back and intermittent right posterior thigh pain who through courage and love ‘faced everything’ and rose-up.

“Rose” developed low back pain in 2019 while pregnant. Post-pregnancy, the pain was largely episodic, but became constant in 2024 after a massive flare-up while doing yoga. She went to the ER on several occasions due to this pain, asking for help. They evaluated her with imaging, which only reported ‘disc bulges.’ Things took a turn for the worse in August 2025 when she developed constant pain and diffuse bilateral leg pain after sitting, and twisting to pick up a drink. She was then admitted to hospital for nearly 2-weeks, where all tests to explain her pain were negative. From here, she stopped her hobbies, valued activities and picking things up off the ground. I bet many of you can’t blame her either: how would you feel if you didn’t have the knowledge you have, went to the ER and they said ‘sorry, nothing to find here!’

By the time she saw me, her pain had improved, and focalized to the low back and right posterior thigh. But her life was still stalled. She was unable to move forward because her experiences had been too unbearable. “This happened because of nothing. Of course everything is scary!” were her words to me. This is where fear of movement, pain and the ramifications of pain may live. Before moving on with this story, let’s learn a bit more about the relationship between pain and fear.

Kinesiophobia and its counter parts are what’s called ‘pain-related cognitions.’ They are influenced by our environmental and social contexts, behaviours and other experiences. Symptoms of pain are oftentimes perceived as unpredictable, uncontrollable and threatening, and are believed to have intense consequences. Finally, the pain these individuals experience doesn’t make sense to them, and pain may just be a legit response to something that they can’t explain (Larrson 2016, Bunzli, 2015).

In fact, upwards of 50% of primary care patients with low back pain present with elevated fear. Also, pain-related fear is believed to mediate the relationship between pain and disability (Bunzli, 2017). People may engage in avoidance behaviours to prevent/postpone encounters with threat and engage in self-fulfilling prophecy (I am avoiding so I must be in danger). The prophecy also comes true for them, because if no flare-up happens through avoidance, they are successful in the short-term. These beliefs are also notoriously persistent as well (Vlaeyen, 2016). Overall, it is important to understand and perhaps target beliefs about pain in treatment of pain. Here’s how this presented in our case…

Our patient is a human being with a past. She described lifelong anxiety, post-partum PTSD, guilt about parenting limitations, and stated plainly that increased pain causes significant anxiety, fear and more disability. What was even more telling was how this impacted her identity. In these cases I often ask: “How has pain negatively affected your life?” Her responses were (paraphrased):

• They keep telling me that it’s nothing. I’m afraid they missed something.

• I’m afraid I’ll end-up in a wheelchair

• I don’t feel confident in my body

• I control it by not picking things up

• [Exercise] is good for your back, so I do it, even though it gives me 2-3 days of extreme pain.

This is a human being for whom we should have empathy and compassion. It is our duty as clinicians to validate these beliefs with compassion: “that sounds really hard. I’m sorry you’ve had to go through that.”

On examination, all her movements were guarded and painful. Her spine remained completely rigid on flexion. Fear, not tissue, was limiting her. (something to be taken in context, not as a quintessential example of kinesiophobia). Neurological examination and nerve tension signs were unrevealing. The key observation here is that her conscious and unconscious behaviours far outweighed any neurological or tissue injury at this point. Her past and examination reveal some of the basic tenants about kinesiophobia we discussed earlier: avoidance behaviours (avoidance of movement and other threatening parts of life), self-fulfilling prophecy (avoidance —> disability —> more avoidance —> more disability), and was indeed persistent.

So what do we do with this information? Turn and run? I mean…maybe? It’s ok to identify this stuff and compassionately refer to another clinician who you believe has skills you don’t. That’s an acceptable example of understanding oneself. However, in this case I prompted her to contemplate some of the things in this narrative that led to misconceptions about pain and bodily injury (ie. imaging findings and her (diagnostic labels that foster safety), introduce new strategies to address pain and stress (ie. safe movement, relaxation, cognitive reframing), a gradual return to goals, and various other behavioural changes (ie. flare-up plans, ways to control pain, emotional responses to pain etc). Here’s how I handled this in Rose’s case:

• I simply said that her pain was mechanical, and reassured her that the probability of something sinister being present was incredibly low and how I knew that.

• I offered an alternative thought about pain, stating that it is more complex than simply tissue damage, and that multiple factors can impact the pain we all feel and how much impact it has on our live.

• We also discussed that potentially, her flare-ups can be attributed to doing too much too soon, and that she can’t tolerate certain movements or loads because of heightened tissue sensitivity. We then recreated a plan to help her deal with flare-ups in real time.

Overall, this series of discussions made her feel safe & heard. There’s no larger antidote to fear than feeling safe and supported. From here, we could create goals for care. Hers were to return to her cake business (which she loves), re-engaging in Pilates, picking things up from the floor and to improve her independence around the house.

After a few blunders (yes, I make mistakes too!), we started on an exercise program on the floor that mimicked Pilates-like exercises. This isn’t because I’m a big fan of “core exercises” but because they were similar to what she was aiming for and also because she could tolerate them. We also gradually exposed her to prolonged standing through baking (of which I was the lucky beneficiary).

(The philosopher Stone Cold Steve Austin once said “Can I get a ‘Hell yeah’!?”)

And we waited. Good things take time. We managed barriers such as unhelpful cognitions, emotional responses to movement experiments and gradually increased tolerance. Over time the following happened:

Now, Rose can still experience pain. Somtimes it’s intense. However, she controls it. She understands that it’s sensitivity and that sensitivity can change based on a myriad of factors (including doing more than her threshold allows). However, her business is thriving. She’s exercising. She can do anything and everything she wants, with the understanding that she she is safe. She has her life back with less pain, and she’s still improving.

In my opinion, this is what “pain management” is. It’s helping people navigate through things that are complex. They are the hero (Batman). You are the guide (Alfred). You win together.

So what should we take from this story:

1. I truly believe that you’re awesome at what you do. Keep helping people and make that the reason you wake up in the morning.

2. Sometimes people have difficulty improving because of cognitions about pain, such as fear of pain, movement or the effect pain might have on their life. Accept that with grace. Your job is to accept that and make the patient feel safe and heard.

3. Don’t go to debunking - we must understand the person in context, and identify a way for them to move forward as a partnership between hero (patient) and guide (clinician).

4. Victories can happen in many ways - pain reduction, fewer flare-ups, changes in cognitions, returning to life. All are on the table. You and your patient together decide what victory looks like.

5. Like I say to my son - people develop skills & habits at different rates at different times. What’s important is to compare yourself to yourself, not to some ideal or others. The ideal/others is the horizon in the desert. The closer you get, the farther away it becomes. So enable patients to compare their progress to where they started, and you won’t fail.

What fear-based pattern do you see most in your practice?

If you liked this and learned something positive, please share it with friends, family or colleagues!

Until next time.

Many of you might find yourself working with patients who continue to struggle despite your best efforts. They have seen multiple providers, tried numerous treatments, and often seem stuck. Progress is slow, unpredictable, or absent altogether. Eventually, many clinicians begin asking themselves the same question:

What am I missing?

The problem is not that you care too little or lack skill. The problem is that most healthcare professionals receive very little practical training in how to assess, classify, and manage persistent pain. We are taught how to diagnose injury and pathology, but many of us are never given a clear framework for understanding the patient whose pain persists despite appropriate care.

Over the past decade, I have dedicated my career to working with people living with chronic pain. Through thousands of patient encounters, I have developed practical frameworks for making sense of complex pain presentations.

This newsletter exists to share those frameworks.

Each week, I’ll share clinical insights, assessment strategies, case studies, and communication tools to help you think more clearly, feel more confident, and improve outcomes for people living with chronic pain.

If that sounds valuable, subscribe and join the conversation.

Subscribe now