Teaching people about pain – why do we keep beating around the bush

A frank approach to interpersonal communication brings with it some challenges, but having to dig oneself out of a hole, created by strategically avoiding the truth, is not one of them. This frank approach is well suited to science – the scientific process requires us to pursue and report the truth, the whole truth and nothing but the truth. We do not tend to avoid aspects of the truth because we think that they are too hard for people to understand; for example, we do not avoid the amazing truth that the brain constructs visual experience from the information available to it, and instead suggest that the eyes themselves actually create visual experience and send the visual experience to the brain to be registered; we do not suggest that the ears capture words and bird-calls and racing cars and send those sounds to the brain to be registered. We tend to endorse the complexity of the brain and its fundamental role in what we experience. Unless, of course, we are talking about pain.

Some 25 years ago, Patrick Wall, as frank a communicator as any, lamented the trend towards beating around the bush when it comes to pain: “The labeling of nociceptors as pain fibers was not an admirable simplification, but an unfortunate trivialization under the guise of simplification” [1]. Of course, equating pain to activity in nociceptors is seductive – nociception and pain seem so tightly coupled. However, are nociception and pain really so tightly coupled? This issue was actually settled a couple of decades ago – there is not an isomorphic relationship between pain and nociception, nor between pain and tissue damage [2]. A very large amount of research has explored the multifactorial nature of pain (see [3] for a clinic-friendly review). Modulators broadly fit into one of three categories: prioritization, meaning and transmission/processing. Prioritization depends on the survival value of a nociceptive stimulus. Observational data abound; for example, the extensive work with military and civilian injuries – the soldier feels little pain until he is safe behind lines [4]. Experimental data have corroborated this – noxious stimuli do not hurt in cases of extreme air hunger [5] – and the pain threshold is higher after a bout of startlingly loud noises [6].

The second category – meaning – is, in my view, the most important to those of us working in the clinical pain sciences. Meaning is a very potent modulator of the relationship between nociception and pain. Indeed, one might argue that meaning is the critical determinant of pain, because if a nociceptive input is not evaluated by the brain as reflecting a threat to body tissue, pain would clearly be an erroneous output, serve no survival function and offer no evolutionary advantage. Again, anecdotal data abound – most strikingly, there are religious or cultural practices that involve severe noxious input, but no pain is reportedly experienced – and experimental data have corroborated this: a very cold noxious stimulus hurts more if there are explicit [7] or implicit [8] cues that provide credible information to suggest that the very cold stimulus is actually very hot, which would be more dangerous to body tissue.

The third category – transmission/processing – refers to both the well-established state-dependent functioning of nociceptive pathways and real-time modulation of transmission and processing by, for example, expectation [9]. Real-time modulation can involve neurally, neurochemically or humorally driven alteration of the response profile of neurones within the nociceptive neuraxis [10].

So, the mislabeling of nociceptors as pain fibers was indeed a trivialization, but was it really that unfortunate? I contend that one need only look at the huge burden of chronic pain to uphold a resounding ‘yes’. Chronic pain is terribly costly to our societies – approximately US$1500 per person per year in the USA [101] – and to the individual sufferers of pain, who often descend into a spiral of increasing economic, social and personal disadvantage. The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain [11], neck pain [12] and knee osteoarthritis [13]). Yet we continue to avoid the truth that tissue damage, nociception and pain are distinct. I would go so far as to suggest that even the use of these erroneous terms – pain receptors, pain fibers and pain pathways – leaves the patient with chronic pain feeling illegitimate and betrayed, and leaves the rehabilitation team lacking credibility when they look beyond the tissues for a way to change pain.

Generally speaking, however, are these issues usually more than just semantics? Can one argue that it might be unhelpful to simplify things when we are talking about chronic pain, but it is fine when we are talking about acute pain? This suggestion requires us to adopt a different understanding of biology once someone ‘goes chronic’. This is problematic, not least because those in chronic pain first had acute pain, and to change our story once they are chronic might give the distinct impression that we are clutching at straws. Indeed, by the time people progress from acute to chronic pain, our previous avoidance of the truth – our unfortunate trivialization – has dug a very big hole from which it is difficult to climb out.

To be continued…

Previously published in: Moseley, G. (2012). Teaching people about pain: why do we keep beating around the bush? Pain Management, 2 (1), 1-3 DOI: 10.2217/pmt.11.73

About Lorimer Moseley

Lorimer is NHMRC Senior Research Fellow with twenty years clinical experience working with people in pain. After spending some time as a Nuffield Medical Research Fellow at Oxford University he returned to Australia in 2009 to take up an NHMRC Senior Research Fellowship at Neuroscience Research Australia (NeuRA). In 2011, he was appointed Professor of Clinical Neurosciences & the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide. He runs the Body in Mind research groups. He is the only Clinical Scientist to have knocked over a water tank tower in Outback Australia.

Link to Lorimer’s published research hereDownloadable PDFs here.


[1] Wall P, McMahon S. The relationship of perceived pain to afferent nerve impulses. Trends Neurosci. 9(6), 254–255 (1986).

[2] Wall PD, McMahon SB. Microneuronography and its relation to perceived sensation. A critical review. Pain 21(3), 209–229 (1985).

[3] Butler D, Moseley GL. Explain Pain. NOI Group Publishing, Australia (2003).

[4] Beecher H. Relationship of the significance of the wound to the pain experience. JAMA 161(17), 1609–1613 (1956).

[5] Banzett RB, Gracely RH, Lansing RW. When it’s hard to breathe, maybe pain doesn’t matter. Focus on “Dyspnea as a noxious sensation: inspiratory threshold loading may trigger diffuse noxious inhibitory controls in humans”. J. Neurophysiol. 97(2), 959–960 (2007).

[6] Meagher MW, Rhudy JL. Noise stress and human pain thresholds: divergent effects in men and women. J. Pain 2(1), 57–64 (2001).

[7] Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain 109, 20–25 (2004).

[8] Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain 133, 64–71 (2007).

[9] Keltner JR, Furst A, Fan C, Redfern R, Inglis B, Fields HL. Isolating the modulatory effect of expectation on pain transmission: a functional magnetic resonance imaging study. J. Neurosci. 26(16), 4437–4443 (2006).

[10] Ren K, Dubner R. Enhanced descending modulation of nociception in rats with persistent hindpaw inflammation. 18 J. Neurophysiol. 76(5), 3025–3037 (1996).

[11] van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine 22(4), 19 427–434 (1997).

[12] Peterson C, Bolton J, Wood AR, Humphreys BK. A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United Kingdom patients. Spine 28(2), 129–133 (2003). 20

[13] Link TM, Steinbach LS, Ghosh S et al. Osteoarthritis: MR imaging findings in different stages of disease and correlation with clinical findings. Radiology 226(2), 373–381 21 (2003).

[101] Website: Health, United States, 2010, with special feature on death and dying. www.cdc.gov/nchs/data/hus/hus10.pdf



  1. Adding to my previous comment,
    I’ve just read part2
    and was delighted to stumble across Patty Nie’s comment (april5th 2013),
    where she gives you full credit for saving her life,
    and believe me that is precisely what you have done.
    To quote her:
    “By stating to myself “You’re OK, there is no danger here” I can just about stop what is going on in my body. I still have some resistance with this because of what my body has been going through, but it’s only been two weeks! ”

    We are on the same page.

    It’s not giving yourself time to believe, not trusting the most subtle shifts, not
    If you can’t believe blindly, then believe in the possibility.
    Allow yourself (your mind-consciousness, whatever label
    you want to put on it, though you don’t have to understand
    how a Mustang is constructed to enjoy driving it) to feel it’s going
    to be okay, that your pain is only FOR NOW, not forever.
    In an age of instant gratification, people must re-learn a
    little patience. Very often, you’re setting things into motion,
    neuronal orchestras that need follow-up, reinforcement
    of message, be a good conductor, don’t walk away
    before your proteges have perfected that symphony.

    At the end of the day all the explanations are just to get
    people to believe its possible. Want some real unlikely wisdom,
    listen to Arnold Schwarzenegger:
    “The mind is the limit. As long as the mind can envision the fact that you can do something, you can do it, as long as you really believe 100 percent.”

    It’s true.

    We don’t have to know everything to participate in the magic.
    We may never know everything.
    Far better to choke ourselves with self-limiting beliefs.
    As Socrates (a more erudite but necessarily wiser source
    than Arnie) puts it:
    ‘I am likely to be wiser than he to this small extent, that I do not think I know what I do not know.’

    So thank you Lorimer.

    Never a greater deed done than to save another’s life.

    People often forget that people in pain have families,
    that pain spreads everywhere, into other people’s
    minds and bodies. Save one, save many.

  2. I am somewhat relieved to read this article

    An article by Paul,Ingraham quotes you extensively
    Here is a section I completely disagree with.

    “The brain may powerfully control how we experience potentially threatening stimuli, but I’m sorry to report that you do not control your brain. Consciousness and “mind” are by-products of brain function and physiological state. (Deep, eh?) It’s not your opinion of sensory signals that counts, it’s what your brain thinks of it — and that happens quite independently of consciousness and self-awareness.”

    I have no qualification in the sciences but I can speak for my own experience. Having suffered chronic pain for over 8 years (I could only walk 20 paces between rests), I focused heavily on the meaning of my pain, or rather it’s lack of meaning. Over a period of weeks, reinforcing this simple focused message, led to my chronic pain disappearing. I now choose to jog to my local supermarket instead of using the car.
    I am helping my grandfather in the same way.

    I am not particularly religious, I am not a new-ager, I am not selling a book, I do not run an expensive clinic. I’m just a plain boring unqualified guy who’s got his life back after an awful time. I’m only motivated by an urge to help others.
    all the fancy science, I can tell you one thing. You can control your brain, you can think away pain. You are a unity, not a set of different compartments. For Ingraham to blithely quote you and tell thousands who read his pages that we lack control, that “Many wise, calm, confident optimists still have chronic pain” is misleading and steals
    hope from many people, for whom hope may be the only comfort.

    We once all thought the sun rotated the earth, that the 4-minute mile was impossible, Even someone far smarter than all of us, Einstein, fervently believed nuclear power could never happen, As human beings, we are more than the sum of our parts and capable of more than ‘common wisdom’ thinks. If common wisdom is limiting, then we
    are all limited. Mechanics and poets, right.Strip down a 1972 Mustang and you’ll never find it’s beauty or meaning, the only way to do that is to take it for a drive.

    If anybody out there’s in trouble like I was, you can think away pain, you are your mind, your mind is you, you’re in control, just keep telling yourself it’s going to be okay, your mind isn’t something that’s out to lunch with the answering machine on, it’s not unobtainable, it’s part of you that you’ve left it in charge of all the boring day-to-day stuff and you have say ‘hey, wake up, we’ve made a mistake here ,you don’t have to trick yourself, just get in tune with yourself, reconnect. Takes time and persistence, or not, but feel it happening.

    I will re-quote your brilliant words:
    “one might argue that meaning is the critical determinant of pain, because if a nociceptive input is not evaluated by the brain as reflecting a threat to body tissue, pain would clearly be an erroneous output, serve no survival function and offer no evolutionary advantage.”
    This was at the heart of my mental focus.

  3. John Quintner says

    Stuart, I agree that Lorimer has given us an excellent working framework for third space negotiations. I very much like your concept of fluid creative exchanges.

  4. stuart miller says

    John, thanks for your insight. My limited understanding of third space engagement would be a fluid creative exchange between individuals without evidence of title. It would include other input such as multi-media possibly. I am open to listening. Having said this, do you think a framework of understanding like Lorimer stated at the start of this blog such as prioritization, transmission/ processing and meaning or another 3D framework such as form, matter, process and meaning (Capra) is helpful for understanding what someone is going through ?

  5. John Quintner says

    @ Stuart. In my opinion there are no ‘rules of thumb’. The key seems to be in achieving a truly intersubjective (“third space”) engagement with our patients. This is easier said than done and we need to spend a lot of time trying to introduce our fellow health professionals (including medicos) to the concept of negotiation within the shared space. Does this make sense?

  6. stuart miller says

    Thanks John. I do admit that after reading that study, I was more hopeful that recovery from a chronic pain condition was possible without the clinician -patient relationship. Therefore, because of this, I have been less eager to intervene and provide ‘quick fixes’ and more likely to look at what the person did as things improve. Having said that, my challenge to you is that even though we are constantly adapting to both our external and internal environment (and that there are shared core areas in our ‘self-referential’ brains for ‘pain networks’ as well as ‘task-related networks’ – Franco Cauda et al) are there simple ‘rules of thumb’ that you use when working with patients ?

  7. stuart miller says

    John, the paper I mentioned before by Anne Mengshoel and K Heggen was on 5 women (very small study) who had recovered from fibromyalgia. What I found helpful was that it was the resistance to the diagnosis and maintenance of a meaningful role in life that was consistent with their self image that was also highlighted as contributing to their recovery. As a practitioner, I am constantly aware of my limitations when dealing with patients with devastating illness and also persistent pain but am hopeful that they can find a way forwards. Perhaps, at times, things should be made as simple as possible, but not more so. Not my words but sometimes making things bigger and more complex is not always the answer.

    John Quintner Reply:

    Thanks Stuart. Beware the “post hoc ergo propter hoc” fallacy.

  8. John Quintner says

    @ Evanthis. I think that we have gone as far as we can. As for circularity, this is unavoidable whenever we try to understand our self-referential brains that possess the property of autopoiesis, amongst others.

  9. Hello Evanthis & John – This discussion is interesting. I had backed off a little to think about your comments to my posts John, wishing to avoid entering the swamp of consciousness debate . Waiting to see what others thought about your comments was important.

    Evanthis tends to echo my thoughts. The body has sensors connected to multidirectional pathways to the brain, where interpretation of the sensor information is determined and acted upon. The action taken by the brain can be mediated by experiential overlays and sometimes modified by damage.

    Communication of ideas at the boundaries of ‘known’ science can be fraught due to what has gone before. To progress we need to accept that a new set of descriptions may evolve to better describe newer theories or postulations. Some latitude of language needs to be accepted in the progression process, without becoming bogged down by semantics.

    Clarifications of terminology are fine if made in the spirit of discussion but could become tedious otherwise. Having said this, I look forward to the continued discussion, both in Lorimer’s Part 1 and Part 2 posts.
    Regards to all.

  10. John Quintner says

    Evanthas, “signaling” occurs at many levels (= the field of biosemiotics). We simply do not know how such signaling ever reaches consciousness.

    Evanthis Raftopoulos Reply:

    Absolutely John, we do know though that there is an existing relationship between signaling and consciousness, signaling and the pain experience. No signaling, no pain experience. I acknowledge that this relationship is indefinable and I also acknowledge that signaling occurs at many levels as you mentioned. How I understand this is that signaling in the brain tissue is necessary for the pain experience to emerge, while we cannot be as certain how signaling elsewhere plays a role (and if) in the pain experience. How do you feel about that? (I hope we are not talking in circles).

  11. Evanthis Raftopoulos says


    I do not disagree that the pain experience involves to a certain extend the entire organism, but I also think that we should be careful not to downplay the role of key signaling processes that have the capacity to modulate this experience (always in the context of our conscious awareness).

    “an experience of central neurophysiological processing” :
    Considering what we know at this point in time, it makes the most sense to me that any conscious experience including the pain experience is only possible thanks to signaling in the brain. We know that damage to certain parts of the brain has the capacity to alter the “unpleasant” part of the experience (eg pain asymbolia) which is also how we humans define the pain experience.

  12. John Quintner says

    @ Evanthis. Yes, I would disagree. My admittedly limited understanding of the pain experience is that it involves the entire organism.

    By the way, what exactly do you mean by “an experience of central neurophysiological processing.”

  13. Evanthis Raftopoulos says

    I agree with your last post John, maybe I was not reading your response to Mark correctly. In your response you stated that there is no place in the brain where the “neurophysiological” becomes “psychological” asking why say “perception of pain”. It appeared to me that you were saying that if we say “perception” we imply a psychological phenomenon that cannot be also described with neurophysiology. My point was that any perception (which is what comes to consciousness) can be considered as an experience of central neurophysiological processing. If that’s true, then describing the pain experience as a perception in the brain should be acceptable. Would you disagree?

  14. John Quintner says

    @ Evanthis. I would vote for “unknowbable” but how would I know? I cannot follow your argument about physiology, anatomy and the pain experience. The point that I was trying to make is that physiological and psychological frames are different ways of examining the same experience. There are many ways to alter the experience of pain but such alterations can be highly unpredictable as well as contextually related.
    @ Stuart. I am not familiar with the paper by Mengshoel. Has anyone else been able to replicate his results? Sounds too simplistic to me but I may be wrong.

  15. Evanthis Raftopoulos says

    John says:
    How about “… how the pain experience is created by the individual”?

    Sounds reasonable to me, although we lack any objective measures to say that”created” is more appropriate than “perceived” in the context of explaining and describing the experience. It is certainly created, and it is certainly perceived. Can we narrow it down and say that the pain experience is created/perceived in the brain?

    @ Evanthis. I must disagree. This is the way we, as biased observers, see the relationship. We are hamstrung by our Cartesian dualistic thinking. Neurophysiology = BODY. Psychological = MIND. The relationship is indefinable because of the category mistake we have made.

    I also think that we should be careful with embracing mind-body dualism. I don’t think that my argument supports that. Also, I wouldn’t say that physiology exactly =body because physiology =/ anatomy. Physiology does needs a body to exist, but so does the pain experience.
    It seems to me that you are arguing that we cannot say that change in neurophysiology is necessary for change in perception to occur, is that right? How would you explain the fact that different drugs established to act through specific neurophysiological mechanisms (altering synaptic activity) are also found to alter perception?

    @ Evanthis. No, we are not entirely clueless. Being in pain is an almost universal human experience. But I do not see that “modern pain science” has moved us any closer to understanding how the pain experience emerges. We know a lot more about the “apparatus” but still very little about the “process”. Sure, we can baffle and even educate our patients about neuroscience but this may not be penetrating the aporia that we choose to share with them. It may even turn out to be that the real value of a “third space” engagement resides in the willingness of clinician and patient to share the aporia. But we have known this all along!

    But we now know that peripheral nociception =/ pain experience. Isn’t this is a big step towards understanding how the pain experience emerges? I agree that there is still much to learn about the process. Do you think that the “complete” process is something that is knowable or unknowable with the scientific measuring tools we have today?

    Thank you for this discussion.

  16. stuart miller says

    Lorimer, thanks for the post. I appreciate the subjectivity of the continuum. Apkarian, in one of his blogs, highlighted that stimulation of one neuron in a primate brain can alter the behavioral response (? to a noxious input). Care to comment ? John and Mark, in terms of a philosophical discussion, I would agree that the idea of observer and observed is important – I know that a hands on approach (and even a hands off approach) is experienced on many levels – perception of the intent of the practitioner is important. This is subjective. In terms of education – the ‘convention that treatment is not self administered’ can be questioned. It is the incorporation of the education into a belief system that depends on many subjective factors. In terms of a syndrome that you know a lot about, John, what would your comments be about Mengshoel (2004) who discussed some women’s recovery from fibromyalgia that happened irrespective of specific treatment but through self perception that pain was a warning signal of too much stress in their life and taking individual steps to deal with it. I’m not trying to imply that dealing with stress is the answer but more that it was an individualized approach based on a person’s perception of their environment that was key. The social relationship is only one part. Please provide insight. Thanks.

  17. John Quintner says

    @ Evanthis. No, we are not entirely clueless. Being in pain is an almost universal human experience. But I do not see that “modern pain science” has moved us any closer to understanding how the pain experience emerges. We know a lot more about the “apparatus” but still very little about the “process”. Sure, we can baffle and even educate our patients about neuroscience but this may not be penetrating the aporia that we choose to share with them. It may even turn out to be that the real value of a “third space” engagement resides in the willingness of clinician and patient to share the aporia. But we have known this all along!

  18. John Quintner says

    @ Evanthis. I must disagree. This is the way we, as biased observers, see the relationship. We are hamstrung by our Cartesian dualistic thinking. Neurophysiology = BODY. Psychological = MIND. The relationship is indefinable because of the category mistake we have made.

  19. John Quintner says

    @ Evanthis. How about “… how the pain experience is created by the individual”?

  20. Evanthis Raftopoulos says

    Some further comments. (I love this discussion).
    While describing the pain experience as an aporia sounds reasonably accurate, I think it’s worth noting that saying pain is an aporia(philosophical puzzle?) can be easily misinterpreted as saying we are really clueless of what the pain experience is, at least for anyone other than ourselves.
    It seems to me that modern pain science allows us to come to some biological plausible conclusions of how the pain experience emerges, we just don’t have all the answers that account for the non linear fractal nature of human biology. While we should always pursuit a better understanding, we do not need to have all the questions answered in order to help those in need. Just sharing some thoughts.

  21. Evanthis Raftopoulos says

    Also, doesn’t the psychological emerge only after a neurophysiological change takes place within the brain? Even though still indefinable, this relationship is scientifically plausible.

  22. John Quintner says

    Thanks Mark. I think we have gone as far as we can without launching into the vexed area of consciousness, which has been likened to entering a swamp from which few emerge unscathed by the experience.

    As for starting a philosophical discussion, if anyone is interested, Milton Cohen and I have written elsewhere: “As clinicians it is necessary to engage the aporia of pain because of our moral and ethical obligation to the person in pain. The clinician and the person in pain share two outstanding characteristics: they are simultaneously observer and observed, locked in a dance that defines the impossibility of objectivity, and haunted by the spectre of self-reference. Thus the clinical encounter of the other in pain is the engagement of two self-referential organisms constructing a unique narrative.” [Cohen M, Quintner J. The lived experience of pain: a painful journey for Medicine. In: McKenzie H, Quintner J, Bendelow G, eds. At the Edge of Being: the Aporia of Pain. Oxford: Inter-Disciplinary Press, 2012: 19-35.]

    Evanthis Raftopoulos Reply:

    Hi John,
    “perception of pain” refers to how the pain experience is perceived by the individual. It accounts for the subjectivity and non linearity that the “sensation of pain” fails to account for.

  23. John Quintner says

    @ Mark. Nice to see another “Q”” contributing to the blog. However, I do not agree with you that health professionals should act as concerned parents of adventurous children. People in pain did not, and do not, want to be “stuck on the fence” and simply telling them to come down so that they can avail themselves of your particular form of treatment reminds me of the biomedical paternalistic approach that clearly has been so unhelpful in this context. By the same token, attributing their biological predicament to the “faulty” beliefs that WE think they hold does a great disservice to them as well as to the cause of pain science. Yes, Lorimer, why do we keep beating around the bush and deluding ourselves that we are omnipotent when the converse may be closer to the true situation?

    Mark Quittner Reply:

    Hello John, Thanks for your response to my post, especially as a fellow ‘Q’. Perhaps I have not explained myself as well as I could. My intention was not to set myself or any health professional up as a parent over a child, adventurous or not. My examples are specific to the original blog. Any example can be extrapolated beyond original intent making such an example unworkable. Lorimer, the original Author of the blog, stated that my comments have understood his intent. A previous post by you mentions a horse, yet no-one has pushed the boundaries of your example beyond its obvious intent.

    To explain myself further:

    As health professionals, we necessarily advise people that require treatment. In the sense that we do carry out treatment, we are escalated to a position of education in this sphere usually above that possessed by the patient. Even if our patient is in the same or equivalent profession, convention dictates that treatment is not self administered as ability to maintain sufficient objectivity would be clouded. Hence, in a sense, we are in a position similar to parents with children via the power interaction. The situation is well recognised in law, where abuse of uneven power relationships must be guarded against. Understanding new concepts and debating such ideas helps to keep us motivated, on track and les open to abusing our position.

    John, I take your point, if my analogy has been extrapolated. All Health Professionals require ongoing education to ensure relevance based upon research. Yes, problems will occur if we as clinicians do not access new views, in this instance, neuro scientific pointers / discoveries related to pain treatment. To clarify treatment options and relevance of treatment implementation based upon the science requires assessment. New ideas examining how treatment outcomes could be improved have been raised in the blog.

    If research can demonstrate that pain is a brain construct and that perception of that pain can be altered by understanding / demystifying / decreasing anxiety / or reinterpreting beliefs, why not intimate that the perceptions are inappropriate, if not “faulty”. At the risk of using further examples, throwing the baby out with the bath water via semantics does a disservice to the topic under discussion. This blog highlights the fact that there are those that are willing to question current practise in pain treatment and put forth ideas for discussion in the hope that advancement will occur.
    The only lack of evidence I see here is that for a claim of “omnipotence”. It appears that neither of us are “stuck on the fence”. That is a good thing, as straddling a metaphorical fence can only lead to chronic pain.
    Cheers, Mark Quittner MrPhysio+ Healesville

    John Quintner Reply:

    @ Mark. Thanks for your lively response. Can you please explain what you mean by “perception of pain”? I know this could turn into a philosophical discourse but, so far as I am aware, there is no place in the brain where the “neurophysiological” becomes the “psychological”. Descartes lives on, as Lorimer likes to remind us. Please excuse my grumpiness, it comes to me along with advancing years.

    Mark Quittner Reply:

    John! Not only do we share a ‘Q’ but also age. Not sure about sharing grumpiness, as this by nature is usually a solo pursuit.
    To address your question to me re ‘perception of pain’.

    Two points. Firstly, it is my understanding that brain plasticity research is consolidating the idea that rigidity of functional brain areas is lessening considerably i.e. the brain can shift function to areas outside of traditionally accepted mapped areas.
    Secondly, if the first point is correct, then there may not be a specific point in the brain for perception.

    As for the separation of the physical neurophysiology from the psychological self or external assessment – I am not sure of the point being made. My understanding, correct me if I am incorrect, is that the first is a physical structure and the second is a behavioural outcome of the first, therefore dependent upon the totality of the first.

    Given the above, my answer is that pain is a perception based upon neural signals sent to the brain, where the brain then receives the ‘template’ or algorithm of these signals, compares the patterns to those in memory, reacts in a way to best preserve health and / or survival, as well as updating this new response into memory strengthening the response mechanism. Self awareness of this process is the ‘perception of pain’.

    Conventional memory areas in the brain have been mapped, however even these areas are now being shown to be variable to some degree, with other areas of the brain taking over should damage occur. So, it is true that there is no specific place in the brain where the neurophysiological becomes the psychological as the whole process is completely integrated, and plastic.

    Yes, a philosophical discussion could occur, but I doubt anyone else would be interested?
    Thanks for the question John. Hopefully I will remain lively for a long time, even if my responses may not.
    Regards, Mark Quittner MrPhysio+ Healesville

  24. Hello Lorimer, Agreed, pain response does not make sense when viewed as anything else other than a continuum. Acute and chronic are terms specific to time, however they have been invested with much greater import by clinicians via their education, then foisted upon patients in further mal educative discussion / misdirected treatment resulting in an entrenchment of their feeling of hopelessness.

    Belief systems can be altered, but only by displacement – the displacing regime must be logical, understandable and demonstrate effectiveness before the hoped for new belief can be accepted, rehearsed and installed. Same applies to any memory – pain memory defers to that that is seen to be prioritised for optimal survival, however this construct is in turn based upon possible false belief foundation.

    For example. A child climbing on a wooden fence can be told to “Get down or you will get splinters” or alternatively “Get down or you will break your neck”. The message is to get down, the import and possible sequelae of the message, on multiple levels, is very different. Pain message interpretation is conditioned over a life time of experience, not all of which is physical experience. Mixed and false messages become part of the response, gradually becoming more powerful by repetition, as in memory. Responses are integrated and subliminal – the fastest way for reflex action to me mediated when safety is at issue.

    It is to be expected that a person moving along the continuum of pain from acute to chronic will have well entrenched belief systems seen as critical to their survival and they will base future over protective pain behaviours upon previous rehearsal, magnifying the effect each time a response is required. Deconstructing such behaviours once chronicity occurs is difficult.

    The answer to the problem requires community education prior to pain occurring. “Get down off the fence, because I have something better for you to do”.
    Just my thoughts. Hopefully I have understood the blogs intent correctly.
    Mark Quittner MrPhysio+ Healesville Australia

    Lorimer Reply:

    Nice Mark. You got the blog alright. I Appreciate your contribution. L

  25. stuart miller says

    Lorimer and others, I really appreciate your insight. Eric, in terms of understanding neurophysiology, there are layers and layers of learning. A number of students that I have talked to have usually only grasped (or been taught) the gate control theory…stop, without any of Dr. Wall’s (especially his last papers) or Dr. Melzack’s recent work or any of ‘modern’ pain science. If modern pain science can be taught to LBP patients, why not to therapists, physicians coming out of school ? I understand that people will do post graduate learning. I luckily work with an excellent psychologist who can provide me perspective when I am failing in my approach to engage with the patient. However, even with experienced therapists in the acute phase, other than presenting the mountain figures from Explain Pain and showing the gap between thresholds and tissue tolerance and how it changes post injury or insult, understanding dysfunctional movement strategies and trying to re-establish return to meaningful function while trying to empathically listen it is tough to do anything else (or even all that). I realize we are trying to present the ‘truth’ to the patient but it has to be conveyed effectively so that it is incorporated into their belief system. The mantra of ‘patience and persistence, courage and commitment’ and the questions ‘is this dangerous ? and how dangerous is this really ? again are helpful to provide perspective however, truth is perception. Other than showing staff and patients Dr. Moseley’s videos on understanding pain which are invariably well received, it is challenging to provide ‘enough’ information that is meaningful and helps the person move forwards with their goals. I would argue from Ewo’s comments, that it is not necessarily the radiographic findings that are the issue but that we still don’t understand management of inflammation or explain it well to patients. The deep learning is something I’m still working on myself. Always appreciate further insight. Thanks.

  26. This is a superb recommendation, and I think the frankness is appropriate…. How loving are we towards the sufferer, when the truth is omitted?
    I wonder though, can we do the truth and the love? Do we have to sacrifice one for the other? What does it look like when we do the truth with love, what would we see? Can we as practitioners work with our left brain, but also with our right? Might the strategy to do both, be especially important with this population of people who are likely to comorbid difficulties?
    PS. Love your work, and have superb bike ride everyone!

    Lorimer Reply:

    Truly chuffed Jono. And, as ever, astute observations and questioning.

  27. Thank you for her name, Lorimer. I definitely agree that there is a slow turning of the tide. Very interesting discussion. I agree with Murray’s point that a wide-spread approach similar to the cigarette movement would be very beneficial. I also agree with Eric’s post that PT schools need to “get with the times” when it comes to pain science education and the context through which our interventions are used. I’d like to finish by saying that I applaud you, Lorimer, and the Body in Mind group for being a great resource when it comes to understanding the patient in pain. Thank you.

    Lorimer Reply:

    Thanks a million Wyatt – this is very much appreciated.

  28. Hello Lorimer! Im a big fan of your work and a frequent visitor on this site. However, I went through your 13th reference on knee osteoarthritis via go internet and found a few links on related search which contrary to your reference did find significant relations between radiographicn findings and pain/function. By finding the study sited in your text you will easily find related studies as I mentioned. Are these weaker studies? Any comment?
    Kind regards,

  29. John Quintner says

    Great discussion, Lorimer, but I suggest that we may be shutting the gate long after the horse has bolted. The “horse” in this case is the claim that chronic pain has in some mysterious way become its own disease. How will we ever dispel this belief once it has been instilled in our patients, in health professionals, and accepted as such by our society? This could result in an even bigger hole that we (with some exceptions) have dug for ourselves!

  30. Lorimer, Great post! A couple things I would add. I think to get PTs to seriously take “meaning” rather than nociception or whatever nonconscious information processing system we conflate with pain we need to ditch the bottom-up method of PT education. Functional neuropsychology should come before or at least simultaneous with neurophysiology. Unfortunately most PT education seems marred in neurophysiology. Lectures about pain should seek to answer the question: “What does it mean when a patient tells you (practitioner) that they are in pain?” IMHO, if you accept the premise that a noun like “pain” can hold multiple layered meanings in each person, then this question needs to be answered in the domain of language with an understanding of psycholinguistics, cognitive and social psychology. This answer depends, on the direct symbolic relationship of the individual to his or her surroundings.
    Unfortunately therapists, or many medical professionals, are not given the tools in school to confront people’s symbolic metal architecture. Essentially in PT school we are given tools that work similar to “fun house mirrors” that distort the bottom up processes enough to “trick” the nervous system into resolving the pain. All the while, not having to confront the cognitive justification systems of the person we treat–cough..biomechanics. Unfortunately, I think we are seeing the limits of this bottom up approach. I think it takes deft skill, tact and interpersonal skills to understand the patient’s psyche and to approach them with the compassion and care needed to create beneficial therapeutic relationships.
    Due to the need to subject the therapeutic process to the gaze of the scientific method the portion of the treatment regimen where the individual confronts and attempts to change the underlying symbolic mental architecture responsible for interpretation (of pain) has been reduced to the euphemism of “pain education.” As if pain education is a passive process like a bottom-up modality. The nuanced semantic map of “pain” that is represented in each person needs more precision than a rote education spiel. I think it is when therapists are given the tools to conscientiously approach each moment as a confrontation with this architecture that we therapists will help their patients transcend the semantic gap.
    In response to the dualism in pain models between acute and chronic states, I asked Steven George how we adopt a language of pain from day one that keeps the hope of fully resolving a pain state yet not stigmatizing the patient if they develop a chronic pain state. In short, a very difficult question to answer. This is one of the hard questions to solve in orienting the patient in pain. The shifting between different pain rationales is not the way to go when pain persists. Finding a way to balance hope and an appropriate expectation seems to be critical in any dialogue about pain. So that the message stays consistent, pertinent but is also flexible to adapt to unforeseen challenges to the resolution of pain. Being up front about the purpose of the treatment encounter is to build skills, mental, physical or behavioral, so that the pt. can manage this painful episode and future episodes also seems like it should be front and center sometimes at the expense of the outcome. Additionally, trying to enhance/maximize the patient’s self-efficacy and or locus of control rather than explicitly or implicitly letting the patient fall into a passive or dependent relationship with us also seems critical.
    Thanks again and I am interested to see where your post goes.

  31. Murray J. McAllister says

    I couldn’t agree more with this post and the above comment. In the US, chronic pain rehabilitation programs are typically the last stop for patients with chronic pain, after a long trajectory of care by interventional and surgical providers who employ a biomechanical/nociceptive conceptualization. Having obtained such care, patients, of course, have also come to conceptualize their pain in this manner. By the time they see someone like myself to be evaluated for chronic pain rehabilitation, it is often very difficult for them to understand just how a non-invasive, interdisciplinary rehabilitation program can be helpful. As such, we find ourselves in the position of not only evaluating the patient, but explaining, say, central sensitization, at the same time, in order to make relevant why and how an interdisciplinary program (involving, e.g., pool therapy, mild aerobic exercise, CBT, relaxation exercises, use of antidepressant and antiepileptic medications) is going to be helpful. It’s understandable, but sad, when patients don’t ‘buy in’ to chronic pain rehabilitation after years of being told to make sense of their pain with a biomechanical conceptualization.

    While I have these conversations everyday as I evaluate patients for chronic pain rehabilitation, I have come to believe that all of us individual providers having this discussion with all of our individual patients is not enough. I think we need to harness internet technologies (like Body in Mind and others do) as well as develop marketing style public education campaigns. I like to reference how science, healthcare, public health, non-profit organizations, and government agencies all teamed up to change the culture of cigarette smoking. I think we need a 21st century, internet savvy, version of doing something like that. Just as cultural belief systems changed with cigarette smoking, we could do the same with changing our cultural beliefs about acute and chronic pain and their management.

  32. As a PT, I try to stress this day in and day out with my patients. It seems the biomechanical/nociceptive model of pain is so engrained that I often feel I’m fighting a losing battle. I feel that this is an area of utmost importance for those in public health roles. I recall seeing a study in New Zealand, I believe, regarding low back pain education through television ads that was reasonably effective at reducing health care usage and costs, but that’s the only study I recall (sorry I can’t provide a link). I feel this is an area of research that is currently underutilized and could be incredibly beneficial for changing public beliefs on pain. Thoughts? Do you know of any other pain education studies that are applied at a public health scale?

    Lorimer Reply:

    I can feel your frustration here Wyatt, however, I do think the tide is turning, not least because key stakeholders are realising that this is one huge problem. I reckon the study to which you refer was Rachelle Buchbinder’s terrific work in Victoria. Google her. She is the real deal. Aside from that work, I don’t know of any attempts on a population level. We have something in the pipeline but that pipeline feels very long at the moment.

    Anonymous Reply:

    We have a study project at La Trobe School of Public Health in the design and ethics application phase at present. It is hoped to be available for evaluation to the public in the second half of this year . The project is testing an on-line application, of an innovative communication tool for self-management of persistent pain, inside the framework of vocational education competency based learning.