Figuring out where “Pain Science” fits into practice is not always easy…..
“Pain Science” has become quite the popular topic in the last several years with the publication of Explain Pain, Aches and Pains, and The Sensitive Nervous System as well as the gradual move away from the postural structural biomechanical model to a more all-encompassing biopsychosocial model as proposed by George Engel (1977).
Much of the chatter around these resources, many continuing education courses, the design of research trials, and countless social media discussions have led to the development of the idea of pain science as an intervention.
More specifically, the concept of pain neuroscience education as an intervention, has emerged. However, many still conflate “pain science” and “pain neuroscience education”.
It is at this point that I would like to take the time to specially state that “pain science” IS NOT AN INTERVENTION”. Pain science is nothing more than the study of pain and is comprised of data including, but not limited to, the fields of anatomy, physiology, neurology, neuroscience, psychology, sociology, immunology, endocrinology, and evolutionary biology.
“Pain neuroscience education” on the other hand, is the specific utilization of education about the truth of what we know pain to be at this point in time in an attempt to reduce a person’s threat, improve their willingness to participate in active care, decrease fear, and hopefully if possible reduce their pain.
With all this being said, I have made a 10 step “guide” that I believe embodies what the best research is telling us today is a manner of practice that uses and understanding of “pain science” and allows one to employ “pain neuroscience education” if they see fit.
Step 1: Start using your ears more and your hands less.
This is not a call to abandon the use of manual therapy. Mark and I have written much on this here. This is instead a call to actually listen to people to hear them, not be too quick to try and fix them with your hands, find out what pain means to them, find out what their goals truly are, and allow them to tell their full story.
Step 2: Validate the beliefs and experience of the patient. They know their pain better than you.
Always remember that pain is a subjective experience. We can’t access what our brain is doing and those observing us and our brains can’t access our own subjectivity except through the constraints of language. We must trust and rely on what others can tell us about their experience…and we must believe them.
Step 3: Ask for permission to present new evidence and offer potential solutions
As simple as it may seem, that act of asking for permission before engaging in examination, treatment, and education can be a powerful way to reduce threat, lessen the backfire effect, and sway an encounter more towards helpful dialogue instead of unhelpful lecture.
Step 4: Pay attention to your language and stop saying stupid shit
There’s no shortage of evidence now to show that the words we use can directly impact how a person feels about their situation and their capacity to get better.
Sticks and stones may break my bones,
but words can also hurt me.
Stones and sticks break only skin,
while words are ghosts that haunt me.
Slant and curved the word-swords fall
to pierce and stick inside me.
Bats and bricks may ache through bones,
but words can mortify me.
Pain from words has left its scar
on mind and heart that’s tender.
Cuts and bruises now have healed;
it’s words that I remember.
– Barrie Wade
The nocebo effect is quite real and quite powerful. There’s no longer any excuse for failing to try and limit the amount of “stupid shit” we say.
NOTE – We have prepared a PDF of this blog post for a handy desktop reference to help you succeed in your practice! – DOWNLOAD THE PDF HERE
Step 5: Stop equating pain with tissue damage and making people scared of pain and start making pain about sensitivity
There is now a wealth of evidence that countless beyond solely the degree of tissue damage present can influence the pain a person comes to experience. We see that sleep or lack thereof, context and setting, expectations, previous learning, priming with colors, immune factors, anxiety, depression, presence of co-morbid conditions, and much more can influence the degree of pain a person will report. To simply equate tissue damage with pain is not only potentially harmful, it is simply wrong.
Step 6: Stop trying to show patients how “smart” you are!
“People don't care how much you know until they know how much you care”
― Theodore Roosevelt
Step 7: Stop trying to be a fixer and start being a facilitator
When we attempt to be the fixer of people, or convey to people that we can fix them we automatically create the assumption that they are broken, we are the mechanic, and their body is the machine. This is concerning as it ignores the valuable role of self-efficacy and locus of control in a person’s long term self-management and also ignores the well documented fact that the context of the treatment including the technique, the provider, the participant, the environment, and the interaction between these factors may contribute to patient outcomes.
Step 8: Stop lecturing at people and start having conversations with people
Lecturing tends to convey a hierarchy and often stifles the opportunity for discussion. When we are busy lecturing at people we may very easily miss the opportunity for them to ask meaningful questions and steer the course of learning and reflection a more individual and effective direction.
Step 9: Don’t try to be a “pain science wizard” and talk people’s pain away
With the increased popularity and study of “pain neuroscience education” there have been some (myself included) who have tried to simply explain people’s pain away with all of my newfound pain knowledge. Understanding “pain science” is not about explaining peoples’ pain away, but instead about understanding how complex their pain is and helping them make more sense of themselves as they actively get moving, challenge themselves, experience flare ups, and deal with modifiable and non-modifiable factors in their lives.
Step 10: Be patient; your beliefs didn’t change overnight and you shouldn’t expect theirs to
As I write this, I recognize that my beliefs have been shifting over several years, and I have spent almost as many years trying to get students and clinicians to recognize the complexity of pain. Yet, here I am writing another article over the topic to hopefully get more people to challenge their biases. With how hard the transition of clinical practice is and how difficult it is to change each of our own perspectives, we must have the same patience we have had for ourselves, if not more, for those in pain we work with while they attempt to wrap their minds around the complexity of pain.