Decoding Physiotherapy and Pain Management: Lars Avemarie's Perspective

Welcome back to another episode of the Modern Pain Podcast. This week we're talking with Lars Avermere. Lars and I have known each other for a bit now and, per usual and for many of my friendships, we really met first digitally. Lars is a physiotherapist in Denmark and someone who has been vocal about his criticisms of physiotherapy and our current approaches overall when it comes to pain and treatment in general. In this episode we're going to talk about Lars' teaching activities and courses, how he got into his interest in pain, some of the difficulties he had going through physio school and getting taught dated information that research was questioning severely the biopsychosocial model and issues with its application that he's seeing out there. We're also going to touch upon his thoughts on challenges we face as physios in the future whether no suception is necessary for pain, and his thoughts on pain, neuroscience, education and much more. Lars has some thoughts. I think you're really going to get some value from Check out the show notes, where we'll have Lars' website, contact information and links to the content we discuss in the episode. Enjoy.

This is the Modern Pain Podcast with Mark Kargela.

Welcome to the podcast, lars.

Thanks a lot for having me.

It's good to have you. I finally got to meet Lars in person at the San Diego Pain Summit a few years back and it was one of those modern day relationships where you get to know somebody over Twitter and social media and I really grew to admire Lars' work. He's got a very inquisitive mind, thinks deeply on topics, really puts out some good content. I'm excited to finally get Lars on the podcast. It's long overdue. Lars, I know of you, of course. I've gotten a chat with you and get to know you a bit, but some of the audience may not. I'd love if you can just tell folks who you are and what you're up to.

Yeah, basically I've worked full-time in the health industry for almost two decades now and I've worked in many different roles sort of started up as a fitness instructor, worked at a big box gym and gym class instructor, then I advanced to become a manager of a big box gym and then the last what would you say my last employment in the fitness industry were as a self-employed personal trainer specializing in training with people with chronic pain. Basically, I did all this before I decided to take my bachelor's degree in physiotherapy. Currently I work full-time in regional rehabilitation as a physiotherapist and there I see a wide range of people, mostly with chronic diseases, but I also see people with hip fractures, foot fractures, pelvic fractures, femoral fractures, the occasional humeral fracture and also chronic pain patients. Most of my patients are, you could say, in the second half of their life, while, because I'm at the hospital, they most likely also have multiple different chronic diseases on top of that.

Yeah, no, it's always nice to have somebody who's on the front lines of clinical practice, who's taking the research, dissecting it but also seeing how does that apply to real people? Nothing to knock against our researchers. I know there's always a discussion of the ivory tower and how they disconnect with the clinical ground, but I think it's good to have a perspective of a clinician. I know obviously that's where I sit myself as in the clinic, primarily Working with a very similar population of what you work with. You also do some teaching and lecturing, lars. I'd love if folks and we'll definitely share some of Lars's links and things in the show notes so if folks can check out what Lars does. He does some great stuff in teaching. I love you could share a little bit about your teaching and lecturing roles that you have.

Yeah, so besides working full time as a physiotherapist, I teach a weekend course when my schedule allows it. So I sort of am a master of how much stress I get myself, meaning the more courses I book in within a year, the more stressful my life becomes. But I teach on the weekends. Before COVID, it was something like eight to 10 weekends a year that I teach a course that tries to reimagine and reconceptualize pain and rehabilitation, basically trying to, as you said yourself earlier, try to integrate all the huge body of evidence that we have available. And then previously but I stopped doing that I also taught a class on multifactile and biosciences of pain rehabilitation at the physiotherapy program in the university in Copenhagen, but I stopped doing that. That's several years ago.

I definitely can relate to the self-imposed stress that you have to manage. We had a little chat about that as far as some of my experiences with overloading the plates and feeling like underdelivering on all fronts and all that good stuff where stress kind of pervades. But I'd love to hear your way of how you got into pain research and your real interest in that. I know for me and for a lot of others it's because of the failings you saw of healthcare meeting the needs of these folks and the complexity that they bring to the table. But I'd love to hear what spurred your interest, I guess, in pain research along the way.

Yeah, so basically it started that when I was working as a personal trainer and a fitness instructor, I got a lot of people who were sort of referred to me. They had done physiotherapy and you could say they failed physiotherapy. That would not be totally correct, because in Denmark you have to pay a sum and then the state pays a sum, but of course the part that you pay yourself will eventually amount up to a quite large sum and not all people can pay like 180 and 200 crowns pay that continually. So many people they go to physiotherapy for a while, maybe even years, and then they stop and then they are often referred to, yeah, basically by their therapist to still be active and a lot of those people ended up on my table or in contact with me because the physiotherapy thought that they should still be active, they still had pain or injuries or and was still rehabilitation from rehabilitating from them those injuries, but they just couldn't afford physiotherapy. So sort of I got a lot of those people in my schedule and I were, unfortunately enough, had some colleagues that were also working as physiotherapists. So I started to ask a lot of questions and advice what I'm supposed to do with this person with knee pain, what I'm supposed to do with the person with shoulder pain, with low back pain, those kinds of questions, and they recommend different articles and basically some of those articles were written by Professor Mosley and that really sort of took me on to a deep dive in the pain literature. And basically after it was only after five years of reading mainly research articles that I actually got recommended by my former teacher that that I should actually well, now you're almost doing the stuff already you need to have a paper to actually say that you know what you know and actually to be accredited. So he thought I should apply for physiotherapy school and then I did so I sort of became, began backwards. Normally you start with the basic stuff and add it anatomy, physiology, neurology and stuff like that Textbooks and then you end up by reading research when you're doing your bachelor's. But I sort of started the reversed way, which I'm very grateful that I started that way. But in the same instances it's also sort of been a curse, meaning that there were a lot of stuff I had to learn where I actually I actually didn't really feel that I needed to learn it, because when I, when I were informed about what the research actually states of these modalities that I had to learn. I actually know it's a big waste of time.

Working at a university myself and it's always such a delicate line I try to walk because I'm more of a clinical faculty member, so I'm seeing patients and then students are coming in and you know, shadowing, mentoring with me, and it's it's always like because they're learning all those things. And again, I always I try to phrase it to students like and those of you who listen to the podcast have heard me talk about this is schools a bit of a history lesson, where you're learning the, the history of our profession, which oftentimes contains modalities and treatments that research has long since questioned and different things. So teaching to a board exam and those things. It's challenging because then students come in the clinic and say well, why aren't you doing ultrasound and and why don't you talk about the upper and lower cross syndrome of Yanda and various things? So it is such a delicate line line to walk, for sure, but but one that I can imagine. If, if I would have went into school having read a bunch of research and then went to school, oh my gosh, it would have been a challenging thing. I was already very challenging, challenging students as far as question things to begin with, but I would have been taking it to a whole new level. I'm sure Was that a pretty decent struggle for you as far as trying to.

Yeah, it was. It was really really. There were some modules that were quite hard for me where I had to talk a lot of a lot of talks with my good friends, jonathan Fass and Jonathan Silvernail Jason Silvernail and Jonathan Fass and yeah, so I had a few rats with them and I really really value my education. I thought that the teaching we got in anatomy and physiology and pathology was really really, really essential really good teachers. What I saw the most problematic, what I found the most problematic, were the when we talked about what physiotherapists actually do. There's so there's a, a topic or class called theory and practice, and that's really where we should kill a lot of darlings or kill a lot of bunnies, because there's a lot within that topic that actually should just be. It should either be taught in a historical perspective, like you talked about, or it should even be just scrapped because it's it's it's already refuted and debunked.

Some good people you leaned on to kind of get through those challenging times when you were learning things you know Jason and Jonathan to to quality humans. We're fortunate to have Jason on the podcast. After reach out to Jonathan, I've appreciated his work and his perspective on a lot of things. But let's move towards the bio psychosocial model. I know you've had some opinions on that and I've read some of your work and discussions on online and seeing some of the discussions on social media. I'd love to for you to kind of discuss what your view is kind of on that controversy that surrounds the bio psychosocial model. There's there's a variety of discussions. Are we, you know, compartmentalizing it? Are we applying it truly the way that it was, you know, meant to be applied? I'd love to hear your perspective on that whole controversy.

Yeah, so I teach at my course and I try to mention this as often as possible. But when we're talking about models and particular pain models, I always try to note the saying by Professor Box, george Box, a famous British statistician, who said essentially he said essentially all models are wrong, but some are useful. So basically I picture, I like to picture different pain models like circles on a van diagram, so basically they are overlapping and each pain model holds in or tries to explain one particular part of the pain experience. But there's not one all encompassing, all explaining, all perfect model. That's that's. That's just that's, in my view, that's just stupid. That's that's a lack of lack of notion or lack of knowledge about what a model is. So basically, anyone that thinks that a scientific model has to be all come, encompassing and like perfect, that's they are living in a utopia and they actually don't understand what a model or scientific model is. So to those people that want to learn about what a scientific model is, there's a great book by by Ford called modeling the environment, where he talks about scientific models, especially a book about models, and he states that a model is a substitute for a real system. Models are used when it's easy to work with a system substitute than with the actual system, and he later notes that they are useful when they help us to learn something about the system they represent. So it's basically like we can make a. We can make a basic model in kindergarten of a volcano, so we get a sense of how a volcano is built and we can even make it like spur stuff up and we can make, but it's not reality. But that doesn't mean that it's not useful. The model even it's it's made of cardboard and it's painted and stuff like that. It still teaches us something about what, how a volcano is and how it functions and as such it's useful and that's. That's a way I view the bio psychosocial model or any model in particular. And I think the bio psychosocial model has gotten a lot of bad rap and to some part I agree. But the problem is when they put it on a pedestal and think it should be all perfect, when that's not in any way supposed. It's not supposed to be like that and even with all the shortcomings, the bio psychosocial model is still the the best current model we have. Even it's not perfect and they are shortcomings, and it can be applied in a fragmented manner and in a in a two causative manner, but it's still the best model we have. We know that pain is not only impacted by biological factors, but it's also impacted by psychological and social factors. We know that. We have the research supporting that notion. We know that pain is also impacted by emotion, our intention, our behavior, and that is supported by the bio psychosocial model. So we have a lot of research. So even the model is not perfect, there's a tremendous amount of research supporting what it states.

And you bring up some good points We've had some discussions about this in past episodes of how it gets applied in this one off, fragmented way of looking at it. Instead of kind of looking at it, you know as a whole of all these factors interacting with each other and you can't just like separate one little piece and feel like nothing wrong with like trying to identify different factors and address them. But it's you know, you can't look at them on an island.

I think dissecting stuff is important as a learning tool, but we should always be able to step back and know that well, this is not how it works within a complete system. It's like we know that from dissecting studies. We know how, where the muscle is, where the muscle is located and what the function of the muscle is. But of course, it's not only one muscle working, but learning about the smaller parts while still accepting the greater whole is a good thing. So honing in on one part, focusing on one part, learning a bit about that and then learning a bit about the next part and the next part can be a valid teaching strategy. It's only when we fail to realize that it's part of a bigger whole and it impacts each other. Mel Stiff has some great sayings. The sports physiologist. They had some great sayings about muscle isolation. Basically, no muscle works in isolation. We can't isolate a muscle. We have many other muscles that work continuously and when we get tired, one muscle gets tired because it's a prime mover than other muscles jump in and help. So muscles are basically never in isolation, and the same it is with the factors. It's not only sleep, it's not only focus, it's not only attention, it's not only biology.

Good points. I think there definitely is some value to understanding the components, but the skills of bringing it to the whole and seeing the whole picture is challenging, and I mean humans. Being as complex as it can get sometimes can be a difficult picture to paint with patients.

Miss Eleven did a great study some time ago where he looked at I think it was something like 200 or almost 300 people with no back pain in a hospital setting and then they screened them for psychological adaptation towards having pain. And then they screened them for two distinct clusters. One group had like pain related fever and a small psychological adaptation and then group two had a lot more and group three were basically all over the place. They had severe psychological adaptations to having pain. But my key point from that study were nobody had single psychological adaptations to having pain. Everybody were impacted to some degree by having low back pain. There was none that just walked in. No, I'm fine. I have had back pain for six months but I'm fine. I'm doing everything I want. The pain impacts me in no way in my personal life or my social life. I can do whatever I want. That person doesn't exist.

It's helpful for folks to consider that we want it to be these persistent, challenging, complex patients. But all humans are complex. They all have thoughts, behaviors and things around what they're experiencing no susceptibility and elsewhere. But let's go into how this kind of gets into some of the challenges we face in physio. Obviously, that's our home, where we practice and do things the discussions of modern physical therapy or modern physiotherapy. How do we, do you feel like we, address the challenges, or what are the challenges and how do we overcome them to stay a relevant profession? We've got some guests coming on in the future, david Nichols being one I know who has some pretty interesting philosophical thoughts on that. But I'd love to hear your perspectives on some of the challenges we face and maybe thoughts on how we can address those.

Yeah, I had an excellent. Just to mention, I had an excellent half-day lecture with Nichols some years ago. We were invited to co-making by the Danish Physiotherapy Association Great lecture. It was just about he had published his end of physiotherapy book, which is the stuff I've read about. It is good and he definitely has some good refreshing thoughts. One thought were to basically leave physiotherapy, do something else and then come back to view the field in new eyes. I thought that was quite a good recommendation, yeah, so basically, to get back to your question, I think the field of physiotherapy has so much potential and it can really be a force for good, but in some way we're sort of still recycling the errors of the past. We are still doing the same errors over and over again and errors that we knew were errors long time ago, and that's really saddening in my view, because it's now. I've been debating for maybe 10 or 15 years or something online or participating in debates, and it's the same errors over and over again. Yeah, so it's really sad, but one of the errors or you could call it actually the granddaddy of errors, and that's not only in physiotherapy, that's also in medicine. That's something called ineptitude. So many think it's ignorance, but I would argue that ineptitude is actually the biggest error, or the granddaddy of errors in physiotherapy and in medicine. And ineptitude is basically the case where knowledge exists but an individual or group, like physiotherapists, fail to apply that knowledge correctly in a particular circumstance. It could be not doing blood pressure measuring, not thinking that the low back pain is due to, basically, lack of stability of the spine. So it's basically we know that this is not true, but still we know and we know that pain is multifactile, but it is not being applied. So that leads me to basically that's like the meta error, or the granddaddy of errors. But there's two sub-shungers of errors, as I see it, that sort of home in on this particular error. I don't know if I can phrase that in another way, but it is basically that there's a foundational error which is this ineptitude we are not using the knowledge we have. And then there's two smaller errors on top of that that actually keep us from actually looking within and actually dealing with these. This bigger error and one of the errors is what I call the outcome error, that's, the outcome errors being committed when we think the outcome or result we get with patients is the effect of intervention we have used. So basically we apply an intervention and then we see an outcome, but assuming that the outcome is a direct correlation with the interventions that we did, that's the outcome error. So basically we should accept that all outcomes in the clinic are multifactorial and that one of my dear teachers at physiotherapy school recommended this paper. This was actually paper for one of the later models in physiotherapy school but I don't know how many read it. But the title of the papers outcome measures measures outcome, not effects of intervention. It's by Herbert et al. So basically we know that outcomes are multifactorial, they are not the effects of one singular intervention. And this sort of makes many clinicians and otherwise knowledgeable clinicians fall prey to what is called the therapeutic illusion, meaning that when we think what we do has an effect, when in some cases, or in many cases, it actually might not in any way be that effect. So that's basically the error, the first error of the siblings of the granddaddy error, and the second error is causal oversimplification and that's also called the fallacy of a single cause, and in the case of pain management. Now this error can be made in many other fields of medicine, but in the case of pain management. It's an overly simplistic view of pain and an ignorance of complexity. And we are committing the fallacy of single cause when we believe that pain is due to some magical dysfunction or facial dysfunction or abnormal muscle activation, or it could be bad posture or abnormal motor control or lack of core strength or any one specific, particular, singular entity. And that's an ignorance of what research currently say, that one pain is a complex experience and that pain is a multifactorial. There's many factors and that's sort of. We are sort of looking at one tree in the forest and then we are totally ignoring all the other trees in the forest and sadly in our case in the musculoskeletal field, there's a lot of other trees and that's really not good. A key point is when that's basically my bullshit filter, or more my bullshit alarm or spider sensor, whatever you call it is. When people say they can find the source of pain in the body, then I know they're sorry to say it, full of shit.

You bring up some good points. I think there's just a lot of logical fallacies and things that I think folks forget about. And I don't see how people can't look across the landscape of everybody having treatments that work and realize that maybe it's not the interventions as much the specific mechanisms and there might be a lot other things at play when people have positive outcomes. But and stop getting so caught up in the latest new shiny intervention and start looking at the complexity of it. There's also some good papers on why and effective treatments work too. As far as there's just a lot of things going on outside that, We'll link some of those articles in the show notes so you guys can take a look at them. And it doesn't mean that nothing works. It just means a lot of things have the potential to work. It's just that there's so many other things around the what makes it technically work that we need to be taken to account. And maybe we can start stripping away to the complexity and over complexity fine intervention and start looking at some of the common basics of just humans moving in a positive direction, which can be complex. There's a lot of things that go into that.

Also, it's a bit like I thought about writing a blog and I might do it at some time that physiotherapists are a bit like parents before Christmas or after Christmas or at Christmas Eve, because parents and anybody who has children know that there's a lot of planning, a lot of doing up to Christmas, like if you have children. There's a lot as a whole social ritual and you work a lot of hard. You need to find this particular specific present and maybe it's not easy to get this present, or so you do a lot of work for this to be a perfect evening or morning or night or whatever, and then you give all this credit, you give it away to some imaginary figure standard loss and many therapists act in the same way. All the stuff that they do, that they are doing, it's not the modality, it's not the magical technique, it's not the ultrasound, it's not the acupuncture, it's everything they do. They talk with the patient, they interact, they empower the patient, they set up goals, they calm down shit. As Gregory Lehman says, they do a lot of this and then they might do this magical technique and then they think this one magical technique that they did for like two minutes or three minutes or even shorter if it's a manipulation, could be something like 10 seconds. Then they give all the work that they did, all the credit that they actually deserve. They give that to this particular technique, totally ignoring all the interactions and complexity and empowering that they did.

That's a good analogy. I like it. It is the way and I know I've spent a good portion of my career because I think sometimes we so identify with our interventions and it gives us this sense of self-worth that we're bringing something that's going to be the knight in shining armor, the thing that's going to save and fix people where. If we could just pump the brakes on that and say, hey, we still bring a lot. It's not maybe the sexy, shiny, magical, but we bring a lot to the table. If we can just get I get kind of flustered with dry kneeling we don't have to go there because that's the whole another ball of worms there. But I just think it's nothing new. I mean, granted, you can scienceify it and try to sexify it with all sorts of science stuff. I've yet to see any mechanistic stuff for a lot of enrich. I've had to face this with a lot of my pet manual therapy interventions that I and again, it's not that they don't help, it's just that they're not special and there's so much more. We can do that if we just stop getting so excited about the shiny new tool in our box and say, hey, we have a lot of tools that you come out of PT school, physio school, with you got to hone them. You need to get in front of people, you need to hopefully have some good mentors to help you master that interaction with the patient and understand the complexity of what goes on in that interaction, beyond what's going on what you think that you're going to fix in the tissues. I mean you can be so much more effective so much earlier on if you just kind of can shelf that gravitational pull towards this new shiny, fix it type intervention.

It's just a tough thing for a lot of physios, I say at my course, it's not the modality, stupid, it's you, it's you. It's you. You are the one in person in front of them, you are the one calming them down, empowering them, talking with them, setting up a plan, doing shared decision making, getting a firm therapeutic alliance. That's you. That's not some magical thingy that you do.

Totally agree with you, 100%. Let's shift gears a little bit, because there's been some debates out there on the social media and academic worlds, especially the one currently going on around. Does nociception, is it necessary for pain? There's this debate whether it even needs to be there. We've had some guests that are very hardened with the thoughts that peripheral nociception is a requirement for us to have a pain experience. I'm just curious were your thoughts fall on that whole debate?

Yeah, so I actually did write a blog on my page not a long time ago, so we can maybe link that. I'll try to take a little bit of a meta-cognitive view going above that and then I'll answer the question later. But I see actually the necessity that this debate has to have so much importance, or gain so much importance is actually really, in my view, a great sign of how indoctrinated some health professionals are into the biomedical model. Now I think the biomedical model has by far done us no favors when it comes to helping people with pain. We can talk about biomedical advances in medicine yeah, there have definitely been some, but when it comes to pain a complex, multifactorial biopsychosocial experience it hasn't done any favors. So it's a bit of. I'm a bit flabbergasted that we still have this focus, that we still are so indoctrinated towards this model. That clearly does not explain pain. That's without a doubt it doesn't. So we can find errors in the biopsychosocial model and yes, there are some errors with it. It's not perfect. But we should also then try to talk about the biomedical model, because that is just one big motherfucking error that there are so many errors within that model. So I see actually the debate as one giant step backwards towards a future where we work with suffering and hurtful human beings. I really hope sincerely that someday we will accept that people are not need packages of pathology or neuro inflammation or whatever a bogeyman we can think of or packages of no seception, but we are here as physiotherapists or therapists or clinicians to help suffering, roaring, fearful individuals and in my view, if we don't accept this, then we are really doing a disservice to the people we are supposed to help. And to hold back on the biopsychosocial model. One thing Engel actually got right with the biopsychosocial model and that the biomedical model gets so wrong is that one we don't work with tissues or pathology. So he had a follow up paper published in 1980s to his other paper where he introduced the biopsychosocial model, but in the title of the paper is the clinical application for biopsychosocial model and in this paper it talks about a continuum of natural systems. So basically the continuum goes from small molecules and cells to larger systems like the individuals and, in the end, society. The biomedical model is all about the small stuff, really geeking out on the small stuff while ignoring the bigger stuff and ignoring the individual. And again, like I said earlier, we work with suffering people. We don't work with cells. We don't work with inflammation, we don't work with pathology. We work with autonomous human beings, and Engel realized or recognized that there's none. None of these systems work in isolation. They're a component of bigger and higher systems. So, basically, cells being part of an individual, that, in part, is is a part of society. So, basically, the biomedical model is still nerding or geeking out about the small stuff and, yes, the small stuff has a is important, but it shouldn't be at the expense of the individual and at the expense of the larger stuff. And that's what I think we are still doing. We're still thinking about, yeah, sort of pain, pain being in the body, because it's no deception when in when, in reality, if there's no deception or no, no deception has a very low clinical relevancy, one we can't measure, no deception in the clinic, and we're still working with people that are suffering. And when we don't recognize that, then we are, in my view, doing the service to our patients. And also, when we geek out, it becomes yeah, that's one of my pet peeves also when we talk about a step up, if we talk about pain location. So oh, my five o'clock low back pain patient is there, or my three o'clock elbow pain is here, or my tennis elbows here, or. But there is the idea that pain location takes precedence is really flawed on many levels. We know from the research that even the same location of pain people can differ widely. So a low back patient is not a low back patient. They can be totally different and their adaptations towards having pain or living with pain can be totally different. One can be very fearful. One person is not fearful. One has maybe has a lot of social stuff going on there, might actually be afraid of losing that job, and and another person with low back pain maybe don't, are not so fearful about losing that job. Yeah, so so I think it's really I when I think about the patients and the advances we have done through modern pain science, and I think about this debate still going on trying to find the bogeyman and homing in all the small stuff while ignoring the larger stuff. Yeah, almost gets sad. I really not almost.

I actually get sad because we are still working with people yeah, and you see kind of the extremes of it sometimes in healthcare, where folks aren't even having those other parts of their complex situation brought into the, where to slap up your MRI and and and that's your pain right there, versus, like gosh, the life-changing events and the unique behaviors and thoughts and in social world they live in, all the things that we know have six chances and capacity to greatly influence pain. But we're gonna, we're gonna strip it down to your X or your MRI and, and you know, fix it. But yeah, it is. It is frustrating. Thankfully we have some physicians and folks who are, who are really pushing for more of this holistic. Let's stop just focusing on the trees, recognize the trees function in a forest and we need to have at least somebody looking at the forest with people and seeing how different tree specialists can fit into that. But ideally all those tree specialists chatting about the forest not just their unique tree and labeling their tree and then getting somebody so full of trees that have problems that they don't realize it's a forest issue versus, you know, each tree having an issue. But that's again probably another discussion we could go way deep into. I want to bring it also to pain, neuroscience education, pain education, you know making sense of pain. There's a lot of different terms that have been thrown out there with with you know this, this pain education, p&e, probably being one of the more common ones. I'm wondering, you know, where do you feel that fits in modern physio? I think there's definitely been the, and we've had guests, and including myself probably, recounting my, my pendulum swing of like, oh man, everybody needs this to be explained to them and if I can just throw an explanation at somebody, I'm gonna just change the course of their care. Now, granted, there might be some things, some aha moments you can get with patients that start really resonating with their unique experience, especially if you can weave it into their story and help them start connecting things versus the pain, explaining that. I probably did a big good chunk of my first part of it in her, incorporating this in the practice, but I'm I'm curious what your thoughts on where you feel this all fits, this whole pain, neuroscience education and clinical practice.

I definitely think it has its place. A lot of the stuff and theories and research that we learn and read, in my view is for me more than it is for my patients, meaning it's for the, for bettering the, the clinical reasoning of me, it's for bettering my clinical reasoning. That doesn't mean I need to explain everything to the patient, and it pain neuroscience education, or pain pain education for patients, as I actually like to refer it as is, is a bit of that. It it was at some point by some small fraction of people maybe like yourself and me. It was over applied in the sense that we thought this, we thought it were a magic bullet. Even the researchers said it was no magic bullet, but even so it was over applied. I think that. And then not only over applied, but it was also misapplied, meaning that lecturing towards a patient is, in any context, normally not a good thing, and then that is not only an error made by a therapeutic neuroscience education or pain education, that's that's have. That error has been done by many other fields and many other on many other topics. So basically, I think the, the central premise behind pain education for patients is good. It's basically helping people with pain, living with pain understand what we currently know about pain in order to facilitate behavior and belief change. That's a really good premise and we mustn't forget that the biomedical model also did. Biomedical model pain explanation. There were back schools cheating, teaching about the anatomy of the spine and stuff like that. That was way before that and now. But now we are actually. We know what were thought before. What people clinicians did teach to patients is wrong. We know that now that's way too simplistic, so now we try to take this updated knowledge and teach that to patients. Actually, there's just published a textbook that has a great primer on on pain education for patients. It's the third edition of pain, a textbook for health professionals where I know certain of the authors, and it states that pain, pain education, should not be something clinicians do to or give to a passive patient. Pain education is a co-constructive learning and a way of becoming more capable. In this way, pain education becomes a dynamic, colloquial, laboratory, transformative process that fastest learning and change, and in that way, that can't, in my book, be bad now, that being said, it's not. It's not a one-trick pony and it's not easy. It's not easy and that's basically not so much because, yeah, teaching people is, of course, difficult, but the teaching part is not only the thing that makes it hard. It's hard to change people's beliefs, particularly when they are entrenched in a biomedical dominant environment. So you're basically trying to teach them something while they're living in an environment that sells them the opposite and that's their maybe their past clinicians, past therapists. It might be on the internet, it might be what the other health professionals tell to them, it might be what their friends and family tell them, and all these work in unison on promoting a biomedical or a biomechanical view of pain and then you as one person try to update this dogmatic view. That is really, really hard. And now, as we go back, that people, clinicians and research are still promoting this pure biomedical view of pain does not help. So the misinformation is not something of the past. The misinformation is going on right now. The debate on the high value of, or that no deception should be the sole focus. That's one such part of misinformation and that really doesn't help. I actually I've been thinking about why this were so hard and then they were actually published research paper by a solvents group that actually showed that in order to change people's biomedical beliefs to a more research based belief that's supported by a biosurgery social model. It requires a strong therapeutic alliance. So basically, if you don't have a strong connection with your therapist, then you're not able to change anything. And then, when it comes to pain pain education for patients, it's also overlooked that we have a lot of patriots actually supporting the notion that it has an effect. It has a small effect, but everything we currently have has similar small effects. There's no magic bullet, but the researchers promoting explain pain did not say it was the end, all be all and then it might not. As a caveat, it might not be as beneficial or have this small beneficial effect when it comes to pain in the acute state. There's some research indicating that that might not be the best way to apply it. It's a bit like my metaphor, for this is it's like a guy standing watching his house burn down and then you're coming and talking about fire safety. That might not be the best time to talk about fire safety when he's standing and watching his house burn. Now, if it has burned down again and again and again, then it might be a better place to start to talk about fire safety, because his house has burned down five times the last 10 years. That might be some value.

That's a good analogy for sure. I like that a lot. I also like the discussions on this. Comes with a necessity of a therapeutic alliance, a good therapeutic relationship. Before you start challenging some of these beliefs and narratives, that's where that visit one becomes so crucial to help get to where you can have these tough conversations and again, do it in a co-constructive way, where you're not just like you're wrong. I'm right, here's how it is. Start having some skilled conversations. Narrative-based approaches, motivational interviewing, even acceptance, commitment principles can be integrated into these conversations to help people just take a step back from these beliefs and thoughts and behaviors and maybe help them evaluate them on their own versus again. That goes into exposure with control and these different things too.

Yeah, there's a great saying I can't remember where I picked it up, but it's to advise somebody, you must first be put by that person in a place in an advisory position. So if I'm supposed to advise you or something, I should first make sure that you actually want my advice and I'm ready for my advice. And I think we often miss that thing. If we don't show that we actually care and then we're just spurring off pain research at Lipitim, then that's not going to help. We need first to actually care and make it relevant to the person in front of us. Then they might be open to alternative views. I use, with my clinical word I use a lot of Socratic questioning, trying to make people reflect and disrupt autonomous thoughts, automated thoughts, and making them sort of help them with looking at this beast, that pain is, from a different angle.

Sounds like a definite, more nuanced approach which I think we could all learn from when we're starting to incorporate this stuff into clinical practice. Lars, I want to respect your time today. I really appreciate you sharing it with us. I've really enjoyed the conversation. For folks that are looking to kind of maybe get to know what you're up to more, kind of find you on the internet, whether it be socials or your website, could you share some of the ways folks can get in contact with you?

Basically, they can follow me on Facebook. That might be my preferred way of interaction and sharing stuff Right now. I'm on social media detox right now but I'll catch up in a couple of weeks, but Facebook is my preferred way and they can follow me there. I'm all maxed out on the friend quota, but they can follow me there. I share a lot of the stuff that I'm learning, stuff that I'm reading, stuff that I have been reflecting upon Basically, a lot of information. And then I also have my webpage, larsavraycom, where I occasionally write blogs on different topics topics of clinical, reasonable and critical thinking, pain education and pain research and pain science.

All good resources and highly recommend you follow LarsAvray. He's always a good source of information. I always see him dissecting some of the new things that are coming out there and always has a great take on it, so I would highly recommend you taking a look at all those things. Again, lars, I want to thank you for your time this week. I really appreciate all the work you're doing. Thanks a lot, and we hope to catch up with you soon.

Thanks a lot, all right.

For those of you listening on your podcast provider. We'd love if you could subscribe and even if you could throw a rating in there. That would be great Grateful for us, because we are looking to see if we can get more of this message out to more physios and actually more patients as well who are listeners, and those of you on YouTube. If you could subscribe, we would also greatly appreciate that. We will leave it at that this week. I hope you all have a great week and we will talk to you next episode.

This has been another episode of the Modern Pain Podcast with Dr Mark Karchela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincarecom. Also visit the Pain Masterminds Network on Facebook for free education and resources. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain this is the Modern Pain Podcast.