Course Notes: Explain Pain

A Whirlwind

I finally had the opportunity to meet my personal Jesus, David Butler, and learn the way that he explains the pain experience to patients.

It was an interesting weekend to say the least. The course started off with a smash…literally.

We had the unfortunate experience of someone breaking into our car to start the trip off. Then once we arrived to the course, we were informed that Dave was going to be 2 hours late. He was staying in Philly (where I also experienced flight troubles last week) and a snowstorm with a name no one cares about stopped his flight.

So Dave drives all the way from Philadelphia, “tilting his head back to rest” for 1 hour, and then what happens?

He, along with the other instructors, drive to the wrong campus.

So after all these crazy things happen, Dave finally makes it to the course, sets up his presentation, plays a little Bob Marley, and………………

Kills it.

I mean, absolutely kills it.

To see Dave present this topic under the above circumstances and be on the entire time is a testament to the type of speaker and professional he is.

David Butler is one of, if not the best speaker I have ever heard.

So I’d like to thank you, Dave, for making an otherwise stressful weekend memorable and exciting. I look forward to applying what I have learned.

If you haven’t taken a course from the NOI Group, please do so yesterday!

So what did me and my friends blossums learn this past weekend? Read on brothers and sisters, read on.

A Paradigm Shift

Conceptually understanding what pain is can be quite powerful. And pain science itself has grown by leaps and bounds.

The number needed to treat (NNT) values of explaining pain to patients is about three. That means that it takes explaining pain to 3 patients before 1 will have a successful outcome (pain relief after 12 months).

To put this value in perspective, most pain medications have a NNT over 10. Taking aspirin in hopes of preventing a heart attack is 50. Knowledge is powerful stuff.

We know lots of powerful things to tell patients regarding pain states. Take the following points as an example:

  • Pain is a critical protective device.
  • Pain depends on how much danger your brain thinks you are in, not how much you are really in.
  • Tissue damage and pain often do not relate.
  • As pain persists, the nervous system becomes better at producing pain.

Great educational pieces that patients ought to know. The problem arises in dispelling this knowledge.

Think about who educates patients on their complaints. How many people do we know are given the death sentence of a bulging disc? How many people say “look at my x-ray!!?” How many people say “There’s nothing I can do. It’s bone on bone?”

There is an obvious disconnect between what is known about pain and what healthcare practitioners educate patients on. It is a constant battle, so how do we combat this problem? As Dave so eloquently put it:

“You have to meet the patient at their story.”

Let’s face it, changing the way one perceives pain is changing a thought process and belief system; something very challenging regarding any belief.

Changing one’s pain beliefs involves first reconceptualizing pain, then translating this message to the audience, and finally altering the narrative to address misconceptions. But the quote above reigns supreme. If you start by barraging someone with pain science when they are so far away from that paradigm, you run the risk of losing them.

You must build a bridge in order to cross a chasm.

Two Models

If you have not been living under a rock for the past 5 years or so, there are currently two combating models in the medical realm.

  • Biomedical (BM…not bowel movement)
  • Biopsychosocial (BPS)

The BM model is still the overwhelming favorite and where most of the world thinks. It combines knowing anatomy, biomechanics, and tissue pathology in order to treat conditions.

If you want a signed print of my work, shoot me an email. For a small fee, you too, can own my wonderful artwork.
If you want a signed print of my work, shoot me an email. For a small fee, you too, can own my wonderful artwork.

One key thing regarding this model is that it is still useful. If I have someone who is having complaints that resemble cancer, I want to utilize this model to determine if that is indeed the case.

The BPS model encompasses the above and much more. Here we take into account the neuromatrix, pain mechanisms, the onion skin model, fears, threats, and challenges, and evolutionary biology.

This one will cost double due to the enriching color scheme.
This one will cost double due to the enriching color scheme.

The important thing to realize is that the biomedical aspects are still present in this model, and can play a role in one’s pain experience. So please, do not forget them.

The BPS model’s goal is to enrich patient’s knowledge and create a conceptual change along with addressing potential problems.

However, each patient we interact with may possess many different misconceptions that we may have to address. The range goes from missing pieces of understanding all the way to lacking the requisite mental framework for understanding pain science.

We can see how sometimes teaching someone pain science can be incredibly challenging. If a patient cannot think in the way you are educating, you may not be able to alter their perceptions on the pain experience. They may lack the neurosignature necessary to understand what you are saying.

To understand pain, one must realize it is an emergent process. Many people conceptualize pain as a linear process – I pinch myself, and I feel pain. But as we know, pain is complex and results from the interaction of many variables. This process is like baking a cake. Small ingredients combine to form an end product that bears no resemblance to the individual parts.

Let’s Build Us a Nervous System, or even Better, a Neuroimmune System

While the periphery is extremely important, more emphasis ought to be put on the neuroimmune system and how it works, especially in pain states. As suggested by Butler, the nervous system works by being:

  • Complex – The hardware and wetware
  • Self-constructing
  • Distributed
  • Representational

I won’t go into great detail into these points, as I have talked about them ad nauseum here , but here are some interesting factoids regarding your nervous system:

  • The anatomy and chemistry of the brain do not match.
  • Over 80% of the brain are glial cells with an immune function and have a bidirectional relationship with neurons.
  • 25% of the brain’s neurons are mirror neurons.
  • The entire brain is replaced every few weeks.

Ion channels, your body’s sensors, change every two days and reflect the individual’s needs.

Now if we want to look at the brain itself, the big kahuna, there are some key points Dave discussed with us regarding this magnificent organ:

  • Although pain experiences are distributed and can vary among people, common areas do activate.
  • The neurotag composes the areas that activate together in a particular experience. Hence, those active during pain would be the pain neurotag.
  • Brain representations do not indicate specific tissues, but more so areas.
  • Emotional and physical pain look similar. Moreover, pain and pleasure have similar neurotags.
  • Brain representations can be modified by cognition.
  • Smudging of key areas can occur.
  • If no problems whatsoever exist in your body tissues, nerves, or immune system, you may still feel pain if the brain thinks you are in danger.

Taking into account the above, the therapeutic goal is to alter representations, deactivate painful neurotags, and reduce the perception of threat.


Nociception is basically a danger message that comes in from the periphery. This “danger” signal is not the same as a “pain” signal, as pain is a brain output. These fibers send quantitative data as opposed to qualitative. So when you hear someone saying pain feels achy, gnawing, tearing, ripping; know that these descriptors are CNS outputs.

Nociception is neither necessary nor sufficient for a pain experience.

There are two basic nociceptive processes:

  • Ischemia: occurs at the end of day and when little movement is applied; address by education and movement.
  • Inflammation: neurogenic and non-neurogenic.

Lets break down inflammation further. The non-neurogenic side contains chemicals from cells of damaged tissues, specialized inflammatory cells, and plasma. We also see the immune system releasing pro inflammatory cytokines to help with the response.

Understanding the neurogenic side requires understanding C fibers. C fibers, peripheral nerve components, are able to send information both towards the brain (orthodromic) and periphery (antidromic). The orthodromic impulses are the danger signals sent to the brain, whereas the antidromic impulses create inflammation via peptides such as substance P.  This release  leads to immune activity, capillary leakage, and increased enzymatic responses.

Aside from the above mechanisms, the periphery also has the ability to become hypersensitive by increasing the ease at which nociceptive fibers fire.  This increase can occur in transient receptor protein channels as well as ion channels.
All of the aforementioned changes are a normal protective mechanism that the body uses to keep us safe. Inflammation helps you heal, and ischemia prevents further tissue damage from occurring. What becomes problematic is when these processes, either by central regulation or potential re-injury, perpetuate.

Stop…Nerve Time

Nervous tissue, like all other tissue, can become injured or unhealthy. However, nerves do not necessarily have to hurt. In fact, cadaveric studies demonstrate that 50% of people who never complained of symptoms undergo connective tissue and nerve fiber changes at vulnerable places.  Moreover, 20-30% of the population has abnormally compressed nerve roots.

Like nociception, nerve sensitivity is neither necessary nor sufficient for a pain experience.

When a peripheral nerve is injured, changes occur at the injury site and centrally. Ion channels begin flooding the injured area, creating an Abnormal Impulse Generating Site (AIGS). These sites do not fire right away, but oftentimes after 3 to 21 days…quite a long time indeed.

The immune system also plays a critical role in neural sensitivity.  A peripheral nerve injury turns on local immune cells and encourages further cell recruitment toward the injured site.

What is crazy about these immune cells is that they can stay active for 25 years. So recurrent pains may not be re-injury, but a helpful survival tool. It’s the body testing the fire alarm.

So how does one treat these problems? The overarching goal is reduce threat by whatever the nervous system requires. This could include unloading structures, movement, education, drug therapies, etc.

Central Sensitization

With the CNS as the overall governor of our experience, it will create responses depending on the value of received inputs. A fixed response does not occur.

In central sensitization, we see an abnormal responses to the nociceptive system by altered sensory responses to inputs and increased pain sensitivity.  This state is most often present when pain occurs past normal healing duration.

There are three states in which the nervous system responds to information:

  • Input = output
  • Input > output (think injured athlete finishing a game)
  • Output > Input (folks with chronic pain)

The last option is the one we will deal with the most. Many changes occur to include decreased central inhibitory control, ion channel flooding by the immune system, C-fiber uncoupling and A-beta fibers (light touch) becoming nociceptive, inhibitory neuron cell death, and nociceptive fibers turning on more easily.

Dave gave us some key points on this condition to think about:

  • No diagnostic test can visualize these changes.
  • Deeper tissues injured lead to greater up-regulation.
  • Contributing factors (e.g. coping strategies) are strongly linked.
  • Sensitivity changes affect all outputs.
  • These changes are more reversible than previously thought.
  • Can occur instantaneously.
  • Tissues can heal though still be unhealthy.
  • Can see changes in 2-point discrimination.
  • Mirror pains may occur, which is an immune response.

Ya Other Systems

We have predominately been discussing the neuroimmune system, but realize multiple systems are involved in and respond to a pain experience. Our ultimate goal is to provide expressive freedom to these systems which creates better brain construction of all our experiences. 

Think motor freedom, pain freedom, output freedom.

Here are some different responses that various systems produce:

Emotions – Anxiety and fear to increase attention, vigilance, and pain intensity.

Thoughts – Nerve impulses that could elicit a threat response.

Sympathetic nervous system – Response system to get us out of trouble by affecting many systems; it is connected to almost every body tissue after all. It can increase inflammation, cause AIGS to fire, initiate an immune response, create nociception via vasoconstriction, and potentially be compromised at the thorax.

Endocrine system –  Working along with the sympathetic nervous system, the endocrine system produces ACTH via the hypothalamus in response to threats. This hormone stimulates the adrenal cortex to produce cortisol, which powers ups defensive systems necessary for survival and turns off unnecessary systems.

Parasympathetic Nervous System: Not much is known about this system, but it is thought to help with recharging and calming. With the heart as an exception however, the parasympathetic and sympathetic systems have discreet actions.
The vagus nerve is a major player here, and along with the hypoglossal nerve is linked to the immune system. These nerves accept immune compounds in the blood because they don’t have to deal with the blood brain barrier; allowing for easy access to the CNS.

Motor System: Chronic pain states are usually accompanied with unhealthy, unfit muscles that may be a nociceptive source. We can also see protective changes to include altered vocalization, muscle imbalances, spasms, and impaired recruitment.

The Immune System: The show of the course. Three components make up this system:

  • Innate: We are born with it (molded by it); kills microbes and stops infection
  • Adaptive – learns, recognizes, and remembers how to ward of disease and illness (immunizations).
  • Immune-like – Immune cells in the nervous system.

In relation to the nervous system, microglia in particular are capable of stripping synaptic connections and may play a role in learning. These compounds are able to move up to 3/4 of an inch to areas in need.

The immune system is also composed of pro inflammatory and anti-inflammatory components; the cytokines and chemokines. These cells are capable of increasing local inflammation, sensitizing AIGS, and decreasing opioid responsiveness. They also play a huge role in CNS plasticity, hence being a major component to learned behavior.

Therapeutic Knowledge Bombs for Patients

So with all the immense knowledge garnered previously, the challenge becomes teaching this information  in a patient-friendly manner.

Rarely do patients truly change their thought process when pain is explained. Dave mentioned that only 8% of patients will undergo a true conceptual change when learning pain science. So it is of utmost importance to tailor your educational style in a manner that the patient will understand and relate to.

The process begins right at the subjective. Let the patient talk and capture their story. This part will help you understand what the patient’s pain perception is like, and give you insight to where your education must focus.

The therapeutic process via both the patient and clinician is often communicated through metaphor. This method is oftentimes the only way patients are able to enrich our understanding of their experience. Knowing which metaphors a patient will use can provide options for educational strategies:

Simple metaphors

Example: “My knee is a rusty hinge.”

The Response: Don’t respond with a metaphor.

Embedded metaphors

Example: “Pins and needles” “Pelvic floor”

The Response: Have them flesh out the descriptors more. Or strengthen what they say. Instead of pelvic floor (something unchanging), call it a pelvic diaphragm (something always changing).

Ontological metaphors

Example: “It hurts like hell” “Pain is a killer”

The Response: these metaphors give abstract pain some structure. Help by telling stories and helping with goal setting (a better structure).

Orientational metaphors

Example: “The pain goes around” “My back has gone out.”

The Response: These are examples of disembodiment, so the goal is to get them to re-embody. Humor can be used here. Ask them “where did your back go?”

Invasive metaphors

Example: “There’s a knife in my back.”

The Response: An immunological response. Often there is a representation in the brain of a knife for example. Tell a story which lets them know these thoughts are unhealthy.

Prognostic metaphors

Example: “I’m riddled with arthritis.” “I’m ready for the scrap heap.”

The Response: These create a permanence to the condition. Let them know nothing is permanent in biology.

Disembodiment metaphors

Example: “It”

The Response: GMI to re-embody the individual. Also, eliminate the good part/bad part dichotomy, as well as using “we’re” going to do XYZ. These can reinforce the disembodiment.

Therapeutic metaphors

example: “Motion is lotion”

How-to: make sure to add stories to give the metaphors context. Humor is also good because it provides an immune boost.

A Great Story Teller

There are many way to explain pain to patients, but stories are often the most common. Here were some of my favorites with one common rule:

If you can give one example, give two.

Favorite strategies:

  • Dermatomal pain: Show the dermatome map.
  • Mirror pains: It is an immune response to protect you.
  • Night pains: Blood pressure drops, so blood has a hard time entering capillaries.
  • Phantom pains: The brain has a template of the affected area.
  • Smudging: Think use it or lose it. The brain will change to look after you and help you do what you need to do.
  • Imaging issues: The kisses of time. We grow like trees, so branches don’t always grow straight.

And to finish this blog, I will show you in video format, two of my favorite explanatory stories:

Neurodynamic findings – The theratube trick works wonders

And one of my personal favorites, David’s drug cabinet.

Read with Dave

On Patients

  • “Meet the patient at their story.”
  • “What is the person trying to protect with chronic pain? What are they escaping from?”
  • “Humans are inhibitory animals.”
  • “Humans are not bilateral animals.”

On Pain

  • “Pain treatment, not pain management.”
  • “Take away the threat value of a defense.”
  • “All pain descriptors are metaphors.”
  • “Treating acute pain shouldn’t be different than chronic pain. What changes is the story.”

Sayings for patients

  • “Well done, that’s a great inflammatory response.”
  • “You little self-healer you.”
  • “Well done, what a great defense.”
  • “Well done, you’ve gotten the best protective response.”
  • “Nerves take up only 1/3 of space in the intervertebral foramen.”

On Therapy and movement

  • “Therapy is re-inhibition.”
  • “It’s easier to change brains than rotten shoulders.”
  • “Distraction disassembles the pain neurotag.”
  • “Anytime you can do a movement and look at it is analgesic.”
  • “Knowledge is the richest context you can offer movement.”
  • “Total-knee arthroplasty is only limited by nociception and swelling. You don’t need to jump on knees because you have full ROM after surgery.”
  • “Faulty movement can be caused by faulty knowledge.”
  • “Give a license to move.”
  • “Forward head posture is an avoiding posture.”
  • “Repetitive movements lift your body’s serotonin”
  • “You are immunotherapists.”

On the brain and body

  • “Your brain will change to look after you.”
  • “When we’re in trouble, our brains weigh the world and judge whether pain is appropriate.”
  • “Your body tells your brain about danger, not about pain.”
  • “The immune system knows who you are from experience and genetics. It will react when you are not you.”
  • “Performance is an output of the brain.”

Funny shit

  • “Alright duckies, grab this”
  • “Neuroimmune. Doesn’t that make your loins tingle?”
  • “Lorimer Moseley. He’s a smart little shit.”
  • “You’ve got the same number of neurons as Albert Einstein…You might want to tell patients that.”
  • [On a sprained ankle] “I had one of those. Worse than childbirth.”
  • “I’d rather a shark bite my ass off than a paper cut.”
  • “The only cure for pain is decapitation.”
  • “Trigger points are clearly cultural because you have way more than we do.” 
  • [On trigger points, which are AIGS] “Get the needles out of it.”


  1. Hi Zac,

    Several of us on have attended David’s course in the past and I began corresponding with him in 1990. I’m a moderator and blogger there. An essay about Butler’s speech at the National APTA meeting in D.C. is titled “Lacuna.”

    I wish you would join us. You’d be welcomed.


    1. Hey Barrett,

      I already am a member there. I occasionally post when I feel I can contribute something worthwhile to the conversation, and would love to post there more…just need to learn more to hang with the big dogs 🙂

  2. Nice summary, Zac! I was SO fortunate to study with David for a year during my second masters degree (DPT and Masters in PT in 2003) in 2007. He’s so personable, so intelligent, engaging, and a wonderful human being all around. I’m glad you got to meet him!

    1. David is the man and can only imagine what the experience of learning directly from him is like.

      Appreciate you reaching out Renee,


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