Explain Pain Section 5: Modern Management Models

This is a summary of section 5 of “Explain Pain” by David Butler and Lorimer Moseley.

So Many Clinicians

There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain.

Here are some general guidelines for someone dealing with pain.

  1. Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination.
  2. Make sure any prescribed help makes sense and adds to your understanding of the problem.
  3. Get all your questions answered.
  4. Avoid total dependence on any practitioner.
  5. Make sure your goals are understood by you and the clinician.

The clinician’s ultimate job is to assist you in mastering your situation.

Models of Engagement

There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain.

  1. The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro.
  2. The Onion Skin Model – Helps describe all the factors that go into the pain experience; including nociception, attitudes and beliefs, suffering, pain escape behaviors, and social environment.
  3. Fear-based models – Fear of pain and reinjury are major forces behind the development and maintenance of chronic pain.
  4. An evolutionary model – Pain protects the tissues in order to ensure species survival.
  5. A clinician decision-making model – Pain is very personal, and therefore a plan of care should be developed exclusively for that person.

When working with a healthcare provider, they should be able to answer the following questions:

  1. What is happening in my body?
  2. How long will it take to get better?
  3. What are all the options for management?
  4. What can I do for it?
  5. What can you do for it?
  6. Is there anything that requires special attention?
  7. What do my physical findings really mean?


Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology.  There are various ways coping can be done, with some better than others. Generally, active copers manage pain and other health issues better than passive copers.

The active coper…

  • Learns about the problem.
  • Explores ways to move.
  • Explores and nudges the edges of pain.
  • Stays positive
  • Makes plans.

Whereas the passive coper…

  • Avoids activity.
  • Does nothing.
  • Waits for something to happen.
  • Believes someone else has the answer.

Relating to Pain

There are several patterns in which we react to pain.

  • Hurts don’t do it – Pain kicks in at a certain amount of activity, then we stop once it starts. Over time we can perform less and less activity before pain occurs, leading to disability, disuse, and likely depression.

  • Boom-bust – Pain comes on but you push through it and ignore it until suddenly the pain becomes unbearable. Here, your nervous system busts. A cascade of danger chemicals floods the nervous system leaving you completely wiped out for days to weeks.

The commonality between these two patterns is that both lead to eventual activity limitation. We want to be somewhere in the middle.