Practical Pain Education

I gave a talk on how I approach pain education in the land of China, and yes I finally got around to re-recording it.

Here were some of the topics I discussed in this talk:

  • The history of pain education
  • The difference between the three pain mechanisms
  • What the current research suggests regarding pain and threat
  • The 14 most common maladaptive pain beliefs, and how to squash those thoughts via education

If you want immediate access to the remainder of the 1 hour and 49 minute talk, and a FREE 21 page PDF file of my talk notes, fill out the form below.

Without further adieu, here is the first 20+ minutes of the talk.

Explain Pain Section 6: Management Essentials

This is a summary of section 6 of “Explain Pain” by David Butler and Lorimer Moseley.

Management 101

The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain.

Tool 1: Education

Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery.

Here are some important concepts to be known about explaining pain.

  • Anyone can understand pain physiology.
  • Learning about pain physiology reduces pain’s threat value.
  • Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life.
And I mean anyone.

Tool 2: Hurt ≠ Harm

It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay.

Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take drastic measure to prevent re-injury. Therefore, the best option is to gradually increase activity levels without pressing past the nervous system’s threshold.

If only there was a neurosignature that helped me stop drinking Redline. So bad yet so good.

Tool 3: Pacing & Graded Exposure

All the body tissues are designed for movement, therefore this is how we will increase activity. Here are the steps to pacing and graded exposure.

  1. Select an activity you want to do more of.
  2. Find your baseline – The amount of activity you can do that you know will not cause a flare-up. A flare-up is an increase in pain that leaves you debilitated for hours to days.
  3. Plan your progressions.
  4. Don’t flare up, but don’t freak out if you do.
  5. It is a lifestyle change, requiring a little bit more planning.

Take walking for example. Suppose you know you could walk for 5 minutes, but if you did 7 you would pay for it over the next couple days. You might walk for 5 the first day, then 5:15. Eventually, you would work up to past 7 minutes, then so on and so forth.

Access the Virtual Body

Just like the body, the virtual body can be exercised as well. Ways to work on the virtual body are as follows:

  1. Imagine movements – a la graded motor imagery.
  2. Alter gravitational influences or surfaces.
  3. Add varying balance challenges.
  4. Vary visual inputs – Eyes closed challenges the virtual body even more. Use a mirror to give the brain visual input and further decrease threat.
  5. Alter the activity environment.
  6. Move in different emotional states.
  7. Add distractions.
  8. Perform the desired movements in functional activities.
  9. Break down functional movements.
  10. Perform sliders.
  11. Perform movements with the surrounding tissues in relaxed positions that do not hurt.
  12. Work out of your glitches – If you walk with a limp from an ankle you sprained in 1962, try changing how you walk.
  13. Let your mind go.
Open your mind…Open your mind.

Explain Pain Section 4: Altered Central Nervous System Alarms

This is a summary of section 4 of “Explain Pain” by David Butler and Lorimer Moseley.

CNS Alarms

While much of talk in rehab deals with tissue injury and tissue pain, realize that the brain always makes the final decision as to whether or not you should feel pain. No brain, no pain.

This sentiment does not mean that pain is not real. All pain is real. However, pain is a construct that the brain creates in order to ensure your survival.

Spinal Cord Alarms

When an injury occurs and the DRG receives impulses from peripheral structures or the brain, the spinal cord neurons must adapt to better uptake all these signals. In essence, the DRG becomes better at sending danger messages up to the brain. This change leads to short term increases in sensitivity to excitatory chemicals. Those stimuli that didn’t hurt before now do (allodynia) and those that used to hurt now hurt more (hyperalgesia).

In persistent pain, this change continues occurring to the point where neurons that do not carry danger messages start growing into space where danger messages are taking place. Now innocuous stimuli such as grazing the skin begin hurting. The pain may be normal, but the underlying processes become abnormal.

When these spinal cord alarm systems become unhealthy, the brain no longer receives an accurate message of what is going on. The alarms become magnified and distorted.  The brain is told there is more damage in the tissues than is actually present.

What is good is that this increased sensitivity can change once damaged structures are under control and/or the underlying physiological processes are understood by the person in pain.

The Animals may have been onto something.


Another change that happens in the brain is termed smudging, in which brain areas devoted to body parts or functions begin overlapping. This process is why some body parts may become difficult to use or other areas become sensitive compared to the injured area.

Fortunately, since the brain homunculus frequently changes, these effects are reversible. The homunculus must be trained just like any other muscle or skill.


It is now understood that thoughts are powerful enough to maintain a pain state, known as thought viruses. These viruses are known to cause and enhance a low back pain experience, and likely have an effect at the whole body. Here are some examples of thought viruses.

  • Pain means something harmful is happening to my body.
  • Stopping social activity because of pain.
  • It is bad if no one can find out what is wrong with me.
  • Pain scares me.
  • Refusing to move until all pain is gone.
Given many medical treatments, I can see why.

Central Sensitization

Central Sensitization is when the brain and spinal cord become overly sensitive to processes. This change occurs in chronic pain states.  Diagnoses such as fibromyalgia, chronic fatigue syndrome, and non-specific low back pain are often given out. The diagnosis given often depends on where you live and which health professional you have seen. Here are the characteristics of central sensitization.

  • Pain persists past normal healing times.
  • Pain spreads.
  • Pain is worsening.
  • Lots of movements hurt. Even imagining movement can hurt.
  • Pain becomes unpredictable.
  • There are other past, present, and future problems in life.

The Autonomic Nervous System

The sympathetic nervous system helps us cope and stay protected from threat. It does so by sending adrenaline to all the tissues among many other processes.

In chronic pain states, there are increased levels of adrenaline, though in some cases adrenaline can become depleted. Adrenaline does not itself cause pain, but does increase alarm system sensitivity.

On the other hand, the parasympathetic nervous system is what slows us down and helps shift us out of a sympathetic state. This system is why relaxation and meditation can help with the healing process.

Bonus points if you meditate in a cave…and go bald

The Endocrine System

Chronic pain states are often associated with high levels are cortisol as well. Cortisol often gets a bad rap despite its role as a protector. What cortisol does is slow down unnecessary body processes which are not needed for immediate protection and enhances those which are.

The Immune System

The immune system has a major link to the autonomic and endocrine systems. The immune system works by releasing pro-inflammatory cytokines, which can create lethargy, loss of appetite, sensitive movements, etc. Even old pains can come back because of cytokines. Here are some fun immune system facts.

  • Immune system becomes more involved in serious or chronic states.
  • Immune system responses can become learnt.
  • Long-term stress and pain can lead to altered activity which leads to more cytokine production.
  • Immune stressors can be major or multiple minor events.
  • The immune system may underpin pain states such as mirror pain and loss of fine sensibility.
  • The immune system can be activated by the brain.

There are also several ways you can boost your immune system to counteract pain causing behaviors.

  • Improve your quality of life.
  • Be in control of life and treatment options.
  • Have strong family and medical support.
  • Have strong belief systems.
  • Humor.
  • Exercise.
I just boosted your immune system. You’re welcome….Unless you don’t like kids.

Movement (Not Gray Cook, that’s coming later)

In threatening states, big mover muscles become primed. This change occurs evolutionarily so your body can escape potential threats. In injured states, prime movers can act as splints.  If this state occurs for the long term, muscles can start to feel stiff and achy. Even if pain is gone, sometimes these muscles do not return to their normal activity levels.

Really big splints.