Key Messages of

Pain Biology Education

Part II
 4 Pain is
Multidimensional
Many factors fill the cup of sensitivity

Key Messages
 Things to consider
getting your patient’s story

• introduce the idea that pain

is multidimensional

• use the cup analogy

• fill the cup from their story

• ask what you might be missing

Key Messages
 What are we accomplishing?
The value of Cognitive Restructuring

• you can change what is in the cup

• or build a bigger cup

• what do they want to work on?

• what can you help them with?

Key Messages
 5 Protection can be amplified
and persists past healing
we get better at protecting ourselves

• Canyou think of examples where

we “overdo” our protective
responses?

• Whyis this advantageous and

perhaps the norm?

Key Messages
 Evidence for this message
choosing what we see in front of us

• Allergic reactions

• Bone healing

• Scar formation and keloids

• Hunger at lunch

• Anxiety attacks

Key Messages
 What are we accomplishing?
The value of Cognitive Restructuring

• wewant to normalize and validate what our

patients feel

• they aren’t weird for having pain

• its not their fault - its a trait of being human

Key Messages
 Angry Dad
Never happens, honest

Key Messages
 What are we accomplishing?
The value of Cognitive Restructuring

• which leads into a positive

message

• we can adapt with exposure

• we can tame our response to

stressors

Key Messages
 …and none of this is weird
Taste is like pain too

Key Messages
 6 Pain is normal
but can seem weird
giving a better explanation for why
things hurt

Key Messages
 altered body perception
Our distorted maps
helping people understand their
condition
“It feels out of place”

“I feel unstable”

“Its just not my shoulder anymore”

Key Messages
 7 You are strong and adaptable
Finding the right stimulus
People should be viewed as inherently
stable and robust

Key Messages
 You are strong and adaptable
Finding the right stimulus
People should be viewed as inherently
stable and robust

• Modeling of injury has shown that a

reduction of intervertebral stiffness
could be compensated by a small increase
of 1–2 % maximum voluntary activation (%
MVA) in trunk muscle co-activation

• Both modeling and experimental results

have shown that healthy controls operate
below this critical 5 % MVA threshold
for most postural activities like
standing, walking, sitting that must be
maintained throughout the day
Key Messages (Cholewicki et al., 1997)
 What are we accomplishing?
The value of Cognitive Restructuring
• we can build up our patients instead of knocking them down

• deviations in posture, symmetry, strength etc can be tolerated

with no pain

• we can adapt to what many would consider faulty patterns

Key Messages
Stories of Adaptability
Stories of Adaptability
…but its a balance
 8 we can respond
positively to stress
we need to find the right stimulus

Key Messages
 Evidence for this message
even discs can adapt

• Its a balance between stress and

recovery

Key Messages
 Evidence for this message
discs can resorb

“The rate of spontaneous regression was found to be

96% for disc sequestration, 70% for disc extrusion,
41% for disc protrusion, and 13% for disc bulging. The
rate of complete resolution of disc herniation was 43%
for sequestrated discs and 15% for extruded discs”

Key Messages
 Evidence for this message
Twin Spine Studies of Battie and Videman

Higher body weight was associated with 6.2% higher bone density in the lumbar spine, confirming
an effective discordance (p<.0001). Disc signal variation was 5.4% higher ("better") among the
heavier MZ co-twins (p=.005), but the 2.6% higher disc heights and 2.9% higher adjusted disc
signals were not statistically significant.

CONCLUSIONS:
Contrary to common beliefs, our findings suggest that cumulative or repetitive loading because
of higher body mass (nearly 30 pounds on average) was not harmful to the discs. In fact, a
slight delay in L1-L4 disc desiccation was observed in the heavier men, as compared with their
lighter twin brothers

Key Messages
 Evidence for this message
More Twins

“More recent results indicate that the effect of anthropometric factors, such as body weight
and muscle strength on disc degeneration, although modest, appear in this work to be greater
than those of occupational physical demands. In fact, some indications were found that
routine loading may actually have some benefits to the disc.

CONCLUSIONS:
The once commonly held view that disc degeneration is primarily a result of aging and "wear
and tear" from mechanical insults and injuries was not supported by this series of studies.
Instead, disc degeneration appears to be determined in great part by genetic influences.
Although environmental factors also play a role, it is not primarily through routine physical
loading exposures (eg, heavy vs. light physical demands) as once suspected.”

Key Messages
 Things to consider
How do explain the brutal pain?

• Symptomatic disc herniation causing radiculopathy

hurts!

• There is a mechanical and chemical sensitizing

component

• It is akin to vinegar on a cut

Key Messages
 Things to consider
How do we broach the idea of exposure and
adaptation

• Look for examples they might already know

• How do you prepare to climb Everest?

• How do you run a marathon?

• How do we treat many allergies?

• How do you confront fears?

Key Messages
 9 altered function is
poorly related to pain
posture, strength and endurance don’t have to change

Key Messages
 altered function is
poorly related to pain
posture, strength and endurance don’t have to change

HOLD ON!

Doesn’t our treatment try to address

some of these limitations?

This Key Message might not always apply

Key Messages
 Evidence for this message
measures of muscle timing don’t need to change

Key Messages
 Evidence for this message
mechanical stability hasn’t been shown to need
to change

People get better with an

exercise intervention but
mechanical stability does not
HAVE to change

Key Messages
 Evidence for this message
lifting techniques are not effective in primary
prevention

But, that doesn’t mean short term changes in movement habits are
unhelpful.
Key Messages
 10
1 You don’t need fixing
before you start doing
No activities need be off limits forever

Key Messages
 Things to consider
Questions to ask

• What are you missing?

• What would you love to be doing if you had no

pain

• What needs to happen for you to start those

things?

• What do you think would happen if you did those

things tomorrow?

Key Messages
 What are we accomplishing?
The value of Cognitive Restructuring
• we are giving “permission” for people to resume
the meaningful things in their life

• the things they want to do can be part of rehab

• “the doing is the fixing”

• “you want to deadlift? OK, lets start now”!

Key Messages
 anecdote alert
not science but a real story
cognitive restructuring lead to changes in activity

Key Messages
 other resources
thanks NOI group
Different key messages or target concepts

Key Messages
 other resources
thanks NOI group
I did Key Messages first :)

Key Messages