Key Messages of

Pain Biology Education

Part I
 if pain is the opinion of the brain

• we want to change that opinion

aka Cognitive Restructuring

The Pain Science Pathway
Pain Science Flips the Scrip
instead of pointing out everything that is wrong

We focus on everything that is RIGHT

When in Doubt

CSD

BSBU
 The Process
• 1-2 Key Messages per visit
• Choose the Key Message that fits the person
• Repeat and support with research, metaphor and
analogy

• Evaluate - ask if it applies to them

• Ask how they would explain their problem to someone
they know
 Targeting Key Messages
• What are some potential false or unhelpful beliefs
that might help perpetuate the pain problem

• What do you need to do here first?

• Is it worth addressing every belief

 Addressing Beliefs
1. Acknowledge prior explanations The basis of a nonthreatening, coherent LBP
(Yes, and...) representation is the combination of:

2. Provide a competing narrative 1. diagnostic certainty (identity dimension)

3. Support the new narrative with 2. that can explain one’s symptoms
elements of the patient’s story
3. which replaces erroneous beliefs in the
4. Implement healthy and new damaging effects of pain
behaviour
and
Modified Motivational Interviewing Approach

4. prescribes procedures for controlling or

resolving the
symptoms Bunzli et al 2017
…and we can add a few others

and

you can too

 With all Key Messages
• You want to consider what situations might this message be
relevant
 1 Pain is an alarm
Which is meant to protect
Alarms want you to do something

Key Messages
 Things to consider
Following up with your patient

• do alarms correlate with the problem?

• do alarms tell you where the problem is?

Key Messages
 Evidence for this message

• heart attack symptoms are odd

• alarms can become more sensitize

• pain can be helpful

Key Messages
 2 Pain is poorly
Related to damage
Lets call it wrinkles on the inside

Key Messages
 Things to consider
Following up with your patient

• who is this message best delivered to?

• we want to recognize that tissue is important but

always reiterate that it is not destiny

• do they have “damage” somewhere else with no pain

Key Messages
 Evidence for this message
a huge amount of research showing wonky scans
with no pain

Key Messages
 Evidence for this message
a huge amount of research showing wonky scans
with no pain

• Even in 20 year olds:

• 37% have disc degeneration

• 30% have disc bulges

• 29% have disc protrusions

• 19% have annular fissures

Brinjikji 2014
Key Messages
 What are we accomplishing?
The value of cognitive restructuring

• We are trying to address fear and perhaps a sense of fatalism

• We are building confidence in a strong, resilient body

Key Messages
 But…
Structure is not irrelevant
Perhaps its like kindling

• Hancocket al (2017) showed increasing

LBP risk with increasing numbers of
MRI findings

• Jensenet al (2018) “subgroups of

multiple and severe lumbar MRI
findings have a stronger association
with LBP than those with milder
degrees of degeneration”

• McAuliffeet al (2016) showing

tendinosis increases future
Key Messages tendinopathy risk
 3 Pain is more about
Sensitivity than damage
its our response to the all of life’s
loads

Key Messages
 Pain is more about
Sensitivity than damage
its our response to the all of life’s
loads

increased self-efficacy,

reduced pain catastrophising,

accurate pain beliefs,

increased pain coping and

increased psychological flexibility

were important mediators”

Key Messages
 Pain is more about
Sensitivity than damage
the response to all of life’s loads

• painis the interplay and

interaction amongst many
things

• ournervous system can become

more responsive and protective

Key Messages
 Pain is more about
Sensitivity than damage
What contributes to sensitivity?

• itsthe balance between the

perception of danger and the
belief that we are safe

• Pleaseread Butler and

Moseley’s Protectometer for
more on this

Key Messages
 Things to consider
questions to ask

• find episodes of large flare ups or large changes

in pain and ask what changed.

• what does it mean that there is more pain when

people are more stressed?

• what does it mean when we feel better when we are

distracted, active or engaged in meaningful
things?

Key Messages
 Things to consider
questions

• What are the new or unmanageable stressors in

your life?

• What has changed?

• introduce the Cup Analogy and ask them to fill

the cup

Key Messages
 Evidence for this message
Not comprehensive

• Central Sensitization

• Peripheral Sensitization

• Expectations influencing pain

• Sleep influencing pain

• Fear and beliefs influencing pain

Key Messages
 Evidence for this message
Some examples to tell your patients

• cold stimulus applied to skin with

different lights (red or blue) with…

• different warnings (red = hot and

blue = cold)

• VAS measured

Key Messages
 Evidence for this message
Some examples to tell your patients

Key Messages
 Evidence for this message
Wiech et al 2010
• Lets zap more people but modulate their
beliefs about damage while inducing some
fear

• With a laser that was either:

• painful
• warm
• On a spot that was either:
• deemed “safe”

Key Messages • deemed “dubious”

 Evidence for this message
Wiech et al 2010

Key Messages
 Evidence for this message
habituation and beliefs

• “Repeated painful stimulation over several days resulted

in substantially decreased pain ratings to identical painful
stimuli. The decreased perception of pain over time was
associated with a very robust increase in pain ratings in
each single pain session, i.e., all participants sensitized
within sessions and habituated between sessions”

Key Messages
 Evidence for this message
wonderful habituation

Key Messages
 Evidence for this message
habituation and beliefs

• same protocol as previous study

• the first group (n =10) was instructed that pain perception
over time will habituate;
• the second group (n =9) that pain will increase;
• the third group (n =8) was instructed that pain will
remain stable over the 8 days of pain stimulation and the
fourth group (n =10) was not given any specific
information and served as a control group”

Key Messages
 Evidence for this message
habituation and beliefs

• “We found that the control group habituated as described

before.

• However, it was abolished in the second (sensitize) and

third (stable) group,

• but was very strongly demonstrated in the first

(habituation) group. In this group, habituation tended to be
increased as compared to the control group”

Key Messages
introducing the concept of
sensitivity leads to the idea
of pain being
multidimensional
sensitivity being influenced by beliefs and context…