James: Welcome to episode three of Supervisions in Pain. This episode’s actually going to be part one of a two-parter where we’ll be focusing in on the topic of pain education. So, for part one, we’re exploring what pain education might look like for our clients without cognitive impairment or communication impairments. And then for part two, we’re going to be bringing in that added complexity back into the picture and discussing how that changes our approach.

So this episode’s a bit of a lead on from episode two where we talked about one of my clients who was very practically minded and needed to be engaged in a very hands-on way. So we’re both bringing a couple of clients to the table this week. Some like my client who really needed a practical approach, some clients who needed quite a theoretical approach, and then some who were really resistive to any form of education.

We’ll talk through how we identified what they needed and then how we tailored our education as part of their treatment plan to make sure we were being as effective as possible. We’ll come back at the end to talk about the research surrounding pain education in general and discuss how the research informed our decisions at the time. And then we’ll leave you, as always, at the end with three practical tips that may help you get started when coming across these clients in the community.

All right, let’s get stuck in. Alex, do you want to bring the first client to the table?

Alex: Yes. So, um, my client is, um, is a woman who I’ve been working with now for like almost seven years. Um, and from a pain education perspective, she really falls into a, um, a category where she’s very, uh, eager, very enthusiastic about gathering as much information as she can, um, and sometimes to her detriment. Um, so she is a classic Googler. She, um, and she can, she can sort of, um, be move into a state of hypervigilance quite easily. So she has a baseline level of anxiety that, … when she feels worried about something, her instinct is to – or her control-seeking behaviours around that unknown is to like incessantly research it.

James: Okay. So, how did she, in the first couple of sessions, how did she initially present?

Alex: Yes. So, she – I’ll just rewind and just tell you a bit about her history. So, she is a, um, 40-year-old woman, … with the diagnosis of MS, which is what I was there to support her with around her MS-related impairments. But in addition to that, she had osteoarthritis in a few joints. Um, and relevant to her pain picture, she was also entering a state of perimenopause, um, which was sensitising her symptoms further.

Camp, she had multiple pain types and they were, they sort of fluctuated in their intensity and, … I guess presence in her life. So, um, she was also – her goals really were to remain working as an artist. Um, she’s a mother. She had a beautiful garden. She, … had quite an active social life and she had a very holistic lens through which she saw, … I guess just through which she like saw the world. So she was also really well linked in to, … uh, medical and allied health support. So she was well supported.

Um, and I guess the thing that, … that signalled to me that, … education was something that I needed to deliver in a considered – in a considered way – was her history of anxiety and health-related trauma. So, … um, I guess the nature of MS being that when you, you know, she noticed unusual symptoms in her 30s and they were signalling to her that things were not right in her body, there was a – like, quite a big delay in an actual diagnosis being made. So from a pain perspective, … she – I, in her situation, the signals she was receiving from her body, one of which was a, a neuropathic pain presentation, were in fact indicating a sinister pathology underlying that.

So, um, and because her MS was, … her symptoms were quite stable, she did have a baseline level of anxiety about the onset of new symptoms. So she was, uh, she was in a state of like constant hypervigilance around her body and the signals and messages that her body were, … giving her essentially.

James: And was it a, a worry and an angst about the unknown, about what might be happening, or she what was happening already?

Alex: I mean, her MS symptoms were incredibly stable. The – any new weird sensations she was getting specifically related to pain took her straight to: “is this a flare-up of my MS? Is this a worsening of my or a progression of my underlying, … condition?” Uh, and, and then a subsequent sort of catastrophisation around those symptoms, which were completely fair enough. So it’s, you know, … and yeah, so, so we had to tread sort of carefully when we were empowering her to manage her symptoms. Yeah.

James: Um, that’s so tricky, isn’t it? Because it’s – the persistent pain presentation by its very nature is varied and changing, and it, it will create a lot of that, the next. And I imagine this is also true for the oncology population. Um, you know, because we’re sort of, … we, we, we know that hurt doesn’t necessarily equal harm, right? And that like the intensity of that pain is not linear to the severity of tissue damage or underlying pathology. Um, you can have no pain but have very serious pathology. So it’s, … but I suppose in a person such as this where their symptoms went – they were seeking help in relation to symptoms that they wanted answered about, and they were sort of, … … those, but they were told by their medical team that those symptoms were not, you know, “don’t worry about it.” It was sort of, … and then in fact it was actually pointing to quite a serious, … underlying condition. So yeah.

James: Okay. So it was the – it was the sort of the hyperfixation, fixation, the catastrophising. Um, were there any other parts of her presentation that made you think this is a person that needs a sort of a more formal theoretical education to really understand what’s happening underneath the surface?

Alex: Well, in the end, I didn’t – I didn’t do any – I didn’t do formal education because I made the decision to kind of use more bigger picture, … concepts that allowed her to, … to, … like reduce the threat of symptoms that she was receiving and, and take it, take a step back and try to, … try to look at the biopsychosocial picture as a whole. And, … and then make good decisions based on all of the different contributors to why her pain might be, … you know, increasing or she might be developing new symptoms. As a – and, and I guess I also felt that those skills would serve her MS management around her fatigue and, … and just like lifestyle decisions in relation to the symptoms she was getting around menopause and, … osteoarthritis.

James: Right. Yeah. Okay. Can you, can you give some examples of, yeah, what that might look – might have looked like?

Alex: So, we did a lot of, … I guess we would, … we did a lot of diagrams because she’s an artist. She’s very like visual. When she would be telling me about, … pain and unusual symptoms and just what was going on in her life, I would – I would jot all of these things down on a big piece of paper and then we would draw arrows and connections to things. Um, and so an example might be, … “my knees were like excruciating for the last month. Um, and I had to go and get all this massage and I saw my acupuncturist.” “Okay. And what else was going on around that time?” “Oh, well, I, I had like, … two exhibits. My daughter was finishing high school. Um, my, uh, I changed medications…” And then all of these things started to, … you know, become clear – this complete picture of what was going on at around this time from a biopsychosocial lens. And can we, … can we sort of paint a picture around load to her system?

It really was about – that was the kind of central metaphor that we chose was: how much load is on your pain system? How much load is on your immune system? Um, and those, … those things could be psychological, emotional, financial, … biological, you know? And so, and then that, that sort of gives a more complete picture about why symptoms might be, … up and down. And also was very effective for her in like, “Ah, okay, that makes sense. I’m not going to catastrophise to this conclusion that, oh my god, my MS is flaring up again. This makes sense in the context of my life for this period of time.”

James: Yeah. Okay. So the – so there were really strong theoretical underpinnings to what you were doing. It sounds very sort of much like case formulation and sort of Dim Sims type, to help her understand why, but just tailored towards who she was as a person, as an artist. Very visual.

Alex: Yeah.

James: Okay. So she need – she really, well, it sounds like you felt like she really needed to know why and understand the complexity and the overlapping, yeah, nature of it all.

Alex: Yes.

James: And then, well, I guess we’ve already sort of discussed how, how you approach that differently to say someone who needed quite a hands-on practical approach. Yeah. That’s really interesting. I like that you’ve been able to tie that to, to her as an artist as well.

Alex: Yeah. And she, she also did very well like, … um, that kind of conversation and or that thought exercise was essentially the treatment because she once she felt assured that she was okay, that we had ruled out any red flags – and of course, within that story, I was like keeping, … I was filtering: are there any reasons why we actually do need to get this investigated, or do we actually need to have a chat with a neurologist? It was, … and and every time it was a no. We just need to, … uh, we need to make adjustments to – it was load management almost every single time. It’s like, how can we, … how can we then make modifications to your routine or your exercise or your workload or, you know, what is within our control, what is not within our control? And making those sorts of changes that way, which she was able to do independently, but she just needed the help to piece it all together. And that was a skill that we worked on for many years. And now we’re at a point where she can do all of that complex, … synthesis of like biopsychosocial factors contributing to her state.

James: Yeah.

Alex: Herself, and make changes herself. Yeah. Um, we also really love the spoon theory. Do you know the spoon theory?

James: Yeah. Yeah. I’ve come across it a bit, but refresh me.

Alex: Yeah. So we use spoon theory again because we – the whole idea with this lady was to use non-threatening, … analogies, metaphors, and sort of, … ideas that she could apply to various scenarios in her life. Spoon theory is this idea of a spoon is an incredibly, … safe, innocuous apparatus. It’s not like a sharp knife or a fork. We use a spoon for a reason. And on any given day, you’re given 12 spoons. Um, no, sorry, that’s not correct. Uh, 12 spoons is the maximum amount of spoons. And a spoon represents, I guess, like your capacity to engage in life. So various things can draw spoons from you or draw energy or capacity, like, … um, you might not sleep very well the night before, or you might have run a marathon, or you might have had a big fight with your partner, or you might, … have your period, something like that. And so every, every day you are working with a different amount of spoons. Um, and she found that to be really helpful, I guess, in just like pacing.

James: Fatigue management.

Alex: Fatigue and pain for her were very inextricably linked in terms of how we would manage it.

James: Okay. Yeah. So this – this it sounds like a client who, who needed to sort of sit down and, and understand the complexity of it in a very visual, … collaborative way with you before getting permission to start to, to delve into that more physical side of things.

Alex: Yeah, she was a – she was a bigger picture thinker and could – and could carry on and apply those concepts to her life. Yeah. Um, but, but it was helpful for her to zoom out and see how everything was connected. Yeah.

James: Okay. So, this is – I mean, it’s a pretty stark contrast, contrast to the client that I brought.

Alex: Yeah. Tell me about –

James: Much more of a, a doer than a sort of conceptual big picture thinker.

Alex: Mhm.

James: So he was, … um, he was a guy in his mid-30s. Um, he’d had a motorbike accident, severe multi-trauma, but no ABI, very luckily for him. Um, he also had a, … previous diagnosis of ADHD and anxiety. He was, … uh, very, a very physical, practical guy. He was a caulker by trade. He was a snowboarder. He was a mountain biker. And he had a very big physical presence. So I remember the first session walking in and him sort of throwing open the door and big handshake. “Hey mate, how are you? Come in.” Like, very sort of, … larger than life. Uh, very bloke-y, very enthusiastic. And he gave me a sense that he just wanted to kind of get stuck into stuff.

Um, but he was also very fidgety and sort of wired, and he – he was sort of constantly kind of moving and doing things. And I – those were sort of the early cues that I was picking up from him that, that if I was to approach him with the kind of approach that you took with your client, … um, that he would have really struggled with that and it wouldn’t have landed. Um, so unlike your client who was more of a conceptual sort of thinker and processor, this guy was a doer. Um, yeah, so that, that very much changed my approach with him and how I wanted to deliver the pain education.

Um, I guess from a pain presentation perspective, he was getting really, really strong flare-ups at home when he was predominantly alone, when it was quiet, when he could – he – he would – he was really hyper-aware of his joint crepitus. Anytime he heard his shoulder click, click and creak, and his knees first thing in the morning, he’d catastrophise and the anxiety would, … would kick up, and then he would become really, really avoidant. Um, and yeah, he’d spiral a bit. He was also very “boom bust-y” in the sense that he’d go out with his son or with his mates and do, you know, hours of walking or trying to help them with a project at their house, and then sort of crash for a couple of days. Um, so, … yeah, that was – that was the first couple of sessions of sort of trying to unpack that and figure out how I wanted to go about approaching him.

Alex: Makes sense. Okay. Hey, because you mentioned he had anxiety, he was presenting with a sort of hyperaroused –

James: Yes.

Alex: – fidgety energy. Didn’t like being still.

James: Yeah. Um, he was a doer. Needed to keep moving to remain distracted or –

Alex: Yeah. Yeah. Yeah.

James: – distracted. And he just loved it. Like, he was an energetic kind of bubbly – and he seemed to – I don’t know whether this was just part of his testament or it was related to the ADHD – but when he was out doing stuff, it seemed like he was just sort of hyperfocused on that thing and not thinking about anything else. And then he’d come home, and then he’d get this flare-up, and then sort of ruminate and spiral and get locked into that.

Alex: Hm. So what way did you decide to go in terms of like, … yeah, building his knowledge around what was happening in his body?

James: Uh, it was – it would was pretty clear to me that the sit-down approach in a quiet room, explaining things in that place where he felt those flare-ups, was not the place to be initially. So I could relate to him in some sense that I get a lot of cracking and clicking in my shoulder. We both had labral tears. And in his mind, that was a real problem – a limiting problem. He was not stable. It was clicking and creaking. It was a real problem. And so, it was really open-chain stuff in his upper limbs that was making him flare. The wiping of the kitchen bench was the big one. He could help his mates get an engine block out of a car, but if he wiped the bench, he’d get this really severe flare-up.

So initially, in that first session, I literally got his hand on my shoulder and said, “feel this,” and clicked and creaked and moved. And I just sort of opened the idea to him of like, “it’s interesting that we’re both getting this creaking and clicking in our shoulders. We’ve both got these labral tears, but you get these really severe pain flare-ups and, … and I don’t, and I wonder why that is.”

And again, I guess sort of like our episode two, kind of just left that with him a little bit, but very quickly we went outside and we started doing sessions outside. He had a, … a beautiful dual-suspension mountain bike – really squishy, really – and it was a – it was a safe thing for him. It was also handy that, you know, holding onto the bars was a closed-chain movement. And then being outside, he couldn’t hear the creaking, creaking of his joints, and we would chat and ride a bit outside. And, … and on those rides, doing something different in a safe space would sort of start to touch on those discrepancies of like, “it’s interesting, you know, we, … we’ve just ridden for 40 minutes, but getting up out of bed and walking to the kitchen bench or wiping the bench with your arm for – like, why is that?”

So it was sort of planting little, … um, question marks. Some education that underpinned, … you know, behind the scenes, was really – we were talking about central sensitization and descending control and misconceptions about joint scans – uh, sorry, scans and joint crepitus. Um, and that was sort of just plants it into us going for a bike ride on his squishy, soft, lovely mountain bike.

Alex: Keep saying squishy. I don’t – I’m just gonna trust you on that.

James: It’s so bouncy. No. Well, I bet it was part of it, but too, because it was – it was so gentle on his body and abs – absorbing and – I mean, we – yeah, I don’t know why he’s the squishy.

Alex: You’re a bike guy.

James: Yeah, I won’t try to understand. So yeah, I, … I guess we got to the stage just by going out and doing things and then loosely talking about things, … um, that he was starting to be able to see that it wasn’t necessarily movement that was ramping up the pain. It was a combination of pain-evoking movement and this sort of fear and overthinking. And then that’s kind of where his rehab took off a little bit because we could separate that and say, “Well, let’s, … let’s just do the movement bit and go out to places where you’re not overthinking and then build your strength up from there and give you some confidence.” So that like, … you know, getting in the gym with headphones on where he couldn’t hear his joints creaking, music blasting, and, … and then, … and start doing some work there.

Alex: Cool. Yeah, that’s so interesting. It’s so interesting how sensory information just from your ears alone can modulate pain in that way.

James: I mean, he was so sensitised to it. He could feel it through his body when he – when he could hear it in the morning. He said, “It – it vibrates up into my chest and think, … you know, it was really – it was so provocative for him.”

Alex: Yeah. And what is his relationship like now to those sounds?

James: They don’t really bother. They’re still there.

Alex: Yes.

James: Um, they don’t really bother. I mean, he – we caught him relatively early in the pain journey, and so he was one that we were able to discharge within six months because he was – he was squatting 100 kilos. He was like – he was jacked by the – into the gym and just went for it. It was embarrassing to go with him because I’d try and demonstrate what to do and then he’d put a couple of other – a couple of plates on and do the same thing. Um, so yeah, no, he was able to relatively quickly, … compared to a lot of other clients, sort of, … um, untangle that belief and sort of move – move past it because he hadn’t – he hadn’t held onto it, you know, deeply for 20 years. Um, and I think because he was a doer and he was doing stuff, … uh, it, … it just sort of stopped bothering him. He got back into work and, … and all of a sudden it’s like, … creaking joints, whatever.

Alex: That’s like the power of pain education, right? Like, just that little moment of reconceptualisation or that disassociation of “creaking equals my shoulder is joint is cooked,” … um, can be enough to just like snowball and let people crack on with their lives.

James: Yeah. And it makes me think too – so, … I mean, might be putting you on the spot a little bit, but if, … if you had have taken the approach that I took to your client, how would that have gone without supporting anything, just got – going out and doing stuff with her body?

Alex: Uh, I think it would have – I think it would have caused a huge amount of fear and anxiety, and because she needed to know. She’s like, “I need to know. I need you to tell me. Is this going to hurt me or is this okay to do?” She – she couldn’t move forward with things until she had that reassurance. And so yeah, completely different approach. And she had a, … um – we want – I wanted to draw focus from her body and make it more about bigger picture. So it was – wasn’t as localized as what you’re describing. Um, … uh, yeah, and I, … and I think, … you know, in the opposite example, if I was to apply what you were doing to mine, he would have totally switched off and disengaged. I would have lost him so quickly.

James: Mhm. Yeah, but they both this underlying anxiety and catastrophising. So there’s like – there’s similarities, but the approach is so different. Impact is so different, isn’t it? All right, so we’ll move on to the, … to the last example. You were going to bring one to the table that was just resistant to any form of education.

Alex: Yeah, he was like – he was, … um, he just wasn’t that he was resisting it, was that he didn’t care. Um, so he, … uh, was a young guy, … had been in a car accident when he was 19 and had sustained, … um, a spinal – incomplete spinal cord injury. Um, he was able to walk, … but he did have, … um, impairments in his legs. So there was weakness and, … um, he also had, as a result of the thoracic lesion, … had, … um, fusion in thoracic spine, … lumbar spine, … I think, … maybe. Can’t remember, … I’ve been – I’ve been working with him for so long, … yeah. Um, he was flat, … really apathetic. He was disengaged from, … I guess, … like therapy generally, … generally. Uh, presented very low affect, … low mood.

So, … um, to sit down with formal education, … I quickly learned was not going to be appropriate from an engagement perspective. I didn’t – I mean, … um, I, … I need to – I needed to instill some sense of like, … hope and belief in, … um, that things could change. That was – that was really missing. And he wasn’t – he, … he just was in such a low place that he just was fully accepting of his disability, … fully accepting that things wouldn’t change, … and that was probably easier for him than to move into the unknown and push.

So that’s really where I focused my efforts was to gently demonstrate to him that his system was plastic and that if we manipulated neuroplasticity in the right way, … that we could get improvements not only in his physical function but also in his pain. We never spoke about pain as being an outcome measure that we were looking to change. It was always like, … let’s just see if we can get into some movement just to build up a bit of strength, … um, so we can feel better in our brain. Um, he was incredibly sedentary and was doing like literally no exercise, … even though he was physically very capable of doing it. Um, and he had no red flags. There was no, … um, contraindications to him getting out there and moving. As you say, … he had a titanium rod in his spine. He was a young guy at the time of his accident. He was like, … you know, … all systems go, … we could get stuck in.

So, … I think the focus of our first couple of years working together was to get some, … um, to get him out and in the community and just like general health, … you know, … … and conditioning. Also, … so we could get some endogenous opioids happening for his mood because the – he, … he was up for exercise because he believed it made him feel less depressed. That was the only in that I had. I don’t think he really wanted to see me. He was referred by an OT, … so it wasn’t really like a self, … um, referral, … and he saw no point in my services initially.

James: Okay. So, … so rather than the first two examples of there being sort of a pretty direct link to pain in the way we were managing it and that being pretty apparent to them, … just in a different version – a theoretical and a practical – this guy, … it sounds like it was: let’s not even – it’s, … I mean, … I can see that there’s some pain theory going on in how you’re approaching it, … but to him it wasn’t apparent and it wasn’t linked to that at all in what you were doing.

Alex: He – um, … it was not necessarily – it was not necessary for me to, … um, to deliver pain education before I needed to get started on other stuff. And the pain education did come, … but it was something that we would do on reflection when we were – when I was going through his outcome measures. So with all of my pain clients, … I, … I’m pretty like strict with outcome measures. I think they’re a really good tool for reassessment and also for pain education, … particularly in a guy like this. So, … we, … we, … we assess baseline and then, … … once he had been, … … getting to the gym a couple of times a week for three or six months, … we reassessed again and we just spoke about how the, … … the scores had changed.

Yeah, … um, … and I wonder like, … what’s your idea? What are your ideas about why that is? Like, … what do you think is happening in your body? Um, … for him, … he, … he had a belief that the stronger he is, … this – the more robust his system is and the less painful it will be, … which, … you know, … in a sense was true. And we would, … … and then it was also a nice springboard for: and how have you been sleeping, … and how has your mood been? We just started to like gather more data. And things were over the course of many years – let me add – were on a very steady upward trajectory.

Um, … and yeah, … he – and then the more rapport and the more trust and the more, … … benefits he was – he was getting from, … from these treatments, … the more open and receptive he was to, … I guess, … getting a little bit more nitty-gritty. But we never really went deep on, … you know, … the pathophysiology of pain. We just spoke about how, … … when you exercise, … you know, … your brain releases, … … hormones which, … … reduce sensitivity in these areas and they also are protective for mood. And, … … it wasn’t – it wasn’t sort of very, … very detailed and very academic.

James: Yeah, … that’s really interesting. So, … I’m trying to think of ways that it differs from the first two clients. What, … what I’m seeing is that rather than getting stuck into the pain education side of things in a different way, … it was very much like step off the pain education completely for a while. Work with his core beliefs, … build some hope, … which coincidentally those things are also, … you know, … helping his pain modulation a little bit anyway because they’re movement and exercise, … and aiming for improvements in mental health. And then once there’s some buy-in and a relationship and some trust, … then you can start to slowly integrate some basic pain education into your management.

Alex: Yeah. And, … yeah. And I guess I wasn’t telling him that change was possible. He was – we, … we could both see it was, … it was, … … … you know, … it was we, … we could not argue that he hadn’t improved. So we needed that like, … … we needed those outcome measures to really categorically say, … “this is different. This is looking better. Let’s dissect why that might be.” And then it didn’t – it wouldn’t have felt as combative if I, … if I had tried to convince him of the, … … like his rehab potential or he, … you know, … the, … the, … the opportunities of engaging in therapy. In the first few sessions, … he would have told me to piss off, … like quite frankly. He just didn’t have any confidence that things could change.

James: Yeah. I find those, … those clients the hardest – the low engagement, … low motivation. Really tricky. You’ve got to be quite tactful, … don’t you, … in the way you approach it?

Alex: Yeah, … it was so interesting. This guy, … he was so flat, … but he never missed a session, … right? He never missed a gym, … like he stuck to what he said he was going to do. It was so interesting. And we also spoke a lot about that. Like he claimed that he lacked motivation, … but he every single day that he said he was going to go to the gym, … he went to the gym.

James: Well done. Well, … I would imagine that if, … if he had have received the type of education that client one or client two received from us, … it, … it wouldn’t have gone that way.

Alex: No, … he was not a get up and go like, … “let’s get cracked in,” … you know, … like your chappy. Um, … and to talk about like, … you know, … the philosophy and sort of bigger picture and holistic nature of pain in those early phases as well wouldn’t have resonated.

James: First couple of sessions in that, … that initial assessment, … so important, … isn’t it? It’s a kind of a make or break for the rest of their, … their journey in that mindset that you build, … isn’t it?

Alex: Yeah. And I think like if I’m trying to like, … … synthesize this into like takeaways, … the, … the learning for me has been over the years that just like, … go slowly and, … … and don’t launch into pain education until you, … … have a good strategy. Uh, … yeah.

James: And you get – and you sort of know where they’re coming from a bit more, … too.

Alex: Yeah.

James: All right, … cool. Thank you for bringing those. They’re really interesting ones. Let’s wrap it up there. We’ll, … we’ll move on to some of the research, … talk about some of the theory about why we chose those approaches and why they were specifically effective for that type of person. Uh, … and then at the very end, … we’ll bring you some take-home messages.

Okay. So, … there were three different examples with three very different approaches. Can you take us through some of the research and evidence, … Alex, … and tell us why what we did worked?

Alex: I certainly can. Um, … so pain neuroscience education is, … … a, … a formal intervention, … … and it has been very widely studied – lots of big systematic reviews and meta-analyses, … … on this specific, … … intervention. And it has really strong clinical efficacy when it’s used as part of a multimodal plan, … uh, … and very weak efficacy when it’s used alone, … … in isolation, … which makes a lot of sense. Um, … so education alone does not equal behaviour change.

Um, … I’ll talk a little bit about how it actually works, … like what its actual mechanism of, … … – the actual mechanism that it has on our central nervous system, … which I find really interesting. It helps me then to, … … I guess pull in all of the other factors that a person might also be experiencing. So the way that I conceptualize pain and the way that I educate on it is that pain is a protective output of our central nervous system. And it is – it is one of many protective outputs that exist, … but it is one that is very loud and obvious and it, … it, … … is there. It is loud and obvious for a reason because it, … it, … … compels us to change our behaviour. But, … … amongst the surface, … there are many other protective processes that are happening in addition to pain when the central nervous system is under threat.

Um, … pain is one, … the motor system is one. We think of things like muscle tension guarding, … … the autonomic nervous system. So spikes in adrenaline and cortisol can have widespread, … … effects on other body systems. There’s a psychological, … … response. So increased, … … anxiety, … hypervigilance, … catastrophisation. And then a big one that not many people understand and have a hard time actually educating on is the immune role in pain and the immune system as a, … as a very critical protective output. Um, … and that involves, … … immune cells, … and there’s a pro-inflammatory response that happens in addition to, … … to pain increases. So all of these separate systems or processes interact with each other, … … and sensitize the pain system and basically maintain its chronicity.

Um, … the purpose of pain education is to lower the nervous system’s threat perception and reduce the threat value of pain. Um, … and by doing so, … you can reduce the protective outputs, … … across all like five of those domains. Does that make sense?

James: Yeah, … totally. It definitely does. Yeah.

Alex: Um, … so it’s all about reducing the threat of what is happening within someone’s body, … and in doing – in explaining what is happening inside their body, … and they – it, … it in turn reduces, … … that person’s perception of how critical, … dangerous that thing is. Particularly if it’s, … … the, … you know, … it’s an example of a broken bone. We can say categorically that bone will heal in 12 weeks for most people. We can demonstrate that healing on a scan. We can say the healing has been – has been effective, … but we have a protective pain system that has persisted beyond what we would expect. Um, … and that then becomes the target of treatment – not to fix the leg, … but to, … … desensitize the pain system. Um, … yeah.

So I guess in the context of that, … why does then just providing generic education to the – same generic education to everyone not work? Mhm, … yes. Uh, … it seems obvious, … but you know, … there’s been many, … many studies where pain education has had a, … … a generic, … … know, … pamphlet model where people are delivered the same education and there’s no – zero impact on pain disability, … quality of life. It really needs to be integrated and concept – like contextually for them specifically.

Um, … and then also there’s the – the importance of learning styles and understanding how a person is able to process, … make sense of, … and integrate information and apply it into their broader life. I guess that’s the power of education and that – that is where our skill comes in as, … … as holistic, … client-centered clinicians because you cannot do that unless you really deeply understand your patient or your client and how they learn, … how they operate in the world, … what is important to them, … … how they understand their body, … … and, … … how they understand their pain.

So yeah, … it’s a very complex thing. Um, … so yeah, … we know that alone it doesn’t do anything. It needs – they, … they speak about it being a like a “primer.” Um, … so a kind of basic example would be: I’m going to deliver pain education within a single session, … … to reduce the threat, … and then I’m going to follow that up with an exercise or, … … support to participate in something. So I find that example to be kind of reductive because I don’t think that always works. Often, … like, … the impact of pain education is a slow process of reflection and contextualization over, … … many days and weeks. I don’t know if you’ve experienced that.

James: Yeah, … absolutely. And I think we’ve mentioned it in a couple of examples, … too, … that it’s not necessarily linear like that, … is it?

Alex: Mhm.

James: In fact, … sometimes it’s more powerful after the fact in the reflection like you said. Giving the education first might fall on deaf ears if we’re doing that and then trying to provide input to sort of prove the education, … right? Sometimes there – were a client in the last episode we mentioned and then this one too, … where the doing and then having a conversation during the doing or after the doing was much more powerful.

Alex: Absolutely. So yeah, … that’s what the evidence says, … but I, … I, … … think this is a classic example where the evidence is overly simplistic. So I, … I take a different approach with every single person that I work with. Sometimes it will be peppered throughout our time together. Other times it won’t, … you know. I might wait several weeks before engaging on some of this stuff and others want it straight up. Um, … so –

James: And you – and you mentioned sort of time as well, … which is I think so important because it’s – it’s got to carry weight and it’s got to land. I mean, … we’re trying to unseat really core beliefs. The pain sometimes defines these people and has done decades. So the time is, … like you said, … peppering it through, … but consistently over time and being patient with it is really important part of it as well.

Alex: Yeah, … the rapport building is really important. And also being respected as a person of expertise and authority can sometimes happen, … you know, … that phenomena develops with time. And yeah, … there’s so many factors. Um, … I was just, … … yeah, … I was just reflecting on as well that pain education can take many forms, … … and sometimes it doesn’t have to be explicit. Like, … even in us using a certain vocabulary when it comes to talking about pain, … that is – that is providing an alternate cognitive framing of pain by, … you know, … by saying “overprotection” and, … … “sensitized,” … … rather than, … … “damaged” and, … … “fraying” and “bulged,” and all of these words that we know have, … … associations which can hyper – which can increase the threat value within someone’s brain. We, … we are – we are doing that anyway.

Um, … I guess even a, … … a study coming out of the – the NOI group from South Australia looking at even the impact that can be made on changing like – the – if you – if you’re using words with more consonants, … sharper-sounding words like “fracture” and “break,” that really – that can have a subconscious impact on the way that people are perceiving their injuries as well.

James: Yeah. So there was a encouraging people to even think about the specific words that they use that we’re trying to think of like, … you know, … smooth tones, … nice round-sounding words: “glide” and “smooth” and “flow” and things like that. Even that can have a subconscious impact while you’re providing that education.

Alex: Totally, … because information is being received as a sensory afferent, … right? And the – the tone of the language, … the volume of it, … all of that stuff means something to the individual. And if you, … yeah, … you think about the brain as being this prediction – this very sophisticated prediction machine – if you are queuing things that are more aligned with safety and confidence and hope and, … … wellness, … it’s going – all of that plays into this, … … And and sometimes education can take the form of, … of doing or showing or guiding or facilitating, … … as opposed to explicit words. So it all just taps into like the complexity of communication. I think I’d love to get a speechie on soon to, … to talk about that –

James: Yeah.

Alex: – in more detail.

James: Yeah.

Alex: So I guess in essence, … there is really strong evidence for pain neuroscience education that is very straightforward. Uh, … to deliver it in a way that is effective and aligned with the person’s cultural, … psychological, … social, … historical concept of their life in the world is, … is a whole another skill set. Um, … and yeah, … really hard to, … I guess, … distill in, … in a neat little summary like this. But, … … um, … I think that’s where learning from exposure really helps and having these sorts of debrief sessions with a clinical supervisor – what’s working well, … what’s not landing. Um, … it’s kind of like any social interaction. Hey, … like, … you know when things aren’t hitting and they’re – they’re not resonating.

I, … I, … … do feel like step one in this process of becoming more comfortable delivering that education is, … … practicing it. I think the nuance can come later. But first things first, … you really need to be – be confident and comfortable in what you’re saying, … that you can actually deliver whatever concept you’re trying to discuss, … that you can deliver that piece of information, … uh, … well and, … I guess, … with without overexplaining it confidently. And for me, … I remember when I started – when, … … we started working as supervisor and supervisee, … I found it really hard to overcome the barrier of actually starting my first discussion about pain with a client because it was just so intimidating and a little daunting.

What we needed to do – I don’t know if you remember – was, … … bring a couple of concepts to a supervision session. And I just had to sort of fumble my way through it and try and explain it and just get the words out and practice a few times – quite a few times – until I felt comfortable delivering that concept to that client, … just with another concept in the context of another client. And just practice. The practicing was, … … monumental in letting me be comfortable to have those conversations. And then once I was able to have a few of them, … then I could learn more about the nuance of, … “I might tweak how I want to deliver this to that client,” or maybe I’m not sitting down with this client and explaining it in full. Maybe I’m just littering it into something else that they’re doing. Or maybe I just need to drop a small hint with this person and then step back for a week or two and let them figure it out for themselves. So I feel like that step one is just like, … you got to – you just got to practice it first.

Alex: Yeah. You got to understand it, … … because there’s also lots of like really interesting evidence that says that the confidence or the perceived confidence of the clinician delivering the education, … uh, … has a, … has a greater analgesic effect than someone who has perceived lower confidence.

James: Yeah, … that’s fascinating. So yeah, … so I guess like step one is: be confident in what you’re actually teaching – like, … understand the underlying processes. The next skill is: how do I – how do I deliver or paraphrase this information to the person sat in front of me? Um, … and then you can start to finesse the skill from there. But it’s absolutely a skill.

Alex: Yeah, … absolutely. And, … … if you’re even one step before that, … if you just are in a position where you don’t have any confidence at all to start that conversation, … the video resources are really amazing. They can be really supportive. And then – so, … so I used to in my first few sessions, … I’d introduce the idea but then leave them with videos that were relevant to that concept and let them look at those outside the session. And I’d come back and we’d reflect, … and I found that a bit easier. And while that was all happening, … I was getting stuck in in our sessions together, … trying to practice, … practice, … practice, … knowing that the conversation was coming. So, … they’re really useful resources. All of the, … the sort of pain science related YouTube videos that you can find are a great support.

Alex: Absolutely. I was going to say, … or you could out-source this to very smart individuals who have spent a lot of resources and time developing these incredible and free resources. So, … … and James and I will link these to the show notes, … but there is so much patient information out there.

James: Yeah.

Alex: Um, … and most of it is free. Um, … there’s great, … … CALD resources as well. You can get it – get these fact sheets or videos in most languages. Um, … there’s online courses that clients can do. There’s so many things that you can do together as well. Like, … there’s that great book that I use from the Neuro Orthopaedic Institute, … the Protectometer, … which I love because it’s interactive, … it’s funny, … it’s, … you know, … very densely littered with metaphors. But that may not – that may not be someone else’s style. Like, … that’s a very specific flavor and tone.

James: Absolutely. Um, … and we’re only just talking about, … I guess, … like a, … a neurotypical population. We’re not adding in the complexity of cognitive impairment, … communication impairment, … which we will be saving for next episode. Adds another layer of complexity.

Alex: Yeah, … different ball game.

James: Yeah, … absolutely. All right, … great. Thanks very much, … Alex. So, … … we, … we’ll be sort of resource heavy in this episode. We’ll dump a bunch below for you to, … to have a look into in your own time. I think you and I developed like – how many pages do you think that resource document was where we had linked every single video, … every single article, … every single podcast, … every single fact sheet? We’ll see how many we can fit into the description.

All right. Thanks, … Alex.

So the take-homes from this episode: first and foremost is the understanding that providing pain education is a skill. It’s not something we just have or don’t have. We really need to work on this. Uh, … Alex mentioned that, … you know, … the evidence is really clear that it’s a powerful tool, … but it’s only effective when we use it as part of a comprehensive multimodal treatment plan. Its impact is further enhanced if it’s tailored to suit the client’s learning style and its pain – and their pain story. And even more so if the client really feels that you’re delivering it with a degree of confidence and that they believe that you’re a competent clinician. And, … … that might conflict with how you actually feel, … but as long as they’re perceiving that, … that goes a long way.

Alex: Like wear a suit that day.

James: Yeah. Yeah, … whatever makes you feel more confident that they really just need to feel that you’re a safe pair of hands for them. So to improve how we can provide those treatment modalities, … first things first, … we just need to understand the concepts ourselves, … … quite deeply before we’re even providing this to our clients at all or patients.

Second step would be to really lean on the resources that you’ve got at your disposal. So the videos, … the podcasts, … the books, … … that interactive books like the Protectometer are really, … really helpful to support your education. And they can also be really helpful tools if you’re quite time-limited. If there’s not a lot of funding available or your sessions are sort of capped to 20 or 30 minutes, … those resources can be really powerful.

I think the third step would be practice, … practice, … practice, … practice. It could be in front of a mentor, … with one of your colleagues, … in front of the mirror. The process of getting the concepts – the pain concepts – out of your brain, … out of your mouth, … uh, … and getting used to that is, … … really, … … important. Um, … so you can start to develop, … … familiar scripts. You can bring in a lot of metaphors and analogies from your own life to make it sort of real. Uh, … and as many examples as you can think of – uh, … that’s a great way to go.

And then the – the fourth step to really sort of power up the impact of your education is to have that deep understanding of your client and their pain story, … their beliefs, … … knowing that their health lit – literacy and their personal learning styles so that you can take those pain concepts and really tailor it with nuance to that individual. Um, … yeah, … I think that’s expert level, … isn’t it? Just like that.

Alex: Just like that. It’s a long process. I’m still on that journey for sure. Been working on it for nine years at least.

James: Oh, … absolutely. And the evidence is constantly – it’s like emerging every day. Think about how – how much pain understanding amongst health professionals has changed in the last 10 years. It’s very radical.

Alex: Yeah, … absolutely.

James: All right. Thanks for listening, … everyone. We’ll – in part two, … we bring in some more complexity into this pain education topic.

Alex: Yeah. We’ll talk about cognitive and communication impairments.

James: Bye-bye.