5 Pain Education

Pain Education

The Human Body is Complex and Adaptable

The human body is not a simple structure, but rather a complex and adaptable network of overlapping systems. We must move from the myth of a simple biomechanical framework, or pathoanatomical model of trying to fix the structure, to understanding the complexity of a biopsychosocial framework and how all the systems within the body interact to experience all types of pain. The “no pain, no gain” mindset is being changed.

Increasingly, research shows that attributing the experience of pain solely to poor posture, minor leg length discrepancies, vertebral misalignment and other structural abnormalities is an oversimplification of a complex process (Green et al., 2018). Even in the case of degenerative changes in the knee, shoulder, and spine several landmark studies have shown that tissue tears revealed on imaging are a part of normal aging (Culvenor et al., 2019; Girish et al., 2011; Sihvonen et al., 2018). This disconnect between tissue damage seen on imaging and clinical presentation often creates confusion for both patients and clinicians. As a result, the medical community has moved on from a traditional biomechanical framework into a biopsychosocial framework.

The shift from a biomechanical framework to a biopsychosocial framework helps put into context the interconnected and multi-directional interaction between physiology, thoughts, emotions, behaviors, culture, and beliefs. Humans are complex and are composed of many overlapping systems, knowing how they interact is important for any therapist. The consensus is that structural abnormalities alone do not explain or necessarily predict pain. The reason people experience pain differently is in part is due to differences in genetics, depression, emotional stress, history of physical trauma and sensitization of the nervous system (Green et al., 2018).

Correlation Doesn’t Prove Causation

There is often a weak correlation between radiographic findings and symptoms – Several landmark studies have shown tissue tears revealed on imaging are a common finding in patients who are asymptomatic. This disconnect between tissue damage seen on clinical imaging and clinical presentation is part of normal aging and unassociated with pain. One study illustrates this concept well is a systematic review published in 2015, it provides important data demonstrating that degenerative changes can exist on a spinal magnetic resonance imaging and people can have no pain.

“Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient’s clinical condition.” (Brinjikji et al., 2015).


Tame the Beast – It’s time to rethink persistent pain

The Placebo Response and The Therapeutic Encounter

The way a clinician presents themselves and their treatment has influence on therapeutic outcomes. The magnitude of a response may be influenced by mood, expectation, and conditioning, this is often referred to as the placebo response. The placebo effect isn’t a single phenomenon, it involves overlapping cortical, subcortical, and emotional responses. Any therapeutic encounter can trigger significant biological changes that ease symptoms.

The existence of placebo-induced effects does not negate treatment-induced results, patients feel better after a therapeutic encounter because of a complex physiological response to the treatment that includes but is not limited to placebo.


Learn more about the placebo response in this 5 min TED-Ed video.

Key Takeaways

Employing an Individualized Biopsychosocial Approach to Pain Management
Ascribing a patient’s pain solely to a tissue-driven pain problem is often an oversimplification of a complex process. This insight provides us with an opportunity to re-frame our clinical models. Over time the supportive theories behind techniques evolve or change completely. It is becoming increasing evident that a biomechanical model as a basis for treatment is outdated based on the latest research into pain science. A shift to a biopsychosocial model of massage therapy helps put into context the interconnected and multidirectional interaction between physiology, thoughts, emotions, behaviors, culture, and beliefs.

References and Sources

Beecher, H. K. (1956). Relationship of significance of wound to pain experienced. Journal of the American Medical Association, 161(17), 1609–1613. https://doi.org/10.1001/jama.1956.02970170005002

Benedetti, F., Frisaldi, E., Barbiani, D., Camerone, E., & Shaibani, A. (2020). Nocebo and the contribution of psychosocial factors to the generation of pain. Journal of neural transmission (Vienna, Austria : 1996), 127(4), 687–696. https://doi.org/10.1007/s00702-019-02104-x

Benedetti, F., & Piedimonte, A. (2019). The neurobiological underpinnings of placebo and nocebo effects. Seminars in arthritis and rheumatism, 49(3S), S18–S21. doi:10.1016/j.semarthrit.2019.09.015

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. doi:10.3174/ajnr.A4173

Colloca, L. (2019). The Placebo Effect in Pain Therapies. Annual review of pharmacology and toxicology, 59, 191–211. https://doi.org/10.1146/annurev-pharmtox-010818-021542

Colloca, L., & Barsky, A. J. (2020). Placebo and Nocebo Effects. The New England journal of medicine, 382(6), 554–561. https://doi.org/10.1056/NEJMra1907805

Culvenor, A. G., Øiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., & Crossley, K. M. (2019). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British journal of sports medicine, 53(20), 1268–1278. doi:10.1136/bjsports-2018-099257

Ellingsen, D. M., Isenburg, K., Jung, C., Lee, J., Gerber, J., Mawla, I., Sclocco, R., Jensen, K. B., Edwards, R. R., Kelley, J. M., Kirsch, I., Kaptchuk, T. J., & Napadow, V. (2020). Dynamic brain-to-brain concordance and behavioral mirroring as a mechanism of the patient-clinician interaction. Science advances, 6(43), eabc1304. https://doi.org/10.1126/sciadv.abc1304

Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. AJR. American journal of roentgenology, 197(4), W713–W719. doi:10.2214/AJR.11.6971

Green, B. N., Johnson, C. D., Haldeman, S., Griffith, E., Clay, M. B., Kane, E. J., … Nordin, M. (2018). A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PloS one, 13(6), e0197987. doi:10.1371/journal.pone.0197987

Hayden, J. A., Wilson, M. N., Riley, R. D., Iles, R., Pincus, T., & Ogilvie, R. (2019). Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review. The Cochrane database of systematic reviews, 2019(11), CD011284. https://doi.org/10.1002/14651858.CD011284.pub2

Hush, J. M., Nicholas, M., & Dean, C. M. (2018). Embedding the IASP pain curriculum into a 3-year pre-licensure physical therapy program: redesigning pain education for future clinicians. Pain reports, 3(2), e645. https://doi.org/10.1097/PR9.0000000000000645

Kaptchuk, T. J., & Miller, F. G. (2015). Placebo Effects in Medicine. The New England journal of medicine, 373(1), 8–9. https://doi.org/10.1056/NEJMp1504023

Kaptchuk, T. J., & Miller, F. G. (2018). Open label placebo: can honestly prescribed placebos evoke meaningful therapeutic benefits?. BMJ(Clinical research ed.), 363, k3889. https://doi.org/10.1136/bmj.k3889

Kaptchuk, T. J., Hemond, C. C., & Miller, F. G. (2020). Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice. BMJ (Clinical research ed.), 370, m1668. https://doi.org/10.1136/bmj.m1668

Lewis, J., & O’Sullivan, P. (2018). Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. British journal of sports medicine, 52(24), 1543–1544. doi:10.1136/bjsports-2018-099198

Louw, A., Nijs, J., & Puentedura, E. J. (2017). A clinical perspective on a pain neuroscience education approach to manual therapy. The Journal of manual & manipulative therapy, 25(3), 160–168. doi:10.1080/10669817.2017.1323699

Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy theory and practice, 32(5), 332–355. doi:10.1080/09593985.2016.1194646

Louw, A., Sluka, K. A., Nijs, J., Courtney, C. A., & Zimney, K. (2020). Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients, but a Primary Focus for Clinician Education. The Journal of orthopaedic and sports physical therapy, 1–12. Advance online publication. https://doi.org/10.2519/jospt.2021.9804

Ongaro, G., & Kaptchuk, T. J. (2019). Symptom perception, placebo effects, and the Bayesian brain. Pain, 160(1), 1–4. https://doi.org/10.1097/j.pain.0000000000001367

Rossettini, G., Carlino, E., & Testa, M. (2018). Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC musculoskeletal disorders, 19(1), 27. doi:10.1186/s12891-018-1943-8

Rossettini, G., Camerone, E. M., Carlino, E., Benedetti, F., & Testa, M. (2020). Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy. Archives of physiotherapy, 10, 11. https://doi.org/10.1186/s40945-020-00082-y

Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … FIDELITY (Finnish Degenerative Meniscal Lesion Study) Investigators (2018). Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Annals of the rheumatic diseases, 77(2), 188–195. doi:10.1136/annrheumdis-2017-211172

Stewart, M., & Loftus, S. (2018). Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation. The Journal of orthopaedic and sports physical therapy, 48(7), 519–522. doi:10.2519/jospt.2018.0610

Watson, J. A., Ryan, C. G., Cooper, L., Ellington, D., Whittle, R., Lavender, M., … Martin, D. J. (2019). Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. The journal of pain: official journal of the American Pain Society, 20(10), 1140.e1–1140.e22. doi:10.1016/j.jpain.2019.02.011

Watt-Watson, J., McGillion, M., Lax, L., Oskarsson, J., Hunter, J., MacLennan, C., Knickle, K., & Victor, J. C. (2019). Evaluating an Innovative eLearning Pain Education Interprofessional Resource: A Pre-Post Study. Pain medicine (Malden, Mass.), 20(1), 37–49. https://doi.org/10.1093/pm/pny105

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