November 3, 2025 • 56 mins
What if pain education got the fundamentals wrong by chasing tidy scripts instead of solid mechanisms? We sit down with researcher and educator Monica Noy to rethink how clinicians learn, reason, and communicate about pain. Rather than leaning on “explain pain” narratives and one-size-fits-all language, Monica anchors care in a clear premise: nociception is necessary—though not always sufficient—for pain. That single shift reframes assessment, reduces blame, and helps us speak to people with honesty and respect.
Across a candid, story-rich conversation, we explore why pain care remains under-taught across health professions despite being the top reason people seek MSK help. Monica traces the evolution of common teaching approaches, the biases that shaped them, and the real-world fallout when clinicians over-educate, over-promise, or quietly fault patients for not “thinking right.” We talk ethics, too: if pain is associated with actual or potential tissue damage, what does it mean to create pain during treatment? When does intensity cross into harm, and how do we decide with patients rather than for them?
You’ll hear a grounded way to use the biopsychosocial lens without turning it into a moving target that justifies endless chasing. We discuss definitions, semantics, and why shared language matters; how better mechanism literacy leads to fewer words and better questions; and what Monica’s new course, Pain Education, No Script Provided, offers clinicians who want to be less wrong and more helpful. Expect fewer scripts, more clarity, and a renewed respect for autonomy—yours and your patients’.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:12):
Hello everybody and welcome to another episode of
Massage Science.
I'm really excited about this,the first of seven episodes with
the most amazing Monica Noy.
We're gonna be discussing hernew course that she created
called Pain Education No ScriptProvided.
And I'm so honored that shereached out to me a couple
(00:32):
months ago to propose this idea,and how could I say no?
So thank you, Monica, for beinghere.
Tell us a little bit aboutyourself.
SPEAKER_01 (00:40):
First, it's wonderful to be here, and I am
glad that we have been able toget together and do this.
I think we've known each otherfor a while now and tour with
each other.
So I'm very happy to see likeeverything put together.
So this is great.
This is what I can remember.
My first sort of I don't know,there might have been on the
podcast, but I can't remember.
(01:02):
But sorry, what was your firstquestion?
SPEAKER_00 (01:10):
Who's Monica?
Tell us some fun things aboutyourself.
SPEAKER_01 (01:13):
Some fun things about myself.
I'm just trying to figure thatout.
I don't know if there's any funthings.
I can tell you a lot that soundslike I do a lot, but I don't
know if it does.
So I have a master's masters ofscience in rehabilitation.
We did our masters at the sametime, you're just across the
country.
I have a Bachelor of Science inOsteography from the British
College of Osteopathic Medicine.
(01:35):
I do have a diploma inosteography, but I was converted
to the Bachelor of Science.
I am a former massage therapist.
I have that.
I also have a Bachelor of Arts,but who doesn't?
And and I have a I work one dayweek at a clinic up here in
Chelvin.
I'm a researcher, so I've donesome more on the clinical
(01:57):
professional commentary side ofthings rather than doing
studies, although I've beeninvolved in one Evans-based
survey study, and I'm involvedin a status osteopathy
cross-country study right now,and that's with University of
Quebec in Montreal.
So I just am lucky to be one ofthe team members.
And I teach at Sheridan at thehonours bachelor degree in
(02:21):
osteopathy, which I was part ofsetting up and had developed two
new courses, of which one ofthem is philosophy and science
of pain, and the other iscritical thinking, and they both
go together.
And I've done other stuff.
I like to garden, I play videogames, I have an adorable kidney
(02:42):
cat.
SPEAKER_00 (02:42):
That's pretty.
SPEAKER_01 (02:49):
Yes, those ones are no longer with us.
They were, yeah, they all madeit to their old age, and we gave
them a lovely retirement home.
But now we got a thanks to thecat distribution system, we have
another one and a little tuxie.
She's quite cute.
She's perfect.
So yeah, that's kind of me.
Oh, yeah.
I I like among several researchcommittees in Canada and in
(03:13):
Europe, and standards committeesand various other things.
And then I'm doing this con edwith you.
So none of it pays very well,but it's all pretty interesting.
SPEAKER_00 (03:27):
We're involved in a lot of I uh I feel important
activities, things that are arethere to make a change, to help
clinicians learn better, thinkbetter, yeah.
SPEAKER_01 (03:41):
I think that's a big part of it for sure, is the
drive to be better is one of theone of the bigger drives that I
have.
And it's from an ethical, like amedical, ethical, philosophical
perspective, that I think hasbeen one of the big drives for
this.
And it's taken a while.
It's taken a long time to get towhere I am and to developing
(04:06):
these courses.
I was really lucky whenSheridan, I wrote about this.
There's a paper in theInternational Journal of
Osteopathic Medicine that Iwrote about the two courses, but
very lucky that when I was thereduring the setup, that I
proposed these two new coursesin Sheridan, didn't they go
blink, and accepted thesecourses.
(04:27):
And one of the a big impetus forthis particular pain course was
the knowledge gap that existsfor healthcare providers who do
not have enough knowledge ofmechanisms and management of
pain.
And that's a documentedknowledge gap for practitioners,
(04:50):
but there's also a documentededucation gap for practitioners
to be able to get thatknowledge.
And there isn't really ameasurement tool for figuring
out whether or not the knowledgewe're providing actually has any
benefit, not only for clinicianknowledge, but ultimately for
(05:12):
the person in pain.
Those are all pretty big drivingfactors, I think, for uh getting
these courses going.
SPEAKER_00 (05:24):
And from what I've and from what I've seen, all the
stuff that you've shared withme, the these courses are
fantastic.
And I there's a huge gap that isbeing filled or potentially
being filled by what you arewhat you will be teaching and
what you have created.
Now, your courses that you thatyou're teaching at Sheridan, the
course that you're gonna bedoing through that through you
(05:46):
and I are gonna be doing, oryou're gonna be doing through
through my company, is thatcourse is based on some of the
on some of the things thatyou're also teaching at
Sheridan.
Is that correct?
So some of the stuff that you'llbe teaching to practice
practitioners through myplatform, this is also stuff
that's being taught at anentry-to-practice level at
Sheridan.
Is that correct?
SPEAKER_01 (06:06):
One of the interesting things about
Sheridan is that I think it's afirst of its kind in that it is
a 14-week pain course, whichwhen we looked into the amount
of education that occursthroughout the world for
specifically pain, it's verylimited.
And there's not a lot ofeducation that fills perhaps a
(06:30):
whole semester, and then letalone being integrated
necessarily into healthcare.
And we see this across medicine,the muscular school of medicine,
probably vets and nurses havemore defined pain care, perhaps,
than doctors or even MSKpractitioners.
Yeah, so it's that big knowledgegap that definitely exists.
(06:53):
And it exists, it exists for metoo.
I didn't come about this on myown.
We operated in the same circleson social media, and we came at
this from very similar placeswhere we were discussing it the
other day about having exposureto pain, neuroscience education,
(07:15):
and the explained pain phenomenathat has become very entrenched
in pain fields, and being slowlychipped away at in terms of
becoming much more skeptical ofthat whole approach and starting
to see that there are ways ofgoing about this that are much
(07:37):
more fundamentally and logicallysound to be able to actually
look at the mechanisms of painand then be able to translate
that to management in some moreeffective way than the kind of P
⁇ E type uh courses that areprovided.
SPEAKER_00 (07:57):
It's funny to think back when we when I when you and
I first connected over socialmedia, it was probably around
maybe 2016, maybe 2017,somewhere around there.
And yeah, we were very much atthe same time we're asking some
of the similar questions.
And it was at the time Iremember feeling very thankful
(08:21):
and very happy to finally haveconnected with somebody that was
having these same conversationsor wanting to have these same
conversations or asking thesesame questions.
And almost 10 years ago, it isfunny to see what a huge leap
those conversations were fromthe previous ones and the
questions you're asking, becauseit all went from this
biomechanical, tissue-baseddysfunction, lots of
(08:45):
belief-based things, intoanother thing which seemed which
is explained pain phenomena,which seemed like it was less
wrong.
But again, when 10 years goes byfrom that, you start to realize
that no, that also had its ownproblems and had a lot of
belief-based things and wasbased on a lot of how do we say
(09:07):
not super robust science andbased on some some
self-referential science.
Yeah.
SPEAKER_01 (09:16):
A lot of kind of the idea was it was a hypothesis
which the authors did do someresearch in, but a lot of that
research was, I think, probablysubject to a lot of design and
report bias, because a lot ofthese people were invested in
good outcomes for painneuroscience education, or which
(09:38):
the explained pain is part of.
And what they provided, and oneof the reasons why I titled this
no script for what provided wasthey provide a script, they
provide something that is easy,it's digestible, it comes with a
way of talking to people aboutpain, and that makes it inviting
(10:02):
for the therapist, and it makesit easier to understand.
But it's a type of heuristicthat when you look into it, you
end up losing a lot of meaningand or assuming a lot of meaning
that isn't really there.
That was part of the problem.
But I remember even when we wereteaching some of these
(10:25):
constructs, we were alsoquestioning them in very similar
ways.
And we were we were very much onthe same page with that kind of,
oh, there's this, and we'relike, Well, yeah, but there's
also this.
We'd both be questioning thoseconstructs, even as we were like
trying to present something thatseemed reasonable and logical.
SPEAKER_00 (10:45):
Yeah, yeah.
Some of those conversations wehad back then were fantastic,
and the three or four times Icame out there to Toronto to
teach and hang out with you werethose were really fantastic
times.
And I do admit now that thestuff I taught then was
incomplete and there was full oferrors, and so anybody that's
listening is I took your coursefive, six years ago, and that's
(11:06):
what you said.
I was like, Yeah, I probably didsay that.
I I don't think I say thosethings as much anymore.
I've definitely moved on fromthe explain pain stuff.
I do still hold on to Iunderstand the value of of
education, people making senseof their of what they're
experiencing, but I no longerbelieve from basically just from
what I've read and just myexperience and the way I think.
(11:27):
I know I no longer think that'sa the best approach or even
always a good approach.
SPEAKER_01 (11:31):
Yeah.
SPEAKER_00 (11:32):
Yeah, and I think that's it's that's how it's
sold.
Because you mentioned thatbefore that it was it created
this kind of package, didn't it,of the explain pain where it's
really when we think about it,that idea was no different than
how every other single modalityempire is.
It was just its own modalityempire that was not based on a
acronymed technique that wassupposed to solve all the
(11:53):
world's problems, it was basedon an acronymed educational
strategy, which I guess couldhave been a technique that was
supposed to solve all theworld's problems.
So when we take a step back, youthink, yeah, it wasn't actually
any different.
SPEAKER_01 (12:05):
It wasn't.
It was just it was packageddifferently, it seemed to be
more reasonable, it uh offeredthe therapist something neat in
particular ways, some strategiesin particular ways that they
could take.
But it didn't really makeassumptions about the end
(12:28):
result, it was makingassumptions about the
neuroscience, it was putting aparticular perspective on the
neuroscience that when youreally looked into it didn't
really hold true.
And actually, if you look atsome of the logical endpoints to
those assumptions, can be quitedetrimental to the person in
pain because it's condescendingand it is one of those things
(12:51):
where we talk about the positionthat we come from that's very
biomechanical, or it's very sortof dysfunction-oriented on a
very physical level.
And this wasdysfunction-oriented, but just
on a different level, on a kindof a mind or a thought process
level.
But it was the same approach.
It's still therapist as expert,it's still at claiming to be
(13:14):
patient-oriented, claiming to beperson-centered, but at the same
time incrediblytherapist-centered, incredibly
therapist as expert, incredibly,I'll tell you what you need to
know.
And leaving at the end part ofthings, leaving it very open for
(13:34):
people to be blamed for theirown pain because they didn't
take on board the knowledge, orthey weren't thinking about it
right, or they weren't feelingabout it, or there was something
then fundamentally wrong withtheir thought process and
therefore their bodily process.
And that was the thing that Iactually found the most
(13:56):
objectionable about what washappening.
And one of the questions I hadof this particular perspective
was please explain to me how aheadache is a danger signal.
And what is it a danger signalfor?
I've never actually had areasonable response.
(14:19):
Like I've never actually had,because I'm just like, I'm the
kind of person who'll be like,oh great, I have brain cancer.
Awesome.
I'm gonna go, I'm gonna gothere.
I'm gonna go to the worst casescenario because someone's
saying to me that's a dangersignal, it's a threat that your
body is providing pain or yourbrain's providing pain in order
(14:41):
for to protect you againstsomething.
And okay, so what am I gonna doabout this?
I'm like, I'm gonna every time Iget a headache, I'm gonna get
it, go get a scan because thatcould be the tumor that's now
stage four or whatever it mightbe.
SPEAKER_00 (14:55):
And you can't think your way out of a tumor.
SPEAKER_01 (14:57):
You can't think your way out of it, yeah.
You can't uh yeah, reimagineyour way or retrain.
Retrain was the other thing.
Yeah, retrain your so I had,yeah, I had a lot of fundamental
problems with that.
But I didn't come aboutquestioning that myself.
I was questioned.
And the people who were doingthe question thing, most people
(15:20):
will probably know about, andyou know about as well, which
was uh John Quintner and AsafWeissman.
And their questioning onFacebook was very Socratic.
It they didn't really offer asolution as much as they did
question.
And if you asked them to providean explanation, they wouldn't
(15:43):
provide the explanation, theywould provide you with a
resource that would enable youto then read and perhaps come up
with an explanation of your own.
So I did learn to engage withthem in a particular way, which
was more to ask the question,get the reference and resource,
uh, try and figure it out, andthen come back and say, okay,
(16:04):
this is what I figured out.
Am I on the right page?
I'm on the right in the rightplace.
So in that way, I started tothink about things more.
But basically, the reason I setthis pain course up, apart from
all of the other things wherethere's a knowledge gap and
there's there were all theseproblems with the pain stuff
that was out there, was that Ineeded to be able to make sense
(16:28):
of what I was reading for mylevel of thinking, right?
I'm not gonna, I'm not aneuroscientist.
I'm I'm not I'm not necessarilygonna be under be able to
understand all of that to an nthdegree, but I needed to set it
up in a way that I was able tothen come to an understanding.
(16:49):
And if I could do that in a waythat I was able to understand,
then perhaps others would alsobe able to understand those
foundations and that thatfoundational thing.
And so I've been following verymuch the blogs that ASEP has
with pain lossophy does, andthen the papers that are written
(17:09):
with with relation to that andvery interesting.
Some of them are quitechallenging, but at the same
time have provided me with aperspective that makes a lot of
sense.
I have no script for it.
I have a perspective that makessense, and I can have a
conversation with people aboutpain on a level that makes sense
(17:32):
without having to explain it tothem necessarily.
But it harks back to that ideaof the patient-centered and the
person-centered and thelistening, where it's like
you're now seeing this person infront of you has pain and
honoring their autonomy.
It's not just having empathy,but it's actually honoring that
(17:55):
this person has incredibleamounts of autonomy and
experience and expertise in thatexperience, and then placing
your own expertise inrelationship to that, as opposed
to coming at that person with,let me tell you this is how it
works.
(18:16):
Which I have done.
SPEAKER_00 (18:19):
Yes, guilty is charged here as well.
And that's something that mostof us I would say I don't want
to say all, you always want toavoid you want to avoid saying
always or never.
But most of us, I would say themajority of us that took the
explain pain, the pain orscience education route would
(18:39):
have easily done theover-explain, over-educate,
thinking that that was somethingthat people needed.
And of course we remember oursuccesses where it maybe it
helps somebody, but we probablydon't necessarily we have
selective memories and in sayingthere's all those people that I
probably really pissed off or Idid nothing for, and I never saw
(19:02):
them again.
And I know I I will admit that Imade those mistakes early on,
and it was through the peoplethat never came back that kind
of left, and you got a bad vibefrom them because you talked at
them too much.
That's where I startedquestioning.
I didn't want to blame them.
Because you can feel it.
(19:23):
But you think, okay, well then Iwhat did I do?
And then I started reflecting onmy own and having conversations
with people like yourself andand others, and just and uh Saf
and John and their stuff online,reading more into that and
trying to make sense of it,really started to get me to
question, okay, so what am Idoing here?
And what have I done?
(19:43):
What have I done?
I just I've had to pull awayfrom that from that aspect, I
think, as much as I can.
But it's not it's hard.
Anything is hard when you'rechallenging and you try to make
sense of new information.
Yeah, and that was 100% withthose two two gentlemen and the
their people, the papers they'vewritten and the stuff they talk
about.
At first I remember hearing itthinking, what I don't
understand what they're talkingabout.
(20:04):
Yeah, it took a while andrereading and seeing them again
and again before it finallystarted to make sense.
And even now, I don't think itmakes a lot of sense, but it
makes more sense than it usedto.
SPEAKER_01 (20:14):
Yeah.
unknown (20:15):
Yeah.
SPEAKER_01 (20:15):
It's true.
And I think what the both of ushave done in some way is dull
back from some of the I think wepushed forward to a large degree
when we first came across thisstuff.
And this is great.
We need to tell everybody, and Istill feel that way.
Like people need to know.
We need to have some way wherepeople can be educated about
(20:37):
pain in a reasonable manner.
But I think what we both endedup doing was just dialing things
back and slowing things down alittle bit because there were so
many changes right up front,whereas we did this, and then
we're like, and then all of asudden it's huh, whoops.
And then you have to then dialyourself back from something
because that's where you'vegone.
(20:58):
We both kind of went to a placewhere we're like, we're gonna
pull back from this particularthing and blank and apologize
for having dived into that waytoo quickly.
SPEAKER_00 (21:10):
Yeah.
And people trust you, they takeyour courses, they listen to
you, they read your stuff, theylisten to your podcast, and they
trust you.
And now, rather than just, ohyeah, you want to apologize, but
it's hard to get in contact witheverybody.
But I try as much as I can nowto say, this is what I used to
teach, this is what I used tothink, this is what I do now.
If you heard something differentfrom me before, I will say that
(21:30):
was the best I knew at the time,but now we're moving forward.
And I think that's something weall should be doing, we should
be honest that way, and thatshould we should have that
humility to say, you know what,this is what I used to think.
It's a big gap that we see witha lot of the other courses out
there on pain or treatmentstuff, is it's the same thing
for 30 years.
SPEAKER_01 (21:49):
Yeah.
And it's it and it doesn'tinvite self-reflection
necessarily, and it doesn'tinvite you examining your own
assumptions, and that's how wemake changes.
That's the that's that's whathappens in the scientific
method, where there's a built-inkind of check-in to see whether
or not these assumptions makesense, and do you need to change
(22:11):
anything going forward?
And that's what self-reflectiondoes as well, where if you're
honest with yourself, and thatcan be difficult sometimes to
get to that place where you'reactually honest with yourself
about what it is that you'rethinking and about why you're
thinking that way.
And it's I believe this, why doyou believe that?
(22:32):
Where does that come from?
Have you ever questioned why youbelieve that particular thing
about pain?
And when you question it, and ifyou see something that actually
challenges your assumptionsabout it and your belief about
it, it's there can be a big sortof defense mechanism that
(22:55):
occurs.
There's dissonance, people feeluncomfortable, and the easiest
thing to do is sometimes doubledown and not actually represent
with fairness, right?
So it's finding a way to, Iguess, straw man the other
argument would be one way ofdoing it, where you actually
just you don't represent thatargument fairly, but that makes
(23:19):
it much easier to then argueagainst.
But if you were to representthat argument fairly, it would
probably mean that you have tochange something about what it
is that you believe or what itis that you're thinking.
Um, and that's harder.
That takes a longer time.
SPEAKER_00 (23:35):
Yeah, we have these beliefs, these feelings that are
often associated with ouridentity.
SPEAKER_01 (23:40):
Oh, yeah.
SPEAKER_00 (23:41):
And how we view ourselves as a human or as a
clinician and or as an educator,and when that gets challenged,
it's easier to just push thataway rather than to take that on
and start questioning yourself,which is I think exactly what
you were just saying.
SPEAKER_01 (23:56):
Yeah, and but it is harder, it takes time.
SPEAKER_00 (24:00):
Yeah, oh it takes a long time, it takes years.
Yes, and even then you're stillquestioning stuff for sure.
The one thing I guess that youwe've you've given us a great
overview of some of these keythings.
If you could summarize thoughabout this course you created,
what is the what's the kind ofkey two or three things that
(24:20):
makes this different from othercourses that are out there?
Like what are the what how is itdifferent?
SPEAKER_01 (25:11):
Well, let me give you something where it's similar
in one way, because it's comingfrom a particular perspective,
but it's a very foundationalperspective, meaning that it I'm
not giving you a script, butit's a perspective where I'm
just trying to find my kind ofslide here on the perspective
(25:35):
where here it is, where thefundamental perspective that
underlies the course is that theconstruct of no susception is
necessary, if not alwayssufficient for pain.
So it's looking at the idea ofnecessary and sufficient
conditions for certainmanifestations of things.
(25:58):
So no susception being anecessary condition and the
necessary precondition for thesensation of pain, right?
And for the perception whensomeone has that sensation and
then a perception related tothat, we can understand that if
someone reports pain or isobserved to be in pain, that the
(26:22):
therapist at the baselineassumes that no susception has
occurred sufficient to lead to asensation.
That's that's the fundamentalunderlying assumption of this
particular course.
SPEAKER_00 (26:43):
Yeah.
SPEAKER_01 (26:44):
So that assumption is then set.
So the first like deck is acontext.
So a little bit about thecontext of pain in Canada.
We have the governor's writtenreports that show the education
gap.
The International Associationfor the Study of Pain has
reports, and they did adeclaration of Montreal that
(27:06):
says pain care is a fundamentalhuman right, but it's based on
the idea that it's accessible byknowledgeable people.
Right.
So there's these huge kind ofparadoxes that exist, not just
within the definition of painand some of the definitions
related to that, but also withineducation and understanding of
(27:29):
pain.
And so that's one of the reasonsfor another reason for this.
SPEAKER_00 (27:37):
Yeah, I and I I think that's sort of to just hit
at some of those points there.
The first one, obviously, thatthat really is important, and
this is something that isprobably not well understood
across healthcare professions,is that no seception is
necessary for the sensation withexperience of pain and the
experience of something thatI've been teaching for the last
(27:58):
couple years now is saying thatif someone has pain we can s
comfortably say that there'ssome no seception going on.
There's no deception going onsomewhere.
But we may not always know whyor why or why or why.
And then trying to turn thatinto why does that matter?
(28:20):
And what's the clinicalapplication of that?
And I'm not, I know what I say,but I want to hear what you have
to say first, and then I'll letyou know if I'm right or wrong,
or if I agree or disagree, or ifI do things differently.
SPEAKER_01 (28:32):
Right.
I think one of the one of thereasons for having this as a
fundamental perspective of thecourse is that when you look at
what is the sort of popular wayof looking at pain, which is the
pain neuroscience education, thesort of saying there was that no
susception is neither necessaryor sufficient for pain.
(28:54):
But what that leads to is thatthis idea that there are other
external things that you canthen, for want of a better word,
blame for a person's pain.
And this fundamental perspectivemeans that you ground that
(29:15):
experience for that person insomething physiological.
So there's a physiologicalaspect that is there, and one
that you don't necessarily havethe privilege to observe.
And this is one of the perhapsthe problems with the definition
(29:35):
because it's associated withtissue damage.
And that's one of the one of theaspects of the definition is
associated with tissue damage,but but certainly people report
pain in the absence of what wecan see as being tissue damage,
right?
Or what we can obviously observeas being tissue damage.
And then this ends up becomingsomething where we start looking
(29:58):
for other reasons.
And this perspective means thatwe can look for reasons, but
within a very logical andphysiological sense.
(30:23):
And that means that we're notthen going to say, oh, this
person's depressed.
And we have this correlation, wehave this association between
depression and pain that'sabsolutely there.
I'm not arguing against that.
But we then don't say thisperson is depressed and has
thoughts about these.
(30:44):
Things and it is partly theirthoughts that are causal of this
sensation, and it just becomes aI'm not sure what the word is
for it.
It's it's a treadmill, it'ssomething that is just cannot be
beneficial for the person inpain to, and it's it if we go
(31:06):
back to our biomechanical, ouranatomical, you have a joint
dysfunction, you have this,that's a cause of pain, you have
this, that's a cause of pain,and we think of it as that
really physical, your knees outof place or your hips out of
place, or whatever it might be,and that's the cause of pain.
It's a similar sort of thing.
We're just reaching for all ofthese different aspects.
(31:28):
I've observed something,therefore, I can attribute that
to as a cause of pain.
And when you can't observe it,then you're finding things that
you can.
You're finding a feeling, oryou're finding some report that
someone has given you about adeath in the family, or
something else that you can thensay, oh, I can attribute this as
(31:51):
causal for this person'sexperience.
And it's quite frankly, aboutbackwards, really.
So I guess, did that answer thequestion?
I don't know.
I started to ramble, I think.
SPEAKER_00 (32:04):
Yeah.
Rambling is encouraged.
SPEAKER_01 (32:09):
There was rambling.
SPEAKER_00 (32:12):
What I liked, there's a lot of things I liked,
but one thing I just I reallywanted to just emphasize was the
shift from that causal reasoningto something that is more the
person's experience andunderstand and understanding and
knowing that no cception isoccurring and that's why they're
in pain without knowing thecause of that no-seception.
(32:34):
Because it, if we think, ifwe're always looking for causes,
and we hear this all the time,don't we?
The root cause.
Come take my course and discoverthe root cause of pain or
techniques.
It just drives me absolutelycrazy because anyone that says
that is they're missing, they'rethey're missing the point.
SPEAKER_01 (32:50):
Yeah.
If someone says that in relationto pain, I'm just like, it's
fairly clear they have afundamental misunderstanding of
mechanisms of pain.
SPEAKER_00 (33:01):
Yes.
SPEAKER_01 (33:01):
And but that's not, I'm not saying that's a problem
that you know that that they'rea problem.
They're just a symptom of thelarger lack of education that
exists in pain.
They're a symptom of theknowledge gap that exists in
pain.
And the way that that knowledgegap has been attempted to be
filled with a whole bunch ofdifferent things.
(33:22):
Right?
We can basically attributeanything as a cause to pain.
And that is just not helpful forthe person who has pain.
SPEAKER_00 (33:32):
Yeah.
Yeah.
And that's something I wanted tojust emphasize too, is that I'm
very critical of things becausesome of this information has
been around for a long time.
And people get upset with mebecause I they're like, You're
too critical, and you got togive people a chance.
I'm like, some of thisinformation is 40 years old, but
you've had your chance.
And I've I'll admit that myselfand people like myself that have
been teaching are sometimes partof the problem too, but we're
(33:52):
trying to be do different.
And but the idea, and I think wesaid that there's a symptom of a
bigger problem, people that areteaching stuff, because that
knowledge gap is a huge problem.
But the best thing we can do,though, with that knowledge gap
is just to admit that it existsand try to fulfill it with
something and try to fill itwith something that is currently
(34:16):
less wrong.
unknown (34:17):
Yeah.
SPEAKER_01 (34:18):
And the we know now.
This is yeah, this is the thingthat is not well understood, and
it's very hard to get people tounderstand.
And that's one of the reasonsfor deck one, which is context
of pain.
It's what does it mean for tohave one in four or one in five
people who have chronic pain onlike the economic and social
burdens that exist and all ofthat kind of thing?
(34:40):
And why do we have all of thesesupposedly amazing treatments
for pain where people aresaying, here, click this pen
over the source of your sourcespot and it'll go away, or rub
this cream, or have thistreatment, or whatever it might
be.
And it hasn't moved the needleat all.
The numbers for people with painare predicted to rise.
(35:05):
The Canadian reports predictthat the numbers of people in
chronic pain will continue torise.
And what we see with theresearch now, which is not being
taken up as well, and that notadmitting that we have these
knowledge gaps in both practiceknowledge, but also education
(35:26):
knowledge and ability to measurethat.
So, what we see is I think I'velost my train of thought there.
What was I saying?
Like I keep moving from onething to another.
Let me think about that.
No, it's gone.
SPEAKER_00 (35:42):
I can't remember actually exactly what we were
talking about that second,anyway.
Listening to it, it was oh,we're talking about the
knowledge gap, admitting theknowledge gap exists.
There we go.
SPEAKER_01 (35:50):
Admitting knowledge, yes.
So that's what we were gettingto.
Is that is that's why the I hadthat context at the beginning,
is that we have to understandthat we don't know enough.
And our explain pain courses orany other courses we might have
done that have these kind offorays into this is a cause of
(36:12):
pain or here's how to treat painor whatever it might be.
They're based on huge levels ofassumption that we don't have a
good grounding for in education.
We don't have a goodunderstanding in education that
these make us reasonable,reasonably knowledgeable people
(36:32):
about mechanisms of managementof pain.
So the documentation says wedon't across the board have the
knowledge in mechanisms ofmanagement of pain that we need
to actually effectively treatpeople who have pain.
And the numbers back that up.
SPEAKER_00 (36:51):
Yeah, it's not just making it up, that's true.
What are your thoughts about thereasons why in an entry to
practice curriculum, doesn'tmatter of the you name the
healthcare profession, why paineducation is so poorly done or
not done at all?
(37:12):
When that's the number onereason why people come to see
anybody in the MSK world isbecause they hurt.
SPEAKER_01 (37:17):
Like 80% of the time it's like coming for pain.
SPEAKER_00 (37:20):
So why is that not fundamental?
What are your thoughts on that?
SPEAKER_01 (37:23):
I think partly it's because the understanding of the
mechanisms of pain has alwaysbeen a bit of a challenge.
And there's just been a lot ofinformation over the years that
has led to a lot of conflationaround the topic.
That is being cleared up muchmore now.
(37:47):
It's like closing the gate afterall of the horses have left the
bar.
So, you know, we have to getthem back in and then close that
gate.
And I think that's part of whatthis is.
It's an awful back from all ofthese different causal
(38:07):
explanations that we've hadbecause we didn't have the
mechanistic understanding andknowledge.
And it perhaps it was just thatit's so hard to translate.
If I'm saying no scriptavailable or no script given, or
whatever it might be, I can'tprovide you with a way of
(38:27):
talking about this to people.
What I can hopefully provide youwith is an understanding of the
mechanisms that are occurringand a way of assessing what
mechanisms may be occurring inany given presentation.
And then that gets translated tosome sort of management aspect,
(38:52):
and we'd have to look at thatfor a musculoskeleteal setting,
but that wouldn't just bemusculoskeleteal, right?
There's there would be a medicalmanagement as well.
SPEAKER_00 (39:03):
Yeah, so the understand the more a clinician
understands no suception andthey understand the ideas of
pain or the experience of theindividual experience of pain,
as much as we can understand itfrom a outside of observer.
SPEAKER_01 (39:24):
Like not a neuroscience perspective, right?
SPEAKER_00 (39:26):
Yeah, but the more we understand it, do you I feel,
and maybe my bias is right orwrong, that the more we
understand about it, the betterwe can be as clinicians, because
it really shapes how we think,which shapes how we communicate,
which I feel shapes ourexpectations as well as the
expectations of the person who'scoming to see us for help.
(39:48):
Would you agree with that orwould you expand on that?
SPEAKER_01 (39:50):
I would say so.
I think the more that I know andthe more I understand, the less
I talk about it to patients.
I talk all the time.
Who am I kidding?
But but the less I talk about itto patients, I don't try and
explain their pain to them.
That's just why would I do that?
Because they provide a lot ofthe information that allows me
(40:13):
to make some sort of assessmentas to what I think might be
going on a no susception level,and also what that means on a
sensitization level and whatthat means for what we consider
to be tissue damage and the ideathat mousseception is
sufficient.
And if there is an associationwith tissue damage, it's related
(40:35):
perhaps to that sensitivity,that low-level CRP kind of thing
that can occur in illness labelchronic pain situations.
So you start to get a little bitmore of an understanding of what
it means when people haveinflammation and what that means
for nosoception, just whatinflammation means.
(40:58):
And I think of it like I don'tknow more than a general level
of how the sort of specializednervous system for sight works
or for hearing, or a bit morefor touch, hopefully, because
that's clear is what we do.
But we have a similarspecialized nervous apparatus
(41:22):
for pain.
So knowing that we have that, Idon't necessarily need to have
an in-depth knowledge of howthat apparatus works in the
minutiae, but an understandingof that knowledge that there is
a there's a sort of a mechanismthat occurs when someone reports
(41:46):
pain, that we have a mechanisticprocess in relation to that,
that it'll ground our thinking,it'll ground our understanding
in reality.
And I think that's part of thebig sort of drive is that
everything that we see aroundpain, when we see all these kind
(42:10):
of causal mechanisms, it'soutside of reality a lot of the
time in terms of a mechanisticexplanation.
And so we're leaping, we'remaking these giant leaps, giant
sort of assumptions about whatthis person's going through and
(42:32):
about how we can then use ourexpertise or I would say
pseudo-expertise for a lot of itto help them.
And we may eat we may just asequally uh cause harm in most
situations.
SPEAKER_00 (42:46):
Oh, for sure.
Yeah, I would agree with thattoo.
You mentioned the grounded inreality, and that is something
that listeners or people thatare gonna take this course in
the future will hopefully reallyget from it is understanding
pain that is no deception, thatis and mechanisms involved that
(43:09):
are grounded in reality, notbased on beliefs or based on
ideas that are un unchallenged.
Because I know also in the firstpart of the course or part one,
we haven't really talked toomuch.
We are talking about the coursewithout giving away too much.
We are talking a bit.
SPEAKER_01 (43:24):
Well, hopefully go into a little bit more depth.
Who knows?
We might just make one podcast.
SPEAKER_00 (43:30):
No, this is all just part one.
The yeah, the grounded inreality, and then the
understanding that yeah, thediffer different things are
involved.
But you mentioned that thethere's human rights, there's
the and then and there's thesekind of ethical obligations.
SPEAKER_01 (43:51):
I was just looking at that night actually for
ethical challenges, yes.
SPEAKER_00 (43:55):
Ethical challenges and for people that are
listening, that is somethingthat they really should stop and
reflect on.
I highly encourage to is that ifwe're treating people who have
pain and we're doing it based onideas that are not grounded in
reality from an ethical that'san ethical challenge.
SPEAKER_01 (44:20):
Well, that's a really fuzzy, yeah, fuzzy
ethical area.
SPEAKER_00 (44:25):
Yeah.
SPEAKER_01 (44:25):
And we talked about that question of whether it's
ethically reasonable for you todeliberately cause someone pain
during a musculoskeletaltreatment.
Because if we look at thedefinition of pain as associated
as it is right now with tissuedamage, at what point in time
(44:48):
are you causing tissue damage?
Because if someone's reportingpain, it's associated with
actual or potential tissuedamage.
And if we look at the foundationor the fundamental perspective
of gnosis is necessary, if notalways sufficient for pain, then
(45:13):
you are impacting nosoceptors inorder to provide this sensation
which is associated with actualpotential tissue damage.
So, yeah, from an ethicalperspective, that's pretty
challenging.
SPEAKER_00 (45:31):
For sure.
Particularly for those peoplethat feel they need to hurt or
they need to experience pain orthey want to experience the
pain, or a therapist who says, Ineed to hurt you to help you.
SPEAKER_01 (45:40):
Yes, pain treats pain or something along those
lines.
Yeah.
It just feels better afterwardsbecause someone stopped hurting
you.
SPEAKER_00 (45:48):
Yeah.
SPEAKER_01 (45:49):
And there's there's other kind of mechanisms,
chemical mechanisms that mayactually mean that you
temporarily feel a bit better.
SPEAKER_00 (45:58):
Yeah.
SPEAKER_01 (45:59):
But yeah, it's an interesting ethical question.
SPEAKER_00 (46:02):
Yeah.
Yeah, something maybe we'll wecould I feel like we could talk
about that for another hour, butmaybe we'll talk a little bit
later.
Yeah.
SPEAKER_02 (46:10):
Yeah.
SPEAKER_00 (46:10):
Just because you mentioned the definition of
pain, I just wanted to read itout here just for people
listening, because I wouldassume that not everybody has it
memorized.
So pain, according to theInternational Association for
the Study of Pain, is anunpleasant sensory and emotional
experience associated with orresembling that associated with
actual or potential tissuedamage.
And that was updated, I believe,in 2020.
(46:32):
And it was for the previous 41years, it had a slightly
different something like anunpleasant sensory and emotional
experience associated withactual or potential tissue
damage, I believe.
SPEAKER_01 (46:45):
And report it was like and reported as such or
something along.
SPEAKER_00 (46:49):
Yeah.
So this one's changed.
I think the key thing with thisis it was changed to resembling
that associated with.
SPEAKER_01 (46:54):
Yeah.
So it didn't rely on reporting,it could be nonverbal as well.
SPEAKER_00 (46:59):
Non-verbal.
I think that was one of the key.
But then the new one they addthose six kind of sub points,
whatever, about it.
SPEAKER_02 (47:07):
Yeah.
SPEAKER_00 (47:08):
And that's all stuff I know that is covered in the
first part of the course, Ibelieve, in the first.
SPEAKER_01 (47:14):
Yeah.
One of the things that thiscourse doesn't go into a lot is
is biosychosocial, apart fromlooking at more looking at it
more on a I guess a critique ofthat understanding.
And I guess asking questions ofan internal critique of people's
(47:34):
understanding of biosychosocial.
It's one of those words thatgets really thrown around.
It's a heuristic, basically, forlearning that has meant from
what I can see in painmanagement, given that we don't
know enough, it's one of thoseheuristics that has meant that
(47:57):
many assumptions are being madeabout what pain is.
It's one of those hugeconflations that exist within
pain care.
And a lot of those conflationsare quite well documented.
SPEAKER_00 (48:12):
Yeah, and bisexual is a term that it is common in
the lexicon of the MSK world orof the healthcare world, but
it's often used as just anothertool to explain away or to blame
why someone hurts.
And you mentioned that earlierabout the relationship between
(48:33):
depression and pain.
It exists.
But people are often said, Oh,if you weren't depressed, then
your pain wouldn't that'scausing your pain.
SPEAKER_01 (48:42):
But I think or it's making it worse or whatever.
SPEAKER_00 (48:45):
And the problem that we have with the biopsychosocial
is that it often it getssegmented into oh, it's this
thing that's causing your pain,is your stress, or you're not
sleeping, or you have thesenegative self-thoughts, or you
hate your job, whatever.
It gets and those things couldall be part of things that could
be sensitized.
SPEAKER_01 (49:04):
They can definitely be aspects about the condition
of being depressed that wouldhave some impact on a sensitized
noseceptic apparatus.
100%.
I'm not arguing that.
But yeah, one of the wholethings is we're dealing with
people on a one-to-one basis,and we only get the information
(49:27):
that they tell us.
SPEAKER_00 (49:28):
Yeah.
SPEAKER_01 (49:29):
So if we're making an assumption that the one thing
or the two things that they'vetold us about the stressful
aspects in their lives are thekeys to their ongoing pain
condition, we've just done thema huge disservice because we're
cherry-picking and not, andthat's where we stop.
(49:50):
We stop as oh, it's this thing.
I can treat this thing byretraining or education or
something or explaining theirpain to them or whatever it
might be.
And we might have missed like awhole mess of things that are
(50:10):
occurring in these people'slives that all come together to
be part of their picture thatwe're not privy to.
The assumption is that weshouldn't be.
We don't know these people, theydon't know us, right?
So we're getting certain we'recoming to us for a particular
reason.
And for us to go outside of thatscope or reason is again another
(50:33):
ethical challenge.
We're gonna have to get intothis.
SPEAKER_00 (50:37):
Oh, much more to say.
Oh, yeah, I know for sure.
One of the reasons I wanted tobring up the biopsychosocial was
because of how it can often beused as a way, as a rather than
blaming tissue or joints orposture, it can be used to blame
(50:57):
other things.
And then the problem is whathappens is the person who's
experiencing or is living withpain, if what happens if those
other things in their life aredealt with?
SPEAKER_01 (51:08):
Right, and they still have pain.
SPEAKER_00 (51:10):
And they still have pain.
It's no different than saying,Oh, you're you've got this
anteriorly rotated hip, and it'scausing this left thing here,
and this is blah blah blah, andthis is tight, and this is
loose, and this is long,whatever, and then the person
goes and fixes all those things,you still have pain.
Well then where you're leftwith, you're just left searching
for another causal.
SPEAKER_01 (51:28):
I think the biopsychosocial, this idea that
you have the biological, thepsychological, the social the
social, which is just like notbeing a human, but when you put
it in that way, you now have alot of outs because perhaps it's
not biological, it'spsychological.
We deal with the psychological,oh, maybe there's also something
(51:48):
biological.
Do you know what I mean?
It's like you can weave in andout of all these things.
It's like we could maybe havemore of this over here and more
of that over there.
So you again, you may never getto a point where you actually
have a you help someone becausethere's always something in the
course of being a human beingthat you can then choose to
(52:12):
attribute pain to.
If pain is a biased psychosocialphenomenon, you've just got like
massive excuse to just treat foras many weeks as you possibly
want for all sorts of differentreasons.
SPEAKER_00 (52:30):
Yeah, because then there's always something to
chase.
SPEAKER_01 (52:32):
There's always something to chase.
SPEAKER_00 (52:33):
Always something to chase, always something affects
you.
SPEAKER_01 (52:35):
Always something to blame.
Yeah.
Whereas this for this is thefundamental, this fundamental
perspective of no susceptionbeing necessary for pain, it
doesn't necessarily removeanything else that's going on.
It's simply a grounding factor.
Like we know what a no-sceptoris.
(52:56):
It's been fairly commonknowledge that there's a
no-sceptive apparatus, that is athing that has been talked about
a lot longer.
It makes sense.
We have this sensation, we knowhow these neurons work, we
understand what activates them,we understand those sort of
basic level of things.
So it allows us to have thiskind of.
(53:20):
I I we'll see.
I won't use the word because I'mI wrote a paper, so we'll see
what happens, but it allows usto have this foundation, right?
That is again grounded inreality, in physiology, in
neurology.
It's not controversial, it makessense, it has documentation
(53:43):
behind it.
A lot of the science behind itsupports this.
We're not talking aboutsomething that we have to make
massive assumptions about.
SPEAKER_00 (53:55):
I love that.
I think we can almost just leavethat there for today's episode.
The what we're gonna do, we justwe didn't really say too much at
the beginning, is that we'regonna do six episodes.
We're gonna talk about all thedifferent sections of the
course.
The first one's more aboutcontext and it's about
obligations, and it's about andwe'll get more into that, I
(54:16):
think more into the what itmeans on an ethical obligation
level as well.
So yeah, I think we'll explorethat in in in the next episode
and then more to come.
That was fantastic, Monica.
I really enjoyed that.
That time flew by quick.
I think we did questions, and Idon't know if we gave many
answers, but that's part of thepurpose, I think, of this course
that you're gonna be doing isit's gonna be asking more
(54:37):
questions and providing answersand getting people to think
differently.
But hopefully by the timethey're done, the six module
program, which is also gonnainclude three live online via
Zoom sessions for people to tryand put this all together, and
you're gonna provide papers toread and questions to think of.
(54:57):
And we'll I can put togethermaybe even a little workbook
that we can I can put togetherfor everybody so they can make
their notes in and do their workin.
I think it's gonna be a good,not good, it's gonna be a
fantastic program and projectthat I think is gonna hopefully
start people going down the abetter way for thinking about
campaign management.
SPEAKER_01 (55:16):
And I think if people wanted to start, they
could go to the ISP and justperuse through the terminology
and get really familiar withsome of that, but also
understand that terminology isconsensus, but not concrete.
There are proposals to change,things have been added.
(55:38):
So as new knowledge comes about,we get new understanding of
things and things change.
So hold on to definitionslightly, but also they
constitute our semantics at thispoint in time, and semantics are
meaning, and we need to makesure that we're talking about
the same thing.
SPEAKER_00 (55:59):
Love it.
Well, thank you very much forthat, Monica, and we'll be back
soon.
SPEAKER_02 (56:03):
Amazing.
SPEAKER_00 (56:04):
Thank you for listening.
Pain Education, no scriptprovided, is now available for
purchase on my website, theCEPE.com.
To listen to more of theseepisodes, please subscribe on
your favorite podcast network.
If you enjoyed this episode,please like and share to your
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If you'd like to connect withme, I can be reached to my
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(56:27):
EricPurfass RMT.
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This can be done by clicking onthe support button or heading
over to buymeacoffee.com slashhello.
Hello everybody and welcome to another episode of
Massage Science.
I'm really excited about this,the first of seven episodes with
the most amazing Monica Noy.
We're gonna be discussing hernew course that she created
called Pain Education No ScriptProvided.
And I'm so honored that shereached out to me a couple
(00:32):
months ago to propose this idea,and how could I say no?
So thank you, Monica, for beinghere.
Tell us a little bit aboutyourself.
SPEAKER_01 (00:40):
First, it's wonderful to be here, and I am
glad that we have been able toget together and do this.
I think we've known each otherfor a while now and tour with
each other.
So I'm very happy to see likeeverything put together.
So this is great.
This is what I can remember.
My first sort of I don't know,there might have been on the
podcast, but I can't remember.
(01:02):
But sorry, what was your firstquestion?
SPEAKER_00 (01:10):
Who's Monica?
Tell us some fun things aboutyourself.
SPEAKER_01 (01:13):
Some fun things about myself.
I'm just trying to figure thatout.
I don't know if there's any funthings.
I can tell you a lot that soundslike I do a lot, but I don't
know if it does.
So I have a master's masters ofscience in rehabilitation.
We did our masters at the sametime, you're just across the
country.
I have a Bachelor of Science inOsteography from the British
College of Osteopathic Medicine.
(01:35):
I do have a diploma inosteography, but I was converted
to the Bachelor of Science.
I am a former massage therapist.
I have that.
I also have a Bachelor of Arts,but who doesn't?
And and I have a I work one dayweek at a clinic up here in
Chelvin.
I'm a researcher, so I've donesome more on the clinical
(01:57):
professional commentary side ofthings rather than doing
studies, although I've beeninvolved in one Evans-based
survey study, and I'm involvedin a status osteopathy
cross-country study right now,and that's with University of
Quebec in Montreal.
So I just am lucky to be one ofthe team members.
And I teach at Sheridan at thehonours bachelor degree in
(02:21):
osteopathy, which I was part ofsetting up and had developed two
new courses, of which one ofthem is philosophy and science
of pain, and the other iscritical thinking, and they both
go together.
And I've done other stuff.
I like to garden, I play videogames, I have an adorable kidney
(02:42):
cat.
SPEAKER_00 (02:42):
That's pretty.
SPEAKER_01 (02:49):
Yes, those ones are no longer with us.
They were, yeah, they all madeit to their old age, and we gave
them a lovely retirement home.
But now we got a thanks to thecat distribution system, we have
another one and a little tuxie.
She's quite cute.
She's perfect.
So yeah, that's kind of me.
Oh, yeah.
I I like among several researchcommittees in Canada and in
(03:13):
Europe, and standards committeesand various other things.
And then I'm doing this con edwith you.
So none of it pays very well,but it's all pretty interesting.
SPEAKER_00 (03:27):
We're involved in a lot of I uh I feel important
activities, things that are arethere to make a change, to help
clinicians learn better, thinkbetter, yeah.
SPEAKER_01 (03:41):
I think that's a big part of it for sure, is the
drive to be better is one of theone of the bigger drives that I
have.
And it's from an ethical, like amedical, ethical, philosophical
perspective, that I think hasbeen one of the big drives for
this.
And it's taken a while.
It's taken a long time to get towhere I am and to developing
(04:06):
these courses.
I was really lucky whenSheridan, I wrote about this.
There's a paper in theInternational Journal of
Osteopathic Medicine that Iwrote about the two courses, but
very lucky that when I was thereduring the setup, that I
proposed these two new coursesin Sheridan, didn't they go
blink, and accepted thesecourses.
(04:27):
And one of the a big impetus forthis particular pain course was
the knowledge gap that existsfor healthcare providers who do
not have enough knowledge ofmechanisms and management of
pain.
And that's a documentedknowledge gap for practitioners,
(04:50):
but there's also a documentededucation gap for practitioners
to be able to get thatknowledge.
And there isn't really ameasurement tool for figuring
out whether or not the knowledgewe're providing actually has any
benefit, not only for clinicianknowledge, but ultimately for
(05:12):
the person in pain.
Those are all pretty big drivingfactors, I think, for uh getting
these courses going.
SPEAKER_00 (05:24):
And from what I've and from what I've seen, all the
stuff that you've shared withme, the these courses are
fantastic.
And I there's a huge gap that isbeing filled or potentially
being filled by what you arewhat you will be teaching and
what you have created.
Now, your courses that you thatyou're teaching at Sheridan, the
course that you're gonna bedoing through that through you
(05:46):
and I are gonna be doing, oryou're gonna be doing through
through my company, is thatcourse is based on some of the
on some of the things thatyou're also teaching at
Sheridan.
Is that correct?
So some of the stuff that you'llbe teaching to practice
practitioners through myplatform, this is also stuff
that's being taught at anentry-to-practice level at
Sheridan.
Is that correct?
SPEAKER_01 (06:06):
One of the interesting things about
Sheridan is that I think it's afirst of its kind in that it is
a 14-week pain course, whichwhen we looked into the amount
of education that occursthroughout the world for
specifically pain, it's verylimited.
And there's not a lot ofeducation that fills perhaps a
(06:30):
whole semester, and then letalone being integrated
necessarily into healthcare.
And we see this across medicine,the muscular school of medicine,
probably vets and nurses havemore defined pain care, perhaps,
than doctors or even MSKpractitioners.
Yeah, so it's that big knowledgegap that definitely exists.
(06:53):
And it exists, it exists for metoo.
I didn't come about this on myown.
We operated in the same circleson social media, and we came at
this from very similar placeswhere we were discussing it the
other day about having exposureto pain, neuroscience education,
(07:15):
and the explained pain phenomenathat has become very entrenched
in pain fields, and being slowlychipped away at in terms of
becoming much more skeptical ofthat whole approach and starting
to see that there are ways ofgoing about this that are much
(07:37):
more fundamentally and logicallysound to be able to actually
look at the mechanisms of painand then be able to translate
that to management in some moreeffective way than the kind of P
⁇ E type uh courses that areprovided.
SPEAKER_00 (07:57):
It's funny to think back when we when I when you and
I first connected over socialmedia, it was probably around
maybe 2016, maybe 2017,somewhere around there.
And yeah, we were very much atthe same time we're asking some
of the similar questions.
And it was at the time Iremember feeling very thankful
(08:21):
and very happy to finally haveconnected with somebody that was
having these same conversationsor wanting to have these same
conversations or asking thesesame questions.
And almost 10 years ago, it isfunny to see what a huge leap
those conversations were fromthe previous ones and the
questions you're asking, becauseit all went from this
biomechanical, tissue-baseddysfunction, lots of
(08:45):
belief-based things, intoanother thing which seemed which
is explained pain phenomena,which seemed like it was less
wrong.
But again, when 10 years goes byfrom that, you start to realize
that no, that also had its ownproblems and had a lot of
belief-based things and wasbased on a lot of how do we say
(09:07):
not super robust science andbased on some some
self-referential science.
Yeah.
SPEAKER_01 (09:16):
A lot of kind of the idea was it was a hypothesis
which the authors did do someresearch in, but a lot of that
research was, I think, probablysubject to a lot of design and
report bias, because a lot ofthese people were invested in
good outcomes for painneuroscience education, or which
(09:38):
the explained pain is part of.
And what they provided, and oneof the reasons why I titled this
no script for what provided wasthey provide a script, they
provide something that is easy,it's digestible, it comes with a
way of talking to people aboutpain, and that makes it inviting
(10:02):
for the therapist, and it makesit easier to understand.
But it's a type of heuristicthat when you look into it, you
end up losing a lot of meaningand or assuming a lot of meaning
that isn't really there.
That was part of the problem.
But I remember even when we wereteaching some of these
(10:25):
constructs, we were alsoquestioning them in very similar
ways.
And we were we were very much onthe same page with that kind of,
oh, there's this, and we'relike, Well, yeah, but there's
also this.
We'd both be questioning thoseconstructs, even as we were like
trying to present something thatseemed reasonable and logical.
SPEAKER_00 (10:45):
Yeah, yeah.
Some of those conversations wehad back then were fantastic,
and the three or four times Icame out there to Toronto to
teach and hang out with you werethose were really fantastic
times.
And I do admit now that thestuff I taught then was
incomplete and there was full oferrors, and so anybody that's
listening is I took your coursefive, six years ago, and that's
(11:06):
what you said.
I was like, Yeah, I probably didsay that.
I I don't think I say thosethings as much anymore.
I've definitely moved on fromthe explain pain stuff.
I do still hold on to Iunderstand the value of of
education, people making senseof their of what they're
experiencing, but I no longerbelieve from basically just from
what I've read and just myexperience and the way I think.
(11:27):
I know I no longer think that'sa the best approach or even
always a good approach.
SPEAKER_01 (11:31):
Yeah.
SPEAKER_00 (11:32):
Yeah, and I think that's it's that's how it's
sold.
Because you mentioned thatbefore that it was it created
this kind of package, didn't it,of the explain pain where it's
really when we think about it,that idea was no different than
how every other single modalityempire is.
It was just its own modalityempire that was not based on a
acronymed technique that wassupposed to solve all the
(11:53):
world's problems, it was basedon an acronymed educational
strategy, which I guess couldhave been a technique that was
supposed to solve all theworld's problems.
So when we take a step back, youthink, yeah, it wasn't actually
any different.
SPEAKER_01 (12:05):
It wasn't.
It was just it was packageddifferently, it seemed to be
more reasonable, it uh offeredthe therapist something neat in
particular ways, some strategiesin particular ways that they
could take.
But it didn't really makeassumptions about the end
(12:28):
result, it was makingassumptions about the
neuroscience, it was putting aparticular perspective on the
neuroscience that when youreally looked into it didn't
really hold true.
And actually, if you look atsome of the logical endpoints to
those assumptions, can be quitedetrimental to the person in
pain because it's condescendingand it is one of those things
(12:51):
where we talk about the positionthat we come from that's very
biomechanical, or it's very sortof dysfunction-oriented on a
very physical level.
And this wasdysfunction-oriented, but just
on a different level, on a kindof a mind or a thought process
level.
But it was the same approach.
It's still therapist as expert,it's still at claiming to be
(13:14):
patient-oriented, claiming to beperson-centered, but at the same
time incrediblytherapist-centered, incredibly
therapist as expert, incredibly,I'll tell you what you need to
know.
And leaving at the end part ofthings, leaving it very open for
(13:34):
people to be blamed for theirown pain because they didn't
take on board the knowledge, orthey weren't thinking about it
right, or they weren't feelingabout it, or there was something
then fundamentally wrong withtheir thought process and
therefore their bodily process.
And that was the thing that Iactually found the most
(13:56):
objectionable about what washappening.
And one of the questions I hadof this particular perspective
was please explain to me how aheadache is a danger signal.
And what is it a danger signalfor?
I've never actually had areasonable response.
(14:19):
Like I've never actually had,because I'm just like, I'm the
kind of person who'll be like,oh great, I have brain cancer.
Awesome.
I'm gonna go, I'm gonna gothere.
I'm gonna go to the worst casescenario because someone's
saying to me that's a dangersignal, it's a threat that your
body is providing pain or yourbrain's providing pain in order
(14:41):
for to protect you againstsomething.
And okay, so what am I gonna doabout this?
I'm like, I'm gonna every time Iget a headache, I'm gonna get
it, go get a scan because thatcould be the tumor that's now
stage four or whatever it mightbe.
SPEAKER_00 (14:55):
And you can't think your way out of a tumor.
SPEAKER_01 (14:57):
You can't think your way out of it, yeah.
You can't uh yeah, reimagineyour way or retrain.
Retrain was the other thing.
Yeah, retrain your so I had,yeah, I had a lot of fundamental
problems with that.
But I didn't come aboutquestioning that myself.
I was questioned.
And the people who were doingthe question thing, most people
(15:20):
will probably know about, andyou know about as well, which
was uh John Quintner and AsafWeissman.
And their questioning onFacebook was very Socratic.
It they didn't really offer asolution as much as they did
question.
And if you asked them to providean explanation, they wouldn't
(15:43):
provide the explanation, theywould provide you with a
resource that would enable youto then read and perhaps come up
with an explanation of your own.
So I did learn to engage withthem in a particular way, which
was more to ask the question,get the reference and resource,
uh, try and figure it out, andthen come back and say, okay,
(16:04):
this is what I figured out.
Am I on the right page?
I'm on the right in the rightplace.
So in that way, I started tothink about things more.
But basically, the reason I setthis pain course up, apart from
all of the other things wherethere's a knowledge gap and
there's there were all theseproblems with the pain stuff
that was out there, was that Ineeded to be able to make sense
(16:28):
of what I was reading for mylevel of thinking, right?
I'm not gonna, I'm not aneuroscientist.
I'm I'm not I'm not necessarilygonna be under be able to
understand all of that to an nthdegree, but I needed to set it
up in a way that I was able tothen come to an understanding.
(16:49):
And if I could do that in a waythat I was able to understand,
then perhaps others would alsobe able to understand those
foundations and that thatfoundational thing.
And so I've been following verymuch the blogs that ASEP has
with pain lossophy does, andthen the papers that are written
(17:09):
with with relation to that andvery interesting.
Some of them are quitechallenging, but at the same
time have provided me with aperspective that makes a lot of
sense.
I have no script for it.
I have a perspective that makessense, and I can have a
conversation with people aboutpain on a level that makes sense
(17:32):
without having to explain it tothem necessarily.
But it harks back to that ideaof the patient-centered and the
person-centered and thelistening, where it's like
you're now seeing this person infront of you has pain and
honoring their autonomy.
It's not just having empathy,but it's actually honoring that
(17:55):
this person has incredibleamounts of autonomy and
experience and expertise in thatexperience, and then placing
your own expertise inrelationship to that, as opposed
to coming at that person with,let me tell you this is how it
works.
(18:16):
Which I have done.
SPEAKER_00 (18:19):
Yes, guilty is charged here as well.
And that's something that mostof us I would say I don't want
to say all, you always want toavoid you want to avoid saying
always or never.
But most of us, I would say themajority of us that took the
explain pain, the pain orscience education route would
(18:39):
have easily done theover-explain, over-educate,
thinking that that was somethingthat people needed.
And of course we remember oursuccesses where it maybe it
helps somebody, but we probablydon't necessarily we have
selective memories and in sayingthere's all those people that I
probably really pissed off or Idid nothing for, and I never saw
(19:02):
them again.
And I know I I will admit that Imade those mistakes early on,
and it was through the peoplethat never came back that kind
of left, and you got a bad vibefrom them because you talked at
them too much.
That's where I startedquestioning.
I didn't want to blame them.
Because you can feel it.
(19:23):
But you think, okay, well then Iwhat did I do?
And then I started reflecting onmy own and having conversations
with people like yourself andand others, and just and uh Saf
and John and their stuff online,reading more into that and
trying to make sense of it,really started to get me to
question, okay, so what am Idoing here?
And what have I done?
(19:43):
What have I done?
I just I've had to pull awayfrom that from that aspect, I
think, as much as I can.
But it's not it's hard.
Anything is hard when you'rechallenging and you try to make
sense of new information.
Yeah, and that was 100% withthose two two gentlemen and the
their people, the papers they'vewritten and the stuff they talk
about.
At first I remember hearing itthinking, what I don't
understand what they're talkingabout.
(20:04):
Yeah, it took a while andrereading and seeing them again
and again before it finallystarted to make sense.
And even now, I don't think itmakes a lot of sense, but it
makes more sense than it usedto.
SPEAKER_01 (20:14):
Yeah.
unknown (20:15):
Yeah.
SPEAKER_01 (20:15):
It's true.
And I think what the both of ushave done in some way is dull
back from some of the I think wepushed forward to a large degree
when we first came across thisstuff.
And this is great.
We need to tell everybody, and Istill feel that way.
Like people need to know.
We need to have some way wherepeople can be educated about
(20:37):
pain in a reasonable manner.
But I think what we both endedup doing was just dialing things
back and slowing things down alittle bit because there were so
many changes right up front,whereas we did this, and then
we're like, and then all of asudden it's huh, whoops.
And then you have to then dialyourself back from something
because that's where you'vegone.
(20:58):
We both kind of went to a placewhere we're like, we're gonna
pull back from this particularthing and blank and apologize
for having dived into that waytoo quickly.
SPEAKER_00 (21:10):
Yeah.
And people trust you, they takeyour courses, they listen to
you, they read your stuff, theylisten to your podcast, and they
trust you.
And now, rather than just, ohyeah, you want to apologize, but
it's hard to get in contact witheverybody.
But I try as much as I can nowto say, this is what I used to
teach, this is what I used tothink, this is what I do now.
If you heard something differentfrom me before, I will say that
(21:30):
was the best I knew at the time,but now we're moving forward.
And I think that's something weall should be doing, we should
be honest that way, and thatshould we should have that
humility to say, you know what,this is what I used to think.
It's a big gap that we see witha lot of the other courses out
there on pain or treatmentstuff, is it's the same thing
for 30 years.
SPEAKER_01 (21:49):
Yeah.
And it's it and it doesn'tinvite self-reflection
necessarily, and it doesn'tinvite you examining your own
assumptions, and that's how wemake changes.
That's the that's that's whathappens in the scientific
method, where there's a built-inkind of check-in to see whether
or not these assumptions makesense, and do you need to change
(22:11):
anything going forward?
And that's what self-reflectiondoes as well, where if you're
honest with yourself, and thatcan be difficult sometimes to
get to that place where you'reactually honest with yourself
about what it is that you'rethinking and about why you're
thinking that way.
And it's I believe this, why doyou believe that?
(22:32):
Where does that come from?
Have you ever questioned why youbelieve that particular thing
about pain?
And when you question it, and ifyou see something that actually
challenges your assumptionsabout it and your belief about
it, it's there can be a big sortof defense mechanism that
(22:55):
occurs.
There's dissonance, people feeluncomfortable, and the easiest
thing to do is sometimes doubledown and not actually represent
with fairness, right?
So it's finding a way to, Iguess, straw man the other
argument would be one way ofdoing it, where you actually
just you don't represent thatargument fairly, but that makes
(23:19):
it much easier to then argueagainst.
But if you were to representthat argument fairly, it would
probably mean that you have tochange something about what it
is that you believe or what itis that you're thinking.
Um, and that's harder.
That takes a longer time.
SPEAKER_00 (23:35):
Yeah, we have these beliefs, these feelings that are
often associated with ouridentity.
SPEAKER_01 (23:40):
Oh, yeah.
SPEAKER_00 (23:41):
And how we view ourselves as a human or as a
clinician and or as an educator,and when that gets challenged,
it's easier to just push thataway rather than to take that on
and start questioning yourself,which is I think exactly what
you were just saying.
SPEAKER_01 (23:56):
Yeah, and but it is harder, it takes time.
SPEAKER_00 (24:00):
Yeah, oh it takes a long time, it takes years.
Yes, and even then you're stillquestioning stuff for sure.
The one thing I guess that youwe've you've given us a great
overview of some of these keythings.
If you could summarize thoughabout this course you created,
what is the what's the kind ofkey two or three things that
(24:20):
makes this different from othercourses that are out there?
Like what are the what how is itdifferent?
SPEAKER_01 (25:11):
Well, let me give you something where it's similar
in one way, because it's comingfrom a particular perspective,
but it's a very foundationalperspective, meaning that it I'm
not giving you a script, butit's a perspective where I'm
just trying to find my kind ofslide here on the perspective
(25:35):
where here it is, where thefundamental perspective that
underlies the course is that theconstruct of no susception is
necessary, if not alwayssufficient for pain.
So it's looking at the idea ofnecessary and sufficient
conditions for certainmanifestations of things.
(25:58):
So no susception being anecessary condition and the
necessary precondition for thesensation of pain, right?
And for the perception whensomeone has that sensation and
then a perception related tothat, we can understand that if
someone reports pain or isobserved to be in pain, that the
(26:22):
therapist at the baselineassumes that no susception has
occurred sufficient to lead to asensation.
That's that's the fundamentalunderlying assumption of this
particular course.
SPEAKER_00 (26:43):
Yeah.
SPEAKER_01 (26:44):
So that assumption is then set.
So the first like deck is acontext.
So a little bit about thecontext of pain in Canada.
We have the governor's writtenreports that show the education
gap.
The International Associationfor the Study of Pain has
reports, and they did adeclaration of Montreal that
(27:06):
says pain care is a fundamentalhuman right, but it's based on
the idea that it's accessible byknowledgeable people.
Right.
So there's these huge kind ofparadoxes that exist, not just
within the definition of painand some of the definitions
related to that, but also withineducation and understanding of
(27:29):
pain.
And so that's one of the reasonsfor another reason for this.
SPEAKER_00 (27:37):
Yeah, I and I I think that's sort of to just hit
at some of those points there.
The first one, obviously, thatthat really is important, and
this is something that isprobably not well understood
across healthcare professions,is that no seception is
necessary for the sensation withexperience of pain and the
experience of something thatI've been teaching for the last
(27:58):
couple years now is saying thatif someone has pain we can s
comfortably say that there'ssome no seception going on.
There's no deception going onsomewhere.
But we may not always know whyor why or why or why.
And then trying to turn thatinto why does that matter?
(28:20):
And what's the clinicalapplication of that?
And I'm not, I know what I say,but I want to hear what you have
to say first, and then I'll letyou know if I'm right or wrong,
or if I agree or disagree, or ifI do things differently.
SPEAKER_01 (28:32):
Right.
I think one of the one of thereasons for having this as a
fundamental perspective of thecourse is that when you look at
what is the sort of popular wayof looking at pain, which is the
pain neuroscience education, thesort of saying there was that no
susception is neither necessaryor sufficient for pain.
(28:54):
But what that leads to is thatthis idea that there are other
external things that you canthen, for want of a better word,
blame for a person's pain.
And this fundamental perspectivemeans that you ground that
(29:15):
experience for that person insomething physiological.
So there's a physiologicalaspect that is there, and one
that you don't necessarily havethe privilege to observe.
And this is one of the perhapsthe problems with the definition
(29:35):
because it's associated withtissue damage.
And that's one of the one of theaspects of the definition is
associated with tissue damage,but but certainly people report
pain in the absence of what wecan see as being tissue damage,
right?
Or what we can obviously observeas being tissue damage.
And then this ends up becomingsomething where we start looking
(29:58):
for other reasons.
And this perspective means thatwe can look for reasons, but
within a very logical andphysiological sense.
(30:23):
And that means that we're notthen going to say, oh, this
person's depressed.
And we have this correlation, wehave this association between
depression and pain that'sabsolutely there.
I'm not arguing against that.
But we then don't say thisperson is depressed and has
thoughts about these.
(30:44):
Things and it is partly theirthoughts that are causal of this
sensation, and it just becomes aI'm not sure what the word is
for it.
It's it's a treadmill, it'ssomething that is just cannot be
beneficial for the person inpain to, and it's it if we go
(31:06):
back to our biomechanical, ouranatomical, you have a joint
dysfunction, you have this,that's a cause of pain, you have
this, that's a cause of pain,and we think of it as that
really physical, your knees outof place or your hips out of
place, or whatever it might be,and that's the cause of pain.
It's a similar sort of thing.
We're just reaching for all ofthese different aspects.
(31:28):
I've observed something,therefore, I can attribute that
to as a cause of pain.
And when you can't observe it,then you're finding things that
you can.
You're finding a feeling, oryou're finding some report that
someone has given you about adeath in the family, or
something else that you can thensay, oh, I can attribute this as
(31:51):
causal for this person'sexperience.
And it's quite frankly, aboutbackwards, really.
So I guess, did that answer thequestion?
I don't know.
I started to ramble, I think.
SPEAKER_00 (32:04):
Yeah.
Rambling is encouraged.
SPEAKER_01 (32:09):
There was rambling.
SPEAKER_00 (32:12):
What I liked, there's a lot of things I liked,
but one thing I just I reallywanted to just emphasize was the
shift from that causal reasoningto something that is more the
person's experience andunderstand and understanding and
knowing that no cception isoccurring and that's why they're
in pain without knowing thecause of that no-seception.
(32:34):
Because it, if we think, ifwe're always looking for causes,
and we hear this all the time,don't we?
The root cause.
Come take my course and discoverthe root cause of pain or
techniques.
It just drives me absolutelycrazy because anyone that says
that is they're missing, they'rethey're missing the point.
SPEAKER_01 (32:50):
Yeah.
If someone says that in relationto pain, I'm just like, it's
fairly clear they have afundamental misunderstanding of
mechanisms of pain.
SPEAKER_00 (33:01):
Yes.
SPEAKER_01 (33:01):
And but that's not, I'm not saying that's a problem
that you know that that they'rea problem.
They're just a symptom of thelarger lack of education that
exists in pain.
They're a symptom of theknowledge gap that exists in
pain.
And the way that that knowledgegap has been attempted to be
filled with a whole bunch ofdifferent things.
(33:22):
Right?
We can basically attributeanything as a cause to pain.
And that is just not helpful forthe person who has pain.
SPEAKER_00 (33:32):
Yeah.
Yeah.
And that's something I wanted tojust emphasize too, is that I'm
very critical of things becausesome of this information has
been around for a long time.
And people get upset with mebecause I they're like, You're
too critical, and you got togive people a chance.
I'm like, some of thisinformation is 40 years old, but
you've had your chance.
And I've I'll admit that myselfand people like myself that have
been teaching are sometimes partof the problem too, but we're
(33:52):
trying to be do different.
And but the idea, and I think wesaid that there's a symptom of a
bigger problem, people that areteaching stuff, because that
knowledge gap is a huge problem.
But the best thing we can do,though, with that knowledge gap
is just to admit that it existsand try to fulfill it with
something and try to fill itwith something that is currently
(34:16):
less wrong.
unknown (34:17):
Yeah.
SPEAKER_01 (34:18):
And the we know now.
This is yeah, this is the thingthat is not well understood, and
it's very hard to get people tounderstand.
And that's one of the reasonsfor deck one, which is context
of pain.
It's what does it mean for tohave one in four or one in five
people who have chronic pain onlike the economic and social
burdens that exist and all ofthat kind of thing?
(34:40):
And why do we have all of thesesupposedly amazing treatments
for pain where people aresaying, here, click this pen
over the source of your sourcespot and it'll go away, or rub
this cream, or have thistreatment, or whatever it might
be.
And it hasn't moved the needleat all.
The numbers for people with painare predicted to rise.
(35:05):
The Canadian reports predictthat the numbers of people in
chronic pain will continue torise.
And what we see with theresearch now, which is not being
taken up as well, and that notadmitting that we have these
knowledge gaps in both practiceknowledge, but also education
(35:26):
knowledge and ability to measurethat.
So, what we see is I think I'velost my train of thought there.
What was I saying?
Like I keep moving from onething to another.
Let me think about that.
No, it's gone.
SPEAKER_00 (35:42):
I can't remember actually exactly what we were
talking about that second,anyway.
Listening to it, it was oh,we're talking about the
knowledge gap, admitting theknowledge gap exists.
There we go.
SPEAKER_01 (35:50):
Admitting knowledge, yes.
So that's what we were gettingto.
Is that is that's why the I hadthat context at the beginning,
is that we have to understandthat we don't know enough.
And our explain pain courses orany other courses we might have
done that have these kind offorays into this is a cause of
(36:12):
pain or here's how to treat painor whatever it might be.
They're based on huge levels ofassumption that we don't have a
good grounding for in education.
We don't have a goodunderstanding in education that
these make us reasonable,reasonably knowledgeable people
(36:32):
about mechanisms of managementof pain.
So the documentation says wedon't across the board have the
knowledge in mechanisms ofmanagement of pain that we need
to actually effectively treatpeople who have pain.
And the numbers back that up.
SPEAKER_00 (36:51):
Yeah, it's not just making it up, that's true.
What are your thoughts about thereasons why in an entry to
practice curriculum, doesn'tmatter of the you name the
healthcare profession, why paineducation is so poorly done or
not done at all?
(37:12):
When that's the number onereason why people come to see
anybody in the MSK world isbecause they hurt.
SPEAKER_01 (37:17):
Like 80% of the time it's like coming for pain.
SPEAKER_00 (37:20):
So why is that not fundamental?
What are your thoughts on that?
SPEAKER_01 (37:23):
I think partly it's because the understanding of the
mechanisms of pain has alwaysbeen a bit of a challenge.
And there's just been a lot ofinformation over the years that
has led to a lot of conflationaround the topic.
That is being cleared up muchmore now.
(37:47):
It's like closing the gate afterall of the horses have left the
bar.
So, you know, we have to getthem back in and then close that
gate.
And I think that's part of whatthis is.
It's an awful back from all ofthese different causal
(38:07):
explanations that we've hadbecause we didn't have the
mechanistic understanding andknowledge.
And it perhaps it was just thatit's so hard to translate.
If I'm saying no scriptavailable or no script given, or
whatever it might be, I can'tprovide you with a way of
(38:27):
talking about this to people.
What I can hopefully provide youwith is an understanding of the
mechanisms that are occurringand a way of assessing what
mechanisms may be occurring inany given presentation.
And then that gets translated tosome sort of management aspect,
(38:52):
and we'd have to look at thatfor a musculoskeleteal setting,
but that wouldn't just bemusculoskeleteal, right?
There's there would be a medicalmanagement as well.
SPEAKER_00 (39:03):
Yeah, so the understand the more a clinician
understands no suception andthey understand the ideas of
pain or the experience of theindividual experience of pain,
as much as we can understand itfrom a outside of observer.
SPEAKER_01 (39:24):
Like not a neuroscience perspective, right?
SPEAKER_00 (39:26):
Yeah, but the more we understand it, do you I feel,
and maybe my bias is right orwrong, that the more we
understand about it, the betterwe can be as clinicians, because
it really shapes how we think,which shapes how we communicate,
which I feel shapes ourexpectations as well as the
expectations of the person who'scoming to see us for help.
(39:48):
Would you agree with that orwould you expand on that?
SPEAKER_01 (39:50):
I would say so.
I think the more that I know andthe more I understand, the less
I talk about it to patients.
I talk all the time.
Who am I kidding?
But but the less I talk about itto patients, I don't try and
explain their pain to them.
That's just why would I do that?
Because they provide a lot ofthe information that allows me
(40:13):
to make some sort of assessmentas to what I think might be
going on a no susception level,and also what that means on a
sensitization level and whatthat means for what we consider
to be tissue damage and the ideathat mousseception is
sufficient.
And if there is an associationwith tissue damage, it's related
(40:35):
perhaps to that sensitivity,that low-level CRP kind of thing
that can occur in illness labelchronic pain situations.
So you start to get a little bitmore of an understanding of what
it means when people haveinflammation and what that means
for nosoception, just whatinflammation means.
(40:58):
And I think of it like I don'tknow more than a general level
of how the sort of specializednervous system for sight works
or for hearing, or a bit morefor touch, hopefully, because
that's clear is what we do.
But we have a similarspecialized nervous apparatus
(41:22):
for pain.
So knowing that we have that, Idon't necessarily need to have
an in-depth knowledge of howthat apparatus works in the
minutiae, but an understandingof that knowledge that there is
a there's a sort of a mechanismthat occurs when someone reports
(41:46):
pain, that we have a mechanisticprocess in relation to that,
that it'll ground our thinking,it'll ground our understanding
in reality.
And I think that's part of thebig sort of drive is that
everything that we see aroundpain, when we see all these kind
(42:10):
of causal mechanisms, it'soutside of reality a lot of the
time in terms of a mechanisticexplanation.
And so we're leaping, we'remaking these giant leaps, giant
sort of assumptions about whatthis person's going through and
(42:32):
about how we can then use ourexpertise or I would say
pseudo-expertise for a lot of itto help them.
And we may eat we may just asequally uh cause harm in most
situations.
SPEAKER_00 (42:46):
Oh, for sure.
Yeah, I would agree with thattoo.
You mentioned the grounded inreality, and that is something
that listeners or people thatare gonna take this course in
the future will hopefully reallyget from it is understanding
pain that is no deception, thatis and mechanisms involved that
(43:09):
are grounded in reality, notbased on beliefs or based on
ideas that are un unchallenged.
Because I know also in the firstpart of the course or part one,
we haven't really talked toomuch.
We are talking about the coursewithout giving away too much.
We are talking a bit.
SPEAKER_01 (43:24):
Well, hopefully go into a little bit more depth.
Who knows?
We might just make one podcast.
SPEAKER_00 (43:30):
No, this is all just part one.
The yeah, the grounded inreality, and then the
understanding that yeah, thediffer different things are
involved.
But you mentioned that thethere's human rights, there's
the and then and there's thesekind of ethical obligations.
SPEAKER_01 (43:51):
I was just looking at that night actually for
ethical challenges, yes.
SPEAKER_00 (43:55):
Ethical challenges and for people that are
listening, that is somethingthat they really should stop and
reflect on.
I highly encourage to is that ifwe're treating people who have
pain and we're doing it based onideas that are not grounded in
reality from an ethical that'san ethical challenge.
SPEAKER_01 (44:20):
Well, that's a really fuzzy, yeah, fuzzy
ethical area.
SPEAKER_00 (44:25):
Yeah.
SPEAKER_01 (44:25):
And we talked about that question of whether it's
ethically reasonable for you todeliberately cause someone pain
during a musculoskeletaltreatment.
Because if we look at thedefinition of pain as associated
as it is right now with tissuedamage, at what point in time
(44:48):
are you causing tissue damage?
Because if someone's reportingpain, it's associated with
actual or potential tissuedamage.
And if we look at the foundationor the fundamental perspective
of gnosis is necessary, if notalways sufficient for pain, then
(45:13):
you are impacting nosoceptors inorder to provide this sensation
which is associated with actualpotential tissue damage.
So, yeah, from an ethicalperspective, that's pretty
challenging.
SPEAKER_00 (45:31):
For sure.
Particularly for those peoplethat feel they need to hurt or
they need to experience pain orthey want to experience the
pain, or a therapist who says, Ineed to hurt you to help you.
SPEAKER_01 (45:40):
Yes, pain treats pain or something along those
lines.
Yeah.
It just feels better afterwardsbecause someone stopped hurting
you.
SPEAKER_00 (45:48):
Yeah.
SPEAKER_01 (45:49):
And there's there's other kind of mechanisms,
chemical mechanisms that mayactually mean that you
temporarily feel a bit better.
SPEAKER_00 (45:58):
Yeah.
SPEAKER_01 (45:59):
But yeah, it's an interesting ethical question.
SPEAKER_00 (46:02):
Yeah.
Yeah, something maybe we'll wecould I feel like we could talk
about that for another hour, butmaybe we'll talk a little bit
later.
Yeah.
SPEAKER_02 (46:10):
Yeah.
SPEAKER_00 (46:10):
Just because you mentioned the definition of
pain, I just wanted to read itout here just for people
listening, because I wouldassume that not everybody has it
memorized.
So pain, according to theInternational Association for
the Study of Pain, is anunpleasant sensory and emotional
experience associated with orresembling that associated with
actual or potential tissuedamage.
And that was updated, I believe,in 2020.
(46:32):
And it was for the previous 41years, it had a slightly
different something like anunpleasant sensory and emotional
experience associated withactual or potential tissue
damage, I believe.
SPEAKER_01 (46:45):
And report it was like and reported as such or
something along.
SPEAKER_00 (46:49):
Yeah.
So this one's changed.
I think the key thing with thisis it was changed to resembling
that associated with.
SPEAKER_01 (46:54):
Yeah.
So it didn't rely on reporting,it could be nonverbal as well.
SPEAKER_00 (46:59):
Non-verbal.
I think that was one of the key.
But then the new one they addthose six kind of sub points,
whatever, about it.
SPEAKER_02 (47:07):
Yeah.
SPEAKER_00 (47:08):
And that's all stuff I know that is covered in the
first part of the course, Ibelieve, in the first.
SPEAKER_01 (47:14):
Yeah.
One of the things that thiscourse doesn't go into a lot is
is biosychosocial, apart fromlooking at more looking at it
more on a I guess a critique ofthat understanding.
And I guess asking questions ofan internal critique of people's
(47:34):
understanding of biosychosocial.
It's one of those words thatgets really thrown around.
It's a heuristic, basically, forlearning that has meant from
what I can see in painmanagement, given that we don't
know enough, it's one of thoseheuristics that has meant that
(47:57):
many assumptions are being madeabout what pain is.
It's one of those hugeconflations that exist within
pain care.
And a lot of those conflationsare quite well documented.
SPEAKER_00 (48:12):
Yeah, and bisexual is a term that it is common in
the lexicon of the MSK world orof the healthcare world, but
it's often used as just anothertool to explain away or to blame
why someone hurts.
And you mentioned that earlierabout the relationship between
(48:33):
depression and pain.
It exists.
But people are often said, Oh,if you weren't depressed, then
your pain wouldn't that'scausing your pain.
SPEAKER_01 (48:42):
But I think or it's making it worse or whatever.
SPEAKER_00 (48:45):
And the problem that we have with the biopsychosocial
is that it often it getssegmented into oh, it's this
thing that's causing your pain,is your stress, or you're not
sleeping, or you have thesenegative self-thoughts, or you
hate your job, whatever.
It gets and those things couldall be part of things that could
be sensitized.
SPEAKER_01 (49:04):
They can definitely be aspects about the condition
of being depressed that wouldhave some impact on a sensitized
noseceptic apparatus.
100%.
I'm not arguing that.
But yeah, one of the wholethings is we're dealing with
people on a one-to-one basis,and we only get the information
(49:27):
that they tell us.
SPEAKER_00 (49:28):
Yeah.
SPEAKER_01 (49:29):
So if we're making an assumption that the one thing
or the two things that they'vetold us about the stressful
aspects in their lives are thekeys to their ongoing pain
condition, we've just done thema huge disservice because we're
cherry-picking and not, andthat's where we stop.
(49:50):
We stop as oh, it's this thing.
I can treat this thing byretraining or education or
something or explaining theirpain to them or whatever it
might be.
And we might have missed like awhole mess of things that are
(50:10):
occurring in these people'slives that all come together to
be part of their picture thatwe're not privy to.
The assumption is that weshouldn't be.
We don't know these people, theydon't know us, right?
So we're getting certain we'recoming to us for a particular
reason.
And for us to go outside of thatscope or reason is again another
(50:33):
ethical challenge.
We're gonna have to get intothis.
SPEAKER_00 (50:37):
Oh, much more to say.
Oh, yeah, I know for sure.
One of the reasons I wanted tobring up the biopsychosocial was
because of how it can often beused as a way, as a rather than
blaming tissue or joints orposture, it can be used to blame
(50:57):
other things.
And then the problem is whathappens is the person who's
experiencing or is living withpain, if what happens if those
other things in their life aredealt with?
SPEAKER_01 (51:08):
Right, and they still have pain.
SPEAKER_00 (51:10):
And they still have pain.
It's no different than saying,Oh, you're you've got this
anteriorly rotated hip, and it'scausing this left thing here,
and this is blah blah blah, andthis is tight, and this is
loose, and this is long,whatever, and then the person
goes and fixes all those things,you still have pain.
Well then where you're leftwith, you're just left searching
for another causal.
SPEAKER_01 (51:28):
I think the biopsychosocial, this idea that
you have the biological, thepsychological, the social the
social, which is just like notbeing a human, but when you put
it in that way, you now have alot of outs because perhaps it's
not biological, it'spsychological.
We deal with the psychological,oh, maybe there's also something
(51:48):
biological.
Do you know what I mean?
It's like you can weave in andout of all these things.
It's like we could maybe havemore of this over here and more
of that over there.
So you again, you may never getto a point where you actually
have a you help someone becausethere's always something in the
course of being a human beingthat you can then choose to
(52:12):
attribute pain to.
If pain is a biased psychosocialphenomenon, you've just got like
massive excuse to just treat foras many weeks as you possibly
want for all sorts of differentreasons.
SPEAKER_00 (52:30):
Yeah, because then there's always something to
chase.
SPEAKER_01 (52:32):
There's always something to chase.
SPEAKER_00 (52:33):
Always something to chase, always something affects
you.
SPEAKER_01 (52:35):
Always something to blame.
Yeah.
Whereas this for this is thefundamental, this fundamental
perspective of no susceptionbeing necessary for pain, it
doesn't necessarily removeanything else that's going on.
It's simply a grounding factor.
Like we know what a no-sceptoris.
(52:56):
It's been fairly commonknowledge that there's a
no-sceptive apparatus, that is athing that has been talked about
a lot longer.
It makes sense.
We have this sensation, we knowhow these neurons work, we
understand what activates them,we understand those sort of
basic level of things.
So it allows us to have thiskind of.
(53:20):
I I we'll see.
I won't use the word because I'mI wrote a paper, so we'll see
what happens, but it allows usto have this foundation, right?
That is again grounded inreality, in physiology, in
neurology.
It's not controversial, it makessense, it has documentation
(53:43):
behind it.
A lot of the science behind itsupports this.
We're not talking aboutsomething that we have to make
massive assumptions about.
SPEAKER_00 (53:55):
I love that.
I think we can almost just leavethat there for today's episode.
The what we're gonna do, we justwe didn't really say too much at
the beginning, is that we'regonna do six episodes.
We're gonna talk about all thedifferent sections of the
course.
The first one's more aboutcontext and it's about
obligations, and it's about andwe'll get more into that, I
(54:16):
think more into the what itmeans on an ethical obligation
level as well.
So yeah, I think we'll explorethat in in in the next episode
and then more to come.
That was fantastic, Monica.
I really enjoyed that.
That time flew by quick.
I think we did questions, and Idon't know if we gave many
answers, but that's part of thepurpose, I think, of this course
that you're gonna be doing isit's gonna be asking more
(54:37):
questions and providing answersand getting people to think
differently.
But hopefully by the timethey're done, the six module
program, which is also gonnainclude three live online via
Zoom sessions for people to tryand put this all together, and
you're gonna provide papers toread and questions to think of.
(54:57):
And we'll I can put togethermaybe even a little workbook
that we can I can put togetherfor everybody so they can make
their notes in and do their workin.
I think it's gonna be a good,not good, it's gonna be a
fantastic program and projectthat I think is gonna hopefully
start people going down the abetter way for thinking about
campaign management.
SPEAKER_01 (55:16):
And I think if people wanted to start, they
could go to the ISP and justperuse through the terminology
and get really familiar withsome of that, but also
understand that terminology isconsensus, but not concrete.
There are proposals to change,things have been added.
(55:38):
So as new knowledge comes about,we get new understanding of
things and things change.
So hold on to definitionslightly, but also they
constitute our semantics at thispoint in time, and semantics are
meaning, and we need to makesure that we're talking about
the same thing.
SPEAKER_00 (55:59):
Love it.
Well, thank you very much forthat, Monica, and we'll be back
soon.
SPEAKER_02 (56:03):
Amazing.
SPEAKER_00 (56:04):
Thank you for listening.
Pain Education, no scriptprovided, is now available for
purchase on my website, theCEPE.com.
To listen to more of theseepisodes, please subscribe on
your favorite podcast network.
If you enjoyed this episode,please like and share to your
favorite social media platform.
If you'd like to connect withme, I can be reached to my
website or send me a DM througheither Facebook or Instagram at
(56:27):
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This can be done by clicking onthe support button or heading
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