Author Archives: beyondmechanicalpain

Reassurance as a Treatment (RaaT)

Today I’d like to introduce the concept of Reassurance as a Treatment (RaaT).

(You may have heard of the acronym Saas (short for Software as a Service). Many of the world’s biggest software companies utilise this business model (think Microsoft, Atlassian etc), where they sell cloud based services instead of more traditional software. The concept of RaaT is a play on that.)

This is not meant to become an official acronym, or even an unofficial one. It’s just an easy way to abbreviate the concept of utilising reassurance as a treatment for pain.

This article is general in nature, and based on a few assumptions:

  • Guidelines for the management of many pain conditions include reassurance as a treatment intervention
  • Practitioners of all disciplines often believe they deliver reassurance during a consultation
  • Despite this, many patients demonstrate pain, disability, loss of function and catastrophising tendencies even after they have consulted with health professionals
  • Delivering reassurance takes both knowledge and skill to do, both of which are likely to be lacking from many primary care practitioners’ direct training

So let’s have a look at these assumptions, and see where reassurance as a treatment sits in the spectrum of pain mangement.

A Look At The Guidelines: Where Does Reassurance Sit?

In Australia, reassurance is part of the acute low back pain clinical practice guidelines:

Guidelines recommend that patients be advised to remain active and avoid bed rest, and be reassured of the favourable prognosis of ALBP. This is arguably the most important aspect of care that health professionals can provide.

NSW Agency for Clinical Innovation

Reassurance is also recommended as part of the treatment process for the management of rotator cuff injuries (in the workplace):

One of the first priorities for the clinician is to provide information and reassurance to the injured worker presenting with rotator cuff syndrome

Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace

In the acute pain management guidelines from the ANZCA, reassurance is only recommendend for low back pain specifically:

Targeted reassurance in acute back pain by physicians in primary care can result in improved changes in psychological factors such as fear, worry, anxiety, catastrophisation and healthcare utilisation (N) (Level III-1 SR).


How ever, the same guidelines also mention reassurance as a treatment for chronic abdominal pain:

The role of psychological intervention with reassurance and distraction in the management of acute pain in an anxious patient is often undervalued.


And in discussing non-pharmcological management of acute pain:

The role of psychological intervention with reassurance and distraction in the management of acute pain in an anxious patient is often undervalued.


So while there is definitely mention of RaaT across multiple clinical practice guidelines, the lack of more global recommendations may be more related to absence of evidence, than any evidence of absence.

Given the low cost (both the actual and opportunity cost) of delivering reassurance, my position is that it should be provided generally, where possible, for both a minor potential effect on pain and disability, as well as simply being a good human thing to do.

How Effective Is Reassurance For Pain?

Like many “soft skills”, it is hard to quantify the delivery and impact of something like reassurance. And just because reassurance sounds like it should be a good thing, doesn’t mean it actually is.

We can still get a general idea of whether targeted reassurance interventions have an impact, and the rough magnitude of that impact.

A few studies have looked at that.

In 2013, a mixed psychology and osteopathic/allied health research group from the UK conducted a systematic review of the role of cognitive and affective reassurance in primary care.

They discussed the differences between both types of reassurance, based on earlier work from Coia and Morely on Medical Reassurance and Patients’ Responses:

  • Affective reassurance is:

heuristic and rapid, and produces an immediate response in reducing concerns and worry. However, such responses are transient, and when
problems return to impact on patients in the absence of the reassuring practitioner, the patient has not been empowered with new tools to deal with them.

  • Meanwhile, cognitive reassurance is:

systematic and time-consuming, but its impact
in changing beliefs and increasing understanding is preserved,
which in turn will improve adherence and self-management

They focused on clinical situations where uncertainty is high (like musculoskeletal and pain management clinics), where there is a high need for psychological support.

They found that:

affective reassurance was associated with higher symptom burden/less improvement, with lower rates of return to work in one and with reduced adherence in another


Four high-quality and 3 lower-quality studies found associations with improvement in symptoms at follow-up. Associations were also found with reduced further health care utilization in 3 studies, one of which
was of high methodology. The relationship between cognitive reassurance and adherence remains unclear

Another study, from 2007, looked at whether reassurance helped or hindered the treatment of pain.

They found that from a physician perspective, doctors typically provided reassurance with information, but:

The effects of information as reassurance may vary depending on the patient’s level of health anxiety.

They also looked at whether diagnostics tests were reassuring, and found:

Providing information about the MR did not show measurable value
for care or outcome but did decrease patient reported well-being.

They also looked at things from a patient’s perspective, and as you might guess, found that the two views did not align:

clinicians attempted to provide reassurance by underscoring the mildness or the early stage of the problem as well as the probability that the patient would recover. However, the results showed that this increased worry for future pain and disability

A more recent (2015) paper from Traeger et al looked at the effects of primary care based education on reassurance and found

There is moderate- to high-quality evidence that patient education increases reassurance more than usual care/control education in the short term and long term.

Of interest to allied health professionals, and no doubt something many of you may have experienced in one form or another:

Interventions delivered by physicians were significantly more reassuring than those delivered by other primary care practitioners (eg, physiotherapist or nurse)

What we can see from this small snapshot of the literature, spanning a couple of decades, is that reassurance seems to go hand in hand with education, but it is not as simple as providing information, and the effects can vary based on the practitioner delivering the reassurance and education, the clinical context, how they deliver it and the patient’s individual physical and mental health status.

How To Reassure A Patient In Pain

One of the most important aspects about providing reassurance to a patient in pain is to ensure they do not feel dismissed.

There is a fine line between saying “everything will be okay” and a patient interpretting it as “they said there is nothing wrong”.

You don’t need a doctorate in psychology to know that if you are not feeling well, being told (or perceiving it as such) that there is nothing wrong does not help validate your experience.

So, the first step in reassuring any person in pain is to listen and acknowledge their experience as real and meaningful.

The second step is to provide an accurate explanation for their experience. This is not easy, but the importance getting a diagnosis cannot be understated. Bronnie Lennnox-Thompson has written on this topic before, and I would highly recommend reading her thoughts.

This is another challenge, as it is very easy to fall into the trap of “structuralism”, and provide a patho-anatomical diagnosis, which will likely lead to increased pain, disability and loss of function in the long term.

Beyond these first two steps, working on a collaborative management plan that involves goal setting and regular check-ins allows you to set up a reassurance “positive feedback loop”, whereby each future session allows you to reinforce your initial reassurance, while allowing the patient to have time to integrate the education with their own experience.

Reassuring Conclusions

Communication is called a “soft skill”, which are considered as part of the “human” skill set that are important for all professionals, no matter what you do.

However, good communication is actually quite hard; think about the challenges you face personally, professionally and as a customer and client of other service providers. How many times have you had to seek or provide further clarification, resolve conflict or follow up due to lack of communication or drop out?

Communication isn’t as simple as saying what you mean. How you say what you mean is crucial, and differs from one person to the next, because using language is learned social behavior

Deborah Tannen

If communication is hard, then reassurance is even harder.

Why? It is a subset of communication – you need to be able to do the first well in order to do the second well (cognitive reassurance at least).

So, just as you would study, practice, and refine your hard or technical skills, communication and reassurance can be studied, practised and refined so that you get better and better at it over time.

Though it is something that you never master – as every human interaction is different – you can definitely become quite adept at it, and use reassurance as part of your overall treatment process for people in pain.


This post was written by Nick Efthimiou, a contributor to Beyond Mechanical Pain.


Medical reassurance and patients’ responses.

Cognitive and affective reassurance and patient outcomes in primary
care: A systematic review

Reassurance: Help or hinder in the treatment of pain

Effect of Primary Care–Based Education on Reassurance in Patients With Acute Low Back Pain


What are soft skills and why are they important at work?

The Power of Talk: Who Gets Heard and Why

3 Clinicians Discuss Their Experience With Postgraduate Study In Pain

The more that you read, the more things you will know. The more that you learn, the more places you’ll go.

― Dr. Seuss

Pain is an enormously complex topic.

Even if it was taught adequately in undergraduate allied health education programs, it would be insufficient to master the topic.

But for the majority of clinicians, a thorough undergraduate pain education is not a reality; one only has to see the dissonance that exists on social media currently, and internet forums previously.

This is even more disheartening given how much more is known about pain and how to treat it.

Less than 10% of people with chronic non-cancer pain gain access to effective care, despite the fact that current knowledge would allow 80% to be treated effectively, if there was adequate access to pain services.

Pain Australia

One positive, is that we are seeing an increased interest in post-graduate studies from allied health clinicians.

Ranging from certificates to doctorates, and once the domain of medical professionals, there are increasing options for anyone interested in increasing their expertise on pain management.

With that said, we have a special blog post, where we have interviewed 3 experienced clinicians with post-graduate pain qualifications about their experience with study, and the impact it has had on their careers.

Blaise Doran

First up we have Blaise Doran, a physiotherapist who presented for Beyond Mechanical Pain on Chronic Pain in Paediatric Populations last year, he also wrote a guest post on loaded adaptation.

Quick background: what is your profession, when did you start practicing and where are you practicing now?

I’m a physiotherapist. Qualified and started practice (in- and outpatient, hospital-based) in 2004. Currently working in paediatric persistent pain as part of a multidisciplinary team.

What post graduate qualification did you do? When? Where? Why?

I have 2 post-graduate qualifications:

a) Postgraduate Diploma in Neurological Rehabilitation. Completed 2010/11. Course was via the University of Western Australia (Perth). I did it because I had been wanting to do so for a few years, as I was working predominantly as a neuro physio. I perceived it as a way of keeping up-to-date with the literature, challenging my biases, and future career planning.

b) MSc in Pain Management via Cardiff University in the UK. Completed 2016. Because I was working as a physiotherapist in pain management, and for the same reasons as above. It was also (even as an international student) less expensive than the equivalent course from U. Syd., and there was an opportunity (actually requirement) to do some kind of research project of your own, and write a “mini thesis”. So, really, as CPD on both counts.

How has it changed your practice? For better and/or worse?

GDNR was one of the instrumental influences in me realising that my approach was probably only slightly more effective than a passive intervention. It made me question the foundations of many aspects of physio, not just neuro physio. This, of course, has both positive and negative consequences. Even the strongest evidence has more than its fair share of equivocal literature. It also honed my research lit evaluation skills, and gave me a better understanding of task-specific, “load” aware, repetitive practice as being the most likely way forward for physios in neuro rehab. And that I was likely “under treating” in terms of load and specificity. I changed that.
MSc Pain Management – similar to above, except with persistent pain, and have come away with a much better appreciation of:
• Ethics
• Philosophy (as applied to PT/rehab)
• Contextual effects
• Pharmacology
• Research methods (qualitative and quantitative)
Yes, changed my practice in terms of being open to both translating research findings into practice more quickly and (I hope) effectively, and OTOH, challenging research findings of efficacy that appear not to be effective in the swampy lowlands of clinical practice.
Probably the worst thing is that that I am now an even worse smart-arse than I was before (although I’ve mellowed of late.)

What were the financial implications (initial investment, has it improved your income/business etc)?

Postgrad. Costs.
I mean a lot. Even a commonwealth supported place cost me about 20% of my salary (all up) at the time.
The Masters was a killer, in particular. And although you get some back in tax… erm, it’s not that much.
I got no financial support from my workplaces for either.
Did it improve my earning capacity? No.
There is an expectation in the Victorian PH system that one of the requirements for Grade 3 (and above) “senior” roles, is that you have a post-grad qualification. A post grad qual gives you a risible “allowance” in the Health Professional’s EBA. But ROI, such as it is, is not skewed to the financial gains, IMO.
But, “bang for $” from a professional knowledge and CPD perspective blows away the “weekend course” style CPD.

How did this study affect you as a person?

I realised I had put a lot of effort in to gaining “kudos” for academic achievement, and that I proved (to myself, and many imagined naysayers) that I could. Those demons are sleeping now.

On a scale of 1-10, how likely would you be to recommend this course to other therapists?

Hard to answer, because “formalised” learning and post-grad-post-nominalism is not for everyone, and you can be up-to-date in terms of lit and practice with or without a post-graduate qualification. (But it’s the critiquing and evaluating skills that are good to hone).

1/10 if you don’t get in with Academe.

10/10 if you like doing “mental kettlebell” workouts.

Pamela Dennis

Pamela is an osteopath based in Tasmania, Australia. She runs a practice called North Hobart Osteopathy, with a focus on chronic pain management.

Pamela Dennis

Quick background: what is your profession, when did you start practicing and where are you practicing now?

I started osteopathic practice in 1999 graduating from Victoria University, Melbourne. I started working in a multidisciplinary musculoskeletal practice in Footscray, and with other Osteopaths in Williamstown and Hobart. I also worked in private practice with associates and worked as a Rehabilitation Consultant. Currently I work in team care arrangements with GP referrals and allied health.

What post graduate qualification did you do? When? Where? Why?

I completed a Post Graduate Diploma of Health Science – credit endorsed in Pain and Pain management over four years from 2014-2018 at Otago University, New Zealand, because I’m a dual NZ and Aust citizen and I consider Otago University a leader internationally in Pain Medicine.

The course had developed components on psycho-social and cultural aspects of pain which was extremely interesting to me. Otago colleagues include the course were from all over the world, lectures from Sydney and very interdisciplinary and inclusive in their approach to pain management. The heads of department are world leaders in pain education and this course is recognized by the IASP. Still have contact with lecturers and have enjoyed linking NZ’ers to Australian friends, OA profession etc in this area of professional development. Sharing knowledge is great.

How has it changed your practice? For better and/or worse?

It has fundamentally changed my practice and the way I communicate with my clients. Understanding my culture, changing my beliefs about pain and offering more of the psycho-social model to my osteopathic practice.

I still provide acute care, sports medicine treatments, dry needling, gentler osteopathic techniques (all of them). My hands on practice is “less is more”, and building self-efficacy with graded exposure, pacing, plans to participate is all aspects of patient centered care.

I can realistically set goals as a team with clients who have persistent pain and talk the same language as other health professionals who are part of my clients team care arrangements. More confidence assisting clients and spend more time with these clients listening to them and writing good letters to GP referrers. Which I’m not properly remunerated for.

What were the financial implications (initial investment, has it improved your income/business etc)?

My course fees, time off work and costs were approximately $25,000. It has improved confidence in me by referring Practitioners, like physios, GP’s, psychologists and nurses, etc. who seem to trust me more because I’m talking the same language and my clinical input is valued. My clientele are becoming more self managed and less dependent on manual therapy.

How did this study affect you as a person?

My studies changed and challenged my beliefs, acknowledging my cognitive biases based on some Osteopathic doctrines that was outdated and based purely in belief.

I fully challenged my culture, personal heritage, family and beliefs that formed my understanding of pain and learnt more about types of pain and cultures of pain experience from all over the world.

Studying the history of medical pain models, the history and culture of Pain for thousands of years. I fully understand the theories models and science of pain.

I now understand the difference of neuropathic pain, allodynia, centralization, the DNIC, the brain, the neurotransmitters the pharmacology of pain, the pharmacology and gold standards for migraines, medical surgical procedures for nerve decompression, I understand more about fibromyalgia, gut and brain health, cognitive behavioral approaches, many more non-pharmacological treatments to assist people with chronic pain, especially back pain etc etc.

I feel way more confident in assisting complex patients and help prevent acute patients from falling into the chronic pain cycle with correct language, information and care.

On a scale of 1-10, how likely would you be to recommend this course to other therapists?

I would recommend this course 10/10 to become a contemporary evidence based practitioner in particular with our growing population of complex chronic anxious/depressed elderly obese patients who need the right treatment model.

Claire Richardson

Claire is an osteopath who owns a private practice called Chadstone Region Osteopathy with her husband Shaun (also an osteopath) in Melbourne, Victoria.

Claire Richardson

Quick background: what is your profession, when did you start practicing and where are you practicing now?

I’m an Osteopath. I qualified in 2011 and have treated in private practices around Melbourne since. I have been a practice owner since 2015 with my husband (also an Osteo). I have recently been conferred as an Advanced Pain Management Osteopath through the new Clinical Practice Group initiative from Osteopathy Australia as an acknowledgement of my studies in the field of pain science.

What post grad qualification did you do? When? Where? Why?

I undertook the Professional Certificate in Pain Sciences at the University of South Australia in 2018. I decided upon this course for a few, mainly practical, reasons.

Firstly, it is offered online via correspondence – which was necessary for me as I did not have the opportunity to take time away from work to study. The study hours are flexible and can easily be structured around existing work commitments.

Secondly, it was relevant. This course was not as intensive as a Masters degree and focussed upon the practicalities of applying pain science in a clinical setting. Whilst the content was heavy going at times, it was practical and relevant to the kinds of presentations we see in a private practice setting. By presenting a course which was streamlined in this way, UniSA was able to offer a course which was one year long and significantly more affordable than a more comprehensive post graduate degree such as a Masters.

Thirdly, it was developed and coordinated by the scientists and academics behind Body In Mind, such as Lorimer Moseley and David Butler. I follow BiM closely and their work has inspired me and resonated with me, so I was confident that I would enjoy and engage with their teaching style.

How has it changed your practice? For better and/or worse?

It has informed my practice to be able to offer more thorough and evidence based care for those living with persistent pain. I feel confident that I am able to implement the recommendations from the current understanding of the science of pain. I have always appreciated the need to remain informed and current, but this course has reinforced the importance of staying abreast of the ever evolving science.

What were the financial implications?

Initial investment was $4400 AUD (2 years ago). I have been able to more effectively network with referrers since completing the course, and as a result, see more patients who fit my clinical interests. Having done the certificate hasn’t directly increased my income, however it has meant that I am more professionally satisfied.

How did this study affect you as a person?

This course emphasised the importance of empathy within health care. Whilst I have always believed empathy to be a fundamental skill of the healthcare professional, it has been eye opening to understand just how profound of an effect a therapeutic alliance with a caring practitioner may have on an individual. I believe that I have been able to carry this philosophy into my daily life and interactions with others.

On a scale of 1-10, how likely would you be to recommend this course to other therapists?

For anyone seeking an engaging, clinically relevant, financially manageable and relatively short course, I would highly recommend the Professional Certificate in Pain Sciences from UniSA.


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This post was written by Nick Efthimiou, a contributor to Beyond Mechanical Pain.

What Is A Good Outcome In Pain Management?

One of the challenges of working as a clinician with people in pain is measuring outcomes.

Pain is an experience, and as a result, it cannot be directly measured.

Instead, we use surrogate measures like a VAS, McGill Pain Questionairre and functional assessments to make an assessment of the severity of someone’s complaint.

Often, improving these surrogates become the focus of the treatment, as they are measurable.

From BPS to Enactive

Earlier this year, Peter Stillwell and Katherine Harman wrote an interesting paper titled An enactive approach to pain: beyond the biopsychosocial model, which looked at the issue of compartmentalisation of pain, even with the biopsychosocial model.

They wrote:

With enactivism at the core of this approach, pain does not reside in a mysterious immaterial mind, nor is it an entity to be found in the blood, brain, or other bodily tissues. Instead, pain is a relational and emergent process of sense-making through a lived body that is inseparable from the world that we shape and that shapes us.

When you conceptualise pain this way, it makes it hard to reduce to a questionaire or numerical score, doesn’t it?

Intensity Is Not Proportional To Suffering

One of the big issues with reducing pain down to a score is that it doesn’t capture the human suffering involved.

This is demonstrated in a 2013 paper from Swedish researchers. The authors wrote:

Common symptoms in patients with chronic pain (such as pain intensity, depression, and anxiety) showed great variability across subjects.

That’s not to discount the importance of gauging pain intensity, as the same paper found:

With respect to the investigated aspects of participation and health, pain intensity showed stronger multivariate relationships than psychological symptoms.

Which potentially suggests that for a majority of people, their pain is the primary issue which manifests as psychological symptoms.

However, another paper showed that people with depression experienced nociceptive pain differently (more intensely) compared to healthy controls:

The present study stresses that the initial evaluation of pain intensity among depressed patients is increased compared with HC. This negative bias might affect the way pain is experienced by depressed patients and serve as a mediator between depression and pain complaints. 

There is also evidence that factors like controllability can positively influence suffering without changing pain intensity:

control over pain primarily reduces the degree of perceived suffering. This effect was modulated by the subjects’ locus of control: The more participants attributed their behavior to chance, the greater was the reduction of suffering when they had control over their pain. Pain intensity and unpleasantness ratings, by contrast, were unaffected by control over pain.

Though caution must be used when applying this research to practice, as it was experimentally induced pain.

As you can appreciate, even with a small sampling of literature, pain is very “messy”, and difficult to quantify and separate into contributing and effected factors.

Proportion of Patients Making Clinically Significant Improvement

Despite this messiness, something needs to be measured.


To try and gauge both clinical and economic effectiveness and efficiency of pain management programs and interventions.

Enter the proportion of patients making a clinically significant improvement number.

This is used to gauge how many patients at a particular clinic or hospital improve by at least the minimum clinically significant amount.

Example: the Brief Pain Inventory

A common measure of pain, the Brief Pain Inventory has two aspects – pain intensity looks at worst, best and average pain, where it is felt and the pain interference part looks the impact of this pain on aspects of life.

The minimum clinically significant improvement for this is 10%, and the benchmark for pain clinics is to achieve at least this reduction (in average pain) in at least 30% of patients.

Real World Outcomes Differ To Social Media Outcomes

Given the complex, multi-factorial nature of pain, and the inherent challenges in measuring outcomes, results in real world chronic pain clinics are definitely not eye catching, however they can be life changing.

The above image shows outcomes from clinics who participate in the electronic Persistent Pain Outcomes Collaboration (ePPOC). When you look at the “all services” column, it paints a picture of how difficult it is to make clinically significant improvements in each area, with only about a quarter of clinics able to improve average pain rating.

When No Progress Is Progress

Sometimes, we have to accept that the best we can do is stop things from getting much worse.

If you can keep someone’s pain intensity relatively stable, help prevent them catostrophising and falling into depression, then it might not show up as a positive outcome by the numbers, but in reality, it is a HUGE WIN.

Be Optimistic, But Realistic

Instead of delivering false hope for people with advertising and what is said in practice, one of the best things you can do for persistent pain patients is be realistic, in an optimistic way.

That is, explain the facts of their situation, and what is factually known to help and hinder this, but spin it in a way that is positive, and builds confidence in you and potentially themselves that this is the right path for them.

Overall, know that any victories in chronic pain management are hard won, and that it is important for your own health as a practitioner to recognise this and acknowledge your efforts and the role you played in someone’s health. Otherwise, it can be a fast path to burnout.


This post was written by Nick Efthimiou, a contributor to Beyond Mechanical Pain.


An enactive approach to pain: beyond the biopsychosocial model

Is Pain Intensity Really That Important to Assess in Chronic Pain Patients? A Study Based on the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Initial Evaluation of Pain Intensity Among Depressed Patients as a Possible Mediator Between Depression and Pain Complaints

Impact of controllability on pain and suffering

Patient Outcomes in Pain Management – Enterprise One Pain Management Service

Spinal Cord Stimulation: Neuromodulation for Chronic Pain

Spinal Cord Stimulation (SCS), a form of neuromodulation, can be used to treat certain chronic, intractable pain conditions that have not responded to more conservative approaches such as medication, surgery, manual therapy, exercise or psychological interventions.

Despite being considered minimally invasive, it is not without risk and is considerably expensive.

Having been in use for over 50 years, the technology is evolving at a fast pace, with newer approaches targeting different anatomical structures and using differing forms of stimulation.

However, the overall success rate associated with the use of the technique has not improved over recent times. (1) 

What Does It Involve?

There are several different types of SCS, but generally it involves the placement of specialised electrodes into the epidural space or around the dorsal root ganglion.

It is typical to trial SCS before implantation. This is done via percutaneous leads, connected to an external battery. This allows the patient to experience stimulation, and gauge their response to the therapy.

If the patient responds, then a complete system is implanted, which consists of:

  • Leads/electrodes (either surgical leads, which require a laminotomy to insert, or percutaneous leads, which can be inserted through a needle)
  • Anchors (fastening sleeves to hold the leads in place)
  • Implantable Pulse Generator (IPG)

The electrodes connect to the implantable pulse generator (IPG), which is similar to a cardiac pacemaker in size and shape. This is typically implanted in the lower back or flank, though sometimes it is place in the abdomen.

The system is then programmed to deliver electrical current to the spinal cord or nerves, like a TENS machine. The system is programmed via a wireless connector through the skin, with the information stored on internal memory inside the IPG.

There are both rechargeable and non-rechargeable (primary cell) IPGs on the market, with advantages and drawbacks to both. Charging is done via a wireless charger, similar to a mobile phone charger.

How Does It Work?

The electrodes generate electrical fields between them and the change in charge influences the nervous tissue in the vicinity, causing either depolarisation or hyperpolarisation of neruons.

It is thought to provide pain relief via several mechanisms.

Early stimulation with some reference to Melzack and Wall’s gate control theory via tonic stimulation of the dorsal column. This involved the patient experiencing parasthesia over the pain area, masking their pain.

Newer paradigms involve multiple waveforms and frequences, with different anatomical targets, such as the dorsal horn. These forms of stimulation can be delivered at sub-parathesia thresholds, and still provide pain relief.

Areas of the nervous system known to be affected in successful SCS stimulation include the dorsal columns of the spinal cord, supraspinal regions and higher order processing within regions of the cortex.  Other, more recently reported  effects of SCS have been identified in glial cells and descending modulatory systems.  Despite a great deal of research on the topic, it is fair to say that the exact mechanisms regarding the efficacy of SCS are still fairly hazy.  (2)

What are the indications? 

Its main use of SCS is for intractable pain conditions. 

Because of the invasive and expensive nature of SCS, it is not used unless the indications for it are clear, and even then, typically after all other approaches have been exhausted. 

The patients who are candidates for SCS are often in debilitating pain and experience a great deal of associated suffering and disability.  This is not an approach for your garden variety back pain! 

Neuropathic pain is the most common indication and some of the conditions include: 

  • Failed back surgery syndrome – chronic back pain following any type of invasive lumbar surgery such as laminectomy or fusion surgery.  
  • Chronic Regional Pain Syndrome (CRPS) of a single limb 
  • Chronic migraines
  • Chronic pelvic pain

Other Applications of SCS

There is a growing area of research for the use of SCS with people who have sustained a spinal cord injury in order to restore some motor function. We won’t discuss this beyond mentioning it.

Does it work?  

To answer this question, first we need to define work

When we are talking about the efficacy of treating chronic pain, the parameters generally used to define success are a reduction of pain on a VAS scale by 30-50%.

Understanding expectations are really important in this field as miracle cures and complete pain relief are fairly infrequent.  Whilst most people might consider a 30% reduction in pain to be insufficient, on a more functional level it may mean the difference between a person being able to tolerate being in the car for an hour compared to just 10 minutes, or a reduction or cessation of opioid or other medications which carry with them a whole lot of life interfering side effects of their own.

Tread Carefully With The Evidence

There are few true placebo SCS studies. This means it is hard to know the magnitude of the specific effect of spinal cord stimulation on pain and function.

Because parasthesia based stimulation was the dominant method for the majority of SCS history, it was traditionally hard to conduct a double-blinded trial. Hence, we must interpret the studies with caution.

It’s also important to note that the multifactorial nature of pain means that some people are likely to respond  to SCS better than others. This is likely due to the pain being mediated by other factors not related to the nervous system itself. Factors that are known to reduce the chances of SCS being effective include depression, PTSD,  the presence of third party compensation, misuse of alcohol or other drugs, low self efficacy and other evidence of poor coping skills  (3, 4).    

Without boring you to death with an extensive review of the literature, it would be fair to say that around half of the people implanted with SCS, regardless of the system used, the type of lead placement or the differing use of electrostimulation types (burst, frequencies etc.)  achieve a reduction in their pain of between 30 and 50%.

This reduction in VAS scores goes hand in hand with increases in function and quality of life.   In practice, having a skilled operator is likely to increase the chances of success and reduce complication rates, and some influential clinicians are aiming for 80/80 – an 80% pain reduction in 80% of patients, given the improving technology and optimal patient selection, which is going to give the best success rates for a particular clinic  (1, 4, 5).

More Than Numbers

In the pain clinic setting, the suffering that often goes hand in hand with neuropathic pain can be almost unquantifiable. 

Ordinary people who are unlucky enough to be afflicted with this condition in its variable forms tend to say very similar things about their situation and often follow an understandable downward spiral of loss of function and increasing misery. 

The depression and fear avoidance with movement that frequently accompanies the suffering  are the target of the allied health team working with these patients.  Whilst they are frequently modifiable to a degree, they are also incredibly understandable given the situation. 

The desire to have an option to at least try to ease suffering is the obvious rational for the use of SCS in the pain clinic setting, despite its lack of overwhelming efficacy.  When it goes well, it changes lives.


1. Sdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain Pract 2018;18:1048-67.

2. Vallejo R, Bradley K, Kapural L. Spinal Cord Stimulation in Chronic Pain: Mode of Action. Spine (Phila Pa 1976) 2017;42 Suppl 14:S53-60.

3. Blackburn DR, Romers CC, Copeland LA, Lynch W, Nguyen DD, Zeber JE, Hoffman MR. Presurgical Psychological Assessments as Correlates of Effectiveness of Spinal Cord Stimulation for Chronic Pain Reduction. Neuromodulation 2016;19:422-8.

4. Prabhala T, Kumar V, Gruenthal E, Collison C, Prusik J, Owusu S, et al. Use of a Psychological Evaluation Tool as a Predictor of Spinal Cord Stimulation Outcomes. Neuromodulation 2019;22:194-9.

5. Brinzeu A, Cuny E, Fontaine D, Mertens P, Luyet PP, Van den Abeele C, et al. Spinal cord stimulation for chronic refractory pain: Long-term effectiveness and safety data from a multicentre registry. Eur J Pain 2019;23:1031-44.

Loaded Adaptation, A Guest Post by Physiotherapist Blaise Doran

What springs to mind when you think of your own adaptability?  Do you think dichotomously about your physical self, and/or psychological self?  Would you say you were adaptable? And if you did, what would that mean, what would it look like, and how would you explain it to others? 

These are innocent enough questions, superficially.  If we paused to think, though, perhaps the concept of adaptability is a loaded one when examined in the context of the professions involved in (physical) rehabilitation.  I suggest we need to give it a bit more attention.

If we were to be pedantic, we all have the capacity to adapt, because we are constantly doing so; responding to stimuli that emanate from our internal and external environments.  Again, an apparently simple concept, and one which was a starting point for a Twitter thread relating to the term “maladaptive”, and why I find it troublesome.

For those who (perhaps wisely) do not use Twitter, here is a précis:  Maladaptive is a term that is commonly used in the context of the nervous system, and neuroplastic activity.  Its use has become popular when describing putative mechanisms that might explain observable and reported phenomena, particularly in the contexts of neurological and persistent pain rehabilitation. (The former is the domain in which I used to work, the later in which I currently work).  

My chief complaints when it is applied in relation to the nervous system might be summarised with the following points:

  • Maladaptive according to whom?
  • The complex systems within people are influenced by many internal and external stimuli, with dispositional loading arising from numerous factors (including, but not limited to, pathology, epigenetics, and environment).
  • The nervous system (as a case in point) simply adapts to the new order of things, so why the value-judgement of “badness” implied by the prefix mal?
  • Might it better be called “adaptive” or “responsive” neuroplasticity; or simply neuroplasticity?

Perhaps this argument may be viewed as a semantic, or even too fastidious.  We may run the risk, however of making loaded judgements based on entrenched concepts of statistical normativity injudiciously applied to a complex adaptive system.  

Some have rightly commented that the mal component of maladaptive may relate to the subjective experience that emerges from the neuroplastic changes, which have an impact on preferred function and participation.  The value judgement in this case is therefore being applied by the individual. This is an interpretation that makes sense up to a point (and it is not an entirely new idea, as this well-written essay expands upon.)  

I would suggest, then, that it would be more semantically accurate to call that an individual’s maladaptive experience (resulting from neuroplasticity).  After all, words matter.

About The Author

This is a guest post by physiotherapist Blaise Doran. Blaise works at the Royal Children’s Hospital in Melbourne in the paediatric chronic pain unit.

Blaise will be presenting for Beyond Mechanical Pain in Melbourne on Wednesday the 25th of September, 2019.

You can purchase tickets via the link below:

These are a few of my favourite things…….. From APS 2019

Conferences are always a great way to stay up to date with scientific information with relatively minimal effort. APS 2019 certainly  was a great way for me to see where changes in treatments for patients with persistent pain are occurring. There were some seriously hard hitting scientists, doing amazing work for us to better understand pain on so many levels. It was like Pain Nerd heaven! 

  • #WomenInScience was probably the thing that floated my boat the most. Incredibly smart, personable and innovative female researchers presenting work that has big impact. Professor Beth Darnall presented some of her research from Stanford university on CBT approaches for pain management programs. Demonstrating that pain catastrophising is a big deal in predicting outcomes in various settings including surgery and how to address this in a variety of ways. The best thing about these solutions that they are developing and studying is that they are shorter than traditional programs, can be delivered by all health professionals with some training on the approach. In some cases they can be delivered with digital access or even virtual reality allowing cheaper, easier and accessible treatments with demonstrable good efficacy.     It was just so practical –> here’s the problem –> here are its scientific parameters –> here is the solution which is ticks all the boxes – check out her empowered relief program and the “my surgical success” site. Beth’s passionate work in the area of opioid tapering is also worth checking out.

  • Dr Melissa Day followed her into the stage and presented her research that looked into the mechanisms by which CBT, mindfulness meditation and mindfulness based stress reduction work in treating persistent pain. My take home from her work was that the ways we assumed these streams of treatment worked is probably not what is actually going on…… but they work anyway! Good efficacy is seen, comparable to surgical interventions and medication approaches with psychological approaches to treating pain.

Melissa Day, Beth Darnall and Fiona Hodson
  • Other inspiring women whom I loved hearing included Associate professor Christine Linn reviewing the literature that tells us that gabapentinoids are not much help in acute radicular pain. She was also part of the team who did the massive paracetamol study out of Sydney, results of which have already changed understanding and guidelines for use of paracetamol in low back pain.

  • Professor Julia Hush presented ideas and her research looking at why studying low back pain is so difficult due to the lack of heterogeneity when we take into account the psychosocial factors that are well known to come into play in low back pain.  Her resume is inpiring and her other research involvements  are  clinically practical and innovative.   Julia speaks passionately about integrating pain science into undergraduate programs as a way to change pain treatment at a society level.  Here are a few of the articles she has been involved in that I found really interesting:

  • Dr Jane Chalmers, who I had long admired before having the chance to meet at last year’s APS conference, presented a poster (which won the Best Poster Award) and short presentation on her recent qualitative work on women with endometriosis  negative experiences with healthcare interactions.  Clever stuff from a clever lady, who also happens to have wonderful dress sense and loves a pop of colour like yours truly. 

Some of Jane’s publications that are changing the world….

Jane Chalmers “accidentally” colour co-ordinating
  • A shout out to the outgoing president of the APS Ms Fiona Hodson who has done a great job and to the incoming president Dr Anne Burke. The hard work that all of the APS team put in to running the conference as well as the day to day runnings of the APS is fantastic.
  • My own work colleagues – hanging out with the Pain Matrix gang at the conference was a wonderful way to get to know everyone better and on a different level.   I work in a private pain clinic in Geelong, Australia.  We deal with patients who are often in seriously difficult and upsetting situations and without a good team to lean on and bounce off, the work would be even more difficult.  Our female dominated team is made up of kind, caring, clever, funny and warm people and it wasn’t the wine at the gala dinner that made me declare “I Loooove you guys…..”  

A section of the Pain Matrix “dream team”

Mentoring, burnout, expectations and persistent pain 

My husband and I went out for a posh dinner this week and the menu didn’t tell you what the dish was, it just listed the ingredients.  This is the inspiration for the title of this post, however the inspiration for the content has come overwhelmingly from my work colleagues over the past month. The dinner was delicious.  Work, on the other hand, has been a bit of a rollercoaster. 

Working solely in the persistent pain setting can be a tough slog as well as ridiculously rewarding at times.  When you reduce the number of acute presentations you see, you lose the natural ‘regression to the mean’ wins which are relatively quick, consistent and satisfying.  You reassure yourself that you were part of the process, the patients are satisfied and you see a larger variety of people and presentation which helps to keep things interesting.  In the persistent pain setting, the gains are often incredibly slow and the “failures” can be frequent. The functional outcomes don’t often satisfy the patient as much as they do the practitioner even despite the best education efforts to shift focus from pain to function. Complete pain resolution is rare and sometimes  good functional gains are viewed by the patient as  a poor second best in the outcome lottery.   

Working part time or having a mixed caseload is a great way to work in this area.  If this isn’t possible though, the frustrations around the ratio of patients making good gains to those seemingly making little change can easily lead a reflective practitioner to wonder where they are going wrong, to question if they have enough skills or if they are missing something.  I reckon I hit this wall about a month ago when the novelty of working solely in persistent pain wore off and the reality of the lack of progress I have made with some of my now long term patients started to kick in.  

Recognising that I was feeling a little disillusioned, I started very deliberately seeking out some mentoring from my work colleagues.  For some, I booked a specific time with them and discussed a few of the cases that I was particularly struggling with.  Others were brief corridor chats, lunch discussions or throwing myself into a colleague’s chair at the end of the day to have a debrief.  It was a great  strategy for me and certainly had the desired effect.  Leaning on practitioners who have worked in the area longer than I, have different insights and expertise was a winner.  

Here are some of pearls of wisdom I have picked up from this exercise: 

  • Make sure your tendency is not to focus on the lack of change rather than the positive outcomes, even if they are small.  It can skew your view on what your treatment efficacy.  It’s a common thing for people with high expectations of themselves to do! 
  • Lower your expectations for those patients with multiple co-morbidities, very long-standing pain or pre-existing mental health conditions that had been debilitating prior to their onset of pain.  The science tells us that these predispose to pain and reduce efficacy of interventions.  We should pay attention to this!    Sometimes you are walking with them on their journey and you may not be able to measure the impact that you are having until later in the story.  Trust that you are helping them by just being on their side. 
  • You should not be working harder than the patient (I love this one!) 
  • Remember that you are part of this person’s journey and you don’t get to choose where along that path you meet them.  They may not be ready to hear the messages you are trying to get across but you may prime them for the next practitioner who sings from the same song sheet to take it and run with it.  People may need a few more treatment failures to realise that your plan was going to be helpful.
  • Review your functional outcomes measures WITH the patient.  When they are in the situation it can be hard to see progress. Sometimes seeing things in black and white with a good dose of perspective can help them to feel more hopeful.
  • Play loud music on the way home and leave work at work.  Be with your family or friends when you are with them.  Work is only part of life and we need to practice what we preach and live a life that fits with our values. 

These words of wisdom have been incredibly helpful for me, but so too has the contact with the people who have delivered them.  Staying connected with colleagues is important to reducing burnout and keeping morale at work high.  It helps keeps us focussed on our goals and reminds us how important our role is.  A few laughs over a glass of bubbles on a Friday after work can also work wonders – I highly recommend it! 

A beautiful gift  with an even more beautiful letter that was given to one of our doctors  this week after a fantastic outcome .  He was gracious and humble enough to attribute the success to the whole team – leading me to create a final pearl of wisdom:

  • Be inspired by the wins of others!

Snippets on opioids for back pain – a summary of a two new research articles


Opioids don’t work well for managing acute low back pain and are not recommended in guidelines for treatment of low back pain as a first line. (1)  There is surprising little to no evidence on the long term effectiveness of the use of opioids for the management of chronic low back.  Despite this, many patients are still prescribed opioids for low back pain and many stay on them for years despite little improvements to their function.   (2)

These two recently published articles give some small insights into the prescription rates of opioids for chronic low back pain, pointing at two factors that can increase the chances that a patient will be prescribed opioids for their back pain.  The articles are both drawing on data from the USA, which don’t necessarily represent other countries prescribing patterns but still give some interesting insights.

The first suggests that presence of higher levels of catastrophising can be seen to be a strong moderating factor as to whether a patient is prescribed opioids or not. This association is seen a lot stronger in women than men.   (3).  Catastrophising is also known to be a moderating factor in pain intensity.  Pain catastrophising is defined as the tendency to dwell on the worse case scenario – a cascade of negative thoughts and emotions.  Their presence is known to be an unhelpful response to pain and amplifies both pain and distress.

Another study that was recently published suggests that depression is associated with higher rates of prescription of opioids in people with  low back pain. Chronic pain populations tend to have higher levels of depression than the normal population, however people with depression are often excluded from clinical trials.  This information informs us that the presence of depression increases the chances that a person will be prescribed, and subsequently remain on opioids for back pain   (4).

Both of these articles tell us things that we already know about pain – that our thoughts and emotions have a large role to play in the progression and maintenance of pain.  Both catastophising and depression have been long recognised as factors in chronic pain – it seems they also have a role to play in whether opioids are prescribed or not.

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016. JAMA 2016;315:1624-45.

2. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162:276-86.

3. Sharifzadeh Y, Kao MC, Sturgeon JA, Rico TJ, Mackey S, Darnall BD. Pain Catastrophizing Moderates Relationships between Pain Intensity and Opioid Prescription: Nonlinear Sex Differences Revealed Using a Learning Health System. Anesthesiology 2017;127:136-46.

4. Smith JA, Fuino RL, Pesis-Katz I, Cai X, Powers B, Frazer M, Markman JD. Differences in opioid prescribing in low back pain patients with and without depression. PAIN Reports 2017;2:e606.

The Blame Game

A person with persistent pain will usually have a long and complicated story to accompany their pain. They often carry this story around like a big battered, heavy suitcase containing all of the crap and misery that has gone hand in hand with their pain since it started. As practitioners we will often notice that anger and blame are pretty quick to spill over from the baggage, smashing on the floor and blocking the way for recovery. It might be the careless driver who hit their car while checking their phone, kickstarting our patient’s journey with whiplash. The uncaring boss who never took their concerns about safety seriously and appears to be complicit in covering up the workplace incident.   The surgeon who “stuffed it up”.   The insurance company who denied the claim. The doctor who didn’t believe them. The list is endless and varied but the common theme is that whilst blame is often totally understandable in the circumstances, it is also unhelpful and can stop a patient from moving forward.



Why does it matter? Often the situations that are “to blame” are well and truly in the past – the people have moved on, may never have known they were “to blame” – but ultimately they don’t care! For the patient though, the power of that external blame can have a strong drive on how they view the world and ultimately view their pain. They can become so focused on the person or scenario they believe to be responsible, that they find it difficult to step over it and walk the road to recovery.

So if we recognize that blame is blocking the path, how do we address it? Often the blame can be a symptom of the fact that they feel that no one really cares or really believes their story, including all of the people who have come along subsequent to the blame. The antidote to this scenario can be simply to spend the time listening, fully getting an understanding of how things have come about. This takes time and it also takes some skill. If we can see that this listening component can be an integral part to getting better, we can start to dedicate it the time that it needs within the consult and also the training that we might need as a practitioner to get better at it. We can start to see this as an intervention in itself and place more importance on it.


Some of the key concepts that you might like to draw on to help this process are:

  • Allow the time in the first place. Recognise that examination, diagnosis and treatment don’t all have to be squashed into the first consult, especially for the distressed patient. Have longer initial consults, relax and allow the patient to spend the time they need to get the information that is important to them
  • Don’t interrupt too much. Trust that the bits that they will focus on are the bits that are important to them.
  • Demonstrate empathy. Practitioners can feel that this is artificial, uncomfortable or forced. You don’t need to cry with the patient for them to feel that you have got the gist of the ugly bits – simply rephrasing the key concepts to demonstrate that you have got it can do the trick. The odd “that sounds really upsetting” or “you are really brave to have gone through that and still be doing as well as you are” can also go a long way to showing you care.
  • Ask open ended questions – What makes you say that? What did you believe was going on at the time? Why do you think that is? Why is that?
  • Give body language cues to demonstrate that you are listening and you want them to continue- you probably don’t need to take notes at this point – you can summarise the important bits later. Face the patient, make eye contact and relax. Don’t freak out when they cry (and they will if you are doing a good job of creating a safe environment for them to talk). Simply pass them the box of tissues and carry on.



Once the patient has had a good chance to be heard, you will often find that a great deal of the work has been done. Addressing the blame can then be like a lock and key scenario to moving forward – The listening component acts like WD40 on a rusty lock. If a patient feels believed and heard, they have less of a reason to hang on so tightly to the blame.


One way to address it directly might be to follow the listening with some pain education. Depending on how you prefer to do this – formally, informally while treating the patient or drip feeding it through all conversations, ultimately one of the goals is to separate the sensation of pain from tissue damage. I also like to aim to help the patient change their focus from pain to function – having them use what they can or can’t do as their benchmarks for progress rather than their pain levels.


Having now got them on your side by demonstrating that you believe them, then helping them to reconceptualise pain in a way that is more helpful to recovery, the next bit might be to address the blame – especially if you feel that it is really driving the process. One of the ways that I find works is to say something along the lines of   “It sounds to me like you are still really angry with ………. – am I hearing that right?” If they are able to engage with these thoughts and they say that yes, they are, you might like to respond with something like this: “I can completely understand why you feel that way after everything that you have been through. It makes sense. In the past I have had people who have had really bad pain situations – a lot like yours, who have found that blame or anger has really held them back – that they were unable to focus on getting better because the blame was such a big deal. When they were able to let it go a bit, or at least recognize that it was unhelpful, they found they were able to focus on the future a bit more and on their progress. Once they did this, they found that things just fell into place a bit easier”  You could then just leave it to the patient to comment on that as idea, or you could ask an open ended question to see if they can engage with the concept.

If they “get it” , you can easily  go forward using an Acceptance and Commitment Therapy (ACT) approach. Whilst the blame is unhelpful, you don’t have to get rid of it in order to move forward. You can encourage the patient to acknowledge that the blaming thoughts are there again, allow them to be there without judging them or engaging with them and then let them go along their way. They will no doubt pop up again soon – these thinking processes become seriously engrained habits – so just repeat the process.

Over time, hopefully the patient can let go of the blame that keeps them in the past and engage more with the rehabilitation that looks towards the future.

A great resource to introduce these concepts to both practitioners and patients is this book:

There is also more information and an online course on the website

If you are interested in learning about how I use pain education in my clinical work, I am running small group seminars in Melbourne in the coming year – check the details on the website under the ‘upcoming seminars’ tab.

Classical Conditioning and Pain – A synopsis of the research done by Dr Tory Madden

In the second of two blog posts inspired by the Paincloud convention, I am going to attempt to describe some of the research produced by Dr Tory Madden, who finished her PhD with the BIM group in Adelaide, Australia.


Tory hails from Cape Town in South Africa, studied physiotherapy and worked as a physiotherapist for five years, including time in a rural South African region.  She decided to do a PhD and in creating a list of potential supervisors, she aimed high and placed Professor Lorimer Moseley at the top of the list.  Her strategy paid off and when she began negotiations to begin her PhD, she had to start with one small but important bit of research  – where on earth was Adelaide?  Her move to Australia was not a completely easy or smooth process as these round the globe transitions can sometimes be (I can attest to that!) and it was confounded by the fact that she had started dating a rather delightful fellow named Matthew just 6 weeks prior to the move!  To her mother’s delight, Tory was able to smash out her PhD in 3 years and return home to her man, who subsequently became her husband.  Back in South Africa she now works as a post doctoral research fellow at the University of Cape Town.

Tory’s research was on classical conditioning and was designed to test the idea that many clinicians hold to be true – that not only can pain occur in the absence of nociception, but it can be brought on by non noxious stimuli such as tactile stimulation or movement. The theory might be that these non noxious cues may have been frequently occurring at the same time as the nociceptive event in its initial phases.  When the initial event resolves and the tissue heals, but the pain has hung around despite there no longer being nociceptive input, is it possible that the non-noxious stimuli that were associated with the initial injury are triggering the pain? This pairing of non noxious and noxious stimuli could be seen as an example of classical conditioning.  My laypersons way of describing it would be to say – When “Thing 1”, which is non nociceptive, occurs at the same time as “Thing 2”, which is nociceptive and results in pain, “Thing 1” and “Thing 2” might be described as being paired together.  So if we remove “Thing 2” and just expose the person to “Thing 1” (which shouldn’t normally cause pain), we may be able to create a pain response.  The most famous example is commonly known as  ‘Pavlov’s dogs’ experiments.  There has been a fair amount of research into classical conditioning in relation to fear and this research has provided some effective evidence based ways for psychologists to help a person reduce fear and anxiety.  Additionally,  classical conditioning has been demonstrated to be involved in the maintenance of fear of pain (1).

In order to better understand what clinicians thought about this scenario, she started with a survey to determine just what people thought was going on and how well backed by research they thought this was.  She found that overwhelmingly clinicians did indeed think that pain can be a classically conditioned response to a non-noxious stimulus and that they believed this was backed by evidence (2).  She and the team then undertook a systematic review to establish what the literature said about evoking pain with a non-noxious but associated stimulus (allodynia) and about amplifying pain with an associated stimulus (hyperalgesia).  They found evidence to suggest that classical conditioning could amplify pain but not enough evidence to draw a conclusion about its role in the eliciting of pain (3).


Armed with this information, the team set out to design an experiment to see if they could pair a non- noxious stimulus, in this case a vibration sensation on the back, with a noxious stimulus – a thermal probe.  Their initial results showed that after a pairing process between the two stimuli, they were not able to elicit pain with the non- noxious stimulus (4).

At this point they went back to the drawing board and thought a bit more about the design process and with some tweaking, came up with a model that they thought would better be able to capture the effect of pairing the stimuli to see if they could create a classically conditioned response.  In this second round of testing they paired a vibration stimulus at one location with a painful laser stimulus, and a differently placed vibration stimulus with a non painful laser stimulus.  After the pairing process they used an “at threshold” laser stimulus – which was designed to be right on the border of pain – and they found that when they cued the participant with the vibration location that had been paired with the painful stimulus, the participant was more likely to report the laser to be painful, than when they cued them with the other vibration location.  Thus demonstrating that pain thresholds can be influenced by non-nociceptive sensory stimuli, via a classical conditioning effect (5). This is not quite the same thing as pain being elicited solely by a non-painful stimulus, because the participants still received an at-threshold test stimulus – but it’s a step in the right direction.

Phew…. tricky stuff isn’t it? So what does it mean?  Well, probably that the clinicians who answered her survey were onto something, despite there being a lack of evidence for their assertions.  Perhaps  associative learning in subacute pain can play a role in the transition to chronic pain in the absence of tissue damage? Understanding this better can help us to direct treatment of both early pain states and chronic pain.  This research also provides a foundation for future studies to look at patients with existing pain states, as it provides information about how a healthy nervous system behaves.

As well as her published academic papers, Tory has written some cracking blog posts on the BiM website – you should check them out.



Tory and I getting our selfie on at the Paincloudconvention

1. Meulders A, Vansteenwegen D, Vlaeyen JW. The acquisition of fear of movement-related pain and associative learning: A novel pain-relevant human fear conditioning paradigm. Pain 2011, Nov;152(11):2460-9.

2. Madden VJ, Moseley GL. Do clinicians think that pain can be a classically conditioned response to a non-noxious stimulus? Man Ther 2016, Apr;22:165-73.

3. Madden VJ, Harvie DS, Parker R, Jensen KB, Vlaeyen JW, Moseley GL, Stanton TR. Can pain or hyperalgesia be a classically conditioned response in humans? A systematic review and meta-analysis. Pain Med 2016, Jun;17(6):1094-111.

4. Madden VJ, Russek LN, Harvie DS, Vlaeyen JW, Moseley GL. Classical conditioning fails to elicit allodynia in an experimental study with healthy humans. Pain Med 2016, Sep 28.

5. Madden VJ, Bellan V, Russek LN, Camfferman D, Vlaeyen JW, Moseley GL. Pain by association? Experimental modulation of human pain thresholds using classical conditioning. J Pain 2016, Oct;17(10):1105-15.