What can we learn from anti-vaxxers? How to change a person’s mind.

Painiacs, like myself, can feel at times like the process of getting practitioners to reduce reliance on reductionist approaches and adopt (even slightly) a more biopsychosocial approach when dealing with patients, is a massive uphill battle.  The fact that you are reading this blog suggests that you are probably most of the way there – but how do we engage those practitioners who are most in need of the “paradigm shift” required for society to be able to approach pain with a better understanding of the evidence about pain?

Social media has become an incredibly powerful medium for information to be spread far and wide.  So whilst things might appear to us to be slow, you can imagine how much harder and slower it would be without the internet.  We are able to get our hands on far more content than ever before, share ideas, discuss approaches, debate opinions – put together these can help us to view different parameters of our practice in the light of an informed mind.

One of the problems with the internet is, our searching tends to confirm our own biases for the vast majority of the time.  Which if you are hoping to expand the depth of your knowledge on a particular topic can be very helpful – forums can help with different resources, and others opinions can help guide your discoveries.  But what happens if your initial inkilings about a subject lead you down a dangerous and ill informed path?

I am fascinated (and at the same time furiously frustrated) with Anti-vaxxers.  What makes a person so convinced that Big Pharma are out to get us despite every bit of evidence telling us that vaccines are overwhelmingly safe?  That the risk of exposing their child to a dangerous and preventable disease is a better option than vaccination?  I ask this very genuinely – I have no doubt that they are looking out for their child’s health.  My curiosity is surrounding how the situation comes about in the first place – because we know that once people strongly hold these views, getting them to change their mind is nearly impossible.  In fact, using techniques such as delivering information that demonstrates the lack of a link between vaccines and autism, or about the dangers of vaccine preventable diseases, can actually make people dig their heals in even more! ( See the article here)   (A subsequent study found that highlighting factual information about the dangers of diseases such as measles, particularly with the use of pictures and descriptions of children infected with the disease, had slightly better success).


In some ways it is understandable – there have been times in the past where government bodies have got it wrong in making recommendations for the public, and plenty of examples of where commercial interests play a big role in influencing public policy and recommendations even in the face of significant evidence that flies in the face of such recommendations – (see this fantastic podcast by Dr Norman Swan on the ABC Health Report reviewing  both commercial and pharmaceutical influences in the calcium and vitamin D public recommendations).  Perhaps hearing about these situations, the potential anti-vaxxer starts to see conspiracies everywhere and feels the need to seek “the hidden truth”.  Dr Patrick Stokes,  a senior lecturer in Philosophy at Deakin University eloquently  laid out how this can be taken one step further:

“Antivax belief may play on the basic human fears of hesitant parents but the specific contents of those beliefs don’t come out of nowhere. Much of it emerges from what sociologists have called the “cultic milieu” – a cultural space that trades in “forbidden” or “suppressed” knowledge. This milieu is held together by a common rejection of orthodoxy for the sake of rejecting orthodoxy. Believe whatever you want – so long as it’s not what the “mainstream” believes.

This sort of epistemic contrarianism might make you feel superior to the “sheeple”, the unawake masses too gullible, thick or corrupted to see what’s really going on. It might also introduce you to a network of like-minded people who can act as a buffer from criticism. But it’s also a betrayal of the social basis of knowledge – our radical epistemic interdependency” ( You can find whole article here)


So, I guess that goes some way to explain how educated (yes, sometimes even very educated), middle class people in affluent suburbs (as that is the most accurate demographic picture of the “conscientious objector”) come around to thinking that not vaccinating their children is the correct choice.  There is probably an element of the entitlement culture creeping into the issue too – “Why should I do something to help out everybody else?”.  Throw in the odd distressing Chinese whispered story about the kid whose autism kicked in right after the MMR needle and I can begin to see how it comes about.  It doesn’t make the situation any better though! (For those of you who don’t know, Australia has just introduced a ‘No Jab, No Play’ legislation change which is likely to vastly drop the number of conscientious objectors via financial disincentives.  You can read more about this topic  on this blog.

So what is the link to pain science?  It’s the digging in of the heels situation – knowing that once people have settled on an opinion that suits their understanding, fits with their biases and pays their bills, getting them to change their mind about their approach can be difficult.  Pushing too hard in the “wrong” direction can have the opposite effect to what we are hoping to achieve.  When formulating  a  message, it probably needs to be carefully worded so that it doesn’t throw the baby out with the bath water – you can keep your trigger points, dry needling, manipulation, ouchy tool massage, strict order based therapy protocols, pilates…….  whatever single modality floats your boat and pays the bills – you probably just need to frame that intervention accurately to the patient and use it as part of bigger picture approach that places a great deal of emphasis on working towards self efficacy.

Can we please stop blaming the doctor (at least some of the time)?

If person expects that a treatment is going to have a positive effect, it greatly increases the chance of that occurring – isn’t that an amazingly wonderful and slightly mysterious phenomenon? Studies that look at these interactions in clinical situations are plentiful and it is such a  well documented phenomenon that it almost seems not worth mentioning.  But it is amazing isn’t it?

When we are talking about interventions that are directed at pain conditions, particularly chronic pain conditions, it is relatively easy to understand why a proportion of a group of people in pain, will have a positive response to even placebo conditions.     A kind researcher or clinician may have taken the time to ask a lot of questions about them and their pain, giving them the impression that they care about their story.  They may have had to review their symptoms and function over a period of time with increased scrutiny and may find that they aren’t as disabled or in as much pain as they rated themselves as being at baseline.  They may decide that “this is the one” on their pain merry-go round of interventions, and choose to get a bit more active and take a slightly more positive approach to life at the same time as the trial.  Who knows?   Fascinating stuff!

What is even more fascinating is when we see our expectations having distinctly measurable physiological consequences.  I was prompted recently to re-read this fantastic article by Alia Crumb et al from 2011, called “Mind over Milkshakes”.  In the study they took 46 subjects and got them to consume a milkshake on two separate occasions.  On one of the occasions the milkshake was presented to them as an “Indulgent” shake, and was labelled as being high fat and high calorie.  On the other occasion, it was presented as a “Sensible” shake and labelled as being healthy, low fat and low calorie. In actuality, the shakes were identical.   They took before and after blood measurements, as well as asking participants to rate how full they felt after each shake.  After consuming the indulgent shake, steep decreases in ghrelin, a hormone responsible for regulating hunger, were seen in the blood measurements and the participants rated themselves as being very satisfied or full.  However, after consuming the healthy shake, a far smaller decline in ghrelin levels was seen and subjects rated themselves as far less full.  How amazing is that? Not only do our expectations change our perceptions of body sensations such as hunger, thirst or pain, but they also change our hormonal response.

Another article that has tickled my fancy in recent times is that by Ben Darlow et al, published this year in Spine, entitled “Easy to harm, hard to heal”.  A qualitative study, they interviewed 12 subjects with acute low back pain and 11 with chronic low back pain, about their understanding of their condition.  Overwhelmingly the themes that came across were those that indicated that the subjects viewed their back as being fragile, vulnerable, unlikely to heal and at risk of further injury.  The flow on from these misconceptions meant that people believed that they needed to rest, avoid activities that they considered dangerous such as lifting, and be vigilant about their posture.  The desire for a diagnosis or label for their pain was a common theme for both acute and chronic low back pain patients, as they felt it was important for management or preventing recurrence.  People strongly believed that the pain was representing damage in their back and that avoiding bringing on that pain was therefore important – a slippery slope to loss of function, disability and misery.

It is a fantastic paper and is well worth a read.  For clinicians, these themes are not surprising – we hear these thoughts expressed about back pain on a daily basis.  We tackle these misunderstandings with reassurance and education and pave a way out of the pain spiral with active rehabilitation approaches.  It is fairly obviously that these extremely commonly held beliefs are at least partly to blame for the transition from acute to chronic pain in many patients.  It begs the question, how do we stop this before it starts?  Medical and allied health professionals are gaining greater awareness and understanding of these themes and are altering their treatment approaches.  The push to reduce reliance on passive modalities, improve our communication skills to deliver education and reassurance, and reduce the use of imaging for cases of simple low back pain is well on its way to becoming established across professional boundaries.  Yet vast numbers of patients will demand that something be “done” for their back pain, and clinicians who are well aware of these principles are often pushed into referring for imaging, owing to demanding patients with unreasonable expectations. And so begins the pain merry-go round for those patients.

The push to create awareness of these issues among healthcare professionals is an obvious place to start and needs to continue for changes to be effectively made.  This study further tells us that a great deal of the patient’s misunderstandings about their condition may have come from influences from health professionals.  However, at some point we probably need to be addressing the beliefs held by society about this common, debilitating and costly health problem, which ultimately doesn’t need to be such a burden on our healthcare and welfare systems.  Public education campaigns in other areas of healthcare where misconceptions exist, such as those associated with the over-prescription of antibiotics, or reducing higher than average back surgery rates,  have had some, albeit small, effects on changing outcomes of the patient/clinician interaction and improving desired outcomes. Perhaps it’s time we turned the conversation around from focusing on the next big cure, breakthrough or development in chronic pain treatments, and started focusing on normalising the experience of back pain.


Guest Post: Carey Wheeler : What a Balinese taxi driver taught me about pain science…

By Carey Wheeler

A couple of years ago I was on a holiday with my family in Bali. On one of the days we went for a trip to the Bali Zoo and we asked our taxi driver if we could take the long way there by seeing some of the surrounding sights and sounds. Religion plays a very large role in daily life for the Balinese, and being the inquisitive type that I am, I was interested in learning about the different rituals and beliefs of this vibrant culture.

One thing of particular interest was how so many religions all got along so well in such a small part of the country. The metaphor that the driver used was perhaps the most succinct and intelligent answer I could ever imagine. Conveniently, it can also be used as a metaphor for physical therapy and pain science.

As we navigated the narrow streets of the outskirts of Seminyak, his story went something like this: “The Balinese people are very welcoming. We are very humble and understanding. For us, God is like this van. If you look at the van from that side (motioning to the left), all you can see is what you see from that side. If you look from the front, that’s all you see. Look from the top and the van looks different again. But you are always looking at the same van. The Balinese people understand this. We understand that even though we may be looking at religion from different angles, we are all celebrating God in our own way.” Wow!


This is not the first time that physical therapy has been likened to religion. The secular, isolated and reductionist models that pervade and divide the manual and exercise therapy worlds see us bickering between manipulative and non-manipulative therapies, between hands-off exercise based therapies and hands-on therapies. There is constant back and forth between the fascia fanatics and trigger pointers, the craniosacral pulsers and lymphatic drainers. The question has been asked before and needs to be asked again: How can they all be right?

When we are faced with a question like this, Occam’s Razor usually cuts to the point pretty well; “the simplest answer is usually correct”. The only way that all of these approaches can be correct is if the mechanisms by which they propose to have their effect are the same. Therefore the posturing, postulating and bickering is unnecessary and frivolous. The specifics and the details of each branch of physical and manual therapy are no longer contentious. We are all looking at the same van from a slightly different angle. Like the Balinese, we can actually all get along in this small world of ours. So rather than argue about what we can see from where we stand, we need to discuss what it is that we are actually looking at.

In physical therapies, the engine, chassis and interior of our van are built from the non-specific effects of what we do. Formerly known as the placebo effect, the non-specific effects of physical therapies include aspects such as expectation, conditioning, descending inhibition and, in some cases, diffuse noxious inhibitory control (1). All of these very real and very interactive mechanisms of physical therapy are at play with everything that we do. The likelihood of us finding more and more relevant non-specific effects is far greater than us chancing upon the elusive specific effects we have been searching so long for. Rather than debate which modality provides the strongest specific effect to a certain tissue we should discuss how we can maximise the role that the non-specific effects play in our interaction with our patients and clients.

The caveat here is that when we have enough evidence to show that a modality or an approach holds no clinical benefit beyond the non-specific effects,  we need to seriously consider the ethics of continuing to use that modality (i.e stop looking at the van from that angle). The retort, and one that I acknowledge is very valid, is that when interacting with patients it is the magnitude to which we can influence the non-specific effects of an intervention that will ultimately determine the effectiveness of that intervention (2). This means that we have to acknowledge the role of the patient’s beliefs and expectations in their outcomes, but to not let patient beliefs dictate an implausible or non-evidence based approach.

However, if we can all agree that the immediate and short term outcomes that our patient’s see are based largely on the non-specific effects of our interventions then we can also agree that it is what happens outside of the clinic that is most important to long term outcomes. Long term structural, psychological and social or behavioural change doesn’t occur in a single session or with two sessions per week for six weeks. We need to stop the bickering over beliefs, shake hands, and acknowledge that we all have the potential to have an effect on pain in the short term. Then we can sit down together and help each other to ask better questions.

What biopsychosocial factors have led this person to be here today? What can I do to give this patient the power they need to make the changes that are necessary for long term change? How can I best communicate this information to this patient to make sure they understand what it is we are actually trying to change? Who else in their circle of influence needs to understand this so they can be the best support for this patient? The questions go on and on but they are infinitely more meaningful than asking from what angle does the van look the best!

1) Bialosky.JE, Bishop.MD, George.SZ, Robinson.ME, 2011, Journal of Manual and Manipulative Therapy, ‘Placebo response to manual therapy: something out of nothing?’, Vol.19, Iss.1, pp.11-19

2) Kalauokalani. D, Cherkin. DC, Sherman. KJ, Koepsell.TD, Deyo.RA, 2001, Spine, ‘Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects’, Vol.26, Iss.13, pp.1418-1424



Carey Wheeler is a Clinical Myotherapist (BHSc) and has been in private practice for 5 years. He lives and works in Geelong, Australia.   Carey’s clinical approach has always been movement based with a strong focus towards active therapy which developed from a background in strength and conditioning as a personal trainer. One of his main practice goals is to help patients bridge the gap between rehab and training.  www.baycityspinalsports.com.au

Pain in children – what role do parents play?

Here we go again – yet another article about how parents are doing things wrong!  Everywhere a parent chooses to look, someone is telling them that they are doing things wrong – too much gluten, screen time, sugar, sun, not enough sun, outdoor play,…..  Mention breastfeeding, co-sleeping or sleep training and social media has a meltdown!  So, in an effort to stay away from parent bashing, I am going to stick fairly close to the science and have a look at the literature around pain in kids, and how their parents play a role in reducing or enhancing that pain experience for their offspring.

It is fairly well understood in the pain community that there is an association between catastrophising (essentially, dwelling on the worst case scenario) and pain related disability (Linton & Vlaeyen, 2012).   The theory goes that worrying excessively about our pain or condition makes us less likely to attempt to do things that might make that pain any worse, and subsequently we avoid things.  These means that over time we lose function and become less able to do the things that are important to us.  The literature also paints us a fairly clear picture about the idea that this tendency to dwell on the worst possible outcomes is a trait that can be passed down to our children.  Families can tend to adopt specific ways of thinking about pain, which can ultimately be very unhelpful (Kralkevic, Banozic, Maric, Cosic, Sapunar et al, 2012; Wilson, Moss, Palermo, 2014).  Following on from this, it can also be shown that children who have a parent with chronic pain, are far more likely to develop chronic pain themselves, sometimes even pain that is similar to their parent (Umberger, 2013).


These are pretty important findings and ones that we should be paying attention to as a society.  Chronic pain is costly, and prevention is always going to be the best way to go.  Government bodies are starting to pay attention to this interaction between parents, children and pain and are taking action.  Knowing that early exposure to painful procedures and the subsequent distress, tends to “prime” a child’s nervous system and make them more sensitive to painful procedures in the future, (Taddio, Katz, Ilersich, & Koren, 1997), and also armed with a growing body of research to suggest that distraction during procedures such as vaccination and venipuncture are effective measures to reduce pain and distress in the infant (Chambers, Taddio, Uman, McMurtry, HELPinKIDS Team, 2009), initiatives such as the “It Doesn’t Have to Hurt”  campaign https://www.painbc.ca/news/it-doesnt-have-hurt-campaign are popping up, and will hopefully draw increasing public attention.


So how does the research help us when dealing with pain in our kids?  Firstly, modelling is incredibly important.  A study done by Goodman and McGrath in 2002 showed that kids exposed to their mum undergoing a painful experience (cold pressor task), where the mums were asked to either maximize or minimise their pain response, were compared to a control group given no instructions.  They found that kids who had seen their mum “carrying on” about the experience tended to demonstrate  a significantly lower pain threshold, when they were subsequently given the cold pressor test.  Conversely, kids who had watched their mum minimise her pain, were found to display much lower expressions of pain during their testing.  Kids are like sponges and the things that we do and say about pain experiences directly shape their own understanding about pain.

Parental protectiveness and parental pain catastrophising also can have a big impact on how children function.  For kids, one of the best ways to measure function is school attendance.  A study by Logan et al in 2012 showed that parental pain catastrophising and parental protective responses to child pain,  both independently predicted child school absences.  This tells us again, that kids take their cues from parents, and that in making the decision to take the day off school, parental anxiety plays a big role.



So can we put it all together to provide some evidence based guidance about dealing with pain in kids?  Hell no!  I wouldn’t dare start telling you how to parent  your kids!  However, I can tell you how I try to use these ideas in dealing with my own kid’s ouchies.

  • Validation – recognise the situation, demonstrate some empathy. “Ouch – that hurt, are you ok?”
  • Reassurance – if you are Ok with the situation, they are likely to be Ok with it. “Let me have a look – Oh, yes that would have hurt.  It looks Ok though and I’m pretty sure you will be fine”
  • Apply placebo procedures as required (if ever placebo has an important role, here is your chance!) “Here let me kiss it better”* and if the big interventions are required “do you think a dinosaur bandaid would help?”
  • Distraction – change the subject as quickly as is practical “Look, the kids are waiting for you on the tyre swing, do you want me to take you over there?”


As clinicians we need to be aware when assessing children in pain, that parental anxiety and family traits will play heavily into the situation.  As in any pain situation, reassurance is extremely important and in some instances, your time and attention may need to be more on the parent,  than the child in pain.  Equally, being aware of these factors, you may decide that parental anxiety is playing such a large role in a child’s pain experience that it needs to be addressed in order for the child to get better functional outcomes.  This is a delicate situation and how you address it as a clinician is probably best navigated according to the specifics of the circumstances.   A referral to a psychologist might ultimately be needed, however you may be able to address some of the issues with the parents using an educational approach.


* Placebo kisses are not routinely applied in our household for any bottom or tongue related injuries

Chambers, C., Taddio, A., Uman, L., McMurtry, C., HELPinKDS Team. (2009).  Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clinical Therapy, 31, Suppl 2, S77-S103.


Goodman, J., & McGrath, P. (2003). Mother’s modeling influences children’s pain during a cold pressor task. Pain, 104(3), 559-565.

Kraljevic, S., Banozic, A., Maric, A., Cosic, A., Sapunar, D., & Puljak, L.  (2012).  Parents’ pain catastrophizing is related to pain catastrophizing of their adult children.  International Journal of Behavioural Medicine, 19(1), 115-119.


Linton, S., & Vlaeyen, J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on.  Pain, 153(6), 1144-1147.


Logan, D., Simons, L., & Carpino, E. (2012).  Too sick for school? Parent influences on school functioning among children with chronic pain.  Pain, 153(2), 437-443.

Taddio, A., Katz, J., Illersich, A., & Koren, G. (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination.  Lancet, 349(9052):599-603.


Umberger, W. (2013). Children of parents with chronic noncancer pain: A comprehensive review of the literature.  Journal of Child Adolescent Psychiatric Nursing, Oct 14, doi: 10.1111/jcap.12055. [Epub ahead of print]


Wilson, A.,  Moss, A., Palermo, T., & Fales, J. (2014). Parent pain and catastrophizing are associated with pain, somatic symptoms and pain-related disability among early adolescents.  Journal of Pediatric Psychology, 39(4), 418-426


How Gurus create disillusionment and despair

Picture this:

A recently graduated manual therapist feels a little frustrated after a busy week seeing patients – some of them aren’t getting better like she had hoped.  Or, they do really well initially, boost her day with praise and adoration, and then the following two weeks they haven’t maintained the initial changes, and are disappointed, hinting that she has done something different in the second two treatments that haven’t worked as well as that magical first treatment.  She beats herself up, worrying that her techniques are not up to scratch.

A professional development course run by a fellow manual therapist comes to town, scheduled for the following week.  It promises a new and fantastic approach to treating a classically recalcitrant condition – one that doesn’t respond well to manual therapy in either the literature or the clinic.  Despite it being drilled into her at university – “don’t believe any claims without asking for the evidence”, she thinks this could part of the solution for her current slump – perhaps I just need to learn how to do it right.

She rocks up to the course, excited to see what magical wonders are going to be taught.  The Guru rises and speaks of the many, many patients he (lets be honest, they are mostly blokes!)  has cured with his patented technique.


Case study after case study, miracle after miracle.  He shows his eager audience the magic – be careful, you need to do it exactly this way, or it just doesn’t work.  Not feeling it?  Do less. You need to do it in the correct order or………, your hands need to be exactly here not there,  you must do it x number of times or hold for exactly x number of seconds……..

Inspired and excited, she goes back to work, and lo and behold on the Monday, in walks a patient with exactly that condition.  Brilliant, she thinks and gets to work, her workshop notes hiding in the top drawer of the desk.  Technique delivered as per the recipe  – job done.  Unfortunately for everyone involved though, the patient does not get better, even with repeated treatments following the exact described protocol.  The patient is devastated – this is their fourth failed treatment and they had really felt positive this time – after all, the practitioner was so confident and enthused that she could make a difference. As for the practitioner, disillusionment is settling in hard and fast.  Underpinning it all is a thought that keeps rearing its ugly head – “I am just not good at the techniques”.

What this poor disillusioned young lass has missed as she plummets head first into her first career crisis are a few key issues:

  • If it sounds too good to be true, it probably is!
  • If the literature has repeatedly demonstrated than manual therapy is not an answer for this condition – run very fast in the opposite direction
  • While he may have helped many patients to get a good outcome, he failed to present all the cases where things didn’t go so well.
    • The ones that cancelled their appointment because the treatment wasn’t working and they couldn’t be bothered paying to go back and tell him that. He is unlikely to ever know that this is what happened because he doesn’t have the time or need to call the patient to follow up – he is busy enough in clinic so doesn’t need the patient to return, and the administrative tasks he needs to complete each night are a much higher priority. Even if he did get the chance to call the patient, it is possible that they may not tell him the truth – upsetting a charismatic practitioner by telling them that they haven’t helped feels a bit icky – better not to say anything
    • The ones who weren’t getting better, but did come back in – and look at him with sad puppy dog eyes, confused as to why they aren’t getting better as he said they would. He is likely to refer them on to someone else if they are persistent enough and hang around – nobody likes to feel that uncomfortable!
    • The ones who claim they feel better, swept up in the practitioner’s enthusiasm and repeated claims that things are feeling or looking better in their opinion, despite the fact that they have no functional improvement. Let not take any objective measurements in these cases – why spoil a good story?
    • The ones that were spontaneously resolving or healing on their own anyway – who doesn’t want to take credit for that and who is definitively going to know?

Pain science is continuing to paint us a very clear picture about the management of chronic pain conditions – any single modality approach is unlikely to be the answer the patient is looking for, especially if that answer is a complete cure.  Pain is complex – there are lots of factors that come together to cause the brain to create pain as an output.  The tissue factors are just one of those factors and therefore solely directing our efforts towards “fixing” those tissues is going to be an exercise in futility more often than not, particularly in the chronic pain setting.

In an ideal world, the practitioner might have spent time with the patient validating their pain experience and previous failed treatments, gaining an understanding of what they believed was wrong with them, helping them to set expectations and educating them about the neurophysiology of pain.  She could easily then have delivered the treatment protocol as part of her bigger picture approach – after all, there is plenty of evidence to say that therapeutic touch can be helpful…… just not on its own!  She then might have spent time setting out some active management strategies and giving plenty of reassurance.  If both practitioner and the patient have a better focus on how they define success, they are more likely to be happy with the progression of the therapy process – and our practitioner might last a few more years in practice!

Got a favourite guru story?  Tell us in the comments on the facebook page.  Might be best to keep identities out of it though…..

Midwives, labour, birth and pain science




Midwives are amazing creatures.  Long before the advent of pain scientists, midwives have known a thing or two about pain:

  • Fear about childbirth will increase the pain experienced
  • A lack of knowledge will enhance fear
  • Fear and anxiety can interfere with our body’s ability to function at its best
  • People’s experience of the same painful stimulus varies incredibly across a population and is influenced by many factors

Similarly, long before the Moseley’s, Louw and  Butlers  of the pain world starting banging on about pain education, midwives knew that if a pregnant woman had a good understanding of the physiological processes that were going on in her body during pregnancy and labour, she was less likely to be distressed and anxious about these processes (aka-bringing a baby into the world!).    Like in chronic musculoskeletal pain1, education and reassurance prior to childbirth has been shown to deliver significantly better clinical outcomes, in terms of reductions in interventions and mental health outcomes2,3 .

In some pockets of the community internet (and Northcote), there is a sense that natural, drug free childbirth is a reflection of a mother’s mother-liness (is there such a word?) and that if she had to have a caesarian section, she just wasn’t trying hard enough/allowed those wretched doctors to violate her/  didn’t read the right books or do the right course.  They can also convey the idea that not achieving (or aiming for) natural birth will mean a lack of bonding between mother and child or blah blah blah bollocks.   There probably exists an argument on the other side of the fence that our caesarian rates are too high compared to the WHO recommended 10% and that we could be putting more attention on reducing the rates to a level that balances safety for mum and bub against the cost and complications that potentially accompany a surgical birth.

So, in honour of my beautiful sister-in-law who is about to give birth to my niece or nephew, I have penned a few thoughts about childbirth ….. and pain:

  • Be careful whose advice you take… including mine! Childbirth is one of the most emotional experiences you will ever go through.  It is rare for a woman to experience it and for it not to leave some kind of mark (not talking about stretch marks or episiotomy scars!)  The emotional toll following childbirth, even in the “best” ones, can feel a little like PTSD (or a lot like PTSD in some cases).  People will want to tell you their story, which is a natural reaction to such a big emotional event, and is an often an important debrief for them.  They might want you to do things the way they did…. Or not do things the way they did.  Then next woman might give you the complete opposite advice.  Keep that in mind whilst politely listening to their stories.  Remember that the horror stories will perpetuate much more so than the cruisy birth stories      (Bad news sells much better than good news – ask any journalist!). Hearing these horror stories can contribute to your fear levels, even if only subconsciously.


  • A little bit of knowledge goes a long way. Take your advice from someone you trust and who hopefully will be caring for you during the birth process.  As I mentioned above, having a good understanding of the process is helpful to normalise the sensations  that you will experience.  The idea is hopefully that during the labour you can experience a level of acceptance of the process, rather than fighting the sensations and this will allow the labour to progress.  As in other elements of healthcare, the rapport you have with your caregivers has an important effect on the clinical outcomes.


  • Have realistic expectations. They call it labour for a reason – it is unlikely to be a walk in the park.  On the other hand, if things go pear shaped, and interventions are needed, don’t get yourself in a twist worrying that things didn’t go to plan.  Be grateful that we live in a country that offers safe and clean hospitals and well trained medical staff that can help you if you need it.  A healthy and safe mum and bub have to be the first priority.


  • Breathing is powerful. As in any other event where pain might be present, deep breathing and other relaxation techniques can be an effective tool with no risks or side effects.  The evidence, although not particularly comprehensive on the subject, suggests that relaxation techniques can help reduce the incidence of instrumental delivery4. Deep breathing helps to engage the parasympathetic nervous system, which can help initiate the body’s own pain modulation.  Most protocols suggest practising the techniques in the weeks leading up to delivery.


  • Set up your support team well.  Let them know your thoughts and values around delivering your baby and trust that during the process they can advocate for you well, so you can focus on…. other things… probably breathing.  Arm your supporters with the same reassuring education material – they can help normalise things for you, when things feel anything but normal.  This will help keep the fear out of the process.


  • Try a TENS machine and heat packs, especially in early labour. It’s pain science in action!  You can often hire the TENS units so that you don’t have to buy them.  For the heat packs, it can be helpful to have a few on the go so that you can rotate them for re-heating.


  • Those in science and healthcare have a solid understanding of the “shit happens principle”. It can be helpful to get on board with this one.  It says that sometimes, despite doing all the right things, they don’t always go as intended.  So whilst the stats might say that doing your relaxation and breathing, staying active during labor and educating yourself will improve your chances of a vaginal delivery, they don’t speak for the individual….. and hence, shit happens.  Sometimes we just can’t be in control of everything and it is best to go with the flow.  Trust that your caregivers are making the decisions in yours and your baby’s best interests.


I could go on….. but instead, let me tell you about the birth of MY first child………….

  1. Mosely, L., Nicholas, M., & Hodges, P. (2004).  A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clincal Journal of Pain.  20( 5),324-332
  2. Johnson R, Slade P. (2002). Does fear of childbirth during pregnancy predict emergency caesarean section?  British Journal of Obstetrics and Gynaecology, 109(11):1213– 1221.
  3. Toohil, J., Fenwick, J., Gamble, J., Creedy, D., Buist, A., Turkstra, E., & Ryding, E. (2014). A randomized controlled trial of a psycho-education intervention by midwives in reducing childbirth fear in pregnant women. Birth, 41(12), 384- 395.
  4. Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., Jordan, S., Lavender, T., & Neilson, J. (2012). Cochrane Database Systematic Review, Mar 14;3:CD009234. doi: 10.1002/14651858.CD009234.pub2. Review.

Career Crisis?

Hands up who has stuck their nose into pain science, or just science in general, adopted some new ways of approaching patient care and got better outcomes?  Hands up, who has then poked their nose back into their profession’s water cooler discussions, be it at a conference, internet discussion forums or the actual water cooler itself, and found themselves despairing, pulling their hair out and declaring I CAN’T DO THIS ANYMORE – I NEED A CAREER CHANGE!!! ??

Over this last week I have had discussions with three colleagues who have approached me about wanting to make a career change out of their respective manual therapy industry.  They have approached me seeking some guidance into what might be possible, affordable, fulfilling career options to take sidesteps from their current careers. The recurrent undertones of discontent seem to follow these broad themes:

  • People in my profession aren’t keeping up with what is going on, in fact there seems to be pushback against any movement forward – It’ s like they WANT to keep us in the dark ages/on the fringe
  • The way that the practice that I work in is structured is designed to keep people sick/broken/in pain/fearful/coming back and I can’t seem to fight against these commercially driven factors to change things
  • My colleagues talk about change or keeping up to date but the other day I overheard him/her telling a patient that “once we get the MRI (for their non specific low back pain) then we can make a plan”.
  • I practice using a current understanding of pain, yet these “gurus” spouting reductionist nonsense often represent our profession to the public and the medical profession. They end up representing me and its not fair!
  • I am stuck in a rut and can’t seem to get my longer term patients to move to a more active management approach – it drives me crazy

I feel like I have been having these conversations almost weekly for a year – and I am no closer to coming up with answers for people regarding a tidy solution.  So, despite admitting to not having the answers, these are some of the suggestions that I have made to various people along the way.

  • Remember that the grass is always greener on the other side. Many people in the other careers that you might aspire to switch over to, have very similar issues and frustrations, sometimes they are exactly the same, sometimes slightly different.


  • Is switching to a different profession (within allied health/manual therapy) going to allow you to practice in such a different way as to dramatically improve your personal job satisfaction? Is the loss of income, costs of retraining and setting up going to be worth it?  If it is, then go for it…. But make sure you have thought it through really carefully. Remember that education is a massive industry these days, and it is buyer beware in terms of whether you will get a job at the end of a masters degree or other course.  Universities are more than happy to take your money and enroll you in a program with little or no reference to whether the industry can support all the extra grads.


  • Instead of focusing on what other people in your industry are doing or saying – just do your job really, really well. Focus on each patient as an individual and try to apply the best approach that you think will help that person, with reference to what the science tells you, but also with reference to your experience. Remember that the changes you can help a person to make in their life can be phenomenal.  The reality of improvements on functional testing or a pain catastrophising scale that we might judge our clinical success by, play out for the patient as things like getting back to work, playing with kids, getting back to the sport or gardening that they love.  That is a massive impact!  It is easy to get wrapped up in prestige, hierarchies and reputations of a profession, (especially in the presence of gurus) and forget that within each of those industries, there are great practitioners and crap practitioners.  Is the label that important? Does it change how you can deliver your service?  Can you slightly change your model of delivery and still stay well within your scope of practice?


  • Take stock of where you are at personally – have you had a holiday recently? Are you regularly engaging in conferences, seminars  or professional meeting to keep you motivated and in the zone? Are you working too many hours? Dealing with patients, especially ones in pain is draining in full time mode. Can you switch to part time or diversify your practice to break things up?  At a low ebb you will find yourself wanting to bail out much more readily. photo-Vietnam-beach-holidays-pics-hh_dp4270659


  • Can you refer those long term, dependent patients who are still stuck in passive mode, and haven’t made the progression to an active approach in line with your own changes, to someone else? It’s really hard to change the nature of that relationship once it has been established.  The effect they have on your mood, and that fact that you are probably not helping them much might mean that the kindest thing you can do for them is suggest that they “start fresh”  with a colleague who can show them a new way forward.  (Make sure you know that whoever you are referring to has a good grasp of a biopsychosocial approach!)


  • Pursue the stuff that you love outside of work. Remember that work is only part of your life and no career is going to give you complete and utter life satisfaction.


  • Stay off the idiot forums!! If that is your exposure to the nonsense that upsets you, just don’t go there, at least for a while.  Stick to discussions with like minded people  and hang out with people who you think can balance things well.


Over a series of weeks I will be interviewing some smart pain people, to hear about how they approach a fictional patient with hip osteoarthritis, who is convinced she needs a hip replacement.  The interviews go for 20 minutes – perfect for the commute or a procrastination session.

Interview #1 Dr Samuel Whittle

Interview #2 Dr Drew Slimmon

Things are changing… just not fast enough.

I hang out with some pretty clever people.  I read a lot of blogs and articles  written by practitioners and therapists with an evidence based bias.  I teach and engage with people who affirm to me that things are changing, practitioners are paying attention and institutions are taking on board newer ways to teach and conceptualise our roles in manual and exercise therapy as being aligned with what the evidence tells us.

……. and then…. a work colleague of a close relative of mine, a lady that I know and have a great deal of respect for, hurt her neck a couple of weeks ago.  She slept funny on a different pillow and her neck was stiff for several days.  Following that she started to develop a headache – it was a busy time at work and there were some stressful things going on at home for her.  Sick of the pain and not sure where to turn, she mentioned it to her work colleagues at lunch and was directed to a practitioner up the road.  He took x-rays of her whole back (at her expense), told her that her neck curve was “almost backwards” it was so flat, she had a scoliosis and that she would need 10 weeks of manipulative treatment twice a week.


She went along with the whole treatment plan, including buying into the “my x-rays were so bad” and the “I have a scoliosis” thing.

This was happening in my neighborhood, to someone I knew and cared about.

…..and then….  another relative hurt their back and asked if I could see them.  I was in the middle of moving overseas and was flat out, so suggested that she see a practitioner she had previously seen and gotten on well with.  She is fit, healthy, young, employed and sensible.  This is the third episode of low back pain she has had in about a year and there was no radiation, leg pain  or other symptoms that might have pointed towards disc involvement.  The practitioner treated her with some manual therapy which gave good relief – she was able to get back to work, but then told her that if it didn’t get better after three treatments, she would need to get and MRI to “check out the discs”.

Groan and double groan.

It makes me so mad to hear this stuff, more potently when it happens to people that we know and love – we know that it goes on every day, and it is what drives those of us trying to bring about change to persist.  But sometimes it just seems so hard!! How do we connect with the x-ray practitioner to show him that he is potentially doing more harm than good before he has even touched the patient? How can we trust that there is not another generation of these practitioners being generated as we speak?   How do we get the MRI practitioner to understand that by handing that referral slip to my relative, she is setting her up for fear and unreasonable expectations and a likely poorer outcome?

Both of these practitioners are fairly young (I am 36, and am definitely young, if that helps to give you an idea of how I am making that call)  and both are bound by their national registration bodies to do CPD on a two year cycle.  The intention of this is obviously to try to keep practitioners up to date with changes in their field.   The problem seems to be, that the interpretation of what constitutes acceptable CPD is incredibly vague and some practitioners ride the waves of “woo courses”, business or marketing type courses and other nonsense that fills their quota, year after year – completely defeating the purpose.  Do we mandate what people need to cover in their CPD cycles, (more than the existing compulsory components which often tend to focus on safety, privacy and other compliance issues)? Do we tighten the rules on what we consider to be acceptable CPD with a reasonable evidence base?  I can’t see it happening in the near future – I can imagine the uproar!

Times are certainly changing and there is movement and momentum.  The most obvious place to be focusing our efforts are at an undergraduate level, and within my profession there are some affirming and exciting changes occurring in our teaching institutions that lead me to feel a lot more optimistic.  In the meantime, for the sake of my sanity, I am going to stick with reading my sensible folk blogs and stay off the stupidity forums – that way I can maintain my own momentum!

Hypervigilance – Why is it a “thing” in persisting pain?

Hypervigilance can play a massive role in the development of chronic pain.

 It occurs when we choose to focus on something in the body, for example an ache or pain, asymmetry, discomfort or other symptom, and continue to revisit the sensations in the area, on what we might consider to be a pathological or unhelpful number of times during the day.  Usually, there tends to be some meaning attached to the sensations.  In the event that these meanings attach a sense of worry, danger or fear to the sensations, then we have the potential for a problem.

At a neurological level, when we constantly use a particular set of neural pathways, they become stronger and more efficient at working in that order.  In effect, the connections become so strong and practiced that it becomes a lot more automatic and takes less effort for the brain to use those particular connections.  This is helpful for us when we are learning skills, as once we master them they can seem effortless.  When this occurs in hypervigilance, it can create a scenario where the pathways to “check in” on that area, wire together with the worries and fears around those sensations.  Over time, they can become extremely proficient – essentially, the brain can rewire itself so that there is very frequent attention on a body component and an accompanying worrysome thought that goes with it.  You can imagine how this can become all encompassing for a person in pain.

An example of this might be the tennis player who hurts their shoulder.

Whilst their pain might be mild, there is likely to be a fair bit of fear attached to the sensation, particularly if the person is concerned that it might stop them from playing the sport that they love.  This is a very normal scenario and as clinicians, we will see this every day.  For some people though, particularly when they haven’t received adequate reassurance about their condition or have sought inappropriate information (Google doctor anyone?) this normal scenario can snowball into a problem.

The research tells us that hypervigilance is a major factor in conditions such as fibromyalgia, chronic low back pain and irritable bowel syndrome.  It tends also to go hand in hand with catastrophic thinking.( 1,2.) From here, the pathway to a deconditioning cycle is an obvious one- for our tennis player with a four month history of a grumpy shoulder it might look something like this:

  • My shoulder is worse today than normal
  • I did some weight bearing and overhead work at the gym yesterday
  • It must have aggravated my shoulder
  • I can’t do anything overhead because it makes my shoulder worse (and I won’t be able to play tennis again) NEW RULE

What the person might have missed though in making these assumptions or rules, is that they had done exactly the same workout the last few weeks with no problems.  This increase in pain may have nothing to do with the workout – at four months the pain is beginning to behave a little bit more like chronic pain – it can tend to have a less defined pattern, the pain can be more widespread and tell less of a picture of what is going on at the level of the tissue.  The increase in pain may have had nothing to do with the overhead components of the workout, and these are likely to be important for recovery.

This is not to deny that biomechanics will be playing a role in this instance.  Addressing the biomechanical components in a case like this is crucial and will be important for recovery – like most things though, it would be much better if this part was managed by a health profession who could better assess these factors, rather than the patient making the assumptions themselves or with the help of Google doctor!

So how do we help?

  • To see if this hypervigilance scenario is at play, look for the accompanying catastrophising thoughts – they will be there! Ask open ended questions that can walk the patient down the path to access those thoughts.  Together you can then debunk the rules and thoughts that don’t fit well with the actual scenario.
  • Set out your diagnosis and management plan so that there is a level of reassurance. Then keep reassuring throughout.  If there is less fear associated with the sensation, there is less of a need to keep checking in on it.
  • Help the patient to feel a bit more in control of their situation by encouraging active approaches. Having that reassuring sense of self proficiency provides an alternative neural pathway that they might be able to access, rather than defaulting to the dark side of worry and hypervigilance.


Posserud, L., Svedlund, J., Wallin, j., & Simren,m.  (2009). Hypervigilance in irritable bowel syndrome compared with organic gastrointestinal disease.  Journal of Psychosomatic Research, 66 (5), 399-405.

Crombex, G., Eccleston, C., Vanden Broeck, A., Goubert, L., & Van Houdenhove, B. (2004). Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain.  Clinical Journal of Pain, 20(2), 98-102.

About The Author

Alison Sim has a keen interest in educating health professionals about the latest science surrounding pain, especially pain that hangs around – chronic or persisting pain.

Alison qualified as an osteopath in 2001. She has a Masters of Pain Management from Sydney University Medical School and Royal North Shore Pain Management Research Institute. She has lectured at Australian Catholic University, Victoria University, RMIT and George Fox University  in a variety of science and clinical subjects. She has also worked as part of the teaching team at Deakin University Medical School and is currently based in Melbourne, Australia.