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00:00:01
Pain Is Not In Your Brain And It's Not In Your Tissues - So Where Is It? | Dr Mervyn Travers (PhD)
151 Plays1 month ago
If you've been told your pain is "all in your head" or that it's purely a problem with structures in your body - this episode will challenge both of those ideas.
Dr Merv Travers is a physiotherapist, PhD researcher and strength & conditioning coach based in Perth, Western Australia. He's a Senior Research Scholar at the University of Notre Dame Australia, working in the areas of low back pain, tendon pain, and exercise rehabilitation.
In this conversation, Merv explains why pain belongs to the whole person - not just the brain and not just the body. He breaks down active inference and predictive processing in plain language, shares a story of a professional athlete he treated for Achilles pain and makes a compelling case for why the RESOLVE trial may be the most important musculoskeletal pain trial we've ever had.
We also explore the common threads between some of the best research that has been done on persistent pain - Cognitive Functional Therapy, Pain Reprocessing Therapy and Graded Sensorimotor Retraining - and why Merv believes the active inference framework ties them all together.
Whether you're a clinician looking for a better way to treat persistent pain or someone living with pain who's been told nothing else can be done - this episode offers real hope backed by real science.
RESOURCES:
- Try Pain Coach for free
- RESOLVE Trial (Bagg et al., JAMA 2022)
- The Fit for Purpose Model (Wand et al., Physical Therapy 2022)
- Recognise App (for laterality training)
- Dr Merv Travers / Optimise Rehab
KEY TOPICS
00:00 — Teaser & Introduction
01:05 — Merv's Mission: Helping Clinicians Help Patients
02:44 — How Do You Understand Pain?
04:13 — Predictive Processing Explained Simply
08:00 — The Teacher Who Said "Your Back Never Heals"
09:50 — Beyond Predictive Processing: Active Inference
12:02 — Pain Equals Body Damage x Nervous System Threat?
14:19 — The Wine Experiment: How Expectations Shape Experience
18:02 — Why Every Person's Pain Is Unique
21:48 — Treating Athletes: The Culture of Structural Thinking
23:28 — The Achilles Story: "I Don't Know What I'm Going to Do"
24:56 — Sensory Acuity Testing: "Foot Fetish Tinder"
27:07 — The RESOLVE Trial: The Most Important Pain Trial We've Had
30:21 — Why The Trial's Rigour Matters
31:40 — CFT, Pain Reprocessing Therapy & What's Coming Next
33:58 — The Common Threads Across All Three Treatments
37:07 — Get To Know Your Patient (Pain Coach Ad)
37:33 — Movement Experimentation & Modifying Symptoms
44:05 — Manual Therapy Isn't Excluded From This Framework
48:56 — The Fit For Purpose Model: Three Pillars
51:07 — Self-Evidencing Through Movement
54:19 — The Placebo Effect Is Not A Dirty Word
58:55 — A Universal Truth For Someone In Pain
01:01:21 — Where To Find Merv Travers
Recommended
Transcript
Rethinking Pain Beyond Tissue Damage
00:00:00
Speaker
Based on this idea that pain is about more than just the tissues, there's hope because we have new treatments. I'm not sitting here waiting for sensory information from the world. I'm constantly making predictions. And what happens to lot of people is they have evidence daily in in the way they move and the experience of pain they have and everything they've been told and the scans they've seen that you're not fit for but purpose. You're not capable. Your body's broken. It will never get better.
00:00:27
Speaker
This podcast is not personalised medical advice. Consult a health professional before acting on anything discussed. Just give me 30 seconds before we start. Whether you're a clinician, wanting better outcomes for your patients, someone living with chronic pain, or supporting someone who is, thank you for being a loyal listener.
00:00:47
Speaker
Most regular listeners haven't hit follow yet. If that's you, please tap it now. It tells the algorithm to show this to more people it can help. And that's the single biggest thing you can do to help me and my guests on our mission to create a world with a little less pain.
Merv's Mission to Transform Pain Understanding
00:01:05
Speaker
Merv, what's been your mission over the last, say, 10, 15 years? Oh, wow. So, look, I spent a great deal of my time trying to...
00:01:16
Speaker
help understand pain and what drives it, what we can do about it ah With the lens on kind of two things, one, you know, ultimately, you know, help patients. So, you know, if people walk through the door and they've been in pain, you know, for a long time and you know it's really affecting their lives. like How can we help me help that in some way? um and then also, you know my involvement in being involved in education is also helping clinicians
00:01:47
Speaker
do that better. And so I've felt for a long time that I'm extraordinarily fortunate in the in the company I've got to keep. I've got to knock on doors of very clever people, fully expecting them to slam the door in my face and say, go away. But they've been very generous with their time and ideas and things. So I've got to learn lots of things that I hope are useful. And so I feel like I can help more patients by helping clinicians help their patients than I could ever see on my own. so that's really what I what i do Yeah, that's that's awesome. And hopefully we'll we'll learn a little bit more about that down the track. I think this is probably going to dive deep philosophical based off my listening of your conversation with Jared Power on the the Shoulder Physio podcast.
00:02:32
Speaker
And then i want to go real practical towards the end, which I think you know you pull out some pretty practical takeaways, which is which is great. But tell us, how do you understand pain?
The Brain-Body Connection in Pain
00:02:44
Speaker
yeah Well, I'm not sure I do, and I'm not sure anyone fully does, to be honest. I think it's it's it's it's been this kind of hard to capture beast for many of us. and But i suppose the way I i look at it, are current my current understanding, which is always evolving,
00:03:02
Speaker
it' It's probably slightly different. I think the pendulum has swung for you know about 20 odd years now to this idea of people saying pain kind of comes from your brain, for example, which I don't i don't fully subscribe to. I think think the brain is unquestionably part of the chain. But I think pain is of of the person, so it involves the brain and their body. And i just the longer I'm doing this, the harder I find it to to separate those things and so yeah my uh feeling or my understanding of it as it as it currently sits or currently is is that pain is a function of of a system and that system is the whole person uh that's you know under threat
00:03:49
Speaker
a Yeah. Yeah. Fascinating. And you talk a little bit about how the, the nervous system is this predictive machine. Sure.
00:04:01
Speaker
And I use the word nervous system because I think, you know, the whole nervous system is involved. And when you, when you say brain, people just think, are you saying that I'm predicting my pain, which is not what you're saying. Yeah. Yeah.
00:04:13
Speaker
Tell us about predictive processing. Give us some, because I'm not that smart, mate. So give us some tangible illustrations to to try to understand how how that all operates. Oh, yeah, sure. And so I think, so predictive processing is is is a framework for understanding kind of human behavior and learning and memory and And in some ways goes towards trying to explain what it is that we experience.
00:04:47
Speaker
And so, like we actually have a lot of examples of this in our day to day. And so the idea is that we're not just sitting here, I'm not just sitting here waiting for sensory information from my body or from outside of my body, but I'm actually constantly making predictions. And none of this is conscious. Well, that's not true. Some of it can be, but it's largely an unconscious process. And so, for example, you know, I'm not sitting here waiting for sensory information from
00:05:20
Speaker
the world i'm constantly making predictions about what is coming in or what is likely to come in because if i was just sitting here having to in real time process all information imagine all information coming in from every nerve in your body light sound taste you know ah vibration touch you know you'd be overwhelmed all the time, right? Absolutely overwhelmed. And so the idea here is that with predictive processing, is it's really an efficiency strategy that our nervous system, and and probably linked to other systems in our body, have. And so we try and predict information and explain away what we already know. So we only have to deal with what's highly relevant or different from our predictions. Like an example of it is, if you drive home the same way every day,
00:06:12
Speaker
you know I'm sure you're paying attention, but then you get to your driveway and you think, was I an autopilot? Yeah, because your system is just explaining away all of the same, you know, sensory information you'd always have, all the same traffic lights, there's the same person walking their dog at the same time every day, et cetera. But, you know, if something's different, like your neighbor has suddenly, i don't know, trimmed their hedges or something, you'll notice that, right? That will be recognized because it's a change, right? And so the idea that we have and and and kind of like in part how that pertains
00:06:44
Speaker
to pain is that you have to think about what your predictions are based on what your systems predictions are based on and they're they're based on you know a number of things but largely previous experiences right so your previous drive home already tells you what sense of information you're going to expect the next time right and so previous experiences social cultural environment that you've grown up in you know what clinicians have told you, the fact that it it you know it hurt yesterday, hurt the day before, hurt the day before, well, you've got a part of your system that's likely expecting the same information, and same experiences the next day, right? So all of those experiences and kind of your implicit and explicit knowledge. So the stuff that you kind of know that you know,
00:07:33
Speaker
right And the stuff that is part of you, but like you'd never be able to drag it to the surface cognitively or consciously. and So that's kind of you know a little bit of kind of predictive processing, I suppose. And and kind of why it matters, I suppose, it matters that the things you've been told and the things you've done and the things you've seen, the things you understand about your body and those explicit beliefs, and implicit beliefs,
00:08:00
Speaker
they have a role in the pain that someone experiences. And so, i mean, I always remember i I had a teacher in school and he was a very kind of influential teacher for me.
00:08:12
Speaker
remember when I was in my final year in high school, he he came in and he was holding his back and he was moving really stiffly and was struggling to sit down and he said to the to the class, you know, you never hurt your back because if you hurt your back, it never gets better. It's the one part of your body that never heals.
00:08:27
Speaker
And like, it's amazing that like, I'm not immune to getting sore and doing things from time to time. And I might be working in the garden or do something, get a bit sore on my back. But like, for some reason, that comes to my mind, despite the fact of all I know and all I've studied about pain and teaching anatomy and understanding how the back works, for example, like,
00:08:48
Speaker
I have all of that information competing with this prior prediction about, well, the back never gets better now, does it? right And so it's a it's it's it's interesting how our our beliefs and our understanding can shape what we feel.
Predictive Processing and Pain Perception
00:09:05
Speaker
I can definitely rate relate to the autopilot. If my my wife is listening to this podcast, she'll be thinking she's she's very frustrated about my autopilot. for what I'll give you an example of it.
00:09:18
Speaker
we have this We have a dog, a Cocker Spaniel. We have a doggy door. And Like she'll be home, she's a shift worker, she's a nurse, so she'll be home from work and i'll be I'll be off to work and I'll close the door behind me just on autopilot and I'll close them both in. I'll even i'll even lock the door just closing them in. And it's just like, it's because I'm not thinking of it. i So I'm glad I've got an excuse now. It's just that I'm i'm a very efficient yes machine. Yeah, youre you're you're a master of energy conservation.
00:09:50
Speaker
That's how it is. But look, if I if i can take a little beyond predictive processing, one of the challenges that I would raise and that others would raise about this idea of predictive processing as a neuroscience concept that might explain pain or help us understand and manage pain better, it's very of the brain.
00:10:06
Speaker
Like everything I've mentioned is past experiences, people things people have told you, you know things you've seen, your beliefs, your your your conscious and kind of unconscious beliefs about yourself.
00:10:17
Speaker
But that's very up the brain, actually. And so they are the thinking has evolved beyond predictive processing to a framework called active inference. which predictive processing, I suppose, in some ways is a subset or a part of the journey towards understanding active inference. It doesn't negate what I've said. what what i've What I've said, I firmly think, holds true. But one of the key things about active inference is that it it it involves the body.
00:10:44
Speaker
The idea, like, you know, i'm driving home is about sensory information from outside. Right. That's all external to me. The light, the sound, that's information from outside. But we've got to think about information coming from inside your body. And so that will be about body temperature, about nociception, which is that you know buzzword we have for sensory information that relates to you know threat to body tissues, for example. so So your system is likely making predictions about all of those internally derived sensory information.
00:11:20
Speaker
and And that's really important because that has implications for how we move and how people move in pain and, you know, hey kind of brings together, there's this idea, some people who are really like, pain is just about what's happening in your tissues.
00:11:36
Speaker
And I don't think that's necessarily true. But I do think your tissues absolutely matter. And some people think that pain is all about your brain. And I don't think that's true either. But I do think that it's it the brain is involved. But I think that that it's about more than just what's happening in the tissue. So if if you're if you're if you'd like, i think maybe active inference might be a better explanatory framework than predictive processing.
Equations and Analogies in Pain
00:12:02
Speaker
Yeah, okay. I have this equation that I do with patients that I see because I work with mainly people with persistent pain, which is pain equals body damage times nervous system threat.
00:12:15
Speaker
So sure just and and it's too simple, simplified, and you'll be able to pick it apart. But from from the point of view that there's two things that matter, there's the body involved and then the nervous system and how that's responding to what's going on in the body. I've always, and this is going way too deep for some, but I've always sort of gone, should I put a plus sign or should it be a time sign? What what should it be? Because, you know, there's different camps that think that you don't need nociception to cause or have a pain experience and others would reject that. um And there's a bit of back and forth.
00:12:50
Speaker
on that. But but for the for the sake of trying to simplify what is very complex and give some practical takeaways, I find that kind of kind of helpful.
00:13:00
Speaker
it I think the reason one of the reasons I've got you on the show is probably because ah you kind of tickle my biases a little bit. Look, if if I can if i can bo back to you there, and like use the the challenge there is when you talk about you know you know tissues, plus or minus nervous system, the argument that some people might get would be, oh, well, you know your body your nervous system is part of your body tissues. And you get into you get into all of these kind of semantics. And some people can get a bit carried away with it. Is it times? Is it plus?
00:13:31
Speaker
That's why, for me, like I'm a bit agnostic of all that. I kind of sit there. with a much broader broader framework, it's about more than just the tissues. Yeah, yeah. it's about it's a you know And that encompasses the people in the world around you The pressure you might have to get back to work, that's not of your tissues, but that can affect your pain, right?
00:13:50
Speaker
And so it's it's not saying the tissues aren't involved. It's not saying the nervous system and the brain, et cetera, aren't involved, but it's about acknowledging it's about more than just the tissues. And so yeah like if we can tumble down that active inference rabbit hole a little bit, like you think about this, let's take it away from pain for a moment because sometimes these examples are more relatable with common sensations, et cetera. So i'm I'm drinking coffee right now.
00:14:19
Speaker
So how do i how do I taste coffee? Right? So I i put in my mouth. Before hits my mouth, before hits my mouth, I get the aroma of it.
00:14:32
Speaker
Yeah. But before i even get to my, and so so so we got the aroma, you got the sensory information your mouth. So now you're integrating multiple sensory streams. Okay. But also I feel like, oh, this is this is my favorite cup. I've got memories of this cup, right? My wife made this coffee for me this morning. Oh, that was really nice. I like the weight of this, you know, et cetera, cetera. All of these things are involved. Then I put it in my mouth. I roll it around my tongue. So it gets on the different sensory receptors.
00:15:00
Speaker
All of these things are part of the process of tasting it, including like my prior memories of this cup and my wife doing it. So what actually happens is that yo your sensory information that's coming in is met by predictions and expectations from higher centers.
00:15:18
Speaker
okay So you've got this downward stream of information that meets this upward stream of information. And what you experience is based on, like Andy Clark, who's one of the people who's written very extensively in this space, would talk about this beautiful dance between your incoming sensory information, so what's coming in from your tissues, and what's actually based on previous predictions. And we know, like, I really like cooking, right? And so for years, were really interested about how how malleable your sensory experience is. So, like, we can give you a really good meal on an airplane, and it will taste terrible. Yeah, we can give you a the same meal, but with heavier knife and fork and a fancier plate. And people will say that tastes better, right? If we give people chocolate in a gold or orange color colored foil, this is why a lot of companies do this. It tastes better for people.
00:16:12
Speaker
If we what we put on the label of chocolate can enhance people's sense of that's extra cocoa-y because it says like it's handmade, organic, blah, blah, blah, even if it's the same as a control piece, right? You know, all of these things. And and one of my favorite studies I ever read, I absolutely love it, is they got a bunch of sommeliers, so people who smell wine, and I'm not no good with this, you know, like wine is wine to me.
00:16:35
Speaker
But they they give them white wine and they you know they swirl it and they stick their nose deep in it and they get them to describe this white wine. And of course, you get these words that you hear as descriptors of white ry wine. so you know melon and citrus and grass and you know, all those types of words that are typical of it. And so then the researchers took that wine away and they went into the little back room and they put in a flavorless and older odorless red wine.
00:17:01
Speaker
So it's got no change to its odor or its or its taste in any way, but it looks red now. it's the same wine that looks red. You give it to the same people and they're smelling ah cherries and chocolate and it's deep and it's rich and it's heavy and you're like whoa, right?
00:17:16
Speaker
And so then you have to realize in that, that what they've experienced, they're not making it up. They're not trying to please the person. That's what they've experienced. They've experienced the odor, the scent of what would be typically red wine. But that has been impacted by prior sensory information. So sensory information has come in before they've smelled it from their eyes.
00:17:36
Speaker
and So hopefully these examples demonstrate there's a couple of things that what you experience, whether it's you know, taste or sound or smell or or even pain is influenced by what's happening in your body,
Personalized Pain Experiences
00:17:49
Speaker
right? Like the the sensory information coming in is undoubtedly relevant. Okay, so if there's damage in the tissues, if there's inflammation or whatever else that's going on, that is undoubtedly relevant.
00:18:02
Speaker
equally what is undoubtedly relevant is the processing of sensory information and the downstream or top-down predictions that are unconscious just a nature of how your nervous system works that are based on prior experiences knowledge social cultural factors all those things and they interact and and what you experience is the end product so so if i can go back to your first question of what is pain Pain is an experience that is based on some stuff that's happening within the body in terms of incoming sensory information, should I say, and top-down predictions.
00:18:40
Speaker
the And I think that's, for me, that's kind of neat as that someone who's trying to help people in pain because I think that gives you levers to pull. right Like if Lachlan comes to see me and tells me a long history of having a sore knee or back or whatever it might be, and and all of these different things, it means I have to work really hard and really closely with Lachlan to try to deeply understand the nature of those predictions. And I'll only ever get that much of a much bigger picture, right?
00:19:10
Speaker
But I really have to try and deeply understand the person and their journey. But I also have to really thoroughly assess and try and understand what's going on from within the body as well. And I don't know if, you know, and this is a gross, so here I am gonna be guilty of a gross oversimplification myself, right? Like I don't know if you come in the clinic, if your your pain that you experience is 90% you're related to inflammatory or autoimmune or damage-based kind of processes within the tissues and 10% top-down predictions and the interactions
00:19:45
Speaker
or 50-50, or 70-30. All I know is I've got some levers to pull on on either side of that equation, and we kind of see what sticks. and And so that is really, for me, really interesting because it makes...
00:20:00
Speaker
Every single person's pain unique, right? Because you could have the same damage as me, but your pain experience is unique to you because we'll never line up on implicit knowledge, explicit knowledge, yeah history, social, cultural factors, all those things. They'll never be the same, right? So it's I think it's really exciting, but it's also a big challenge because everybody's different and that means there's no single recipe for everybody.
00:20:26
Speaker
It's interesting because I often deal with people that have sort of They've explored literally every single option possible. I work in a multidisciplinary pain clinic here on the Gold Coast. And it includes pain physicians and all those psychologists, physiotherapists.
00:20:45
Speaker
and And they've usually explored all the body stuff, right? And they think, or that what you would call bottom up, the signals being sent. And they've kind of exhausted that.
00:20:56
Speaker
And they feel like there is no hope. And and what what you're saying and and what i I sort of stand with as well is that, no, there still is some some control that you can have over that. Now, control, I mean, let's not get it. Yeah, yeah, I get what you're saying. You know, there there are still options, I guess. There's things that they can do. And and just full disclosure, Merv, you probably don't know this, but if people listen a fair bit, they probably already know. I've got a lived experience with with chronic pain. So,
00:21:28
Speaker
it's It's a personal thing for me as well, as much as anything. And so I'm always mindful of my words. But for me, it it feels like there is some hope beyond, say, like just the structural realm um and what we would traditionally see as pain treatment yeah for musculoskeletal injuries.
00:21:48
Speaker
I wonder, because you work with professional athletes, it's a task to go from their worldview and understanding of pain and to to open their lens a little broader to these kind of things. And I can imagine with professional athletes, it's only only all the harder.
00:22:06
Speaker
because of their cultural context how do you go about doing that yeah so i don't just work with professional athletes i i i have worked in like in professional rugby in the past and and i do consult to to clubs and stuff where they've got uh athletes stuff who aren't um getting better but by no means are all of my patients professional athletes these days at all um but uh but you're right like the the social culture concept of sport is everything's tissue based, right? You you see it like someone someone pulls up on a footy field or whatever sport you're watching and within like five seconds, it's being diagnosed by the commentators, right? That's something, you know, so like it's a structural world with lots and, you know, they'll have scans and MRIs and all those types of things. And so that can be challenging. I had an experience there recently where I was, I'm sure we we'll get onto some treatment-based stuff later, but where i was consulting to a club and I went in and they had an athlete with persisting pain in the Achilles, couldn't run, lots of pain, going on for three seasons. So really, you know, hampering performance and career and all those things.
00:23:12
Speaker
And that you know athletes have stresses associated with how their body works, right? Everyone has stresses associated with how their bodies work bodies work, but you know their bodies are their livelihood, right? And so it has all sorts of connotations for them and and implications for them.
00:23:28
Speaker
But what's really interesting is I went in and and and you know and I remember being asked by the club before I came in, they're like, oh look, we're going ask you to come in and have a look at Lachlan whatever. What are you going to do?
00:23:42
Speaker
I was like, what do you mean, what am I gonna do? Like, well, you know, we're gonna bring you in and, you know, presumably you don't work for free, so we're gonna pay for your work. So we kind of need to know what it is that you're going to do. And I said, look, I'm i'm really sorry.
00:23:55
Speaker
I don't know what I'm gonna do. like could I could see how they had lack confidence very quickly. Like, well, what do you mean you don't know what you're gonna do? said, well, I've not met them yet.
00:24:06
Speaker
Right. And so that's really important. I'm not going in there with a lens on I'm going to fix his Achilles. I've i've got to meet Lachlan. I've got to understand this because there's there's more to it. like it's I'm not going to ignore his Achilles. Of course, I'm not going to.
00:24:19
Speaker
But there's more to it than Lachlan's Achilles. And so when I went in there and. yeah i You know, I was asking lots of questions and probing different stresses in life and different things. I think that was a bit a bit different and and seemed thorough. But then during my physical exam, I started, and this is a real thing that's and related to this active inference idea. we can come back to it. I started doing a a number of tests on his kind of sensory acuity. So how, necessarily testing how well his nerves work in terms of reflexes and strength, et cetera, but how well he's able to process sensory information from that body part.
00:24:56
Speaker
Okay. So if you will, how well the radar works, how in touch with that piece of his body is he? And of course it turned out, as we often see with people in pain, he wasn't, you know, so he wasn't performing very well, but I think for the,
00:25:12
Speaker
clinicians, so that the team physios, et cetera, were sitting in on the consult, of course, who were doing it collaboratively. I could see they had this moment where like, what is this witchcraft? You know, and and, but for the athlete, you know, I'm showing him, and you'd have done this stuff in South Australia, but like, I was looking at two point discrimination, and I was looking at tactile localization, and yeah laterality testing, and all that kind of stuff. So so I'm showing him pictures of of left and right feet, and he's he's having to discriminate between left and right feet. You know, it's it's like,
00:25:41
Speaker
tinder for people who like feet. And so he's swiping left and right on foot fetish Tinder. But you know, the thing was, he was 100% accurate and really fast on his non-affected side. And on the affected side, so the sort of the leg that's sore, his his accuracy dropped a little bit, but it would take him almost twice as long to respond.
00:26:00
Speaker
And he even said to me, i I'll not forget it, like in the console, he goes, why do have to think so hard to find my right foot? i was like... its let's Let's explore that. But it was the first thing for him that like, okay, this is about more than just the tissues. This is about more than just what's happening at the Achilles. if If I can't register that body part so well, if I can't find it in space, if I can't distinguish different types of touch and all that, that's not about Achilles, right?
00:26:28
Speaker
And so I think what's really interesting for me is like experientially, and I've done it and I've had years where I tried to sit there and explain people's pain to them almost like Mervsplaining pain.
00:26:39
Speaker
you know and tell them it's not just about your tissues, it's these other stresses, were but they've got no credible evidence of that, right? Like I'm not demonstrating modifiability in any way, I'm not doing that, but with clinical testing that shows, hey, there's other things that we can work on that aren't about the tissues, but are clearly related and fit within this framework that we're operating, like that gives hope as well, because, you know, firstly you're saying actually maybe the tissues are better than we thought, which is wonderful. And there's something else going on with that we can resolve, but it gives us options to intervene, right? So that's a positive thing.
Innovative Treatments and Trials
00:27:15
Speaker
And so those things are based on, I don't know if you've read the papers, but if any clinicians are listening to your podcast, highly recommend that people read. The primary author was Matt Bagg and the paper was in JAMA and it's about graded sensory motor retraining for low back pain. So a large randomized control trial on about 270 low back pain patients. So they had I think average duration of pain for about five years and kind of six out of 10 average pain each day and kind of moderately disabled. So these are patients who are not having a great time. with their back pain and there was a large randomized control trial where greatest sensory motor retraining was the intervention, it was controlled compared to a truly credible sham. So it's a really unique and extremely well done randomized control trial and they demonstrated clinically important and sustained improvement in pain and disability over at the one year point after 12 treatment sessions that were spaced over 18 weeks. And so that was in Jam, I'm going to say 2022 or 2023. But mean, I can flick you the reference if that's any use. But like, so some of the stuff that I was doing with this,
00:28:24
Speaker
um and patient this this football player was based on that treatment. And of course the the assessments were new and they and the and the and and the treatments were new. and they the so and this But the staff were well, what is this? Because this was so different. And for him, he was like, what is this? Because this is so different. But he bought in because he had evidence that it was you know not just about the tissues. And you know here we are down the line and he played 19 games straight last season. So where were're we're calling this a win. yeah So we'rere we're not pain free, but our pain scores these days are one or two out of 10, not nine out of 10. You can play footy on one or two out of 10 in your Achilles during your warmup. I think you can live with that. Is that was that the resolve trial? Is that the...
00:29:11
Speaker
is that the yeah that's the resolve trial yeah it is a resolve trial but but in the title of the paper resolve isn't used in the title rule of the paper yes yeah yeah because yeah because that was the the fancy brand name of the trial but the treatment was great at sensory motor retraining so yeah yeah and then wonderful i mean if you look at the team of people who are behind it in just a stellar stellar cast of of of really really smart and and really interested in really caring people to to like what What impact does this trial, like, cause it's obviously, i think it's, it's quite, ah quite a good trial. I figure you do too. What is it that,
00:29:50
Speaker
that this changes for this realm of of low back pain for instance which has been something we're just really crap at trading to be quite honest across the board yeah well i i think i don't think that's unique to back pain i think that applies to pain in general look i think this is the most important trial and that's that sounds like a very strong statement i think it's the most important trial we've had for you know, musculoskeletal type pains, if you will.
00:30:21
Speaker
Not just because it had a yeah a you know remarkable result. It did have a remarkable result, but they the way the trial was conducted was so robust.
00:30:34
Speaker
So they had a clinically or they had a truly credible sham such that when they asked the people who are getting the sham treatment, you a few weeks into treatment, are getting the real or the sham? Most them are like, we're getting real treatment, right? So those people are probably going to improve because they believe they're getting a real treatment, right? But then you've got this better improvement in the people who got the true treatment. And what that demonstrates is a true treatment effect. So we have other...
00:31:00
Speaker
treatments that seem to be plausible and that seem to have merit in some trials, but they haven't been tested as rigorously as this.
00:31:12
Speaker
That's what makes it stand out for me. And I declare my bias, right? Because So many people on the paper who are, who are part of that trial are friends, colleagues, and mentors of mine. Right. and And so I declare that immediately, but I stand, I stand aside of that. The reason why it stands out for me is because of the rigor, which, which the science was done and the longer term data. So the five year follow-up data will be probably coming soon. and and And so that's wonderful, but there are other treatments, you know, I mean, you've had Pete Sullivan, um, on this before and CFT so cognitive functional therapy which he's kind of a huge driving force behind that has an awful shows an awful lot of promise and that's something I'd be looking for as well and I don't know if you've looked into kind of pain reprocessing therapy so there was a trial Yoni Ashar was the the primary author on that one that was published a couple of years ago on knee pain and and that showed a remarkable
00:32:05
Speaker
positive results for that intervention for improving people's knee pain the only problem was it wasn't compared to a credible sham so the what has been compared to in the trial likely amplifies the result and so we don't know how much of that result is actually a true result or how much of it is because it wasn't compared it you know people were given an open label placebo so they were given one injection and told it was a placebo injection so that's not a very hard very high bar to to beat, right? But nonetheless, the change that was observed was large enough that we should take note and say, please, please, please do a bigger trial because they didn't have enough people in either. and But get more people and do this intervention and compare it to something more credible as a sham and we'll look. at
00:32:53
Speaker
but But for me, that's hope, right? Like in the last, that means all those trials are published in the last three or four years. So in the last three or four years, There are three, at least three, couple of others that are probably not as strong.
00:33:07
Speaker
Really promising treatments. which didn't exist before. And like, as a clinician, that's really hopeful for me, because it's really easy to get despondent and say, gosh, nothing we do works, and we don't have evidence for these things, et cetera, cetera, to come to a point now where like, hey, we have one trial that's been incredibly rigorously tested and has come up with outstanding result. And we've got a couple of others that are really promising, and and the data is amassing behind those, right? And you kind of go, okay, that's that's a really good place to be as a clinician. not even better place to be as a patient.
00:33:44
Speaker
I want you to, I'm going to come back to that because I want to actually ask you the question around, actually, I'll just do it now and then we'll go to the next one. then what What are the, because all of these have a common thread.
00:33:58
Speaker
Yeah, they do. Some key ingredients that actually make them all very similar, although their methods are slightly different. But what are the key ingredients in all of these? Because I think it would be a really good takeaway for for people in pain to go, okay, these are the the key threads of these amazing studies.
00:34:18
Speaker
Yeah. what What can I practically do to to sort of help myself? Yeah, that's it that's a really good really good question. And there are unquestionably... There's some differences, but there's definitely common ground. and i almost see them as overlapping circles on a Venn diagram.
00:34:34
Speaker
And so if I can go back to the best way probably to answer that is if I can go back to this idea of active inference. One of the key principles, as we said, is there's predictions coming down, there's sensory information coming in, but your system doesn't only make predictions. Your system also makes, or it doesn't make predictions, it doesn't just make predictions about what's coming in. It makes predictions about the trustworthiness or the amount of attention that should be paid to either incoming information or or or top-down predictions.
00:35:07
Speaker
And so that's really important. So think about it this way. Like, I put my socks on this morning, and at no point have I registered how tight they felt since then, because it's not important information for the system or experience it before. But if I bought new socks, they're my first time wearing them, my system will be registering and paying more attention to that. I'm not consciously doing it, but it would be on the radar more for the system. so there's this idea around, like, the prioritization of sensory information.
00:35:33
Speaker
And what I was describing with that football player was, and what we often observe with people in pain is they they are very good, their system is very good at prioritizing and noxious information, so information that's telling you that your system is broken.
00:35:49
Speaker
and and And the flip side of that coin is then everything else is going to be treated as noise. Right? And ob beasts it's gone. And so it's like, think of it like it's like it's an attentional spotlight within your nervous system. So think about everything being in the dark and instead of it, the the spotlight going around and finding and probing for different sense information, it is just locked onto that information that tells you that it's broken. So that's reinforcing those constant predictions that something's wrong.
00:36:18
Speaker
and and and And those nociceptive, that incoming traffic may be very real and highly salient, right? For a reason. So that's really that's a really important thing because that prioritization of sensory information is sub-component of some of these treatments. That's why I mentioned it.
00:36:41
Speaker
yeah so you're asking about the common ground. The common ground is they both very much acknowledge top-down influence. Like you think about what what CFT is, and by no means, like I'm not trying to sum up CFT in 30 seconds because one couldn't do that, right? But you know, it's it's a about deeply understanding the person and their pain experience, their knowledge, their behaviors, their understanding, what they've been told, what they believe, their hope for the future, all of those things.
00:37:06
Speaker
Yeah. that's That's seeking great insight into your internal model on which your predictions are based. like That's it's it's what I kind of said. Get to know Lachlan. And speaking of getting to know your patient, that's exactly why I built Pain Coach.
00:37:19
Speaker
It helps clinicians find lifestyle targets for their persistent pain patients. Visit paincoach.online to grab your free trial. Link in the show notes. so So that's a really, really big component of it.
00:37:33
Speaker
And another component of it is is kind of around movement experimentation and trying to modify symptoms. all right And so that that that's a really important component because within this active inference framework, what we think is that you move in ways that fulfill the predictions of your system.
00:37:55
Speaker
So if your nervous system, excuse me, nervous system is a wrong word to use there. If you have a system, if you are predicting pain, not consciously predicting pain, but you've got a neuronal hierarchy that is operating in a way that suggests that, then you'll move ways that fulfill it. And so what we try do? We try shift and change how you move and see if we can generate a better experience.
00:38:18
Speaker
Right? um And then there's elements of exposure with control over time. Yeah. Okay? If you go to and pain reprocessing therapy, which is very top-down, right? It's very top-down. It's about almost, there's big parts about understanding your pain, about your story, about your knowledge, about your beliefs, and within that, trying to identify evidence of modifiability. So that's all in CFT as well, like this idea that we can modify it. You know, and we can always modify pain. I mean, if your back is hurting and you're under a lot of stress, that's you probably feel worse on that day.
00:38:55
Speaker
Ideally, you want to modify it positively. and So evidence that it's not just about the tissues, right? That other factors can influence it, for example. And so with that, they they do a lot of body scanning and almost kind of meditative work where people actually really pay attention to the pain and the sensations they're feeling. Can you move it? Can you shrink it? Can you change it in ways? So it's it's very top-down.
00:39:15
Speaker
right Very, very top down, where CFT is a component of both, top down and bottom up, because because moving differently and exposure control, all things are in part about altering sensory information coming up up the chain.
00:39:28
Speaker
Greater sensory motor retraining starts with similarly trying to understand Lachlan and understand his pain and discussions about you know the future and all of those things, right? So understanding your internal models that your predictions are based on.
00:39:39
Speaker
But where it stands out is different is proceeding getting into more movement-based therapy you embark on this journey of playing with and experimenting with and assessing, of course, and how well the person prioritizes different sensory information streams. So like I said, do they have an attentional spotlight that's based on ah you know always being on the kind of nasty information or or can you train them to have improve the the kind of trustworthiness, precision, saliency within their system of non-noxious sensory information?
00:40:18
Speaker
so So now you've got competition, competing streams, right? And so that's what where greater sensory motor retraining stands out, is it has that component of playing with the weighting of sensory information from the periphery, which the other two don't have. their they The great brain reprocessing therapy has an element of of kind of playing with precision of of of top-down predictions. And CFT has a movement-based component, which does it in a slightly different way. But but they oh they all have a common ground. And the really common ground is about being deeply personal pain experience and understanding the person and in part understanding the predictions. They they don't use that parlance, right? And so they use different words. But I know I've i'
00:41:03
Speaker
taught on this to some physios who are who have done research and worked in the CFT world extensively. And and after you know talking about this stuff, they kind of go well, now I know why we do what we do. for so it's oh It's an overarching framework for me. The active inference overarching framework is the common theme because they all fit consistently in part with what we how we think the nervous system operates. And that's kind of new in fairness, right? We've been saying for a long time,
00:41:31
Speaker
Pain's a biopsychosocial experience, right? And I don't, loathe that terminology, in fact. But the idea we're saying is pain's not about just about your tissues. And then we'll go, come into my gym, I'll make you stronger. Yeah. Well, hold on.
00:41:44
Speaker
Or pain's not just about your tissues. Come into my clinic and I'll give you an injection. You're like well, hold on. like those treatments don't reflect both sides of that equation. I think the the thing about and pain reprocessing therapy and CFT and and certainly great sensory motor retraining is they're much more aligned with our common understanding of how pain works. yeah I think as clinicians and as researchers, we have to think about that. like how do we understand pain works and are the things that we're testing in studies and and and using in clinic actually consistent with that? Because if they're not, what are we doing?
00:42:23
Speaker
Yeah, exactly. Yeah. Yeah. If you don't mind, I'm going to just summarize slightly and just correct me if I'm wrong, but I think the the common threads are to be curious for patients to take away, to be curious about your pain and your understanding of how that that works. And then how those beliefs actually move into certain actions that you do and then be curious about those those particular actions, which is what CFT does. it It explores different ways to move and, oh, does that feel better when you move this way? And it's like an experimental process of rather than being...
00:43:00
Speaker
ruled by these defined dogmas that you must lift like this way or that way. and And, you know, from pain reprocessing, it's more a top down the way you think and can you change your perceptions?
00:43:12
Speaker
There's that that that common thread of being curious about pain itself and why why it's there and how how it works. And then also curious about how that belief actually changes the way you do things and interact with the world.
00:43:25
Speaker
Would you say that? And it's so, here' this is what frustrates me, to be honest. It's so kind of like nuanced and non-tangible. And it's like, you know, and and I think patients don't always like it, to be honest. Like they they just like come in and they're like, okay, push on the sore spot and then that'll feel better. and And I can see because it's tangible, right? It makes sense. Whereas this is like, this is like quite a...
00:43:54
Speaker
philosophical and nuanced and i think probably I think more accurate, but I don't think patients always grasp these concepts and and buy into it. Well, if they don't, I think that's on us.
00:44:05
Speaker
yeah know it's not you know They've come looking for help and and and and and and that's on us. And I think what's invin interesting is with the active inference framework, like manual therapy and and all those other things are not necessarily excluded from that because they can be compatible with it. Why? Because they can be mechanisms for playing with the precision of sensory information.
00:44:26
Speaker
And so so here's the thing. like You said about being curious about pain. like Curiosity isn't ah sufficient. I think it's about experimenting. And like you know in CFT, like they layer on lifestyle factors and that kind of stuff as well. But they're making genuine changes, right? And so the way I view it in clinic is every, as I said, every patient's individual because of the nuanced factors that make you, you.
00:44:51
Speaker
And so that means that Every clinical encounter is an N equals one experiment. And so ideally between two consenting adults and I'm operating under a framework that is, you know, makes sense. and You know, you're not just wildly doing anything. You know, experiments have hypotheses and testing and retesting, right? And so it's an N equals one experiment.
00:45:12
Speaker
And so what am I ultimately trying to do? Well, if you read, and there's a wonderful paper for clinicians, it's called the fit Fit for Purpose Model, which is authored by Ben Wand, who's a major driving force behind greatest sensory motor retraining and a friend, colleague, and, and, and a very influential mentor of mine professionally.
00:45:33
Speaker
The greatest memory of retraining is basically based on this framework. and And the idea here is that we have to help the person understand that it's safe and helpful to move. So there's cognitive behavioral component. and And so being curious isn't enough to help someone understand.
00:45:48
Speaker
asking You've got to experiment. You've got to create an environment where they have credible evidence that it's safe and helpful to move. But if you're if you're if you're, and I'll push back just a little bit, if you're not curious, are you going to experiment? Oh, sure. it Yeah. and yeah um and like one leads One does lead to the other. 100%. it's not sufficient just to think about it. For sure. 100%. Yeah, i agree. I mean, if someone's got really fixed beliefs and they aren't willing to change or try, well, you know, then, you know, we're we're we're probably on on a loss to start with, right? But so so the first component is about like,
00:46:21
Speaker
understanding they're safe and helpful to move. So you have to you have to challenge that, right? Challenge someone's prefixed ideas that that it's not helpful to move.
00:46:31
Speaker
Now, of course, this is assuming that they don't have a compound factor of the femur, that it wouldn't be safe and helpful to move, right? So that does there is that element that we that we have thoroughly investigated. that There's nothing structurally unsound or that's going to be dangerous to do this, right?
00:46:45
Speaker
um So the second kind of, if you will, pillar within it is that you have to help try to help the person feel that it's safe and helpful to move. And what I mean by feel is not that it's you know an emotional feeling. It's about, as I said, how well your body feels to you, right? If your body feels strange or foreign or crooked or lopsided or swollen or shrunken, like that it doesn't feel normal because the attentional spotlight of your system is constantly on the nasty information and not on the normal sensations that you should be getting from there.
00:47:20
Speaker
Well, then it's unlikely to be successful trying to use that body part, right? Because your system can't make useful information. predictions and can't kind of resolve the prediction errors associated with that equation, right? So that's where the greatest sense of your motor retraining comes in. And so that football player was speaking about, he couldn't really feel his Achilles and that area, his calf, the way he should. So we spent a lot of time working on that stuff in conjunction with and preceding a lot of the preparation for football, you know, the squats and the stuff that i happened in the gym.
00:47:53
Speaker
So, go ahead. In travel, what did that look like tangibly? Yeah. So there's the recognized app where he was, you know, the foot tinder, the same way. So I had him playing with that. So that's showing him, you know, 50 different pictures of feet and he's having to decide if they're left or right, which means you're accessing, you know, parts of your brain that we think are associated with that body part and sensation of that body part and planning movement around it, et cetera. you're not actually loading So he's doing a lot of that, but then also tactile localization tasks where, you know, I've drawn a grid on his leg or on his back whatever, I'm sorry, his leg was the example. And, you know, I'm touching him on this grid and he's trying to locate where I touched him, right? Right. So exposing them to different sensations and can discriminate between the different sensations as well. So a lot of tasks around just getting really sharpened attention to non-noxious, normal sensations that body part.
00:48:56
Speaker
Right. So so and that's the second pillar. The third pillar is to to experience that it's safe and helpful to move. So that's a about experiential learning and very much like for me, movement experimentation and trialing things and doing things different and altering how we do things to see it if we can find a way that someone does something. and and And what success looks like for me is when a patient says, that's it's better than i thought it would be.
00:49:20
Speaker
It's not it's pain free. It's not that it's anxiety free or stress free. Of course, how could it be if you've been afraid to do this for 30 years? and And rightly so, because every time you've done it for 30 years, it's really hurt. Right. So so so. But if if if you get to a point where like that was better than I thought it would be great, we can reinforce that and make that the dominant prediction, right, the dominant way of doing things. And so then finally, the the final capstone, if you will, above these three pillars, so I always think about like looking like Stonehenge, is and is is to kind of explore movement and explore and expand the movement repertoire. and If I can bring us back to active inference, as I said, one of the key things is that you you make predictions and what you experience an interaction between the the incoming sense of information and those predictions.
The Role of System Predictions and Placebo
00:50:08
Speaker
You make predictions about the trustworthiness of that sense information. But what I've not mentioned is your system is geared for reasons of energy efficiency to always or to almost always be led by.
00:50:25
Speaker
should I put this?
00:50:30
Speaker
The easiest option to not be challenged. OK, so. The issue or or the challenge that we have and the opportunity that we have in overcoming that is your system, if there's a prediction that's really strong and you've had it for ages and ages and ages, it's really great in the system, that's hard to overcome, right? And it's hard to challenge that. And so you have to try and do that in different contexts and in different ways and and play with it. But within that, you are constantly making predictions about how you move and the outcomes of those movements.
00:51:07
Speaker
And there's a line of thought that means that every time you move, you're generating information to your system about you, you're self evidencing. Am I broken? Am I okay?
00:51:19
Speaker
Can I do this? Am I capable? Am I fit for purpose? And what happens a lot of people is they have evidence daily in in the way they move and the experience of pain they have and everything they've been told and the scans they've seen that you're not fit for purpose. You're not capable.
00:51:35
Speaker
Your body's broken. It will never get better. All of those things, right? They're not just thoughts, they're experiences and they're reinforcing the way you move and way you behave. And so by building a repertoire of movement, and some people could hold this an exercise program, but for me, the the rep sets pounds, that's all irrelevant at this point. it's It's a repertoire of different movements and valued tasks.
00:51:56
Speaker
Are you self-evidencing that you're capable or at least becoming capable or that's better than I thought it would be? right And so that's why I call exploring yourself, exploring movement, because you are constantly self-evidencing.
00:52:10
Speaker
Your system is constantly self-evidencing. And so for me, like it doesn't matter if you're subscribed as a clinician, if you're subscribed to using greater sensory motor retraining or there are pain reprocessing therapy or CFT or ACT or CBT or any of the myriad of different types of treatments that are out there.
00:52:31
Speaker
Like for me, the most sensible explanatory framework is an active inference and the operationalization of that is this idea of help persons feel or sorry, thanks ah understand, feel, experience that it's safe to move and then kind of explore themselves through movement and function and tasks.
00:52:51
Speaker
And and so It doesn't matter what treatment line you subscribe to or you know whatever else, provided you're able to link that to those outcomes, right? That you're you're shooting towards those outcomes. So I don't see myself as a CFT physio or a Pilates physio or a gym physio or an acupuncture physio, but the the levers I have to pull are are towards those goals and outcomes, yeah right? And they'll be individual to...
00:53:20
Speaker
um Lachlan, so for example, when I was assessing that football player and I'm seeing, know, is he able to detect light touch and various different things around his Achilles and is he able to delve difference between left right, he wasn't very good at that.
00:53:33
Speaker
Like that's assessment. I'm like, I'm trying to get a baseline measure on these things. But equally he said to me, why can't I do this? Like, there's a few times the way, he goes, that's really weird.
00:53:44
Speaker
Like, why would I not be able to do this if this is just my Achilles? And so the the penny's dropping for him that this is about more than just his tissues. So then was that assessment or was it pain education? Cause he's realizing it's a about more than just his tissues or was it treatment, right? like I don't know, maybe maybe all those. to and So it's it's it's it's it's about being fluid. Like you said, it it is about being fluid. It's not about kind of very you rigid processes and rigid kind of treatment pathways because everyone's different, right?
00:54:19
Speaker
and And that lever, that that really made a difference for him, stuck for him. and For sure. Could you talk about The placebo effect, because you you obviously, you talked about how this one trial had a really convincing sham and the others didn't. And to the clinicians, that'll make sense. you know They'll know what you're explaining. But can you talk about the placebo, but put it in the context of ah predictive processing or active inference?
00:54:49
Speaker
Yeah, look, the placebo effect is real. Like it's a thing, right? Like, and I think really what we're saying is if
00:55:02
Speaker
If you have a high expectation that something will work for you, that's usually because it's worked for you in the past. And there's nothing wrong with that. Like if you have something that's useful for you, like you know if your patient comes if a patient says like, look, I know it's not a long-term fix, but I'm coming to see Lachlan. I know not a long-term fix, but when someone does some dry needling or rubs or clicks or whatever the body part in question is, I get some temporary relief and that's that's helpful for me.
00:55:33
Speaker
If that's safe and you're licensed and experienced to do it safely and that we're between consenting adults, I don't think a clinician should say, no, I'm not going to do that for you. i'm going to do this newfangled way of doing it. i Actually, they say, yeah, sure. Like, let's let's integrate that and build off that.
00:55:48
Speaker
Right. sure i mean And I think that's really important, like that to a patient. If if you have found that something has helped you, then it has helped you. right And that's a good thing. where Whether it's a long-term fix or not is a different story. And you know obviously we strive towards that. But the idea of a placebo effect, it really matters because and if you expect that you're going to get better, if you've got a positive expectation about getting better, it increases the likelihood that you will.
00:56:17
Speaker
And the reverse of that is true. Okay, so the reverse of that is true. If you feel like, and if you've lost hope and and and people lose hope for good reason, because maybe they've tried everything and nothing works, or they've been told by credible sources that nothing's gonna work for you. That's really suboptimal because it it makes it hard to recover. And so that's why i think it's about being willing to, and kind of experiment and explore and try things because that's how you get evidence that maybe things can get better and and maybe improve hope.
00:56:49
Speaker
But I think the placebo effect is really about your expectations. And if your expectations are that you can't get better and won't get better, well then unfortunately that's going to feed into the predictions of your system and then likely one won't. And and and bringing it back to those trials, one of the challenges we have, so one of the key things I'm saying is in that trial that had a credible sham, The people who think they're getting a real treatment think they're going to get better.
00:57:12
Speaker
Whereas if you're comparing it in some of the other trials that that come up, you know you measure people's expectation of recovery in the control arms and it's extremely low. And the people who are getting the real treatment in that trial, their expectation of recovery is is really high.
00:57:27
Speaker
and and And in some ways, it may be that your expectation of recovery is as important as what the actual intervention of interest actually is, like whatever the the treatment actually is. And so we know that. We know that if people have a high expectation that acupuncture will work for them, for example, or dry needle and work for them, then they're much, much more likely to report a reduced pain from that treatment.
00:57:53
Speaker
Right? So it's not, it's, you know sometimes people think that, like,
00:58:00
Speaker
but placebo is is this kind of negative thing like and and that your work your snake oil salesmen are selling them you know magic. beans that are gonna get them better. And that's that's exploitation. That's an entirely different thing. But I think with the in the case of credible care, having an expectation that you can recover and taking autonomy and and and being part of the decision-making process and part of the experimentation to see how we can positively modify this is is really, really important.
00:58:31
Speaker
And so I just think that like, Placebo has almost become a and dirty word. and so but So for me, I think about this idea of expectation of recovery.
00:58:42
Speaker
And we have this tons of data showing that it's people who don't expect to recover have have a harder trot than people who do. Yeah, for sure. Makes sense in your framework as well that you've outlined.
00:58:55
Speaker
i Lastly, if someone's struggling, they're in pain and you got to speak to them. So obviously you don't know them yet.
00:59:05
Speaker
Yeah. But a universal truth that they should take away from today, what would what would that be? Gosh, I don't know if there there there aren't many universal truths. I'll say that because we are so individual and various different things and and all those caveats aside.
00:59:21
Speaker
Look, I think that... people's pain is real and it's not in their heads. I think that's really important. i think pain is is is is, you know, a function of predictions in the system which are not conscious. So it's not, you believe this, so this is happening, you know. and So predictions in system and incoming sensory information.
00:59:41
Speaker
And I think if you've been told your pain is all in your head or you're imagining it, that's it's very unlikely that that's the case for a lot of people. okay I think that's that's really important. And based on this idea that pain is about more than just the tissues, there's hope because we have new treatments that have been developed and that have been tested and are showing real promise.
01:00:04
Speaker
And they make sense. What's different is they align with how we understand how pain works. Right. And so if you were to reverse it, if you were to look at how we think pain works and reverse engineer treatments, they would look like those ones that have been tested. Right. And so that's
Closing Thoughts on Future Treatments
01:00:20
Speaker
really positive. and I think for for patients and clinicians is is to have hope because we I certainly have more tools in my toolkit than I had in 2020. There's no doubt about it. There's absolutely no doubt about it. And hopefully more of this information, more of the skills kind of permeate into the clinical world and are therefore accessible for patients.
01:00:42
Speaker
you know so so so And and i don't I don't say that lightly. You've mentioned that you've had a journey with chronic pain. I've had a journey with pain personally myself. And so I i get it. And I get how for someone like me to go on a podcast and say, well, have hope and be patient. you know when When you've been in pain for 30 years and and nothing has worked, like i get the frustration of that and the futility of statements like that. But I think we are in a better place to help people. and than we than we were. But certainly if one has an expectation that they won't or they can't recover, then it that makes recovery hard. For sure.
01:01:21
Speaker
Thanks, Merv. I've really, really enjoyed it. um If people want to reach out to you, where would they find you or just want more information about what you do? Yeah, sure. and So look, i so I'm a physio and I still do some clinical work and some consulting on on second opinions and things and and for kind of complex presentations. And I'm based in in Perth, WA.
01:01:41
Speaker
And I have a website, so Optimize Rehab, or I'm on kind of Instagram, add on Optimize Rehab.
01:01:51
Speaker
And so, yeah, I spent i still see some patients. The way I work is a bit different, Lachlan. I take on two or three patients at a time and usually go on a very long experimental journey with them.
01:02:05
Speaker
So i'm I'm not wall to wall with 25 patients a day. i kind of operate a slightly different way. So I spent some time doing that. I since spent some time teaching in in kind of a couple of different universities, spent some time involved in research.
01:02:18
Speaker
And I spent some time trying to help clinicians um integrate these principles into their practice. So helping patients by doing it that way. But if you need to find me, and optimize rehab.
01:02:30
Speaker
That's optimize with an S. We don't do American spelling.
01:02:36
Speaker
All right, mate. Good to chat. Yeah, great. Thanks so much. and Thanks for having me. Appreciate it.