Episode 2: Unpacking Pain Neuroscience Education (PNE) - Benefits, Misconceptions and Criticisms

Transcript

Sophie Shephard: Hi, everyone. And thanks for joining us again for our second episode of Beyond Pain and Fatigue. My name is Soph and I'm really excited to welcome everyone back, but also to welcome my co -host, Ollie.

Sophie Shephard: Hi, Ollie. How are you going?

Ollie: Good, so keen for today's topic.

Sophie Shephard: Yeah, absolutely. So today we're here to talk about a little bit more about pain neuroscience education or PNE. And we have a lot of thoughts, a lot of different things we're keen to sort of unpack in today's session. But guess before we dive more into pain education and I guess some of the the nuances around the research and application of that and and some of the clinical takeaways. Ollie, I'm keen to just check in with you generally. How has the last week or two been? And I'm wondering if maybe just in general there's been anything you've been reflecting on or anything you've learned in the last week or fortnight maybe that you'd be comfortable to share.

Ollie: sure I, as, as, uh, people might know, we see a lot of, uh, dysautonomia related conditions, especially, uh, pots or postural orthostatic tachycardia syndrome.

Ollie: And I've been reading into this current state of the evidence around exercise for pots. It's, it's potential benefits, it's potential dangers and everything in between.

Ollie: And, it's got a lot of parallels to what we'll be talking about today that it might not be curable, but it has an important spot in management.

Sophie Shephard: Yeah, awesome.

Ollie: How about you?

Sophie Shephard: And I'm really keen, I'm really keen actually to chat to you more about that and some of the takeaways, because I know we're kind of planning to do a bit more of an episode on POTS soon.

Ollie: future episode.

Sophie Shephard: So it'll be great to hear that come through. Sorry, I cut you off. In terms of things that I've been reading and something I've learnt, I am currently halfway through digesting a ah very

Ollie: okay

Sophie Shephard: dense but very amazing paper that recently came out, really unpacking the idea of the nervous system and the neuraxes in Ehlers -Danlos syndromes and how basically the nervous system might be explained through that lens of connective tissue to explain a lot of the comorbidities we see in EDS. So it's an amazing paper.

Sophie Shephard: Highly recommend and it might be something that we are again dive into in a future episode as well but Yeah, that's what I've been getting through and I'm still digesting and and know fully sitting with that so I'll be keen to keep everyone posted but thank you for sharing and Yeah

Ollie: so Thank you.

Sophie Shephard: I guess if we were to launch into you know the the the bulk of our podcast today, so pain neuroscience education, pain and E, not particularly a small topic.

Ollie: and anyone

Ollie: No, no.

Sophie Shephard: I'm wondering, Ollie, maybe if you're comfortable, yeah you know I think it's probably helpful when we're having these conversations to get a bit more of a sense about what P and &E actually is and what we mean. Because i I mean, my sense from what I've seen is that there is quite a lot of conflating of different terms and sometimes the the actual clarity around what we're talking about with that is maybe not always consistent between different people. So would would you be comfortable maybe giving people an idea as to what we're talking about when we talk about P and &E?

Ollie: For sure. So PNE or pain neuroscience education is, I guess it's two things in my mind and and but and this the tension between these two would be the large bulk of what we talk about today. you it's It's researched and and published as as an intervention on its own, a way of of reframing and and educating people around the I guess actualities of how pain emerges through the complexities of our nervous system and its interrelated systems and and and its distinction, I guess, between the idea of tissue damage or nociception and pain as ah as a key concept and and its potential clinical benefits in in different conditions and different you know clinical variables, like whether it's

Ollie: pain intensity itself or disability. But the second thing is that sort of pain neuroscience education comes out of it maybe a bigger so bigger idea of explaining pain itself or making sense of pain that's ongoing still, that emerges from two famous people, Laura Moseley and and David Butler. and And it's maybe more of a looser umbrella across it. but That's sort of how I make sense of it, from the conflicting definitions and and phrases in different papers.

Ollie: But how how about you, Soph? Because it's I can find you get different answers depending on who you talk to.

Sophie Shephard: yeah Yeah, look, it's i think I guess maybe the common conflation that I would see and and sort of the the mixups that we see in these concepts is that I think at its core pain neuroscience education or PNE, it's really a educational intervention and and it's really specifically targeting helping

Ollie: How do you describe it?

Ollie: yeah

Sophie Shephard: someone to better enhance or change their understanding of how pain actually works in the body and how it comes about. So it's really honing in on the I guess the process and the experience of pain itself. I think a common misconception that I often see and where maybe things kind of get mixed up a bit is when people kind of almost conflate pain neuroscience education or explain pain with with um education about specific pain management approaches or like, you know, sort of assuming that it means we're talking about

Sophie Shephard: the entirety of pain self -management, like talking about coping skills or relaxation training or goal setting or all of the other things that we know kind of come into that interdisciplinary approach. So I think sometimes I see those two things conflated. So I think just bringing it back to this idea when we're talking about pain neuroscience, education, P and E,

Sophie Shephard: And, you know, explain pain is kind of like the the most recognisable sort of form of that, I guess, and probably the form that has been researched more, I would say, is that we're really looking at that sort of more narrow educational intervention that specifically is looking at improving someone's understanding of pain itself.

Sophie Shephard: So it's possible to do education in pain management that doesn't specifically go into the neurobiology of pain and that wouldn't be PNE. And likewise it's possible to kind of do PNE alongside discussion of of coping skills and we'll kind of talk about that more I think later in the episode about how this should fit. But it's it's you know quite a ah ah narrow sort of definition. I think that's important then when we're talking about what the research says in terms of its efficacy and I guess some of the criticisms that come about because I think sometimes that that different framing really influences some of the conversations we're having in this space. so yeah That's my my take on it, I guess, and and probably just for full disclosure as well we're talking about pain education, just so that people are aware from from my background. so um'm I'm obviously a pain physiotherapist by training, but I was also part of Pain Revolution, which is a not -for -profit that

Sophie Shephard: you know their their drive is to really help support and upskill health professionals and communities in rural and remote areas to be able to better manage pain in their communities. And so as part of that, they have what's called the local pain educator program where they actually sort of sponsor and mentor local clinicians to undergo further training. So um did a professional certificate of pain science through University of South Australia.

Sophie Shephard: which is very much based around a lot of the concepts that we'll talk about today. And the expectation is we then go back into our communities and help support other local networks and and sort of help share and disseminate that. So I think that's important for transparency for me because I am clearly coming from a very P and E positive background and and I want to make that clear that generally, yep, I'm very pro this.

Sophie Shephard: But that being said, I think it's also really important for us to acknowledge that there are some, you you know, some valid sort of concerns or criticisms or I guess issues with maybe how PNE is actually applied. So I just thought I'd throw that out there. But Ollie, I guess I'm keen to hear you talk a little bit more about, you know, when we think about PNE and we think about the clinical context, why do we need it? why Why do we bother with any of this at all?

Ollie: It's a great question and one that's been close to my heart and led me into this area of practice in the first place. When I graduated, I came across, or just before I graduated, my final presentation research kind of project thing was was around Bendalo's research. So Bendalo is a physiotherapy researcher out of New Zealand. ah Really Really wonderful research. He's done some great work.

Ollie: validating a long held belief by many people out there that a biomedical view of of pain, particularly more chronic pain like like low back of pain can actually be harmful and and get in the way of people's recovery because of the nature of the conceptual sense making itself the that the way people see their bodies, the way people see the problem that they're experiencing actually gets in the way of them getting better.

Ollie: and and that I think that there is is is something that people like David Butler and Lauren Mosley saw a long time ago and many other great clinicians around the world. and and it's And it's this need to go, okay, well, if a biomedical view of pain doesn't work, then then how do we change that? And I guess maybe trying to understand a biomedical, like define that in the first place, it's something I'm kind of,

Ollie: clutching at straws as I try and think of the right words and maybe yourself. So if if you were to say, to to briefly describe what a biomedical understanding of back pain or pain itself is, as opposed to a non, how would you describe it?

Sophie Shephard: Yeah. And I think this probably reflects the general trends and shifting in our understanding as well, because we know that for a really long time, you know, going back as far as Descartes and, you know, philosophers way back when, you know, we've we've kind of historically always had this very, you know, very strong, and I think a lot of the time quite instinctive understanding of pain as something that is

Ollie: Yes.

Sophie Shephard: basically the direct result of tissue injury and I think that makes sense right when we've most of the time when we've experienced pain and when most people have experienced pain in their life it's usually in the context of an injury or something identifiable like that's that's kind of the the typical experience you know you might maybe break a bone or you might you know have some other sort of injury and it hurts and so that association between injury and pain makes a lot of sense and and often pain does happen in association with injury. But the last few decades, I think particularly, has really shown us you you know this huge shift in our understanding of pain. and I think one of the troubles we had was that that very biomedical or that that older way of thinking about pain

Sophie Shephard: It worked for some people and in a lot of cases maybe didn't cause issues. you know A lot of people might have recovered or traveled along their recovery journey quite fine with that with that process.

Sophie Shephard: But there was this reality of a lot of people not fitting in that model particularly well and that understanding didn't go far enough to explain a lot of the complex real world experiences we see with people.

Ollie: Okay.

Sophie Shephard: so We know that, for example, sometimes pain can occur well after an injury is healed. And this is the case for many, many people who might have chronic pain that, you know, for all intents and purposes, you might you might image them or, or you know, have a look at their image, at their injury and kind of on surface level, everything we can tell looks OK, but their pain has persisted. Those ways of thinking about pain don't explain that particularly well. also know that people can experience pain

Sophie Shephard: quite spontaneously sometimes and in the absence of any obvious sort of tissue pathology. So that you know really left people in a horrible spot because when we're viewing pain through this lens of being so closely tied to injury and that's kind of the main driver, when people, as a lot of people do, we're experiencing pain or symptoms that didn't have a clear biomechanical or anatomical cause,

Sophie Shephard: it basically the only natural assumption was well this person must be faking or there must be drug seeking or malingering which is like has been horrible and and unfortunately that that view and those sort of assumptions still are quite prevalent but you know even just thinking more broadly about everyday experiences we have like you know we know that say our finger like a paper cut tiny, tiny amount of tissue damage, but how much does a paper cut bloody hurt? Like, you know, these sorts of things or getting the flu and feeling like you've been just absolutely hit by a bus or a lot of people who have chronic fatigue, for example, might also resonate with this idea of just whole body aches. And we know that we haven't

Sophie Shephard: structurally injured every part of our body, but you know the pain is no less real. so I think it reflects this this change over time that we know that just seeing pain as a result of tissue injury didn't go far enough to explain the complexity. and Basically, the last few decades has led to this explosion of research and this recognition that pain is way more complicated than this. and so While the old way of looking at it might have been what we call sort of the biomedical model,

Sophie Shephard: Really, this is now expanded to try and understand pain as biopsychosocial, which is acknowledging that there's a range of biological factors, psychological factors, social factors that contribute not just to how well someone copes with pain, but actually the experience of pain itself. And what PNE or pain neuroscience education and and most, I guess, up -to -date approaches to pain management are informed by is this acknowledgement that there is complexity in a lot of different factors that influence pain. And so taking that big picture approach and trying to sort of work with as many of these factors as we can unique to that person's experience is how we're likely to get

Sophie Shephard: the best outcomes and and I mean you kind of touched on it before but there have been there's been a lot of research to show that when when clinicians stay completely stuck in this very biomedical or outdated model of practice, at best it's limiting because we're only ever looking at injury injury factors.

Sophie Shephard: But at worst, it can actually be harmful because, you know, theres there's a lot of research now to show that in different situations that that very biomedical focus might lead people on to sort of unnecessary sort of investigations and even potentially surgical interventions. But yeah, I think that's about as ah brief as I can get it. It's fairly complex thing to try and unpack in a very short space of time. yeah, what are your thoughts? How does that resonate with with your understanding and how you'd explain it?

Ollie: Yeah, I mean, completely agree. It's that that evolution in sense making. And I think you can't quite make sense of this conversation without some key scientific viewpoints and philosophies. And I think what we talk about throughout this is the failure of reductionism, and that that you can explain something by reducing it down to its parts and understanding it. It's sort of a yeah the the hard sciences and and much of biological sciences led us very to very successful outcomes, you know wonderful life -saving medical treatments. But as we know with so much chronic disease, the complexity, and that that word that you mentioned comes up again and again, flies in the face of of of reductionism. Being ultimately useful is the sole way of making sense. and and

Ollie: I think one of the, one of my favourite papers to sort of explain the, to relate the real world experience of this when I'm trying to share these ideas with people is one that, it's over 10 years old now, I think it's 2013, you'll know it well, so Stephen Lin and Peter O 'Sullivan and some other authors out of Curtin University looked at Indigenous Australians in I think Central Australia and Western Australia, so Southern Northern Territory in Western Australia and their experience with chronic low back pain.

Ollie: and how they made sense of and sought treatment in either a ah ah cultural context, indigenous or in a more, I guess, Western biomedical sense. And what was really interesting around that paper, separate from Ben Dalow's work, but confirming the same thing was that people tended to get more pain, more disability, more chronicity of symptoms if they engaged in and Western medical, biomedical treatment pathway, as opposed to more cultural, you ways of exploring and making sense of it. And and that that always blows my mind that that we could actually make pain worse, that iatrogenic idea of pain and

Ollie: And it's and i guess this is where we we can talk about maybe the the evidence for it now like where where did it actually how have we tested this because out of this great need came a lot of great work from people like adrian lowe and we've come to so see it in a different line.

Ollie: where Where was the first trial or first bit of evidence that you saw, Soph, that started to see whether this was working or not?

Sophie Shephard: in terms of what I had come across, like my first exposure to it personally, or yeah, to be honest, my initial introduction to like, it was a very, very rough introduction to pain education.

Ollie: hello Yeah, yeah, your first exposure.

Sophie Shephard: Like I think this is probably the experience of a lot of people going through physio, particularly.

Ollie: Yes.

Sophie Shephard: Like I think the grand total of my pain education as a clinician was like a single tutorial in my fourth year, hidden amidst one of our other subjects on like chronic disease.

Sophie Shephard: And it was literally just like a one hour tutorial where most of it was spent watching Lorimer's snake bite video, which 10 out of 10 can recommend. I'll link it to anyone who's interested because it's fantastic.

Ollie: It's the best.

Sophie Shephard: I'm, I'm, I'm fully convinced that if Loz wasn't and amazing neuroscientist, he probably should have been a comedian. but that But that was kind of like the sum total of it, right?

Ollie: Great. Yeah.

Sophie Shephard: Like it was kind of just this afterthought of like, by the way, pain's maybe a bit more complex than we thought.

Ollie: Wait, what?

Sophie Shephard: And then it was like back to operation normal and we kind of went back to all about other learning. and and And again, I think it probably reflects a bit of what we're going to talk about today because I kind of came away from that going, great, how does that help me in terms of strategies that someone can use or like, you know, how do I translate this in a clinical setting? And I think it kind of comes back to what we were talking about before when we were talking about, you know, why does PNE matter or like, why, why has this need come about? And I think,

Sophie Shephard: you know we We know that just being rigidly adherent to maybe outdated medical, biomedical views on pain can be harmful and often do limit people's capacity to recover but because we're inherently adopting a very limited view of of the factors that might be influencing that experience. And certainly, you you know what will probably end up being another episode at some stage is maybe the impact of of language and some of the complexities around imaging. And there's so many different things we could talk about here.

Sophie Shephard: but I think what it comes back to is the reason that the PNE matters is because we, what we think and how we view a situation and how we make sense of our experience has a direct impact on our behavior and the things that we're likely to do to manage. So it makes total sense. For example, if like many people do, someone with back pain,

Sophie Shephard: sees their back pain and has been sort of given information in the past that suggests that their back pain is because their spine is degenerating and have a degenerative disc that you know needs surgery at some stage. if you think about I guess what that what meaning that has for the person, if you imagine sitting in that, and I know for for many people listening to this, this might be an experience that is already something that you have, but I'd encourage the clinicians particularly to think about what that means, to reflect on what it would feel like to inhabit a body that fundamentally feels unsafe to exist in, because reflecting on how that would feel for me, if I were thinking about my back potentially degenerating and and falling apart, and we know that there's often a lot of maybe unhelpful language that does get used, but

Sophie Shephard: Even just the concept of degenerative disc disease, you know it implies decay and degeneration. and and If people feel fundamentally unsafe in their body, what's the likelihood that that person is going to feel comfortable to move or to exercise in a way that we know is conducive to recovery?

Sophie Shephard: And if if that's sort of the the only the only explanation or the only sort of context that they're given as to why their pain is persisting, then of course the treatment strategies that they might engage in are going to be those A, that their health professionals advise, which often are very much more biomedically oriented anyway because of that persistent sort of biomedical approach to pain generally. but

Ollie: And.

Sophie Shephard: you know, it's it's also going to limit the scope of things that they see as opportunities to help manage and and the things that we know research has shown us are so important in an interdisciplinary approach. So, you know, it's it's it's not so much the understanding and the and how someone makes sense of their pain is really important and how they understand pain itself is important because it influences behavior and how they manage. And and I think that's the the key thing here. We don't necessarily inherently need everyone to have a full blown neurobiological understanding of pain, but where those understandings may limit their

Sophie Shephard: their opportunities for management in in an effective way, that's where we need to do it. And as clinicians, I think it also comes back to making sure that through the process of delivering care, that we're not maybe creating those you know unhelpful effects inadvertently, you know through not through any malice, but by adhering to some of these biomedical models, that we might unintentionally be causing harm and limiting someone's recovery. so Yeah, I guess it was it was a very early on sort of exposure to it and probably very slapdash, which will be good to chat about. What about you though, Ollie? What was your experience like early on first becoming exposed to some of these ideas?

Ollie: Same. i had had the Lorimer Lecture and Physio from the pain unit, the interdisciplinary pain team at Townsville Hospital, because I studied at James Cook Uni in North Queensland. and And it kind of felt a bit insulting, not because she was in any way incompetent. She was actually brilliant. And of course, the Lorimer Snake Lecture is is brilliant. I still marvel at his, like,

Ollie: ability to to to weave humor and like really challenging intellectual concepts into a short little story like that because it's done so good so much good but I had this feeling of you're telling me you're giving me this little oh by the way uh you know tissue damage and no deception doesn't always matter and it can potentially get in the way and i kind of went like hey wait wait wait wait what it was it was it was like being told the world was flat for three years and then all of a sudden i was introduced to a heliocentric model of the universe and kind of went what do i do now exactly

Sophie Shephard: Yeah, you're like, what about the last four years I just spent looking all at tissue stuff? Like, yeah, where does this fit?

Ollie: Exactly. I mean, we've been talking about like, yeah, all the, you know, the low low back pain is completely because of some little muscle called the multifidi was placed by fat in in people with low back pain. And anyway, it's a bit of a nerdy one for people out there that are clinicians, but I guess it just came back to the sense of going. and And I guess maybe this can be our point of talking because it's a challenge as PNE has been applied and researched and and used by many people out there is Well, if tissue damage doesn't always matter, when does it matter? Because this has been probably the central pivot point around my clinical journey as I've evolved as a physio, is that sometimes it matters, sometimes it, I think it always matters, but perhaps how much is the question?

Sophie Shephard: Yeah, absolutely. And I i'd like, i I totally agree. I think it's the application, I think is the hard bit and it's, it's coming back to what you said before.

Ollie: Yeah.

Sophie Shephard: I think reductionism is a huge issue, right? And I think, Throughout probably, I reckon the rest of this podcast, we're probably going to be really deliberately sort of leaning into maybe being a little bit more critical from from both angles because I think that's important when we're unpacking the application and some of the issues or difficulties with some of this stuff. But I think it it does come back down to this core issue of reductionism, you know, our old models of pain.

Sophie Shephard: want to try and reduce the experience of pain down to a single cause and that often isn't particularly effective for a lot of people. But, you know, I think maybe one of the fundamental misconceptions and and probably isn't helped by the way it's taught is that the biopsychosocial model of pain and more of the P and E type approaches are fundamentally at odds with biomedical Approaches and i actually you know that's a myth really like you know if if we're taking a complex nuanced view of pain and really embracing the research we have it it actually incorporates

Sophie Shephard: tissue pathology, it incorporates disease. It's not saying that we're ignoring these things. It's just that it sits within that bigger context and it encourages us to maybe be a bit more critical about the relative importance and the unique contributing factors for that person that are contributing. And I think that's the bit that gets missed. So as much as maybe there might be a tendency for I don't want to say newer clinicians because certainly very experienced clinicians as well who might have learned more about pain. like one I'm going to speak to observations I've seen just on social media and maybe professional networks. and This is not representative of everyone, of course, but in terms of looking at both ends of the camp.

Sophie Shephard: I think there can be a tendency for us to see, we're very quick to criticize people who might be stuck in those very biomedical models.

Ollie: ram.

Sophie Shephard: right We're like, it's very reductionist. you know You're seeing pain as just tissue injury or pathology and you're causing harm because you know it's pushing people down you know unnecessary surgery and it's limiting their recovery options and you know all of that.

Sophie Shephard: so We see a lot of that and I think that we're generally a lot more comfortable with that than maybe I think we should be. but Because I think the the the issue we have is that there's also a lot of reductionism from the side effects from the side of the fence that people are sitting in from a P and &E perspective. And you know there is trying to reduce this down to you know pain is just a perceptual output and maybe, you know, not appreciating some of the more tissue based factors. I see a lot of people slipping into almost that over, you know, that very neurocentric perspective of pain and maybe missing some of the more important biomedical aspects that we need to incorporate.

Ollie: Definitely, definitely. i Because you're a you've had this experience rich experience as a local pain educator, maybe we can come at it from, because to me, where like where it goes wrong and where it goes right pivots around these key messages, the the key points of that include PNE.

Sophie Shephard: Mm.

Ollie: Because I'm mindful of the fact that many people listening are going, yeah, OK, but explain what it actually is and what it involves. and so Maybe if we can go through the points that are generally included, at least in and in an explained pain version of pain neuroscience education, and why they're there, and then like the the the reductionist pitfalls of people grabbing onto those too much. Because that's I think that's where you're going to, and it's a really rich thing to talk about.

Sophie Shephard: Yeah, yeah, for sure. And I guess like before i I explain some of those concepts, I guess the thing to highlight is that one of the miscon another one of the misconceptions I think we see is that PNE is like this very prescriptive, like very defined, here is the education you give people and this is what it looks like.

Ollie: Master.

Sophie Shephard: like I think the amount of times that I've had people assume that because i I deliver pain education sessions that that must mean I just literally sit people down for 45 minutes and explain pain at them.

Sophie Shephard: And like, look, don't get me wrong. i will I will cop out to this and say that when I was early on in my career and I just started really delving into this, I was so excited by the like the the possibilities that opened up because I was seeing so many patients who were just not not progressing and I was struggling to help using those older models.

Sophie Shephard: And so for me to come across something that's like, wow, there's there's more out there. This is more complex. there's There's more we can do to help people. I got really excited and this is very clearly a special interest of mine is is pain and pain education.

Sophie Shephard: So I absolutely have been guilty of being that person that probably just sits down and explains something.

Ollie: Me too. Me too.

Sophie Shephard: Yeah.

Ollie: yeah

Sophie Shephard: But that's kind of the persistent view of what PNE is. and And when we talk about what's included in it, I think it's important to recognize that PNE is an educational intervention and it has its roots in educational theory.

Sophie Shephard: So if you go and actually do an explain pain course, A big part of that course is actually talking about educational theory and how there can't be one size fits all because everybody is going to be working with a different baseline conceptualization of pain. They're going to have different experiences and they're going to have different you know sort of yeah i guess views of their their situation. and so Not only are they starting from a different point, but also the purpose for education might be very different depending on the

Sophie Shephard: the impact it's having and what we actually need to change. So straight off the bat going to debunk that it's this idea that there's a set, you know, explain pain. I think the challenge is that sometimes that's how it's been applied.

Sophie Shephard: And I think that's a huge thing to, you know, dive into. But in general, what, what I'm going to talk more specifically about explain pain because it's kind of the the recognizable sort of model of this that we have, but effectively explain pain.

Ollie: Eh.

Sophie Shephard: and the core concepts that sort of feed into the education is that you know pain is much, much more complex than just what's happening in the body tissues and effectively that nervous system is very complex and so the nociceptive or danger messages we might get from our tissues to inform us of things going on in the body tissues is definitely part of it but there's also a really potent influence of things like context and past experiences and other things going in on in your body systems at that time as well as just the broader environment and the meaning and and context in which that pain is occurring and the person's belief and interpretation of the level of threat. And so it kind of conceptualizes pain as this really concepts, complex perception that you know it's it's framed as as normally being protective. So normally pain would serve a protective role because when we have pain, it's ah ah it's a signal for us to think, oh, there's something not right. And it influences behavior. We might slow down. We might stop. might influence what we're doing in some way.

Sophie Shephard: And so it it sort of goes into some of the biology of that and the different sort of messaging pathways that might exist in the body, but also some of those you know higher up sort of processes in the nervous system that happen and different ways in which the body can affect that output.

Sophie Shephard: So it's pretty like it's complex stuff and I can kind of understand I guess why there has been a bit of a challenge into practice with this. But I guess to to give like a more concise sort of explanation as to how we could think about or view pain that I found works really well as a clinical and metaphor when I've been working with people.

Sophie Shephard: I kind of see pain as ah ah similar similar as a perception, similar to hunger, right? Like we know hunger is a ah ah perception that we have within our system. It's a signal for us to inform action, you know, it informs us that we might need to do something to eat and it's driven by survival and keeping the body, you know, safe. So it's similar to pain in that sense.

Sophie Shephard: Definitely we know that hunger is influenced by what's going on in our stomach and if our stomach is empty, you know, we're getting messages from our stretch receptors in our stomach to see how empty or how full. so those signals, of course, matter. But when you think about hunger, what happens to our sensation of hunger when we are generally unwell? What happens to our sensation of hunger when we're stressed?

Sophie Shephard: what happens to our sensation of hunger when we're maybe otherwise distracted or the context is different. even thinking about that idea of protection, you know I apologize in advance if anyone has a bit of a queasy stomach, but those of you that have had like a really significant episode of food poisoning in the past,

Sophie Shephard: think about what sort of response even now you might have if you think about the food that gave you that really bad, bad of food poisoning, right? Like that almost visceral sort of reaction. Sometimes I know I have that.

Ollie: on my

Sophie Shephard: And so that's that element of past experience and memories. And a lot of people will struggle to eat anything that has triggered that for them in the past. So kind of similar in, in, if we think about pain in that sort of light, you know, these are kind of similar ideas, really.

Ollie: So you're speaking to a way of, brilliantly described by the way, I've never I mean, i'm everyone knows I'm a big fan of how Soph describes things, but that was a brilliant way of describing hunger and and pain because they're they're so similar in that way and all the hormones that go into it and ghrelin and now the things we're seeing around these GLP agonists.

Ollie: it's it's It's quite quite an apt parallel to it. But with as you describe the beliefs and everything that you're talking about, ah ah guess, a model of how we make sense of pain that was made famous by Louis Gifford, the late great Louis Gifford, the mature organism model. And you're far better at explaining this than me.

Ollie: how How would you briefly describe the mature organism model as opposed to perhaps a ah more reductionist model of pain?

Sophie Shephard: Yeah, for sure. And I'll try to, you know, keep too much in depth conversation of pain models, like to a minimum, because I know we could be here forever, but yeah, yeah, absolutely.

Ollie: It's a guilty pleasure. yeah

Sophie Shephard: Like I'll hold anyone hostage for as long as I like and talk about this stuff. Um, in the interest of conciseness, so yeah, you know, the, if we think about maybe our old school sort of biomedical way of thinking, it was basically like pain is something that happens in the tissues.

Sophie Shephard: Maybe you, you know, if we use the classic nail in the boot story, you know we We say you know we may be a step on a nail or we have some injury to the tissues. we Our nervous system detects that pain and then shoots the pain message up to our brain and it's when that happens that our brain becomes conscious and that's how we that's how we perceive pain, basically. That's the the old way of thinking, but like we kind of mentioned before, that often doesn't explain a lot of the complexity of experiences what actually plays out in the real world. when you challenge it, maybe that doesn't hold up so much.

Sophie Shephard: And the mature organism model is really kind of the basis of a lot of the explained pain, education, and sort of where it stemmed from. And it's a little bit more complex. So like you mentioned before, it kind of separates out the idea of nociception or danger detection, which is basically our nerves that are monitoring our tissues for big changes in things like pH or mechanical disturbance or inflammatory molecules or things that might indicate there's something awry.

Sophie Shephard: we We do have that nociception or danger detection happening all the time, all the way throughout our body. and That certainly can provide information that can inform pain when we've had an injury. But the mature organism model of suggests that we're having both that nociceptive information being sampled at all times and coming up through the nervous system to the brain.

Sophie Shephard: But because our our nervous system is much more sophisticated than you know just a simple set of wires, there's also a lot of very subconscious processing happening of all of the other information that our nervous system has available to it. And so it's not just that nociceptive information that might be being processed, it's also things like What else is happening in other body systems and and how's the general level of body functioning homeostasis and and is there you know are we sitting in a good space for that? The nervous system is also sort of sampling information about the broader context and the environment and and what's actually happening in this moment around me, but also what meaning does this situation hold? and

Sophie Shephard: I guess, drawing on things like you know our our brains are amazing in terms of learning and sort of adapting to past experiences. and so Even past experiences of pain or coping or adaptive strategies are being processed. and It's only after the nervous system sort of processes all of this information that there's sort of potentially a perceptual output of pain. and the idea is that the more evidence of potential threat there is amidst all of that information that it's more likely we'll experience pain or that pain will be more severe and likewise if there's sort of more evidence of safety then it's it's it's more likely that will be dialed down and there's sort of this perceptual output which is the actual I guess the pain aspect of things but often there's also this behavioral output as well which is where the person takes action in response to that

Sophie Shephard: and and ah often automatically too.

Ollie: Yeah.

Sophie Shephard: So often the responses we might have, you know, happen before we're even necessarily conscious of of pain as well. So it's really complex. And I guess just to highlight, like you touched on, there's a lot of different models coming out now.

Sophie Shephard: i'm the one thing that I'm really aware of is that you know, the explained pain model, the mature organism model, it it isn't without criticisms. And in many ways there are, you know, concerns about whether it is reductionist in and of itself and whether it goes far enough to actually explain the complexity. So, know, even, you know, some of the phrasing around, you know, is, can we truly say pain pain is protective in some of the more, you know, philosophical arguments around that, you know, that's all up for debate. But yeah, I guess that's sort of the

Sophie Shephard: you know, the the model we're using. And so you can see that's very different to just our more traditional sort of biomechanical, biomedical view of pain.

Ollie: sort of I guess the evolution from that that you're saying there and and despite its you know potential criticism around semantics and philosophy which is definitely another episode um is that is the context matters that meaning is an important part in addition to the biology of whatever's happening in our tissues and I guess that example for those who haven't had the the joy of watching Lauren Mattelli's snake story. Spoiler alert, he he brushes past what he thinks was initially just a twig scraping his leg as many people would when they hike wherever they are in the world. But in Australia we've got lots of things that want to kill you and so one of those things was a snake and he later realised it was a snake.

Ollie: massive problem went to the hospital and then on a later hike with these new updated experiences that threatened his you know survival and existence the meaning of scrapes on his leg suddenly took a turn and what was thought to be an actual snake bite was the opposite was now just another twig scratch that he thought the first experience was and so it's this There's so many examples like this and and I guess they're used in many pain neuroscience education programs and and ah ah curriculums around the world that there's these fun examples that show it. But I think we can all attest to an example, right, where where meaning changes. One of my favourites from a great scar on my knee was when I was running along in tropical North Queensland and it was raining and I tried to

Ollie: jump around a puddle and there was I went up onto the ledge of a footpath and as I jumped back down off that ledge my foot slipped and I and i landed on the footpath and a a nice perfectly um sorry for anyone who's a bit uh squeamish scalpel -shaped rock hit the front of my knee just underneath the kneecap and opened it up and I didn't realize at the time that I got up and was like, oh, my knee feels a bit warm, but I'll just keep jogging. And I jogged around the corner and went, oh, it's not really letting me jog. That feels a bit weird. It's a bit like warm, a bit vague, maybe a little bit prickly, but it didn't feel uncomfortable at all. It was just a bit odd. And then I looked down and I saw the extent of what had happened and all of a sudden the the the the intensity of the experience hit me. And it always amazes me how

Ollie: Yeah, how that perception comes in, and people can get into arguments for hours about this, but I guess it's the perception and context matters at the end of the day.

Sophie Shephard: Yeah.

Ollie: Yeah. okay

Sophie Shephard: I think my favorite example, because I think, you know, often we, we talk about examples that maybe seem a little bit more extreme, like, you know, the nail in the boot story and and all these things.

Ollie: yeah He's outlined.

Sophie Shephard: But I actually, I think the interesting thing is like thinking about the actual real clinical examples of this we see. And I think, you know, particularly speaking from a physio context, I don't know if this is something that you'd seen, Oli, but it's something I've seen at least a handful of times in the past where when I, back in the days when I was maybe doing more general sports and musk.

Sophie Shephard: you know I've had several people now who have sort of presented for an acute you know knee injury who have previously done an ACL and had an ACL reco and they've come in and and you know had really significant pain and even sometimes you know the swelling and the feeling of instability and all the stuff that would have alarm bells you know going for acute you know ACL re -rupture.

Sophie Shephard: and I found it interesting on ah ah and at least a couple of occasions now, how, how distinct that feeling is and how, you know, that, you know, it'll be like, get the pain is exactly how it was when I did it the first time.

Ollie: I dare to move on.

Sophie Shephard: This feels identical. And you sort of would swear based on that, that they have reruption. And of course, I, yes, absolutely. People do re rupture their ACL after, after doing that.

Ollie: there part

Sophie Shephard: We know there's a high risk of that. But I've had multiple people who have had that and when we've actually assessed them, their ACL is completely intact and there's actually no structural issue. But I just found it really interesting because I think reflecting back on that, to me, it makes sense when we're thinking about some of these these models because ACL rehab, for those of you that are fortunate to not have had to be experienced with it, you know it's a really it's often quite a significant knee injury. It's often quite painful, often quite you know limiting in terms of function, but the actual surgical process and the rehab process, often an ACL injury and surgery often represents like more than 12 months off sport. For example, you can't return.

Sophie Shephard: and There's a lot of intense rehab involved. so you know It's a pretty significant event. and so It makes total sense if we're thinking about the the learning that the nervous system does and and trying to protect us against potential threat that if a similar mechanism happens, our nervous system is thinking, shit you know this has happened to us before and this was really bad, protect, protect, protect.

Sophie Shephard: and you know then You know, they seem to, these people in particular who hadn't necessarily re ruptured once they kind of can have that reassurance that actually know things are intact. You know, it's not like it's an instant.

Sophie Shephard: Yeah, they're good, but they do, you know, had seemed to resolve pretty quickly. And I thought maybe this was just a weird thing that I'd seen, but I'd speak spoken to a few physios who have sort of had a similar experience.

Ollie: right

Sophie Shephard: I actually haven't spoken to you about this specifically. all Is that something similar or and are there experiences you can think of where you've seen a similar thing?

Ollie: Yeah, for sure. I am ACL rehab is not something I've had much experience with or seen many cases on. But the I guess the the level of um swelling and and and And symptom intensity and in knee and ankle and hip injuries after big operations is something i've seen a lot of minutes it speaks to perhaps where we'll talk in future episodes about the complexity of how. Biology still matters and that and that and a threat response to a feeling of oh my god this is the same thing happening again even if the.

Ollie: specific tissue whether it's the ligament or the labrum of the hip or whatever hasn't been damaged in a bad way again. Perhaps mildly irritated in the joint induces this whole protective response that's you know involved from the neurons in our cortex all the way down to the you know cartilage in the joint.

Ollie: it's and And it speaks to maybe where, where you were going to before, but what I'd love to come back to is the, the, the reductionism within PNE itself, like where we can go wrong. Where perhaps the, you know, the biopsychosocial model can be unfortunately dichotomized or trichotomized. I love saying multi -syllatic words.

Sophie Shephard: yeah Yeah, absolutely. like Well, I guess before I do that, though, i'd I'd love to throw back to you, you know, with you reflecting on some of those experiences that you've had in the clinic and seeing, you know, that sort of pattern where people might have this sort of, you know, enhanced sort of protective pain response, you know, after a sort of similar

Ollie: Yeah.

Sophie Shephard: injury or mechanism, I guess. For you as a clinician who's worked both in musk and sort of sports stuff, as well as more recently kind of working in more of a ah ah pain space, do you do do you sit that person down and do 45 minutes of pain at them? What does it look like?

Ollie: gosh, behind the cloak, no, no, no, I learned very quickly my first two months of being a physio. Thankfully from from one or two particular clients that have quite complex histories of chronic pain that talking or talking at someone is never a good idea. And so I think I've learned maybe not as explicitly early on. And now I've got ways of explicitly knowing what I'm doing when I do it, of of going, no, I need to make sense of what's important to them. And so, you know, I might think in my head, there's a whole bunch of things that would be great for them to know, but really, that's just what I think it would be fun for them to know. what what What I come back to now, and maybe what we'll talk about is a much more person centered thing of going, okay, well, within their context, what are they most concerned about? What do they want to know? What are their goals? And then maybe if there's something that

Ollie: will get them to their goal you know a bit of information oh actually yeah you know the tissue is not that damaged then i'll focus in on that but sometimes it's just worth not even you know rustling any, ruffling any feathers or challenging concepts as is so often misconstrued with this that it always involves being a know -it -all and being a Hermione and going no actually you're wrong like

Sophie Shephard: Yeah, yeah, absolutely. and And I think that's the thing that annoys me most is like, I'm convinced that a fair chunk of people out there would think that when they see pain physio on my little, you know, Soap Chef pain physio that literally that's the view they have is that we're just sitting down and talking pain at people.

Ollie: Yeah.

Sophie Shephard: And I think particularly from an acute setting, because I think that's another sort of misconception is that there's this idea that explain pain is or pain neuroscience education is only relevant to chronic pain. And I think when we embrace that complexity, actually, it's important for all pain. It's just that we acknowledge that.

Sophie Shephard: not always, but at different stages of recovery and different levels of chronicity, there's likely to be different contributing factors. and you know like I think that's one of the things that I find gets in the way the most is that there's almost this, again, very reductionist idea of like, well, why would I look at you know pain education when they're still in that acute phase or like it's not relevant to people who are in that acute phase but i think what you were describing before about you know when you're sitting there talking to someone and they're maybe having these experiences in that acute phase you might have ten thousand things going on from a clinical reasoning perspective and you're kind of going

Sophie Shephard: I could see, you know, there's an explanation for why that might happen. We don't necessarily need that person to have a full in -depth understanding of pain, but there may be elements of it that can be drawn out in a way that's helpful. And I think for me, the the the critical piece in that that sort of interaction would be thinking about, does is there a need for education in order to helpfully support recovery for this person. And so, you know, I would say that bits of it probably come through in terms of, you know, if I go back to my, my example with the ACL that, you know, you'd swear up and down, they'd re -ruptured their ACL and actually everything's okay. You know, I think bits of that pain education can bleed through in a more sort of organic way in the sense that

Sophie Shephard: We're able to actually, by understanding these processes, actually validate someone's experience and go, yeah, like I would have sworn it to based on what you were telling me, but actually from an assessment perspective, everything looks good. But also what you're experiencing is actually still very real and we could explain why.

Sophie Shephard: Why that's happening, um because there's a very biological reason. you know you I sometimes joke with people in those sort of settings. like You're not going crazy. like there's a very like What you feel is real, and it makes sense why you would feel it, but it it doesn't necessarily mean that there's the rupture, which is great news in this case. and I think sometimes it can be helpful from a reassurance perspective. of But I guess that like possibly also leads us into one of the other criticisms of P &E as well, and this is something that I, and I know you do too, feel really strongly about, is that one of the biggest criticisms I think is that, and probably fairly one of the shortcomings of P and &E when it's not applied well, or with nuance I think, is that

Sophie Shephard: there can be a tendency to, I guess, ignore or downplay tissue based factors.

Ollie: Yes.

Sophie Shephard: And I think that's one of the biggest criticisms and probably where the biggest divide comes from in terms of, you know, the the biomedical versus, you know, more sort of EP informed clinicians is, is this idea that, you know, explain pain can kind of ignore tissue injury and I'm guess I'm interested to get your take on that early around. Yeah, I guess what have you observed in terms of some of that or maybe what are some of the experiences you've heard from patients around that side of things?

Ollie: Oh, I have a wealth of stories thanks to a mentor of mine, Robin Kerr, who's really brilliant physio, who's done a lot of traversing over different, you know, clinical areas from like high level sports to women's health to chronic pain.

Ollie: And one of my favorite stories that sort of cements the point and perhaps a point of caution and where it can all go really bad is a young gentleman who she came to as a sort of later review third, fourth opinion type clinical scenario where he disc replacement and it had in his lower lower back, in his lumbar spine,

Ollie: and he had some low back pain and he'd reviewed unfortunately with a few physios and they'd sort of because of the persistence of his pain and because of the operation I'm not really sure they hadn't they hadn't touched him which was the classic criticism they hadn't maybe assessed as fully and so they palmed it off as more stress -based nervous system immune -based in the sense of maybe more psychosocial contributors to his symptoms or drivers of his symptoms than an issue in the tissue. And in this case, there was a significant issue in the tissue. There was a forward translation of the of the artificial disc into and and it was impacting and his abdominal aorta. So for those who aren't anatomy nerds out there, there's a big old highway, a large

Ollie: artery that that comes down from your heart in through the center of your belly to supply out to your pelvis and legs blood flow. And and it's if it is ever damaged or occluded or there's an aneurysm and if it's life threatening. And unfortunately for this gentleman it was life threatening and Robin just through some simple assessment found that this was something was off. you know there was ah There was a big gap in in his spine just from touching it and listening to the story and contextualizing it and realizing that in this case, I mean, of course, you know, all those other factors matter, but there was a there was a significant issue in the tissue and it wasn't as the common criticism is all in his head.

Ollie: I guess it never really is. But the challenge of this circumstance and maybe where we're at now is integrating all of this, because in that case, the, you know, he had to go off and get emergency care, but the

Sophie Shephard: . . . .

Sophie Shephard: Yeah.

Ollie: This stuff can, it matters. and And I guess where we came from that biomedical sense making and models of pain can make people worse. yeah And that iatrogenesis, which is every clinician's worst nightmare that you make someone worse from your attempts to help can happen just as much perhaps and if we mistakenly apply these ideas to naively.

Sophie Shephard: Yeah.

Ollie: and

Sophie Shephard: And I think that echoes a lot with what I would say. So, you know, in the context of our clinic, I've, I've in recent years, particularly done a lot of second opinion type work and often see people who have maybe gone through physio and other treatments and sort of not necessarily, uh, responded to the extent that they would like.

Ollie: Yeah.

Sophie Shephard: And so, you know, it's, I think the hardest thing is that often this is really well intended and, and, and I don't think it that that comment is limited just to physios who are maybe falling in more the P and &E camp.

Sophie Shephard: you know I actually think it applies to even biomedically -oriented clinicians as well.

Ollie: Yes, yes.

Sophie Shephard: you know Everyone is coming at this with the intent to help and to do what they can. like it's not There's not malice. This isn't intentional. I think what it is is that there's this process of trying to find out ways of doing that seem to be manageable and feasible within the clinical context.

Sophie Shephard: and While people might fall in different areas on that, there's there's risks to both. and you know i think I've certainly seen my fair share of people who have been you know gone through either pain clinics or even just seen other clinicians who have come away feeling really horribly invalidated. They feel like they've come away being told you know their pain is psychological or it's in their head and because it's the brain.

Sophie Shephard: and you know, we know, I mean, if we just look at, at, at PNE, we know that that's not what PNE is. That's not a core concept of PNE. That's in the, in the translation and doing the education in a way that is helpful and meaningful to the person. So it's not so much a problem with PNE, but in how we are actually implementing it in practice. but there's real harm that comes from that. And, and I think like.

Sophie Shephard: If we don't acknowledge the risks that come with doing P and &E poorly and commit to really embracing a nuanced view of it, and actually, I think it comes down to actually making sure that clinicians have a really good understanding of pain because that makes it so much easier when you're then trying to figure out how do we help this person make sense and what bits of this are relevant to this person's experience.

Sophie Shephard: It's so much easier to do that when you're coming at it from a really deep understanding. Whereas if you're only getting kind of the surface level snippets of it, which is the case for most people because we don't have a great degree of undergraduate training in this, is that we're then very restricted in the way in which we communicate these principles because we we lack that flexibility to kind of tailor it and explain in different ways or have different ways of drawing from it.

Sophie Shephard: you know we're We're only ever giving people really the tip of the iceberg, but if the tip of the iceberg is all we've got, then that inherently is going to be problematic for how well we can adapt it.

Ollie: Be harmful.

Sophie Shephard: I think that that's that's a huge problem and that invalidation. and I think the other thing, that um um particularly in the context of our clinic that we see, is that there are There is, ah ah again, a tendency from a pattern recognition perspective to kind of almost fall into this very reductionist idea of like, well, someone's had pain for more than three months, which means it's chronic, which means that it's it's you know these injuries should have healed. So it's there's going to be more central drivers that are keeping pain persisting. And certainly for some people that might be what's going on.

Sophie Shephard: The challenge we have is that we don't we have a lot of conditions that are really under -researched, under -recognized, and under -diagnosed as well. that you know there For example, one we that we see a lot in the clinic, you know we see a lot of people with a hypermobile Ehlers -Danlos syndrome, for example, where there is actually very

Ollie: and was done yeah

Sophie Shephard: significant ongoing structural stuff going on that requires specific management and support and tailored approaches. But if we don't acknowledge that and we just focus on the fact that they've got chronic pain and and that's all, then we limit ourselves.

Sophie Shephard: And you know while your example maybe was a more extreme case of something tissue -based that was missed and might not be the most representative you know example of that by any means,

Ollie: No, sorry guys apologies, I don't know where

Sophie Shephard: No, no, no. I think it's it's valuable though, right? Because I don't think it's about deciding whether or not we look at tissue -based factors. That's never the question. I think P &E, when applied properly and with nuance, actually accommodates tissue factors really well. And we can still tie in all of our sort of, you know, sort of evidence -informed assessment approaches. You know, as a physio, it's not to say that we're not touching people, that we're not assessing movement patterns, that we're not looking at biomechanics.

Sophie Shephard: I think the challenge is we just have to be better at being critical as to what we decide is a problem. So I think a lot of the the things that we know maybe are maybe less relevant or a bit more questionable or maybe some of the specific sort of biomechanical theories or the relevant importance of certain aspects of that. It's not to say that we're throwing out tissue back -based factors completely, it's just about being able to apply a critical lens to what we're considering and sort of thinking, well,

Sophie Shephard: you know, is what we're observing and is our clinical reasoning based and supported on what the research sort of can tell us about that. but there's lots of variation in that and you know, there are certainly underexplored tissue factors that might not be looked at yet.

Ollie: For sure. And and what um'm what's coming to mind in my head as you say that, Soph, is that we so, I mean, we see it in the world of today, particularly thanks to social media or lots of other factors, is this tendency to be polarized. And rather than there being a battle between this or that, it's it's it's not or, it's and. It's that yes, tissue matter, tissue factors matter. And you know um psychosocial factors matter, immune factors matter.

Ollie: you know So everything, as I remember said like warren when it comes to pain, like everything matters. And for me, it's been trying to bring all of that in because we're pain neuroscience and has has shown me and I've been grateful maybe just lucky to come across it early on and where it's maybe ruffled feathers is is that it comes back to our intolerance for uncertainty that I've seen so much in the research like Mitch Gibbs is one of my favourites, shout out like anyone go and read his research it's just wonderful. The people who have a biomedical tendency in their practice tend to be really at least from what he's seen from what I remember

Ollie: is that they tend to be a little bit more intolerant of uncertainty. And it's not just Mitch's research that's shown this, but I might even suggest that those who have a, as you say, it's like a superficial reductionist understanding of of explained pain and a more psychosocial, overly reliant view on making sense of pain as a physio, that they might have an intolerance to uncertainty, as I've noticed in my own practice. And so what it's about is, is as you always say now in our like case conferences, is is confronting the complexity of the scenario and recognizing that uncertainty is a fundamentally unavoidable part of of of this picture for each person because it's probably in the avoidance of that that I think we tend to fall into these these problems, perhaps.

Sophie Shephard: Yeah, for sure. And I think, you know, the the principles and the under underlying sort of framework that we draw on for PNE and for how we explain pain, you know, I think those at their core are are really important principles for every clinician. I think we we all have an and a a need to understand pain in an informed way.

Ollie: Agreed.

Sophie Shephard: I think that's, you know, it has to be a blanket thing, right? Because, you know, from a clinician's perspective, we need that perspective in order to better understand the complexity of the experiences we're seeing and to make sure that we are not inherently limiting our perspective on things.

Ollie: Yeah.

Sophie Shephard: And again, it's not that we're then getting rid of biomedical, you know, aspects. That framework really does incorporate biomedical approaches within that, it just adds that broader scope to it. But it also requires that we be a bit critical about yeah like what we consider as problems within that and and maybe being a bit more questioning of maybe some of the assumptions we're making about why certain treatments work or some of the mechanisms. And the thing I would say, you know we've sort of already said that

Sophie Shephard: you know If we're drawing on those principles, whether whether we're working with someone who is maybe experiencing more acute symptoms versus chronic symptoms, it doesn't necessarily matter. Those principles and the complexity of pain can inform our clinical reasoning and our approaches at any stage in that and knowing that you know, there might be people who are experiencing acute symptoms that actually don't have much from a tissue perspective to address and likewise we might have people with chronic symptoms that actually do have very specific pathophysiological processes that need to be addressed.

Ollie: Yes.

Sophie Shephard: But that framework gives us the ability to actually look at these things and really clinically reason strongly within a complexity framework and whether or not that then translates to actually doing P and &E as an educational intervention, where we're communicating all of that to the patient, or whether it's, you know, there's maybe more subtle or intrinsic ways in which that comes through in our in our treatment, then that's that's a totally different thing.

Sophie Shephard: And, you know, I think coming back to

Ollie: Yeah.

Sophie Shephard: what we were talking about before from a PNE perspective and what that looks like in practice is that there isn't there isn't a one -size -fits -all by any means when it comes to this and PNE is really underpinned by good educational theory and education is a skill just like anything else so it's something that needs to be developed and to assume that we can sort of take snippets and then do this really well is hard I think all of that sort of speaks to what the research really says about P and &A, which is that, you know, when we view it just in isolation as a standalone, we're sitting down someone and we're, you know, providing pain education. That that can have positive effects in terms of pain knowledge, in terms of our

Sophie Shephard: what we call pain self -efficacy. So, know, the degree of control or or sort of ability that someone perceives to sort of take action in response to their symptoms and also to reduce what we call catastrophization.

Sophie Shephard: I hate that term, but that's a topic for another another thing.

Ollie: Yeah.

Sophie Shephard: But the way in which people perceive and make sense of their pain and they I guess their attitude towards recovery and how they perceive their outcomes.

Ollie: you

Ollie: yeah

Sophie Shephard: Pain education in isolation does seem to help that there's been lots of studies that show that but what has been really stark is that pain education as a standalone does not necessarily cause direct pain or disability improvements and I think that's where you know It's really important to highlight that P &E is never, never meant to be delivered as a standalone intervention. you know And even, you know, Lorimer and Dave you know really clearly in their previous work have kind of come out and highlighted that it isn't a standalone and it's a vehicle to help someone

Sophie Shephard: better understand their their symptoms and their experience so that they're in a position to better engage with opportunities for rehab. And that's what that's how it's intended to be used. that's why I think it's applicable across all all ends of the spectrum and we need that nuance in how it's applied.

Ollie: Yeah. We do, we do. Something I think maybe we could finish on, and it's a nice segue into a later later episode on on, I guess, contextual behavioral approaches to so therapy, is the idea of functional contextualism, which is maybe a broader, you know, multi -syllabic word, again, fancy word to to describe where and how this stuff matters. Like you said, the fact that not only pain itself is always emergent and contextual and organic, but out the way in which we make sense of it as a theory and then help people with it is emergent and contextual and needs to be considered. Could you could you speak on that so far, on what that theory is perhaps first and what it means?

Sophie Shephard: Yeah, I mean, I think taking that sort of functional contextualist approach is, I mean, honestly, I think you captured it pretty well in what you just said. It's it's about, you know, if if we're talking about pain education specifically, it becomes about not just thinking pain education is important. And so everyone I see is getting a full explain pain discussion. It's about considering the utility of education and even the utility of that person's understanding in their context. So I would consider it along the lines of how does this person's existing understanding influence their management and their current situation? And is it potentially unhelpful in the way that it's limiting their recovery or influencing their recovery? And if it is, is education in some form needed to help open up opportunities for that person? And so you might, for example, have someone who doesn't have the most up -to -date understanding of pain. For example, if you're seeing someone with an acute ankle injury, for example,

Sophie Shephard: you might see them in clinic and do that initial assessment and you might pick up from a few things that they're saying that they probably don't have the the most up -to -date as the vast majority like 99 .9 % of the human population don't have a modern understanding of pain. Does it matter for that person in that context? Probably not. like you know An acute angle injury that's uncomplicated, you know they might there might not be much need for really explicit pain education. right But what I would be considering in that situation is making sure that I as a professional still have an obligation to make sure that my explanations and narratives are at least consistent with an up -to -date understanding of pain.

Ollie: Yes.

Sophie Shephard: Because the last thing we want to do as a clinician is see someone in that acute phase and maybe set them up with some really unhelpful, very, very bio -anatomically inclined beliefs that maybe aren't That accurate or supported by research and then have to backtrack when they get to three months and they're not better But it doesn't mean that we have to sit people down and give them that full explanation and it's it's about thinking What purpose does education serve? How is this what what behavior or what? what way of coping or what opportunities is this person missing out on because of that understanding and then

Sophie Shephard: How can we deliver this education and that knowledge in a in a nuanced and tailored way to help best support them to integrate it within their context and they their current daily life to see that change happen?

Sophie Shephard: so But yeah, great great topic for a future podcast.

Ollie: Yeah, yeah.

Sophie Shephard: so

Ollie: Definitely.

Sophie Shephard: with

Ollie: So I guess maybe what we're hearing saying is that it all just comes back to the the clinician themselves needs to respect and understand the complexity and maybe um throwing the textbook at a client isn't isn't necessarily helpful.

Sophie Shephard: yeah

Ollie: Even those wonderful people have done some very challenging and hard work around researching it.

Sophie Shephard: For sure. And I think it, yeah, all of that, you know, with everything we've spoken about, I think it just really highlights that there is nuance in this and that reductionism is unhelpful, you know, to to say it has to be one or the other or that it's separated out.

Sophie Shephard: You know, even, you know, one thing we didn't talk much about in this session is even this idea of, you know, I guess pain -informed therapists. There's often this perception of people, you know, being very anti -manual therapy and hands -off.

Sophie Shephard: And like, if you if you take if you embrace

Ollie: Oh yes, didn't cover that.

Sophie Shephard: Hey, if you embrace painting, you know, that means your hands off and like, again, that's an assumption I've come across a lot with people. And I mean, to be clear, as of this year, I did go to a telehealth model.

Sophie Shephard: So yes, technically I am hands off now. But up until that point, I was, you know, I still very much used manual therapy because

Ollie: Yep.

Sophie Shephard: it It forms, you know, there's a lot of really valid reasons why manual therapy might form part of a treatment approach. And I think we're definitely going to have an episode on manual therapy and some of the, you know, sort of pain informed considerations, because it's something that doesn't, can't do it, do justice in a very short space of time.

Sophie Shephard: But, you know, we can embrace these modern updated models of pain and be critical of some of the mechanisms and ways in which we might have thought about these things in the past, but still

Ollie: No, no.

Sophie Shephard: not necessarily be all or nothing when it comes to different, you know, interventions, because at the end of the day, bringing it back to that person's context and situation is super important.

Ollie: That's great.

Sophie Shephard: So yeah, there's just so many things there. And and I think to kind of...

Ollie: Ten more episodes.

Sophie Shephard: Yeah. So to kind of wrap it up, like I know we've we've spoken about a lot of different things and there's so many angles and so many different sort of perspectives we can take on this, I'm keen to kind of get as a bit of ah ah a closer, I guess, from that conversation and and sort of the key things that stand out to you.

Ollie: yeah

Ollie: Yeah.

Sophie Shephard: what What do you see as being kind of the standout like takeaways from our discussion or sort of key things that jump out at you?

Ollie: guess that... overcoming a long mistaken notion that I myself had that just telling someone, even if they're interested, even if they're fascinated and they're and they're you know listening to every word you say about the complexity and emergence of pain and and its biopsychosocial nature, even if they know that it doesn't necessarily make them better.

Ollie: that it's really important for clinicians ourselves to have it as just a professional responsibility to know this stuff and to know as as much breadth and and depth of this as possible so that we can know when it matters and why. And then lastly I think I keep coming back to the uncertainty stuff it just seems to be a real underpinning thing that our tendency towards reduction is more relying on anything is is so And this is me getting a bit therapisty because I love the the psychology side of it is this intolerance to uncertainty that that humans have, right? It's a scary thing. It's threatening in itself to be uncertain. So we hate experiencing it, but I think coming to terms with that is really important.

Ollie: to

Sophie Shephard: It makes it hard when you're looking at something like this, right? Because it would be it would be lovely if there could just be this nicely packaged, like, here's how you do this for every patient ever.

Ollie: Great.

Sophie Shephard: And it makes sense to them and it helps them put stuff in practice. And, you know, yeah, I think I i would agree with all of that. And I actually think you've summed it a lot perfectly,

Sophie Shephard: know, that idea that, you know, there's reductionisms on on both sides of the camp here. And I think, if we all kind of got a bit more comfortable with embracing the complexity and more nuanced views of stuff and kind of I guess being willing to challenge ourselves as to the the pros and cons and that's something that I've really tried to do you know like I said I came from a very pro P &A background and so it was easy for me to fall into this oh this is amazing and I still think there is a huge amount of value in it but

Ollie: So yeah.

Sophie Shephard: and the way in which I think that looks now and the way I put it in practice is very, very different. And I think you know i how i what that means for me now is very different to a couple of years ago. And I think that this's on both sides of the fence, there's a risk of missing potentially really positive therapeutic opportunities if we can embrace that uncertainty and that more nuanced view. So I think you've you've summarized it all really, really lovely. I think my takeaway overall when talking about this is just really emphasizing that, you know, while we don't necessarily need to explain pain to everyone, everything

Sophie Shephard: It's so important for clinicians to have an up -to -date understanding of pain because that that needs to be the framework through which we're viewing all pain. It doesn't matter whether it's acute or chronic, because if we do that, then we're in a much better position to appreciate that complexity and and you know at best,

Sophie Shephard: adhering to that old school biomedical way of viewing pain is limiting because we're going to not see these other opportunities that exist to help someone's recovery. But at worst, it can be harmful. And we've seen that in some of the research. And it's not to say that it's always drastically harmful and that, you know, there's obviously lots of nuance in that. But I, you know, thinking about how really these models can incorporate the supported biomedical aspects, I think it just comes down to giving us a vehicle to really expand our perspective on the complexity of pain and to best help support people to engage in treatment and rehab approaches that are evidence informed and the coping strategies and sort of holistic management that from the research perspective we know is just crucial for helping people move forward.

Ollie: yeah

Sophie Shephard: And also for, you know, making sure we can reconcile when there are specific tissue based factors, how can we then sort of make sense of this within that broader framework and still give people as many opportunities as possible to improve their symptoms and their function.

Sophie Shephard: So that's great. I think, you know, like I said, at the start, I think we could talk for three hours on this stuff and it's a lot different in a bit over an hour now.

Ollie: Yes We're good

Sophie Shephard: We didn't.

Ollie: We did well, not bad. i We kept it under an hour and a half. So for anyone that's still with us, thank you. um appreciate your attention and we hope it's been valuable. But yeah, thanks so much, it's nice to have a full, like nice to record a conversation like this for once. There's been so many without.

Sophie Shephard: Absolutely. And it's so hard because I think even talking about it, it's like I can feel myself wanting to go off and talk about the nuance involved in one aspect. And and there's so much for cram in one episode.

Ollie: Yeah.

Sophie Shephard: And so I'm sure that, I mean, even potentially seeing some of the responses and feedback we get from this episode, you know, there might be elements we'd maybe do a bit of a follow up on and and talk a bit more to, or even just addressing some of the, more specifically the complexities of you know, how this sort of looks in practice, you know, maybe that's something we can follow up with because, you know, I'm aware we've maybe spoken about the importance of nuance and how it needs to be individually tailored. But, know, there's still that challenge of what does that actually look like and how do you implement in practice. So I'm i'm sensing there might be a bit of a follow up episode at some stage. But

Sophie Shephard: That sounds brilliant. So I think that just about brings us to a close. So thank you, everyone.

Sophie Shephard: Like Ollie said, for anyone who's hung around this long, really appreciate it and really appreciate your feedback. We had some really great feedback after our last episode. So keep it coming.

Ollie: Yeah.

Sophie Shephard: If there's anything in particular that you would like to hear us talk about or you know suggestions for follow up episodes, really would love to hear your feedback and you can check out more about the podcast as well as submit any ideas through our podcast page in the links. I might include a few links as well for those of you who are interested in learning a little bit more about P &E. I'll look to put together a bit of a blog post a bit of a summary of today's session as well as some resources for anyone who wants to learn more.

Sophie Shephard: and really, really look forward to welcoming you for our upcoming episodes as well. and We've got a few more exciting things in the work, so really looking forward to being able to share those with you. Ollie, anything you'd like to finish up with?

Ollie: No, you covered it all, so we'll see you all next time. Thanks for listening.

Sophie Shephard: Thanks so much.