How do you educate people about their pain and NOT make them think it’s in their head?

Apologies for being away for so long,.  The 2nd part of the ‘centralisation’ piece will happen when I get time and am in the mood.  In the meantime….

I have recently been in contact with a South African Physical Therapist called Adriaan Louw. He is based in the USA and has been heavily involved in researching aspects of neuroscience education as well as teaching courses on it, with experience in this area going back to the mid 1990’s.

Adriaan has recently released a book with co-author Emilio Puentedura called ‘Therapeutic Neuroscience Education: Teaching patients about pain.’  It is receiving excellent reviews is packed with information and is impressively referenced too.  It is available through this website:  — and highly recommended!

Adriaan runs a teaching organisation in the USA called the International Spine and Pain Institute (  which has a regular newsletter to which I’ve been contributing.  In the most recent newsletter ( Adriaan asked me the following question:-

Question: How do you educate people about their pain and NOT make them think it’s in their head?

The quick answer is don’t even mention the head!  I’ve covered this problem in my book and I find it very interesting.  I go into hallucination of smells, but that’s another interesting story.

In the old days, and still now occasionally, I will often explain to a patient that pain occurs as a result of two types of processing.  Here’s the chat:-

‘Think of a computer keyboard, a computer and a screen. The keyboard is your skin or your back, the computer is your nervous system and the screen shows what you feel.  Tap 3 times on the letter X on the keyboard and the processor produces three X’s that come up on the screen, Times New Roman font size 12 colour, black. That’s normal processing.’

Patient nods, but has an interested slight frown as if to say, what’s he on?

‘Right, I now tap 3 times on your skin, – and you feel three simple taps if you’re awake and concentrating, — and the taps are size 12 Times New Roman, — pretty mild!

Patient grins and nods, — Good, he’s listening and interested….

‘Right that’s the first kind of processing, it works fine.  If I bend your finger back, the harder I go the more it hurts.  If there’s an injury, the more inflammation the more pain. You do small movements it stops you. Your finger gets released, the pain goes down, the inflammation settles, same, the pain subsides, your movements get easier and bigger again.  Think of a healing cut finger and how the pain comes and goes as it mends.’

‘Got you…’

‘Here’s the second type of processing that we now know occurs in many ongoing pains. Same kit, keyboard, computer and screen….’

He’s still listening….

‘Tap 3 times on the X and then watch the screen and these XXXXXXXXXXXXXXXXXXXXX’s keep coming up one after another and they keep going and going, scrolling down the page and as they go they go from font 12 to 18 to 36, — then they change from standard black to purple to bright red, —  and they just keep on going.’

He’s nodding, he’s getting it… on I go…and ask him…

‘What’s the problem?’

‘Computer’s gone weird, processing gone nuts…’

‘That’s it! Tap 3 times on the skin, — and it’s agony when it should be simple taps, — not only agony, it goes on and on and gets worse and worse.  Normal sensation somehow gets channelled into the pain system when it shouldn’t.  Modern pain science tells us that this is what is happening in many pain states that have gone on long after the healing has finished.  So, you injure your back, it gets inflamed and it rightly hurts.  Normally the tissue heals and the processing goes back to normal, – you move and there’s no pain, – the inflammation goes, and the constant achy pain goes. Nice.  Sometimes though, the healing finishes and for some reason the pain processing gets stuck where it was in the beginning when it should have wound down and stopped….’

Now he’s looking concerned!

‘So my back’s healed but my processor’s gone wrong, that sounds serious.’

(Now you could go and get into deeper and deeper water here and end up talking about brains and in the head.  If you do, you need to know how to deal with it.  My advice for this short piece is: Try to keep it simple, and the best way to go is go towards how it’s dealt with not circuits in the mind stuff unless you’re really confident and think it worthwhile, which it usually isn’t.)

I address the patient again, — (What I say here varies depending on the patient and their presentation)…(and don’t be cocky here – that’s English for ‘smart-ass’)

‘Don’t panic, I deal with your sort of pain a great deal and there are plenty of positives and plenty of ways of helping and plenty of successes, especially once you’re comfortable understanding what I’m telling you.’

He raises his eyebrows and looks a bit more hopeful, – I continue.

‘Let me put it another way, there are two types of pain, the first one is called ‘helpful’ pain from the normal processing and the second one is ‘unhelpful’ pain from the weird processing.  I’m wondering if you can think of any ‘unhelpful’ pains that you may have come across, it doesn’t matter if you can’t, but have a think?’

There’s a pause, he looks puzzled.

‘The only thing I can think of is my mother-in-law had neuralgia’

I respond eagerly –

‘That’s a great example!  That’s pain from a nerve being irritated. The best nerve pain example that most people have heard of is shingles, it’s a form of neuralgia.

‘That’s exactly what she had!’

‘Good. If hers is like most, it starts when the person gets eruptions or spots on the skin where the nerve runs, they then become incredibly sore, and for some people after a few weeks the skin spots disappear but the incredible skin pain and sensitivity stays.  The skin looks normal, you touch it lightly – 3 taps… and you get the thousands of ‘X’s’ come up on the screen, it’s agony and it goes on and on.  Healed skin, huge amount of pain, –  ‘Unhelpful’ pain!’

‘She’s over it now; it took around 5 months to go’

‘Good, example, and if that can get better so can your back problem, all your scans and X-rays are fine and I’ve tested all your reflexes, sensation and muscle strength so there’s no nerve damage. What we’ve got to do now, is get you going again physically and shut the pain up by whatever means possible.’

‘Hey Louis, I’ve thought of another useless pain – the phantom pain that soldiers get when they’ve lost their legs or arms….’

I’m in with this guy now. Whenever he looks worried about the pain maybe coming a bit… I say, ‘processor’!  The talk can go into desensitising, — wherever’s productive and appropriate.  The key is to get on and start a graded normal movement recovery programme – and prove to him that the pain is not of importance via experience.


26th September 2013.

14 thoughts on “How do you educate people about their pain and NOT make them think it’s in their head?

  1. Pingback: La metáfora del ordenador en el dolor crónico | magmasalud

  2. hi louis, my mate phil sizer who is the brains behind pain association scotland has used variations on this for years (phil is a philospher not a physio and tends to think more laterally as a result) —he uses the amplifier speakers and record player analogy …. this works well for most people- apart from the ones that don’t know what a record/ CD is (my car still has a cassette player). The record may have scratches on it but the amplifier and the speaker settings control what we hear.

    Many people however are so structurally focussed(or have been ‘medicalised’ into it that no amount of metaphorical manipulation will make a difference . You could look up Iain McGilchrist RSA lecture on youtube for possible explanations relating to this ….

    • Ian, agree completely re structurally focused – the majority of patients. In my experience explanation is one thing – and the patient often appears to follow and understand, but when it comes down to it doesn’t actually ‘believe.’ To give such a radically different explanation and for a patient to accept it might be hugely helped by a white coat and a ‘title’ I suspect. I’ve never been prepared to label myself as anything more than a ‘Physiotherapist’ – I’m not keen on being a ‘extra specialist specialised hourary pain god’ in order to cajole the gullible. Success comes with ‘proof’ though – the patient finding out for themsleves – with our guidance, Good to get the patient to find they can trust their body once more. Over the years I’ve found that I’ve asked the successful patients when we’re parting – ‘What did you think of that ‘keyboard’ explanation for your pain that I gave you back at the beginning?’ Mostly the answer has been along the lines of ‘I thought you were off the planet and I nearly didn’t come back again.’
      Funny you should mention Iain McGilchrist – I have his huge tome by my bed! ‘The Master and his Emissary’ – been trying to get into it for several years, but nightly codeine prevents justice being done!

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    • Well, if it has a positive impact in terms of the patient’s relationship to their pain – it must do. For example, it may help the patient put the brakes on directing nociception so strongly to the ‘threat’ processing centres of the brain. The key thing is to not just expect this little bit of information to ‘fix’ the maladaptive attitude or beliefs of the patient to their pain problem, but if it helps to get the patient’s physical confidence up a bit then you’re going in the right direction.

  4. Wish I’d come up with this computer analogy – genius! I use analogies when I teach/educate patients and health professionals about pain because it works for me. As soon as I get technical and start trying to explain neurotransmitters etc I wrap myself up in knots. Understanding pain physiology and being able to explain it to a third party are two different things. I think it’s neccesary that we understand pain physiology at the technical level so that when we explain it as a ‘computer gone wrong’ etc that we actually BELIEVE what we are saying and can then adapt the analogy appropriately when the patient asks questions specific to them. If we don’t truly understand/believe that some pain can be ignored then we’ll never kid our patients and inadvertantly we’ll reinforce the hurt=harm belief.

    • Thanks Zara. I agree, forget the complex stuff, it makes most clinicians turn off and go to sleep, let alone the patients. Keep it as simple as possible an get on with rehab in a new, hopefully ‘better’ context…
      Regarding us ‘believing’ – I often think to myself, ‘If I could magically get rid of the pain right now, could this patient and their body walk from here to John-O-Groats without causing a permanent problem?’ if the answer is yes (and it mostly is), you’re off with confidence. You shouldn’t do this if you’re crap at physical examinations/interpreting them though!!
      Louis xx

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