Matthew Boyd Physio

Helping Runners Overcome Injuries and Smash PRs

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Pain does not equal Damage | E16 with Mike Stewart, Physiotherapist

“If I keep running, will I be causing more damage?”

I think all runners have asked themselves this question at some point. If you have knee pain, and your x-ray shows that you have arthritis, we think that makes sense right? What if your x-ray shows that you have arthritis, but you have no pain at all and you can run as much as you want?

This kind of thing happens all the time. People with scans showing “damage” or “degeneration” but have no pain. How are we to make sense of this?

The difficulty here is that we are talking about pain. While we may think that pain is a fairly straightforward subject, nothing could be further from the truth. Today on the show, Mike Stewart will be joining me to help shed some light on this very confusing and strange subject. Mike has a wonderful gift for taking immensely complicated subjects like pain neuroscience and discussing them in a way that is easy to understand and often quite entertaining. He uses metaphors and stories to explain complex biochemistry and biopsychosocial concepts. If you have not come across Mike before, you will be very glad you did.

Mike is a physiotherapist, researcher and university lecturer with over twenty years experience of helping people to overcome pain. He has an MSc in Education and Physiotherapy and is planning a PhD focusing on how people in pain make sense of their experience.

Mike teaches across a variety of clinical settings including elite sports and is an advisor on pain management to the International Olympic Committee. Mike has taught his Know Pain courses to over 1000 clinicians in 17 countries all over the world.

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Cool stuff mentioned in the show:

Discussed in the episode:

  • Pain and Damage are not well linked
  • Pain science is delivering good news for runners
  • Pain is highly unlikely to be harm or damage
  • Have you ever tried to remove the leg from an uncooked chicken?
  • Marathons and knee arthritis
  • Do our thoughts impact our pain?
  • Are you focusing on your pain too much?
  • Not running can shut off the happy hormones
  • Pain is about threat, not damage
  • Knee pain from a chondral defect
  • Phantom limb pain shows us that pain is not “in the foot”
  • Understanding knee pain is key
  • 99% of medical education is about anatomy and physiology. What about pain science?
  • Have you had a weird pain experience?
  • Is pain all in your head?
  • Courage is resistance of fear, mastery of fear, not absence of fear

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pain and damage are not really good
bedfellows there’s not a very good link
between these two things
that you can have lots of pain with no
injury and you can have lots of injury
with out any pain so uh
there’s there’s a disconnect here which
confuses people and
and uh i think that’s what i spend a lot
of my time doing is trying to
uh make some clarity see something clear
out of the confusion of
all of this
what what are you doing at the minute
for work what kind of people do you work
with and
what’s your interests most of the work i
do is teaching so i’m i’m
sort of a lot of the work that i’m doing
is is teaching healthcare professionals
doctors and physios and chiropractors
and osteopaths and then
clinically i see a mix of patients um
some patients
are people who’ve had pain for a very
long time and they’re struggling doing
very simple things other people are
athletes
uh i’ve recently been working with a
gymnast who’s an olympian
so we get a mixture of uh the people who
like to go and exercise on a regular
basis and go out of a weekend and
anything up to those people who are
competing at international level
okay and what do you teach about pain
so pain my my the course that i teach
are no pain courses
helping people make sense of pain which
sort of comes directly from the work
that we do with
patients which is trying to help people
understand why pain’s there and
uh how to make sense of it how to move
beyond it
um in amongst that when pain’s a really
big complex topic so
we consider ways to help people talk
about their experience of pains we know
that that can be a hard thing
to get it out and to express your
experience uh
how it affects you in your life the
psychology of pain
uh and most importantly which i think
we’re going to touch in today is
you know how do we make sense of it and
get over it and
start getting going again and from a
running perspective how do we
get you back to running with confidence
yeah and that’s um
the reason i wanted to bring you on
specifically is because you know
i’ve done a few episodes with people on
on different things and related to
you know biomechanics and pathology
related to
running injuries and things like that
and then there’s almost this
this big missing bit that i’d like to be
able to refer people back to where
um just because you know we have some
changes in let’s say the example i
mentioned we could use would be like
knee arthritis right so you’ve
got a scan that shows some knee
arthritis and then a runner’s got knee
pain
but there’s this sort of on top of that
whether it hurts or not the pain side of
it is this
whole big i mean it’s a massive area
of um i guess intellectual inquiry
and that’s that’s what made me think of
you um
so can i wonder if you could what i’d
like to do is try and
dig into the difference between
pain and damage because you know when
people when someone
comes in to see me and they say my knee
hurts when i run i’ve got us do
arthritis i don’t want to run anymore
because
i’m damaging my knee or i might be i’m
worried i might be damaging my knee
is that a reasonable thing to think are
these two things connected uh um
what what’s going on there
uh oh i think the first thing to say is
uh and this is good news for these
uh for these times we’ve just been
talking about how kovid’s made everybody
very miserable and quite rightly so
uh but it’s time for some good news i
think if we consider where we
are at present in terms of the science
of
and the evidence of well what is pain
and what does it mean for
you as a runner uh or for anybody really
and the message is overwhelmingly
liberating and positive
so uh i’ll explain i think in the past
we’ve always traditionally seen pain as
something that’s intrinsically
linked to damage which is
the natural thing to think i mean i i
went out for a run yesterday
uh i got some niggly pains in my ankle
as i’m running along and the first thing
instinctively
that you do is think oh what have i done
you know if i and you you visualize sort
of these images especially it’s even
worse when you’re a healthcare
professional you’ve got a
a knowledge of anatomy as you’re running
along you visualize what’s happening
inside the ankle you think about the
anatomy you think or am i
am i causing a tear is there you know so
all that
catastrophizing that worry that that is
so in
intuitive and instinctive with pain is
still there
when you understand the science of it
it’s
that’s that’s how strong our belief
systems are about pain and and
uh our culture our upbringing what our
parents told us to do when we have pain
for example these these things all
matter
so i think that’s a really interesting
point to make is that
even though you know what pain is which
we’ll talk about
and and it is a far more liberating and
positive experience
than what we used to think pain is still
you i worry i know other people who work
in the industry who work in pain science
they worry when they get pain we
immediately
jump to the conclusion that something’s
causing harm inside there
but we know that categorically
that pain and damage are not really good
bedfellows
there’s not a very good link between
these two things that you can have
lots of pain with no injury and you can
have lots of injury
with out any pain so uh
there’s there’s a disconnect here which
confuses people and
and uh i think that’s what i spend a lot
of my time doing is trying to
uh make some clarity see something clear
out of the confusion of
all of this the shift in our thinking
about pain
so yeah there’s a disconnect there so we
take that example of you running
yesterday and your ankle is starting to
hurt
and you can feel it um why does that
not indicate that you’re damaging your
ankle if that’s the case
well for me particularly i mean if you
think about it we always think that you
know
a classic case of of thinking about pain
would be
pain is my alarm system pain is my
warning device
it’s telling me to stop it’s telling me
i’m causing damage
um now for me with this ankle
uh problem that i’ve been having i’ve
had that now for maybe
five years six years on and off and
we don’t have an injury that will last
for five or six years
so for this situation i’ve had to sort
of in a way
master my thinking over this because we
know that pain is based in
not injury not damage but perception and
particularly
your perception of threat how confident
you feel
how much concern how much anxiety you
have
all of what we call technically the
psychosocial factors
so how you think how you feel how you
react how you behave
these are the more important indicators
of a problem
than the anatomy than the muscles and
the tendons
so i know for me
with this with this ankle problem that
it’s not something that’s causing injury
or harm because it can’t be it’s been
there so long
uh i i think one of the best ways to put
it is a way that one of my patients said
um when she tried to understand the
difference between
pain that’s useful and telling you that
there’s a an injury
and pain that’s actually just a bit of a
nuisance she said to me um you know
so when my back pain started 10 years
ago
when i lifted a chair at work that was
useful that was my pain being my friend
it was saying watch out you’ve done
something you know so it is like your
your mate
who’s protecting you um but now
she said ten years later it’s become
almost like that friend who refuses to
leave my house party you know it’s 4 a.m
uh i’m just wanting people to go home
and they’re checking out where the jack
daniels is and
and that in a nutshell is the issue with
persistent pain
um or pains that keep sort of niggling
and returning and coming back so it’s
less to do with harm
and more to do with sensitivity okay
so what do you mean by sensitivity well
again if we think about you know a
classic thing would be a sensitive tooth
if you think about this the pain that
comes with a sensitive tooth very often
there’s very little in the way of harm
or damage
but what’s happened there is the tooth
has started to almost
learn how to become sore so you’re sore
but you’re safe you know we just need to
find a way of reducing that sensitivity
and it’s very similar with if i look at
my ankle for example
um i know that i continue to run
on this ankle when it starts to hurt uh
in the confidence that i’m not doing
harm
but in doing so i sensitize it
um you know i i flick that sensitivity
button back up again
and we know that pain is just like
learning
anything so i i sometimes say to people
you know if you want to get really good
at french
you just have to keep learning french
again and again
and again if you if you keep repeating
something that the rule is
nerves that fire together wire together
so if if for me for example if i keep
setting off that
sensitive ankle i’m going to make it
more sore
but that soreness doesn’t relate to harm
or damage
that soreness relates to me almost
becoming fluent
in sensitivity like learning french
are you learning to feel ankle pain
there is that um
yeah but not in a way i mean the word
learning might be an issue because we’re
not
consciously you know i’m not sitting
there running along thinking about it
but at a subconscious level which 88
of what our lives existed for is is
subconscious processing of data
so as i’m running along that sensitivity
that i’m picking up from is going to
return easier next time
not because it’s causing any harm but
because
it knows how to do it just like the more
i make spaghetti bolognese the more i
don’t need the recipe
it becomes sort of an instinctive learnt
response
so i think that’s one very confident
thing to recall from this conversation
is that
pain when you’re out and doing things is
is
highly unlikely to be harm or damage uh
but but it is a sensitivity issue and
maybe the old-fashioned way of dealing
with that would have been to either
stop and protect and rest
which causes more problems or the other
option
is to do the old-fashioned thing of no
pain no gain where we just keep sort of
running through it and plow on through
and
but that causes a problem again because
you’re just then opening those textbooks
of french or
repeating how to make that spaghetti
bolognese again
and so then where does tissue change
come into that so like um you know i
mentioned that
we could take the example of a like a
female runner in her
60s with knee pain when she runs like
10k
and she gets an x-ray that showed like
moderate
osteoarthritic change in the knee joint
and then she’s running this 10k and she
she she understands what you just said
so she’s
you know i’m i’m making the knee more
sensitive as i run
but i understand that i’m not doing
damage
how can she be confident that she’s not
doing damage and and where would the
damage
fit in to the actual experience of pain
you know could she potentially make it
worse
um and when i say worse
i suppose i could i mean sorry right
yeah i think there’s a couple of there’s
a couple of ways to answer that question
i think the first way i mean i’m one of
these strange people i’m a bit weird i i
i wanted to be a physio
from about the age of 14 so i always
knew what i wanted to do as a profession
which is
which is really strange i meet some
other physios who who are like but do
you
the same man or did you did you you got
older when you wanted to be a physio
no about the time when i was around 16 i
realized i wasn’t good enough
football to be a professional footballer
so i had to do something else
that’s when i decided to be a physio
i’ve i’ve never quite worked out why i
had this unerring drive to be a physio
i’ve got a twin brother
and uh we’re now like 45 years of age
and he still doesn’t know what he wants
to do
um but i was dead sure about being a
physio
and and actually interestingly to answer
this question
one of my first ever experiences in
physio was
working with uh an old school physio who
was like in his
late 60s coming up for retirement
trained in the army
as what they used to call in britain a
remedial gymnast
so uh somebody who’s working with
soldiers and
uh can you hear me okay yep yeah i think
it cut off for a second
no the sound is being fine it just the
video skipped a bit
ah perfect so um yeah this guy had a
he had a patient in on uh
neck neck traction which is essentially
you know one of these
torture chamber type machines that they
put this harness around your head and
it pulls with weights the the head up
off your body
so it stretches your neck and this guy
was looking really really
uh worried and the physio stopped
machine
and said what are you worried about he
said it feels like my
head’s going to fall off you know that
it’s going to snap off my body
it’s uh you know it’s pulling all the
weight off there and
he asked him a question which i think is
really relevant for your listeners
and the question was a really weird
question he said have you ever tried to
remove the leg
from an uncooked chicken with your bare
hands
and the bloke was like um yeah he said
how easy was it
he said it it was impossible you know in
the end i had to go and get the cleaver
you know this is why butchers have
cleavers so and he said
exactly if you think of a of a small
animal and human beings are
animals you know we we like to think of
ourselves as distinct but
we are a bio-mechanical uh
moving organism an object and he said
look you know if a chicken if it takes
so much to cause harm to a chicken
um that you have to use a cleaver you’re
you know you’re a
six foot four forty two year old human
male you’re like a bear you know
it takes a lot we we we have this notion
that the
humans are inherently fragile and
vulnerable
and we see this a lot a lot of the
evidence shows this particularly in
sport
one of the myths of working with people
with pain in sport is that
you know the the athlete the human is a
fragile
vulnerable uh
organism that needs lots and lots of
protection and we know that actually
that leads to
more problems than it does solutions so
um one way is to think about that think
about how strong a chicken is
and then upscale that to you as a human
being you know
it’s an interesting way to think about
it
yeah yeah but it’s that classic thing of
you know focus on what’s strong
not what’s wrong and this is the problem
i i i know and
anyone who goes running knows that um
running is partly
physical and partly psychological you
know we know that
how you feel when you’re running if you
feel confident and robust and strong
you run better you run further and
faster you have you’re more
happy you know um the other way to
answer that question though
is um we know again if you look at the
data if you look at the science
that there’s a very low correlation
there’s a very low link between
how you look on the inside how for
example that lady’s knee might look the
60 year old runner’s knee that you
mentioned
and actually how she is on the outside
so we can look at huge data and we can
pull up statistics and we could do it
that way
but i think actually from a learning
point of view maybe a better way to do
it
is to look at a thought experiment so to
think about uh
two scenarios um so one scenario would
be
uh imagine that you are like an x-man
a superhero you’ve got a superpower
and your superpower is mri vision
so you can see the world in mri you can
see everybody you can see how they look
on the inside
imagine take your mri superpower
to the finishing line of marathon maybe
you know i know
in ottawa or toronto or london or new
york
take that mri superpower to the
finishing mark the finishing line of the
marathon
and now think about using that mri
vision superpower
to watch as people cross the finishing
line
you will see like you always do in a
marathon you’ll see some people who
are 75 85 90
95 years of age some people are in their
hundreds when they won
marathons and you know how does how does
their spine look
with your mri superpower how do their
discs look in their spine
what are their what do their knee look
like do they have any signs of
arthritis or those scary words we often
hear like degeneration
of course the answer is yeah they they
look
dreadful on the inside anatomically yeah
we know that
people you see wrinkles on the outside
you see wrinkles on the inside so you
would fully expect with your mri
superpower
to see lots of damage which we know is
largely irrelevant and that age
changes normal uh
perfectly things that wouldn’t worry a
healthcare professional
these days based on the science we will
see that in people who run marathons
and and do it very comfortably
then if you use your mri superpower to
go to the local pediatric hospital
and go and look at like a seven-year-old
girl who
can’t stand up from a wheelchair because
she’s got disabling back and leg pains
and then think about how that
seven-year-old girl’s
body looks with mri supervision it’s
by and large you’re looking at a brand
new motor car you’re looking at a
you know a human being that’s
anatomically perfect
so pain pain and
pain and injury pain and arthritis are
not necessarily
as a as clear-cut as we used to think
um and why is that why can you get that
90 year old going across the finish line
and they’ve got
you can see with your mri vision they’ve
got knee arthritis they’ve got back
arthritis
they’ve got all sorts of degenerative
change
but nothing hurts and that they just run
42 kilometers you know what
why why is that
yeah well it’s a great question and
again that’s it’s a question that’s sort
of uh you know
puzzled people for many many years those
people who
you know you get so many situations in
life when you think about pain
pain is really weird and the more you
look at pain the more you find
weird pain stories that they don’t fit
at all
with what the textbooks taught us you
know i remember
i’m sure you did matt i remember sort of
as a healthcare student as a physio
student
you’d see patients and then you think
this doesn’t fit with what it says in
the books
you know these these things aren’t you
know they’re not seeming to match very
well
uh so why does that person not get pain
it’s generally speaking it comes back to
what we were talking about before it’s
it’s about they have a lack of
sensitivity they have reduced
sensitivity it’s not that it’s not the
arthritis that’s producing
the pain it’s the nervous system
you feel the pain in the 60 year old
runner would feel the pain in the knee
but that’s not where it’s coming from
that’s not where the sensitivity and
when they
the sensation of pain is originating
from
um that that human experience of pain
is not produced in the knee it’s
produced in the brain
at all times i mean there’s never excuse
where it doesn’t come from the brain
so so they
say that that um
the runner you know they they will go
back to the runner who does have knee
pain
you’re saying that those changes those
arthritic changes
the pain isn’t there the pain is in
the nervous system is that is that what
you’re getting at yeah
you feel the pain that’s where you feel
the pain you feel the pain in the knee
for example but that’s not the part of
your body that’s responsible for that
sensation for that for that for that
experience you know
pain is this this really complex
experience
which to answer the question why would
the 90 year old not have pain in her
knee
well we know that pain is based in
perception of threat
so for example for that 90 year old even
though they have no cartilage left in
their knee
or knees and spine their
nervous system hasn’t had that ability
to learn about pain
it’s not switched on its sensitivity two
three four years ago say for example
and the person doesn’t really have any
sense of there being a problem in that
area the nervous system is not picking
up on data
one a good way to think about it
think about um a question i sometimes
ask people to try and make
sense of pain is have you ever had an
annoying boss
right so you know most people have had a
boss who’s a bit annoying
you know they’re constantly coming in
checking on you they won’t let you get
on with
uh your work sense that the boss of the
company
for a human being is the brain the brain
is the part of your body that makes all
those decisions
it’s it’s not uh the ankle or the knee
but
from the brain’s perspective from the
boss’s perspective
all of those different parts of your
body are like departments of the company
that the boss is in charge of so the
ankle will we
will be one department the knee will be
another department
so if we think about it for the person
who’s 90 odd years of age
they may have some arthritic change
which is perfectly normal
just like they’ll have wrinkles on their
on their skin on their face
but the boss is happy with the
department of the company with the knee
because the knee functions well the knee
we go out running all the time they’re
doing training so the muscles are strong
everything’s working okay so the boss is
happy the brain is happy with the knee
department
and therefore just like a boss who’s
happy with a department in a company
they go to the golf course
you know they don’t bother her and this
we know um
patrick wall who’s one of the classic
neuroscientists
uh patrick wall said in the 1970s that
ongoing pain for example the the niggly
pain in the knee when you’re out running
is less to do with
injury it’s less to do with damage and
it’s more about your brain’s opinion
of the body part so one way to think
about this whilst you’re out running is
think
my brain my boss the boss of the company
has an opinion about my shoulder and my
elbow my finger and my wrist and my
knee and my ankle and if
those areas are functioning well you
know if i’m using my shoulder and i’m
using my knee and
the department’s coming back with good
results to the nervous system to say
well look you know
i’ve just been out for a run and the
muscles are working well and you know
everything’s nice and flexible i did my
stretching and my warm down and my warm
up and
then the boss the brain tends to be
pretty quiet you know there’s no need to
bother that part of the body
but if we start underperforming if that
niggle
stops you from running and then the
worry
associated with that that instinctive
thing we started off talking about where
we think
well that must be damage inside the knee
and therefore it stops you from going
out
as running as much and it maybe stops
you from doing exercise
very very quickly that becomes a problem
because
now the boss the brain now starts to
interpret data interpret uh like
annual reports from that part of the
body
to say hang on you used to perform your
job well
uh the muscles used to be strong and you
know the joint used to be loose
now things are tighter and stiffer and
that in a sense then perpetuates its own
cycle of events where we
uh as as uh ecclestone and cromwest two
pain authors once said pain is an ideal
habitat
for worry to flourish so once we start
developing that pain
it’s not due to the arthritic changes
but it’s due to that
boss department of the company
relationship
now all of a sudden we start to have
other problems where the world rebuilds
uh we become more concerned we start to
think oh god can i really go and do that
10k
run am i going to end up in a wheelchair
in 10 years
we we find other horror stories from
previous runners who say
god you know don’t do that because i
ended up in this situation
so uh i think pain is very very hard to
make sense of
unless you’re looking at that broad big
picture context if you’re just thinking
about the anatomy
it makes no sense right okay
well i think an example that other
learners would be familiar with and it’s
kind of similar to what you were just
saying my uncle was bugging me about
you know three weeks ago and um
there’s no verses right there might be a
race this year
and i can just contrast my reaction to
it um
even consciously i i did not care you
know i just
i was like yeah if it hurts a bit i’ll
do a bit less tomorrow
you know but in the past when i know i’m
like
eight weeks from a race or something
that i’ve paid for i’ve trained for a
year for
my reaction to that ankle pain is
drastically different
and i’m just wondering is that will the
actual
ankle pain in that situation for me
would that
actually be worse given my my
the worry that is flourishing or would
it just be that the pain would be the
same and the worry would sort of sit on
top of it
good question but it’s uh you know as
you say from based on
past experiences it you can notice more
pain and that pain can very well be
related to
anxiety about performance and all of
this hard work i’ve put in
am i going to be able to do okay
whatever other worries i mean it might
be something completely
unrelated to your training it could be
uh you know
you’ve had an argument with somebody or
things aren’t going so well at home or
works there’s problems there so we again
it’s
you have to keep your eye on that big
picture because if we don’t understand
that if we can’t
put into context uh all of the factors
that can
um exacerbate pain can make pain worse
then then it makes no sense maybe a a
good way to do this and again a very
practical way because
often one of the problems when we’re
talking about pain it can all be a bit
sort of
uh thinking and
rather than doing and feeling and
actually i think sometimes
doing and feeling can actually be a far
more powerful
experience rather than just cognition
thinking about it and trying to change
your thinking on it that could be tricky
um so maybe we could try something can
get people to try something
um if we’re thinking does our do our
thoughts
impact on our pain
then there’s a really easy way to prove
this um
for years ever since the 16th century
there was a french genius philosopher
rene descartes
and descartes had this idea that the
mind and the body were two separate
things
that they didn’t connect that they were
two very distinctly separate things
we know now based on huge amounts of
evidence that that’s wrong the mind and
the body are very very well
interconnected
which is what was behind what you said
before matt you know sometimes i find if
i’m coming up for
a big performance the worry builds the
pain builds
so a really nice easy way to do it is
sit down on your own sometime when you
you know maybe when you go to the toilet
or somewhere
and focus on your thumb it sounds weird
it’s an odd thing to do but if you spend
like maybe a couple of minutes somewhere
on your own nice and quiet
put your thumb out in front of you and
stare at your thumb
and just keep observing your thumb and
it’s hard to do
now as we’re doing this talk but you
know
what you’ll find some people might find
that nothing happens
but if you were to do that and pour
every ounce of focus
and attention into your thumb you often
notice within a minute or two that
things start to happen inside there you
get you know
a whole variety of different things some
people make an observation that they
didn’t have before they notice a freckle
that they’d never seen or
when did that wrinkle appear uh some
people will
notice a sensation it gets pins and
needles or numb
or some people say it changes shape my
thumb felt like it got bigger
or it was throbbing i could feel my
pulse inside there
now you know i ask people when they do
that and they have that physical
sensation
is that real or did you imagine that you
know is that an imaginary thing that you
just did
or did it feel like your thumb was
getting bigger
were pins and needles and of course the
answer is no of course it felt real
and this disproves that idea
that the mind and the body are separate
they’re very much together
and it’s we had one patient who was an
athlete who said to me
we did that experiment together and she
came back a week later when she’d been
doing it and she said
two things first of all she said that’s
not a light bulb moment that’s a
chandelier moment
that this idea that that basically you
know
if i’m thinking if i think about my
thumb if i sit on the toilet and i think
about my thumb or the kettle’s boiling
and i think about my thumb
i now the more i do that nerves that
fire together wider together like
learning french the more i do that
the more easy it is for me to make my
thumb
feel different to feel sensitive
so for her the chandelier moment was
she said well i’m always you know i’m
always thinking about my knee she had a
knee problem as a gymnast and she’s like
you know i’m
i’m always conscious of it being a
problem and and it gives her real
worries about when i go to the next
olympics if it goes to head
uh am i gonna end up flat on my backside
and the whole world are laughing at me
and
creating memes about this terrible
moment and you know where where i fell
to pieces in performance and
so we have all these worries and all
these concerns
which feed into the sensitivity of the
nervous system and uh just
just thinking about your thumb can make
your thumb feel different
as i was doing it and yeah it started to
feel tingly but then you were saying
like about it feeling bigger and it was
it wasn’t so much that
was feeling bigger but i really had to i
noticed a strong urge that i didn’t want
to look at it anymore like i didn’t like
it
you know what i mean it was weird
because it was it was starting to look
different i was noticing little
imperfections in it
more the way we often do with our face
right we like my nose is wonky
and this eyebrows higher and you know um
i was like oh i don’t like that i don’t
like that and i was like
really keen to look away and um
i can imagine like if if that was a
painful part of my body that was then
you know threatening to spoil something
that was quite important to me
i can imagine that really embedding
itself in my
uh perception of the area exactly
and this is this is the liberating thing
we’ve had patients who come to see us
and they said you know that the main
overriding message is i feel
free for the first time in years because
you know if you’re thinking about your
back or your knee or your shoulder being
painful because it’s injured or painful
because it’s old
you know that it’s got degenerative and
arthritic and you hear all those
scary words that people say and you know
doctors sometimes in a rush will say oh
you’ve got some signs of some
spondylolisthesis and then of course the
first thing we do is
find out what that is via wikipedia and
all these scary things come up and
remember what we said that pain is an
ideal habitat for worry to flourish
and uh and it drives that worry those
thoughts
keep going around they ruminate and uh
and that again in itself it sort of
leads to more sensitivity in the nervous
system leads to worse performance
uh think of a good example if we’re
thinking about
a high level performance think about
those that those people who
perform at their best uh we often show
people montage videos of usain bolt
warming up for 100 meter olympic final
or
roger federer serving tennis balls or
lionel messi taking free kicks
uh you know what do you notice about
these people
they’re chilled they’re chill they’re
relaxed they’re positive it looks
effortless you know it looks like
messi looks like a ballerina on a
football pitch it’s effortless and easy
and
usain bolt’s listening to music and
distracting himself
probably from those worries that we all
have so
we know when i when i’ve done work with
the olympic committee
on pain management um we know one of the
common themes that we see is the people
who perform best those people who win
gold medals rather than silver it’s not
a
case of how well they train their body
it’s how well they train their focus
you know how well they’re able to sort
of uh attend
to information and block out certain
worries and anxieties and that’s all
part of this
whilst i’m thinking about it i’ll share
one more story from a patient that we
saw and i think it sums it up
beautifully
um we we did some pain education we went
through some of the
concepts that we’re talking about today
and then
she went away for six months and tried
living with it and
putting into action all of the ideas
we’ve been talking about
she came back six months later and she
said i’m i’m doing loads better i’m
doing really really well
i’m back playing tennis i’m doing things
so i said well
how how can you explain to me how you’re
doing better how’s that happened
and she did something really interesting
i always talk to other people about sins
she
she walked over to a window so she
walked over to the window in the in the
gym in the physio department we were in
and she started staring out the window
and she said do you know
before i could make sense of my pain
before i understood what it was
uh i used to really worry about it being
injury or harm
arthritis those and things said it was
almost as if thinking back
it was almost as if i was constantly
staring out the window
looking at what was happening to the
weather outside so her focus
was 100 of the time the
clouds are moving in from the west and
it’s got a 30 chance of rain and
it’s this time of day and so her focus
was so
on her pain it was like a horse with
blinkers on
running a race it’s just not looking at
anything else
and she said the biggest change for her
is now that she’s understood her pain
and made sense of it which was a
challenge but she worked through that
process
and shifted the way she looked at it
change the way you look at things the
things you look at change
she she said now look you know i’ve
moved away from the window i’m not
looking at the weather anymore i’m not
focused on my pain
uh and i’m back doing things i’m back
running playing tennis playing with my
kids
she said but when i’m in the middle of a
tennis match sometimes i sit there and
think
oh yeah it is still there if i really
stop and think about it and i really
look for it
like we can stare at our thumb she said
i i can still feel that i’ve got some
back pain
but it’s just background noise it’s not
stopping me from living my life from
playing sport from exercising with
friends whereas in the past
she had stopped because that worry that
attention to the window to the pain was
such an overriding factor that it just
it got in the way of life
and so why then can we not just think it
away
you know my uncle and your uncle you
know still hurts
um yeah why if
if it’s a if it’s a matter of focus and
attention and
and worry why can we not get it to go
away
if we want to i i think i think
one word to say would be because it
wouldn’t be
wise it’s an evolutionary response if
you think about
why in response to that question you
know why do we still
why do i as a pain scientist i i really
like to think that i have a good grasp
on the understanding of pain in 2021
why when i went out for a run yesterday
did i worry about my ankle
um it’s because i’m evolved i’m a human
being with a
an amygdala that primitive threat system
that makes you frightened of snakes and
spiders and
death and getting old and being in a
wheelchair and all those things
these are all normal so
you can’t even though you know about
these things you can’t turn it off
right a good way to think about it is um
i have a friend of mine who’s a vet
and she always says when when when i
work with patients
dogs and cats and rabbits and
they show when they’re distressed you
know if they’re if they’re not
doing well you can really see when a cat
or a dog
is not doing well they display it um but
when a human’s not doing well often we
have these worries and these anxieties
but we
we sort of hide it a bit we wrap it up
and
and uh there’s a simple rule i i think
again
when you’re out running it’s a it’s a
sort of rule to remind yourself of
almost a mantra
if you’re low you hurt more easily and
it’s a rule that applies to squirrels
and dogs and cats and human beings
and again a thought experiment to think
about this
would be imagine stubbing your toe
on the end of the bed at 3am in the
morning you know you wake up to go to
the bathroom
you stub your toe now think about how
much that hurts
uh if you’ve got man flu
you and i both know what man flu is like
man so
if you’re really unwell you know if
you’re really systemically unwell you’ve
got a really
nasty hideous cold or flu
and you stub your toe on the end of the
bed at 4am or 3am in the morning
that hurts a lot but now if you imagine
you do exactly the same thing the
following day you
stub your toe on the end of the bed
you’ve got that horrendous sort of coal
still
but you’ve just found out that you’ve
won 20
million dollars
you don’t care you’re buying your your
thought is you know
great um i could buy a new titanium toe
you know so
if you’re low you hurt more easily pain
makes us vulnerable
and that vulnerability drives that
sensitivity and makes us
concerned and worried and which stops us
from doing things which then in turn
makes the boss come looking for problems
in the
knee department or that you
the function fine uh but the opposite of
that rule is true as well if you’re a
bust if you’re strong
in answer to that question why does the
90 year old
who has no cartilage left in their knees
why are they running a marathon with a
smile on their face
it’s uh partly about perspective partly
about outlook about perception
the way you view things uh and it’s
partly
the fact that due to those things
they’ve managed to continue
to keep functioning at a good level
and they’ve done things within
moderation maybe they’re not the person
who’s doing the no pain no gain
plow through it make it hurt it will get
better it’s uh
it’s it’s changing a few ways you you
think
and you do you’ve got to alter a few
things and we always say
nothing changes if nothing changes it’s
a case of just
adapting something yeah that
as you were giving that example of the
the stubbing the toe i thought of them
yeah it’s very cold here at the minute
and then like a polar vortex or
something and
i take that dog for sucks for a walk
and we make it really brief but i still
get very very cold
and then you know i was getting home
yesterday and he sort of
pulled he wasn’t going to sniff
something and it just sort of pulled on
my finger
a bit i mean the pin was negligible but
my reaction was so
i was so angry you know because i was
already cold and uncomfortable and i
just wanted to get back to the house
kind of thing
like it was completely disproportionate
to the actual sensation in my
finger and then i was thinking as you
were telling that story i remember
mountain biking once i was i was in
i was in whistler and i had sort of gone
off the beaten path a little bit and i
was going down this hill it was way too
hard for me
and i flipped over my handlebars the
bike went up in the air landed on me and
the cogs hit me in the
side of the ribs i’ve made this big like
thing that looked like i’d be bitten by
a shark
and i it really hurt and i was like
lying on the floor laughing
because i was like on my own and i was
like it’s kind of silly
and kind of fuddy and that was
actually like painful wise it was very
painful
and the finger wasn’t painful at all but
my reactions to them were very different
based on their sort of circumstances
yeah i it’s it’s you know
it’s it’s a hugely complex and also we
should say idiosyncratic you know my
pain is different to your pain and
this is one of the big problems with
pain that we’ve not really touched on
yet is
the fact that we like to think that pain
is something that you can measure
you know health care professionals
always do this naught to ten how much
pain you at the moment whereas
in actual fact you know it it’s a very
personal individual experience you
trying to trying to describe what your
pain feels like and what it’s like to
live with it
is like trying to describe what wine
tastes like
you know you you can’t just say a wine
tastes like grapes it’s
uh people have these very nuanced sort
of
ways of talking about wine or uh
about you know or if i said well why do
you love your partner
you can’t just go because sh she or he’s
really nice you know
you you you it’s really difficult to try
and
to try and express an experience and
pain is one of those experiences
pain is a human experience that’s really
quite
difficult to talk about and uh that
in one sense makes it worse because when
we don’t talk about these things
the worry builds we have these little
niggling concerns
and doubts that sometimes build up the
other thing to say
before i forget is and and we haven’t
really
uh considered yet is chemistry
simple chemistry i mean human beings are
you know animals with
bones and muscles and joints but we also
have a chemistry set built inside and
one way to think about this and it’s
really important for
runners um is we have a
drug store we have a pharmacy inside our
brain
and uh you know it would any runner will
know about this the the runner’s high
you know the endorphins and keflans and
serotonin and
you know all of these really good pain
controllers they’re
they’re um they’re much better than
morphine in fact if you look at
endorphins they mimic
morphine so we have these really
naturally
effective uh controllers of pain
uh built in but there’s a problem
because
when you’ve been if you stop you know i
i know if
if i stop running if i if i can’t run
for a week or two or whatever it is
we just had loads of snow here so i i
didn’t go out for a run for a week or so
um it’s terrible you know i feel low my
mood drops
uh i’ve it’s easier for things to hurt
when you’re low you hurt more easily
like we said
um and this is because the in a sense
all of these really good happy hormones
these effective
hormones that we have
uh which reduce pain they dry up
you know the pharmacy closes if you like
you’re not secreting all these amazing
wonderful
uh chemicals that help people win gold
medals and
that you know that enable people to
escape a battlefield
in a war zone where they’ve had their
legs shot off you know they’ll still
run people who have an arm shot off will
still run they don’t notice the arm
until later
so this is one of the biggest things
i’ve seen in
my 25 years of clinical practices
particularly with runners
and people who ride horses i would say
would be the other group
of horse riders there’s a
huge amount of pleasure gained in
running
particularly if you’re used to running
on a regular basis
there’s an enormous amount of pleasure
and
one of the problems is if you stop
running
because you’re worried about injury or
harm
that pleasure those happy hormones that
we naturally have
they dry up the drugstore closes and
that then immediately makes that boss
the brain
start looking for problems it’s like a
boss who comes checking and going what’s
going on
how why isn’t this why isn’t this knee
doing its job as it used to you know you
used to go out running four times a week
and now you’re
you haven’t been out for three weeks and
you’re sacks worried staring at the
internet at these jargony words
you know it’s it so all of these things
matter
they really do yes it’s not just one
aspect here there’s a lot of things that
can
sort of and sort of it’s almost like
they can sort of trend you towards you
know less pain and
and and more performance or trend you
towards
more pain and less performance kind of
thing depending on
lots of different variables that’s it i
i think it’s you know it’s
it’s uh very easy to see pain as this
sort of very binary thing
very simple yes it happens or no it
doesn’t
um another good real story again
pain is weird there’s lots of weird pain
stories out there
one came from the london 2012 olympics
there was an american
four by four hundred meter sprinter
manteo mitchell
and you can look him up on youtube and
manteo mitchell
broke his leg he’s running along the
track he’s coming around the bend i
think he was like the third guy with the
bat on
and he broke his leg and you don’t see
anything he continues to keep running
and hands the baton over
and it’s interesting if you watch the
interview that he gave to the sports
journalists after the race
the sports journal says you must be a
superhero you know you broke your leg
but you
you continued to keep running and he was
like well it didn’t hurt
you know it hurts now but it didn’t hurt
at the time
and if you think well why did that leg
not hurt
on the track at the final of the london
2012 olympic games
uh i i work with some people some
patients and they’ll say but that’s just
adrenaline
surely that’s just adrenaline uh which
is a bit like saying you can make a
really
delicious gato you can make a really
nice award-winning
michelin-starred cake with one egg
you know the the the idea of that of
just saying
it’s just adrenaline right it’s like
saying well you could make a really
complex cake with one egg just throw an
egg in a bowl and hey presto you get a
beautiful
you know chocolate cake
it’s one ingredient in that mix so um
we cannot make sense of of
the of a pain experience unless you’re
looking at
all the factors that surround it the
culture your expectations
uh you know what you’ve your experiences
in the past about pain
uh whether you slept well the night
before have you had sex recently
uh have you eaten any food are you
hungry you know all these things
have a big impact yeah and uh
and when you put it like that you know
this and i think that story quite nicely
illustrates
what i was hoping to get to today which
is this you know
it’s not as simple as the more damage
you have the more pain you have
and and that you that there is a lot
more
going on when you feel pain and then i
think that story with the runner
illustrates that quite nicely and i
think that the thing to remember when
you hear those stories because
i’ve heard others right it’s not that
they were in horrendous pain and pushed
through it because they’re very brave
it’s a it didn’t hurt they didn’t know
what was there
or they only felt a small amount of pain
so they carried on because they didn’t
know
exactly yeah it’s it’s not advantageous
for manchester mitchell to to drop to
the ground and have pain in that moment
it’s not to his advantage
as an organism as a human being as an
animal
and uh you know that’s not a conscious
thing he’s not thinking i’ve broke my
leg but i won’t stop
um at a subconscious level the brain is
constantly interpreting information it’s
constantly seeking out
warning signals so one way to think of
the brain might be to think of it like
um a grandparent or a parent
you know it’s constantly if you’re a
parent or a grandparent or even if
you’re
you i don’t have kids i i don’t have
kids but i’ve got nieces and nephews and
uh you know if i’m looking after a child
um i’m constantly scrutinizing every
situation i’m looking at
where’s the danger coming from you know
is there a problem in the road is that
this
is so your brain our brain
is constantly scrutinizing every single
situation
and without you even thinking about it
because the brain processes about four
million pieces of data every minute
you can’t be in charge of all that
but you’re processing that information
and if the brain
thinks there’s a threat here there’s
there’s something you know that
that i need to be aware of then we get
an output we get we get a we get a
sensation we get pain or we get muscle
spasm more
and it’s wrong for us to think of those
things as
uh a useful indicator of damage or harm
so a better way to maybe think about it
would be if you get a muscle spasm
uh when you’re out for a run or you the
day after
it’s not damage or harm but it’s maybe
that parent or grandparent pulling the
reins on a little
you know if if you’re looking after a
three-year-old toddler and they keep
running for the road
you put them on reins and if they keep
running for the road you pull those
reins hard they
make it tense so it’s a protective
response
not uh not terrible damage that’s going
to end you up in a dreadful situation
where you can’t run
yeah i think that metaphor of the the
parent
i think you know different ways of
explaining it resonate with different
people that really works for me when i
heard that explanation because then i
thought well
if you had a kid and you they ran
they sort of wandered off in the in the
mall one time
and you lost them for like two hours and
it was really
terrifying you know what are you gonna
be like
going to the mall with that kid in the
future you’re going to be a nightmare
you’re going to be an absolute
helicopter parent you don’t you won’t
let alone your site you’ll put about
raids
even until they’re like 18 years old you
just won’t forget
and i think that happens sometimes with
especially with like traumatic injuries
right so
you know you you twist your knee running
and you don’t end up running for another
three months
and then that knee bothers you forever
you know and and i think that might be
part of what’s happening now is that is
that fair
very much so yeah i think you know
there’s a again a general rule for human
beings which is
um people aren’t distressed by things
they’re distressed by their view of
things by their perception by how they
view it and perceive it
so a good example would be i mean the
amount of times that we get people who
they haven’t been with back pain for
three or four years
uh they haven’t put their shoes and
socks on their wife’s putting their
shoes and socks on
and obviously based on the conversation
we’re having this isn’t
good because now you’ve got a department
of the company the back that’s
gradually becoming stiffer and weaker
and tighter where it used to function
fine
thank you very much now it’s not and as
a result
the boss the sensitive nervous system
now starts looking for more and more
problems in that area
and it might then start looking in other
departments of the company
for other issues so before we know it we
seem to have pain all over the place and
you know
people say oh god it started here and
that’s gonna hear and i’ve got it all
over the place
and so yeah i think you know it
it’s important to consider that bigger
picture of how these things really
impact on
on us in our life um we have to think
about all of the things that we’ve been
considering
uh mood uh whether you’re uh
happy and content whether there’s some
worry about what impact does that have
what does your beliefs do to it what
does your culture do to it
past experiences so for example the
the person who can’t bend to pick up
their
shoe and sock you know and their wife’s
been doing that we would say
it’s not the bending that’s the issue
it’s it’s
how you view the bending or it’s not the
going out for a run
for the issue so you know
if you think about it in the past when
you’re a kid
bending was the same thing but you never
thought about it
you just bent you just bent and picked
up a ball and you played with your
friends and you did stuff
bending was bending it’s exactly the
same
thing that it is now if you’re 45 with a
10-year history of back pain what’s
changed is your view based on negative
experiences
you know i tried doing this and it made
it worse and you know so
it it’s the the perception and the
experience that makes the situation
worse but
as a thing running or bending is no
different it’s exactly the same
it’s a tricky one to get your head
around but it’s uh it’s important that
we do
and um i think as well i i’ve heard you
talk about
um experience learning from experience
and
like they’re the example with the the
the back pain
for a long time and they they don’t bend
because it hurts and they’re scared of
bending
because it hurts a lot it’s no good
just talking about bending they’ve got
to start to engage with it
and then reflect on it and then do it
again and then reflect on that and then
sort of
have a bad experience and come through
it and then have a good experience and
carry on and
it’s sort of a process it’s not
something that you can just
you know so if we take it back to the
knee pain example
i can’t just explain you know pain and
damage is separate and all these things
share this podcast with them to help
explain it
and then expect that the next time they
run when they get to 10k their knee
won’t hurt anymore
because they’ll probably will you know
and then if if she’s going to move
beyond it there is
um there is a process to go through a
process of experience as well as
um sort of um learning cognitively
as well there is and i love this idea
that uh i’m an educator and uh dewey
who’s a
godfather of educational theory he once
said we don’t learn by experience
we learn by reflecting on experience so
you you know it’s only when you actually
have
having the experience is one thing
learning from it is really another
so i’ll give you an example um
we’ve already we’ve spoken about how
pain is not linked as much
to thr damage as we used to think but
it’s more about threat and it’s more
about this big picture of
you know um worries concerns anxiety
sensitivity all these things that throw
themselves into the mix there
and that’s perfectly normal for a human
being or a squirrel
you know it’s but i think the thing that
we’ve got to really start considering
is um how can we use experience
to make sense of it and overcome it
for example um we see people who
let’s take bending with your back again
we take people who
they can’t bend they’ll say i can’t do
this this is you know it’s gonna
my disc gonna explode out my back we
have all these concerns and worries that
we’ve been having
but so they they find it physically
impossible to bend
but then if if as a physio
we know that if we can find ways of
tricking people
if we can get ways of tricking the
nervous system into
doing that activity that they don’t
think they can do
without recognizing the threat if we can
disguise the threat
you know if you if you’re scared of
snakes and i throw a snake at you you’re
not gonna like it
but if i can disguise that snake inside
a bag
and say oh could you just hold my bag
here for a minute um
then then you’re fine so what we often
do is um
we’ll disguise will will mask
the threat of bending with the back or
the threat of running on a treadmill
by disguising it as something else so
you know
for example with somebody who can’t bend
we might start getting them to
go into positions where they’re like
being like a dog having a stretch with
their back or
and we’ll do silly dog noises and dog
movements and scratch our ears and this
is
just purely a bit of fun and distraction
but it’s interesting that suddenly
people find that they can do things
they can function without the spasm
without the pain
without the worry and when you stop and
think about that does that there’s that
moment from people often where they go
this is weird what’s that about and it’s
only through that experience
that you can suddenly now go ah this is
this threat thing we’re talking about
if if the brain doesn’t see the threat
of
pretending to be silly like a dog on the
floor and using your back fully and
bending
then you can do things if if the answer
to the question
is how dangerous is this from your
brain’s point of view
and the answer is it’s not that
dangerous i’m just on the floor being a
dog and playing around and doing stupid
then then it doesn’t do it
and interestingly i’ve got a colleague
of mine a doctor in spain
uh he’s uh a doctor has been for 20 odd
years but he
um also is a trained magician and it’s
interesting because
he uses magic tricks to help people
understand
perception so you know we can
we can use fun creative experiences like
we did with our thumb for example
rather than thinking about it i think
thinking about it sometimes
information doesn’t really change the
way we
do things and the way we think yeah it’s
like it’s like they say with kids they
learn from
you know your example they don’t you
know you telling them stuff
it just goes in one ear and out the
other they kind of have to
live it with you kind of thing when you
were talking about
the that’s it um the back pain
it really reminded me and not forgotten
about this but i just
was it last week or the week before i
had a lady comment she’s been coming for
a few weeks and
the first time she came the first thing
we did she handed me a sheet and it was
an mri report
she’d had knee pain for like three or
four years and couldn’t going up the
stairs hurt so she would do this at a
funny one at the step of the time thing
and there was a chondral defect on our
tibia which is a
sign of uh arthritic change for the
listeners
and then and it was quite big and um
you know i tried to get her to do a step
up in the assessment and she couldn’t
because it hurt too much
i tried to get her to do like a lunge
and that hurt too much
and anyway we got on with our therapy
which was a variety of like
strengthening exercises and that kind of
stuff avoiding those
positions because they hurt so we did
other stuff
other exercises and
just last week i was just reassessing
and i got her to do a lunge and a step
up and they didn’t hurt at all and i was
like hang on didn’t they hurt lords like
the first time you
you couldn’t do them right and she sort
of looked at me sort of quizzically and
said
oh yeah and i was like does it hurt to
walk upstairs and she was like no
and she hadn’t noticed and and i think
the thing is as well
looking at the mri and i think this is
an important part for all of us because
i like everybody else looked at it and
thought
uh we’re not going to do so well yeah
you know i couldn’t help it you know i
i’d never i’d never
met her or the first thing i did was
read this report because she handed it
to me and i knew she wanted me to read
it
but i i was in this sort of tram line
there with oh we’ll see
you know we probably won’t get that far
but then within three or four weeks
she’s doing the two main things that
bothered her which was sort of getting
up and down and
going up and down stairs and it doesn’t
hurt anymore and and i can only presume
that
if we took another mri it’s not going to
look any different it won’t look better
no and this is you’ve just touched on a
really good point there
i mean quite often you know we’ll get
people who they’re
transfixed and quite rightly so by what
the scan shows
and often this can be a problem in our
culture
you know that we often think that pain
is something where we can find
the magic holy grail off button
this is why you know obviously that that
thing of you know if we remove the part
that hurts with surgery that
it’s like removing a dodgy bit out of an
old car
you replace it with a new bit and you’re
all good but human beings aren’t
cars and healthcare professionals aren’t
mechanics
uh you know it’s it’s it’s way too
simplistic to think of things in those
terms
so yeah i i think you know
we have to we keep coming back to keep
thinking about that big picture
and the big picture for an mri scan like
that would be
i often say to people well look you know
um
imagine if if we begin working together
and we get those departments of your
company functioning at a better level
so the boss goes back the golf course so
that you know the brain goes well okay
fine
i’m back getting stronger which is
essentially what
you were describing with your patient
she started to move it was pain-free
fun movement the nervous system is going
oh this is good you know this is this is
what my body is designed to do
um if we do that through a process of
rehabilitation and training
uh and gradually increase it a bit like
somebody who climbs everest will
acclimatize and gradually increase their
tolerance
to those levels of the mountain you
gradually go up you go down a bit you go
up a bit you’re down a bit
but you reach a point where your body is
physically doing really well
and your nervous system as a result is
much quieter
and if you came along and repeated that
mri scan again
after that process if you did the scan
again six months later
uh the scan won’t look any different
it’s not that
you know the scans gonna look like
wonderful like when you were seven years
of age
you’re still going to look 52 years of
age on the inside just like you do on
the outside it
then that in a sense it goes to prove
the point i love it when patients
get that because i always say how do you
think your scans gonna look if we did
another scan in eight months
after you’ve been doing all this uh
rehab and
those that really get it they understand
that of course
you know it looked the same but i’ll be
different
that’s that’s the difference there yeah
and that can be
can be a hurdle sometimes because people
are like well you know that lady could
have said
how is doing exercises going to help
with this condyle defect in my knee
and you get that sometimes don’t you
with people am they don’t
see at all how we can help them because
we are not surgeons we’re not going to
fix what they perceive the problem to be
which is the you know the structural
change
but that doesn’t mean that we can’t fix
the real problem which is the fact that
it hurts when she goes up and down
stairs yeah
yeah it’s this is it this is exactly the
problem we always say you know that
the problem isn’t the problem the
solution is the problem
and the the problem with how people
think about pain and it’s so normal and
instinctive when you’re in pain all you
do is think about pain
and think and you worry about what it is
i’d do it everyone else does it
it would be you could argue abnormal not
to do it uh so i i
i think that you know um if you
take your focus if you if you put all of
your focus into
why is this hurting and you don’t get
answers to that question
or the answers to that question are
based in
what we how we used to think about pain
in like the 1970s or 80s which is
it’s coming from the damage to your knee
or your back
then you’re on a hiding to nothing
because that’s a really
pessimistic long-term viewpoint that
you’re just going to get gradually worse
and
one day you’re going to meet a surgeon
who’s going to have to replace it and
then you’ve got this high expectation
that when the surgeon does give you the
new bit
that you’ll function like a brand new
motor car and of course the reality of
the situation is
that’s not the case often you know the
results for surgery for these problems
are not great
and you know it proves the point in a
sense that
it why why are these results not very
good it’s because
we’re doing something to the part of
your body that hurts
but that’s not the area that’s not why
it hurts
another way to think about this would be
um you know i’m sure lots of people
listening
uh of uh aware of people who’ve lost a
limb of phantom limb pain
there’s a great example you know we see
people who uh you know they’re
so desperate to get rid of their leg
pain that they’ll have their leg chopped
off
i’ve met people who’ve made that really
dramatic decision
and then they’re hugely disappointed a
year or two later because
the pain hasn’t gone they can still feel
the pain in
their foot which isn’t there anymore so
uh
you know think about that it’s uh again
it’s like thinking about your thumb
even though you’ve lost that body part
or you’ve got a new bit
from surgery you still have the brain
that’s been processing that information
for years and has
learnt it like you could learn french or
how to make a spaghetti bolognese
and that’s the like trying to think
about that because it’s one thing to
know okay there’s this weird thing
called phantom limping but it’s another
thing to really reflect on and think
well how does that work how can
something hurt if it’s not there
well it must mean that the pain wasn’t
in
the foot because the foot’s not there
you don’t mean to and then trying to
wrap your head around that and what that
means is
it’s trickier than just sort of
acknowledging phantom olympian as this
weird thing but
it happens in other parts of the body
too you know where they have
tears in the rotator cuff that they
stitch up or they have
um meniscal tears that they remove or
they have um
disc bulges that they remove and spines
that they stabilize and the pain
ends up exactly the same and it’s
because that’s not where the pain was
you know and my understanding is that
surgery generally doesn’t work that well
for pain
works very well for function sometimes
and but not that well for me in most of
the reading i’ve done
well it’s one of the problems and and
again it’s a cultural problem you have
the same
cultural issue that we have here in the
uk as you do in canada
um that pain is often seen in the west
as like a war that you fight we do the
same thing with cancer
you know we fight against cancer we
battle uh
we you can see this through the language
that we use you know stabbing
shooting burning throbbing the words the
metaphors we use to describe our pain
uh you know that they’re all battling
sort of we don’t call it helpful or
informative or
uh it’s not looking after us or keeping
us safe
it’s trying to kill us it’s trying to
kill us it is it’s uh you know it’s we
call it the language of agency you know
we
in the healthcare world we use words
like gradual insidious onset
i mean yeah i don’t know
you know it people say it crept up on me
my pain
it crept up in me like like it like it’s
some sort of you know
evil devil when we get people to draw
what their pain would look like or say
what
would your pain look like if you were to
draw it and the amount of times that
people will draw something evil
a devil attacking them or doing things
and the problem with this
way of thinking is
it it really sort of gives us this
uh what one person calls
arthur frank called the restitution
narrative that i’m broken today
but you will fix me and i’ll be perfect
again tomorrow
it’s this it’s a very western
preoccupation
that you know we will overcome the pain
problem western healthcare will
solve the issue surgery will resolve
this and i’ll be right as rain
and it’s not the case i mean in fact if
we think about back pain
um here in the uk we have a a recognized
medical term
called failed back surgery syndrome
people who’ve had
you know two or three lots of back pain
surgery
when the back pain is still there or
it’s got worse because somebody’s been
jabbing at you with a knife
you’re then diagnosed with failed back
surgery syndrome which is essentially
the
surgeon’s way of saying i did a good job
but
so this this idea of of seeing
um you know pain killers to kill the
pain
well pain control is a better word you
know to control the pain is a better way
of thinking about it
it’s interesting historically as well um
we uh historian joanna bork looked at
this
and she said that in the past we in the
western world
used to see pain as something that you
sort of got on with
you know so here in the uk uh
we in the past in the victorian days
would have had a
touch of lumbago they would call it a
touch of lumbago
and then you’d get back down the pits to
the mine
working again and doing things now we
have a problem we don’t have a touch of
lumbago we have
chronic degenerative disc disease in
your back and it leads to
people dropping out of work and then the
boss really
well physically and metaphorically the
boss starts to
get into trouble well there’s a problem
so um
this idea that that we to fight the war
on pain
we begin with the small troops you know
we often start with the tablets and the
paracetamols and stuff and if they don’t
win the war
where you know we essentially scratch
the itch and then the itch comes back
if the paracetamol doesn’t win the war
then we escalate the
war we bring in the tank division the
physios
then we go for the injections and the
mri scans the fighter jets and
eventually of course you end up with the
surgeon with the nuclear warhead and
this is a really
unhelpful sort of way of thinking about
healthcare
um this is uh it’s not how
we it’s not how other parts of the world
think it’s not how they think in south
america or in
in asia for example i see very different
ways of thinking for example
uh when i was teaching in brazil
there was a a brazilian physio who said
they’d been working in paris for a while
and they said
french people were really weird mike um
because they kept saying
uh you know my pain it hurts it hurts
here and it’s seven out of ten and it’s
achy and it’s sharp
so a bit like we were just staring at
our thumb or staring out the window
he said all these french people that all
they kept doing was thinking about their
pain
it’s like they were just so focused on
their pain all the time
he said back home you know here in
brazil people that
they come in and say i’m struggling to
do this so they’re focusing on
function on i can’t pick up my kid or i
can’t go out for a run or i can’t
but it’s not the pain that’s the focus
it’s the
it’s the as we said the problem isn’t
the problem the solution is the problem
how do i focus on how do i get back to
work or
sport or running or whatever it is yeah
and i think sometimes we get
stuck in the well i’ll go back to all
that stuff when i get rid of the pen
um and it’s again it’s focusing on on
the pain
and instead of focusing on the
impact of the pain and what the pain
means and
how to change the impact of the pain to
be more in line with
the way up we want our life to be which
is i want to be able to run
i don’t want my knee to hurt you know i
want to be you know i
want to be able to do my 10k three times
a week or whatever it is
let’s talk about that yeah
well it’s it’s it’s a really interesting
point because um
the people generally speaking the people
i see who do best
you know have a really good outcome with
physiotherapy
with all sorts of different pains
regardless of how long it’s been there
um they often get better and you say
well you know how are you better
unlike the lady you said i’m i’ve
stopped looking out the window
metaphorically
they’ll often say well i’m back playing
tennis and i’m back doing sport and i’m
back doing things
and then you asked another question
which is well how how’s the pain
and they go oh oh good question i’ve you
know i’ve not really thought about it
and that’s the point they’ve shifted
they’ve found a way of shifting that
attention shifting that focus
and they’ve poured their energy and
their efforts into what do i do about
this
what are the solutions what are the
physical things i can do
they make sense of their pain and then
they move beyond it quickly
um whereas if we if we go down that road
of of worrying about pain
and not having a meaningful explanation
as to why it’s there
not having some knowledge in place then
it’s a problem because
there are without the knowledge there
there are very few foundations you know
they’re very rocky foundations that you
can
build your rehab on so the the knowledge
and the understanding
and having meaning for why it’s there is
uh is a really crucial part of it that’s
often
uh it’s often seen as as by people
living with pain
i get the feeling sometimes that they
often feel it’s not essential
you know often patients will say well
when do we start the treatment
you know they think of treatments as
actually physically
prodding and pushing on that knee and
doing massage and putting machines on
but without the knowledge without the
understanding
and the meaning that you need all of
those
treatments tend to be a bit short-term
quick fix
you scratch the itch but it doesn’t
actually make a big difference
yeah because what you’re really looking
for is a change in that person’s life
they don’t
they don’t come in because they want you
know something done to their knee they
come in because
they want their life to be different and
and
part of that might be
having to learn to understand what is
happening with the knee and what
what is not happening you know um
i think that’s um yeah the relevance and
the irrelevance
yeah i think that’s a really nice place
i’m conscious that we’ve uh
we’ve gone on for quite a while now but
it was super interesting so i i feel
like i could keep talking
for another two hours but i don’t want
to keep you all afternoon so
i i could talk they call people like me
painiacs you know people who like
pain and studying pain oh yeah all right
ask my wife we’ll sit there on holiday
when when we used to have holidays that
is
before covered uh yeah i’ll sit there
reading books on this subject and
but i’m i’m fascinated i find it uh i
have to say that when i first went into
the world of healthcare
like i’ve always wanted to do that
physio job i actually found
the work really quite dull you know it
was when it used to be
uh well you know this is where pain
comes from it’s the knee and if you
if you do this to the knee that the
problem gets better and it was very
formulaic and recipe based and and
actually
thinking back the results that we used
to achieve when yeah they’re not that
good we know this i mean if you talk
about learning from experience ask
ask a healthcare professional who’s been
on the road for a good while
the training that we received did not
lead to good results because
um there was a study done here in the
united kingdom that found that
in 2012 99
of all of the learning that doctors and
nurses and physios and osteopaths and
those people get
is anatomy biomechanics and
when you spend all that time learning
about
muscles and joints and all of this
technical stuff about the anatomy
um it’s no wonder that we then have a
bias towards
thinking and talking and educating about
those things which then
perpetuates the problem because by
focusing on the anatomy and those
problems
we make all of the other problems the
worries the concerns the distress
we make those worse and it’s those
things
that are the biggest indicators of a bad
outcome of a poor prognosis in the
future
and then um that’s why we have to be
careful like because we can be
part of the problem and you know in some
cases it’s not always but you can get
instances where the person who comes in
can’t run because of their knee
they would have been better off just
kind of getting on with it and and they
actually
engaging with the healthcare system they
end up taking
you know they end up doing less they end
up being more fearful they end up having
more
unhelpful beliefs about their knee
because of the scans that were done you
know and
their actual trajectory can be sent down
uh on a very negative road and that’s
something we have to be
careful of and for their listeners it’s
you know
are you heading in a direction that
you’re happy with or you’re going where
you want to
you might be you know heading down the
um
sort of a more structurally biased
path that is not taking into
consideration the other
and the other aspects of your pain
although or your problem
oh it it definitely i mean definitely
it’s uh
you know i i think we we have to always
keep that context
that big picture view and something you
know we see in sport all the time we see
um whenever you work with with elite
athletes
and elite sports people they often talk
about
their experiences with healthcare and
actually what you see is not very good
because in elite sport often these
people are not seen as human beings
they’re seen as a very expensive piece
of machinery
you know they’re seen as a piece of
expensive kit
so if if the expensive piece of
machinery if
you know um i don’t know tom brady is it
the american football player
if if he’s out injured um then uh
whoever his team are uh as a business as
an industry
have reduced productivity so it’s like a
it’s like a business buying a very
expensive piece of machinery of peaks
expensive piece of kit whereas in actual
fact of course
athletes are human beings and all of
these things that we’re talking about
uh you could argue are somewhat
magnified
in that intense scenario that intense
situation
of elite performance with five billion
people watching you at an olympic event
or a world cup final or
so you know there’s uh i i think we have
to consider
where we’ve gone wrong and sport is
definitely one of those places where you
know there’s been
far too much very passive care treating
wrapping people up in cotton wool
treating them as
uh vulnerable fragile which then
perpetuates and makes the problem worse
yeah yeah and that’s um my last episode
was with uh
dr murph travis was on exactly that
concept of sort of fragilizing
people and i think you’re right i’ve
noticed the better
the athlete when i come across them the
more
unhelpful beliefs they have about their
body and the more unhelpful information
they have
yeah yeah i i mean uh bendarlo who’s a
who’s a kiwi
um researcher pain researcher
he he spent some time asking the general
public about uh the back you know what
do you think about the back what do you
think about back pain
and the title of his study
gives away the findings easy to harm
hard to heal so people generally
speaking and i’m sure this is not just
in new zealand
it’s all over the world people generally
speaking have two notions about
the spine about the back that it’s easy
to cause harm
that it’s you know it’s mind your back
all that sort of stuff uh you only get
one back
you know once it’s gone it’s gone that’s
it and hard to heal once it’s gone it’s
you know it’s not coming back again it’s
damaged forever and
we know i mean the evidence shows that
these are um
what’s the what’s the uh the the the
invoke commenter alternative facts
alternative truths in other words
you know fake news it’s uh it’s a it’s a
belief but it’s a belief that’s not
based in science it’s not based in
evidence
and maybe the situation we’ve lived with
covid shows the importance of evidence
and science
and and i you know i think when we think
about
pain we have to keep our view on what
does the science show what do we
understand about this
and then interpret that based on our own
personal experiences
uh so i i would leave you with one final
thing which is
always always think about have you had a
weird
pain experience in the past because
when when you’re in pain it’s easy to
become so convinced as we started today
by talking
that that you’ve got some damage or some
harm inside there you visualize and you
catastrophize what’s happening inside
the
ankle in my situation um but actually
if you think back you can often think
about some sort of
weird experience even years ago that you
had that
doesn’t seem to make sense when you
think about pain
linking to damage or harm i’ll give you
a quick example
some of the hardest patients to work
with are healthcare professionals
you know because we have all of this
knowledge about like we said 99 of our
time is spent thinking about anatomy and
learning all of the where the origins
and insertions of muscles are and which
nerve you know
so we spend all our time thinking about
anatomy
so uh i i was working with a gp with a
doctor
and she was convinced that her pain was
coming from damage to her disc in her
back
and she’s a runner it stopped her from
running and
i was thinking how can i help this
person so
we started talking about have you ever
had any weird experiences any
experiences that don’t seem to
fit with your understanding of pain with
what the textbooks have taught you over
the years
and we sowed the seed she thought about
it she came back a week later and she
said yeah
should i i when i was 14 you know i went
on holiday i was running with my friends
along the beach and
uh i was so competitive and determined
to get to the end and win the race along
the beach that
uh she won and then she looked down at
the floor and all her friends were sort
of you know being sick and there was
blood everywhere and
she’d stood on a glass bottle and there
was uh you know
blood pouring out of her foot so there
was blood everywhere
the beach was a bloodbath she had a
smile on her face she said she said you
know
i i was like so intent on winning this
race like manti mitchell at the london
2012
games i was so intent on running winning
that race against my friends as a
teenager
that i didn’t notice the fact that i
stood on a glass bottle only afterwards
so sometimes you know
think about how pain is weird and think
about those personal
meaningful experiences that you might
well have had in the past
and and try and use that experience to
think about what we’ve been discussing
today
and then for our listeners and is there
any way they could find you
if they wanted to hear more from you and
learn a little more about this
yeah i have a website so uh www.nope
and no is spelled k-n-o-w
so k-n-o-w payne p-a-i-n
dot co dot u-k and there you’ll find
there’s a
um resources section a big big aim of
mine over the years has been to
have a space where people can share
experiences and
uh clinicians and patients to sort of
talk about what they’ve experienced with
their pain and how they’ve been helped
and
what coldy sacks they went down you know
they went down dead ends and
tried treatment strategies that didn’t
have any uh meaningful impact for them
so go to the website you’ll find a mix
of stuff really
podcasts videos there’s so much out
there these days
that it’s uh it’s knowing where to look
sometimes and finding a clinician or
somebody who will signpost you in the
right direction so
hopefully the website is is designed to
signpost people
towards the latest evidence yeah i’ve am
certainly around there and i am personal
recommendation i would give is the um
you’ve got the podcast that you’ve done
previously on there which i
honestly not because you just done the
show but i think they’re some of the red
best podcasts i’ve ever listened to they
are hugely
helpful you talk
some of them are you know more for
clinicians but even so i feel like you
talk about it in a way that
pretty much everyone can understand with
the odd little bit of jargon
you know because they might be for
clinicians but you can still understand
the underlying meaning and
there’s a lot in there that we didn’t
get into today so
um i would certainly encourage people to
check those out and i do have some
listeners who are clinicians and stuff
as well now i can certainly recommend
your course
if you ever get to do it live again i
don’t know if you’ve got an online
version
uh yeah i’ve been teaching online
courses which is good fun
uh but yeah i’m looking forward to
getting back into classrooms with people
and
uh having lots of discussions and
experiments and things but
uh yeah the world is where we are at the
moment it’s a weird place
so uh but i think you know i think kovid
has actually taught us a lot about some
of these subjects we’ve
we’ve looked at um you know what the
impact that
sort of situations and ongoing anxieties
and concerns have
on people generally and what that does
to
the nervous system and how we think
um yeah i’ve personally found it quite
hard it’s been a really
hard challenging year yep yeah i think
uh
that’s certainly something we can all um
we can we all got our own little it’s
all it’s strange with cover because
this is the first time especially when
it first started i remember thinking
about
i was listening to music and i remember
thinking
the person who’s singing right now like
this
superstar is probably sitting at home
worrying about covet
like this is the first time i can ever
think where we’re all thinking about the
same thing
um it’s a very strange situation
well again it comes back to that idea
that you know in sport
often athletes feel uh elite sports
people feel like they’re
treated like a machine like they’re not
a human and and uh you know i’m a big
football fan my football team liverpool
have not been doing so well
at the moment and used to sit there and
think well no wonder
i mean think of the impact that these
things have that the the world
you know performing in an empty stadium
in itself you know you take away
we were speaking about those happy
hormones that help you to perform better
those endorphins and keflan’s the
runner’s high
if you’re used to getting that huge high
from
50 000 people cheering you on or booing
you or either way
you know now you don’t have it so it’s
again um we cannot make sense
of pain and performance whether that’s
at an elite level whether that’s
somebody just going out for
you know 5k fun runs uh we can’t make
sense of these things in isolation you
have to join the dots and look at that
big picture
and that’s yeah that’s exactly what i
wanted to talk about today to just try
and
you know when people listen into the
other episodes
and if we start talking about pain to
sort of have something to signpost to
because
it’s not as simple as um just
running technique for example there’s so
much other stuff going on
that um it’s important that everybody
it’s not just people who have pain
problems it’s everyone because we all
feel pain sometimes
we all get injured sometimes we have to
have a little bit of an understanding
and how this um what this experience is
and
and importantly what it’s not
well and and with that in mind i think
it’s crucial we haven’t said about this
but
what what it’s not is we’ve been talking
about pain perception
and the brain’s uh you know take on
threat like the parent or the boss
checking
on problems but when we do this
the downside of talking about pain
perception often in
in clinical practice is that of course
if you’re living with pain and you’re in
agony and it’s in your knee and you can
feel it in your knee
um then in one sense it sounds like the
clinician is saying that it’s all in
your head
that you know if you you can just you
can just think happy thoughts and that
the pain will get better
and that it’s not real it’s an imaginary
thing and it’s it’s all based in
what you what you’re doing here and um
that’s a tricky one because it’s we know
that it’s real
we know these experiences are real it’s
not it’s not that you’re faking it or
imagining it or thinking about it but
it’s really important to grasp that that
when we talk about pain perception we’re
not saying that it’s some sort of you
know
um thing that you’re considering that
you’re thinking about
it’s it’s a process that’s learnt and
wires itself in over time and
is a subconscious thing like we’ve been
talking about with all of these
experiences
and anecdotes and stories so it’s very
very real
it’s as real as your thumb felt uh
tingly and throbby and you know it’s
that real yeah it’s
it’s as real as that time where you’re
lying in bed and you suddenly feel like
you’re about to fall off a cliff
you know that moment where you suddenly
go oh god i’m about to fall off me
that’s that’s threat perception that’s
real
uh you can’t stop it just like you can’t
stop your heart beating or your pancreas
doing things it’s
it’s just your body doing what it does
but um
uh i i think a really important thing to
leave you with
mark twain um once said uh
courage is resistance to fear mastery of
fear
not absence of fear so
uh you might be somebody who runs
regularly and you’ve listened to our
chat today
and you’re thinking oh great i can now
you know
run without any concern any worry
but that’s not the case at all as mark
twain says you know it’s about mastery
not absence when i go out for a run i’m
dressed for my run
when i go out for my running again in a
in a minute um
i may well have that ankle pain that
returns
and i might well have those uh worrying
thoughts that spring into my head and
those visions of what’s happening to the
tendon but actually
it’s it’s whether you can master that
and overcome it and continue to keep
performing that’s the trick
and i think that’s okay to eradicate it
yeah that’s a lovely place to leave it
because
you’re right you often get when i’ve
talked about some of the more
complicated aspects of pain with people
they often think i’m trying to say it’s
in their head and
it’s like you said when i run a couple
of weeks ago and my ankle was hurting
i know it wasn’t in my head but i also
know it wasn’t
in my ankle it’s it’s not quite that’s a
sort of sort of
false black and white it’s not that
simple and and i think that’s a really
important
point to make is that not what you’re
saying that’s not what i’m saying it’s
not what we’re talking about here we’re
talking about how there’s
lots of different aspects to pain not
just
what you see on an x-ray
very much so but i think that’s a
crucial point to bring up because
it’s something that we know is is the
question the challenging question of our
time when we’re talking about pain
and perception rather than just talking
about our old version of pain which is
damage to tissues uh yeah
the real problem is and i i i’m sure
there’ll be people who are listening to
this who have
felt like that when you go to see a
clinician you felt like the
clinician didn’t believe you and it’s
quite a common occurrence it’s quite a
common problem
and a lot of my work with clinicians is
trying to help them
find ways to help patients feel believed
because again we know if you if you
don’t feel believed with this if you
don’t feel validated with these things
and you do think that someone’s saying
it’s in your head then um
it makes the problem worse you know you
don’t get better
okay let’s end that thank you very much
again mike that was um
extremely informative and um i will do
my best to get it out there to as many
people as i can
thanks matt and i hope people find it
helpful and uh it helps them to continue
and keep enjoying their running all
right well hey you’re further now
i’m off for a run now yeah i’m uh a slow
ploddy 5k along the coast i live by the
coast so i’ve got a nice coastal
it goes to run the snow and the ice has
finally melted so i can go out without
there we go another worry about whether
i’m going to slip over and fall in the
ice
so uh it’s finally cleared so i can i
can relax
and uh perform better hopefully well
enjoy you run thank you again for your
time and uh hopefully we’ll uh we’ll get
to meet again someday
cheers matt thanks everybody okay
you
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