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“I’ve explained pain but they still don’t get it”

By David Butler Metaphor and language, Education for all 08 Jan 2014

Over at our friends at BIM, Laura Rathbone asks the most common Explain Pain question of all. Basically it is “I have been through all the Explain Pain stuff with my patients but some of them still don’t get it”. By the way Laura, if it’s only the odd patient who isn’t helped, you are doing very well. Your curriculum content sounds good.

I don’t have a specific answer, but I am driven by the notion that education should be for all. I have a few broad suggestions to start with.

Seven suggestions:

1. Remember that obstacles to conceptual change may reside in the domains of the patient (eg commitment to existing beliefs) , the education deliverer (eg knowledge), the message (eg media) and the societal context (eg who is paying).
2. Things may be different on the next visit as Laura notes so hang in. “Anchors” for your educational material may have been found.
3. Education is two way. A common error is that clinicians give knowledge displays without attention to the level of misconception that a patient may have. This is a complex issue, now only just being discussed and researched in education science. We have started discussion here but it appears a reasonable assertion that some people with chronic pain who have only linear neurosignatures (eg A must happen before B rather than together, singular blame sources etc) will have difficulty taking on the notion of chronic pain which is an emergent phenomena.
4. Time and repetition and information in different contexts may be needed.
5. Any other support out there? Or perhaps the patient is returning to the community with your message which is a delicate and easily knocked off schema only to quickly return to the usual existing societal mental framework – that of linear biomedicalism.
6. How is your story store? Do you have enough adaptable metaphor and story?
7. Maybe in some there is nothing too wrong with an educational joint wriggle, muscle stretch or massage. Maybe we can get a bit precious sometimes.

Perhaps let’s not forget that while knowledge enrichment is easy and suitable for many patients, conceptual change requires conflict. There is quite a skill in conflict resolution.

– David Butler


  1. Yo David,

    I think that much of the answer to Laura’s problem lies in the last part of your blog: “Perhaps let’s not forget that while knowledge enrichment is easy and suitable for many patients, conceptual change requires conflict. There is quite a skill in conflict resolution.”

    The educational material that we present creates quite a conflict in most patients’ minds. I know when I first tried to really grasp this material, there was a part of it that made sense. BUT and this is a BIG BUT, I had a hard time conceptualizing it and making it real. All of what I heard about pain from the time I was a child. What all of the other professionals that I trained under or who I had been treated by in the past, and all of the media presented information that directly contradicted this new information. I had no direct experiences that made this new material real and tangible. Besides the only ones telling me this material was real were two crazy people from the other side of the world.” It is in the brain, the spinal cord etc?” Come on, get real, the knee hurts!!! Everyone knows that David and Lorimer are certifiably daft!!! I had no model to compare this new material to the realities of past sprained ankles, cuts, bruises, and noiceptive experiences that were real to me. I could touch them. I could move and make them hurt. Why should I believe D and L? Nociception and pain are not the same? I used them interchangeably all of my professional career.

    If I, who had known David for a long time for his work on nerves, couldn’t quite believe him, why should any patient believe me when the rest of the professional world is telling them something different? In actuality it really didn’t become real to me until I blew up the symptoms of one of my first patients misusing “mirror therapy”. I did nothing to that arm. We did not move it. Why did she experience such an intense bout of pain afterward? This material became real to me more through my mistakes and failures than through my successes which took a while to come. It took some time for me to realize that my successes came about more through my facility with the language of pain and my communication skills than through anything else. One of the most important communication skills that I developed was one that encouraged the patient to challenge me just like I was challenging the patient. How do I get the patient to express to me the challenges that are going on their minds? Do I have the knowledge base and the verbal skill to create good answers to the challenges? Am I a confident enough clinician to actually let patients challenge my expertise? That is scary!!! This was certainly nothing that I had been trained to do in PT school. Luckily I had practiced closely with a group of clinical psychologists for a long period of time and was able to model many of their verbal techniques, communication skills, and abilities to query that helped me immensely in developing my skills.

    TREATING PAIN IS DIFFICULT. TREATING NOCICEPTION IS SIMPLE. The skill sets required for the two have overlaps but there are tremendous differences. I am convinced that pain patients can not make the leap to do what we want them to do until they truly understand the differences between nociception and pain. THAT MUST BECOME REAL TO THEM!!! I do not think that we, as therapists, can get them to make that difference until we, the therapists, truly understand the differences between the two anatomically, physiologically, clinically, and in “real to life” experience. I can not say that I am good at this. I have no data to prove that statement. As a clinician, I feel that I have come a long way over the last five years. I feel more confident in what I am doing and I know I am harming less patients. (At least that is something) It has taken a lot of introspection, study, and struggles with understanding my failures and my successes to get there. Treating pain patients is not easy. There is a real learning curve. I am only part way along that curve. I understand what Laura is experiencing. JohnB

  2. robertjohnsonnoi

    in my experience and my practice, many of the ones who “get it” more comfortably embrace the ‘psycho-social’ contributions… those that have difficulty with the bio-psychosocial way of looking at the world seem to be the ones who ‘don’t get it’…..

  3. I agree with what is said later in the article about not being too precious about an educational joint wriggle or massage. At the end of the day most of us are hands on,physical therapists. Skilled hands (where the patient feels comfortable and safe), can surely add a lot of positive neural input back to the brain. So dont be scared to put your hands on a patient.
    Secondly, all the explain pain info is great, but it is no holy grail to the resolution of peoples problems. So some practitioners may need to question why they are trying so hard to explain pain to someone, just make sure its not because you are struggling with someone, or are having poor outcomes with them, its not a trump card you can throw at the difficult patient.
    Let patients tell their story and then ease into things, especially if they have strong views that dont align with yours or science. Dont spend the first half hour with every new patient giving them a pain education lecture!!

  4. davidbutler0noi

    Thanks all –

    Nigel – I think “hands on” is really important and it often upsets me to see conferences which have the the session on “hands on or hands off” – what an ugly dualism! “Hands on” is rarely defined in these sessions and yet it may range from the parting touch on the shoulder as you say ‘this is going to be OK” to various forms of manual therapy. Explaining pain has never been a replacement for any therapy though some think it is an end of road intervention for chronic pain. And you are right about letting patients tell their story and meeting them there. There are far too many knowledge displays out there still, given under the guise of Explain Pain.


  5. I would appreciate more examples of story/adaptable metaphors. Story-telling would especially help with patients who are illiterate or with limited education. This is also where we need to draw on our creativity!

  6. davidbutler0noi

    Hi Lezanne,

    We all need a store of stories and metaphors and we need to keep making them up. I have kind of classified my stories into one liners (neuroscience nuggets) (eg dethreaten night pain when it arise from peripheral nerve) longer stories (eg stories around why doesn’t anyone believe me, tennis elbows in the brain) and then longer classic stories such as “the drug cabinet on the brain” which is on this blog.

    Happy to share suggested stories for particular problems here.

    Ever tried dethreatening a “ruptured disc” into a “slightly flat tyre” ?


  7. Hi David and Noi-Jammers!

    First of all – my apologies for the length of time between your post and my reply.

    I think your advice is absolutely key and has been extremely helpful – we should not give up our hands, Explain Pain is a treatment tool and can work wonderfully well in isolation in some patients, but also with the right amount of therapeutic manual/restorative manual work to reduce the localised nociception and sensitivity, restore movement and allow the pain-brain-block to free up a little space for extra knowledge.

    One of the things I have seen the most this last month is that patients get the pain-modulation element of education really well if you can show how easily the sensation of pain can be altered in a session. Now I work hard to ensure that my education is inter-twined with any hands on work. Highlighting that we are altering the state of the sensitive tissues (love the issues with tissues stories) and that this ability is something each of us have. I must admit Mr B, the Sensitive Nervous system book has really helped here with this!

    Now I see my hands on therapy as a way IN to the education – rather than a block or barrier. Some patients need a little oxytocin in order to feel safe enough to accept a new paradigm of pain and treatment – our hands as therapists can be a great way of doing that, providing we fully explain the process underneath the skin and what the patient thinks or has been told is happening previously. I’ve noticed my patients even talking this new language now and explaining it to their friends and partners. The seed grows beautifully if we give it a little bit of space to cultivate and settle – this is what I’ve learnt the most. Let the patient connect the dots instead of showing them the dots connected. It makes for some significant changes in understanding and coping.

    I think having a big bank of stories is key, patients all have different cultures and beliefs and relating the mechanisms in a way they can relate to and own is helpful. One thing I have done more recently is to understand what the person knows about their brain and their body and their pain. I remembered on the course, you brain-stormed the brain with us and I have found this extremely helpful as an inter-active patient led session – also great to look back at how it has changed too – people love to see improvement and not just in their range of movement, but also their knowledge. So we use our initial brainstorm as a baseline and then re-do it a few sessions in – and they are often joyful and impressed at how much they now understand. it helps the person to feel like they are the master of their body and pain, and I think this confidence is a helpful motivator. I love to here the way patients explain massage as the ‘afferent barrage’ that is re-organising how their brain processes the area! Fantastic! I only hope I can learn more of the science in order to give my patients a deeper understanding. It never ceases to amaze me how much a builder, or an accountant, or a taxi driver really gets the complex elements of this teaching!

    I hope this all makes sense, I appreciate any tips or advice, so thank you to all that have commented.

    Wishing you a peaceful and joyful start to spring!


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