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Pain Education and Emergence

By Noigroup HQ Science and the world 26 Jun 2013





Education for all is a NNT of 1

Education for All (EFA) is a UNESCO movement. If it really works then it means that the number needed to treat (NNT statistic) or number needed to educate (NNE) should be 1; i.e. everyone benefits.  This is the goal of the Explain Pain movement. An aggregate analysis of Lorimer Moseley’s initial work on therapeutic neuroscience education suggests a NNT of around 3, i.e. 1 in 3 benefit. While this figure would make a pharmacological company salivate, we can and must do better. Good clinicians probably are these days. There are many avenues to seek improvement – one may be the introduction of the notion of emergence.


Traffic jams kind of “just happen”- they emerge, often surprisingly. A collection of cars interacts with each other in complex ways. When water molecules interact with each other, a cloud could emerge, when insects interrelate, a swarm or an ant’s nest could emerge and when many brain cells fire together, thoughts, movements, love and pain may emerge. The critical elements of emergent patterns are that the players or agents have reasonably equal status, the pattern is a result of all the agents working together and just a small action of one of the agents can have out of proportion effects – the “butterfly effect”. For example, the actions of just one car may set off a massive jam.  Check out the emergent patterns of thousands of birds flying together.

Emergent patterns contrast with sequential/linear patterns such digestion, tissue healing, moon phases and children stories. You can read more about emergence and links to pain in the recent NOInotes and references below.

Emergence and therapeutic pain education

Explaining pain is not easy sometimes. Maybe those patients (and colleagues) who just can’t ‘get it’, or those who seem to know a lot about a lot of things, but can’t pull it all together (i.e. “can’t see the forest for the trees) don’t have emergent schemas?

How hard can it be at times to explain pain to a person in chronic pain who just wants to know what the singular anatomic cause for their pain experience, so that it can be manipulated or strengthened or mobilised or stabilised or just plain cut out?

Renee Descartes was probably pretty linear with his thinking.  His linear and sequential idea that pain goes into the body and up to the brain where it’s given some emotion is old, dangerous and needs removal.  Maybe the damaging persistence of these ideas in health professionals as well as those people experiencing pain could be related to a lack of a well-developed and frequently exercised emergent neurosignature?

When I mark assignments where the question requires some understanding of emergence (e.g. “Describe pain as a brain output rather than an input”) some students are all over the place with piecemeal answers, others can pull it together – maybe they have emergent schemas?  With pain we well know now that there are many agents and contexts which collectively interact to result in the emergent outputs.

Ever think how sometimes you are educating about tissue healing (a linear sequential process) and then jump to a discussion on pain or cognitions (emergent) and see the patient’s eyes glaze over.  This switch from linear to emergent schemas is probably hard for many and likely impossible for some when their emergent neurosignatures are under-developed or even completely absent.

Maybe we need to teach our patients (and ourselves) about emergence first? Maybe we need to try and work out if they have emergent schemas first and if they don’t, spend some time explaining emergence first?

We have recently developed an emergence module as part of the NOI Explain Pain course.   Research is following but we suspect that teaching people in pain just a little about emergence and helping them to construct an emergent neurosignature could make a real and positive difference to their understanding of their pain experience and realisation of the different ways that they can start to take back control and change their experience.

How helpful might a quick explanation of emergence and the “butterfly effect” be for a person reporting that their entire body and life is falling apart as a result of chronic pain following a minor injury?

How much more powerful could an explanation of pain be for a person who is convinced that surgery and “cutting the painful bit out” is going to fix their problem, if it is accompanied by a discussion about the complex interaction of self and environment and the emergence of pain?

Here’s a thought; if you have a patient who is a keen baker, how might a story about baking a cake be relevant to their understanding of pain?

Lots to discuss here. Share your examples of emergence and pain education.

– David Butler and Tim Cocks

Chi, M. T. H., R. D. Roscoe, et al. (2011). “Misconceived causal explanations for emergent processes.” Cognitive Science 36: 1-61.

Yong, E How the Science of Swarms Can Help Us Fight Cancer and Predict the Future

Neil Johnson N. (2011).  Simply Complexity, a clear guide to complexity theory. Oneworld Publications

Johnson, Steven Berlin. (2001). Emergence: The Connected Lives of Ants, Brains, Cities. Scribner. New York, NY


  1. Thanks for this interesting topic guys! Perhaps I’m not on the right track, but there are certainly people I discuss pain with who will manage to summarise an hour of chat / exploration / education with ‘so you are saying the pain is all in my head then?’ which is a little disheartening!

    I’ve tried (with mixed success) to use models with multiple factors that all interact (rather than any single ‘thing’ generating and maintaining pain) and certainly analogies and metaphors can be helpful with that. It’s also really helpful in explaining why so many different strategies may be helpful to them (exercise / relaxation / GMI) and the context in which they are applied.

    Looking forward to hearing how people are trying to put across this concept.

  2. Andrew – I think you are right on track with the use of multiple factor models. We have given some examples in the noinotes and the story above.

    Many thanks for adding to the story – some people get fixated and often demand a singular treatment to end the problem whether it be the fusion, the “golden click” or a particular medication. (Unfortunately some therapists only offer a singular treatment too!). The notion of emergence, with one of its essential features being that many agents contribute simultaneously to the emergent output should help people understand that there are likely to be many treatments that could help. Maybe we do need to check out if our clients/patients can see the critical differences between a mother duck leading ducklings (linear patterns) and a swarm of locusts (emergent)?


  3. I am not sure that explaining pain actually assist patients to cope with chronic pain. If a patient is regularly woken at night by, for instance, Carpal tunnel syndrome causing acute severe pain in her hand, does it really matter whether she thinks in terms of brain output and emergence, or she thinks of it as caused by the pressure on a nerve in her wrist? Some patients may be able to cope better with the experience through mindfulness, but not all can, and no matter how well they can practice mindfulness, they will still have the regularly broken sleep, and perhaps the nightmare that was stimulated by the pain experience. It makes sense that the patient would seek an injection into the site of the pressure on the nerve or some other way of preventing the acute experience, just so as to be able to get a good night’s sleep.

    1. If performed well, explaining pain, by itself and linked to other evidence based tools such as graded movement is currently the most powerful tool of all for treating chronic pain, with NNTs (number needed to treat statistic) far better than that for any oral or injected synthetic medication. Injections make little sense in all but the most severe carpal tunnel syndrome where various antiepileptic medications may quieten mid axon ectopia. Much chronic carpal tunnel syndrome is now understood in term of altered wrist and arm representations in the brain – ripe for educational strategies. In a more acute carpal tunnel presentation, all patients should be offerred an educational intervention which includes the usual self limiting nature of the problem, knowledge that not everyone needs surgery, information on the role of blood pressure changes and link this to nerve and tendon gliding. If they wake at night some nerve and tendon gliding usually allows them to get back to sleep. And of course with mid axon sparking they should also know that immune and stress factors can worsen it. With a bit of knowledge they may work out their carpal tunnel syndrome themselves.

      Nothing wrong with a bit of mindfullness, but I suggest that it’s powered up with targeted knowledge first.


      David Bbutler

  4. Fantastic discussion David and Tim. AS you say looking at the body in the linear Newtonian way when discussing pain is unsatisfactory and incorrect and will never give the insight that patients need to resolve their problem. I use emergent framework with every patient when helping to resolve their persisitent pain. However, I have found that there is a skill in finding the’zone’ for both the therapist and the patient to allow this emergent process to take place. Rather than the therapist suggesting metaphors the’zone’ allows for their own personal explanation of the neurosignature to evolve and all componenets of tte ‘traffic jam’ be examained and then dealt with. These insights change physiologic and chemical outputs from the body

  5. Hi Guys, Interesting ideas. The idea of linear schemas is consistent with people who appear (and feel like to us) to be stuck. Similarly the emergent schema idea is consistent with people who seem to ‘get it’. The idea of schemas has been around for a while in psychology, e.g. see Schemas in this sense are used to describe emotional patterns that develop through life experience, especially during childhood and strongly affected by our caregivers (mostly parents). It would seem likely that linear or emergent schemas develop similarly, and it makes sense of those situations where we see familial trends in chronic pain. So the multiple factor approach would make sense. I would add one other aspect and that is patience and persistence. In psychology these schemas are slow to change having been there for a long time for most people. To go from linear to emergent, I would imagine, is likely to be a similarly slow process. if only there was a pill……just kidding!

  6. Thanks Alison and Mark – we would love to hear more about Alison’s “zone” as it links, I think, to the slowness to change that Mark discusses. I wonder if conceptual change, especially if intentional, has to be slow. In some cases patients will get the pain story quickly and instantly grab the opportunities that open up – such people probably have emergent schemas existing that easily link with other neurosignatures – a radical restructuring as educationalists say, or a revelation for some.
    The variables that allow this are somewhere in Alison’s “zone”. We would love to hear more.


    1. davidboltononoi

      Every baker has his own recipes to make the perfect cake. Our skill lies in finding the recipe for that being and using the brain as the mixing bowl so that the patient can make sense of the knowledge we want to share. That takes us back to the skilful use of metaphors and analogies…..whether the injury occurred yesterday or ten years ago I feel we should always take our patient into their brain/soul as quickly as possible.

  7. Thank you David for your interest in ‘the zone’ . Having a very deep rapport with the patients affords the space of potential for their imagination and internal inquiry to find their own answers/metaphors, making sense of why the problem still remains. ( is a fab research group which is worth a long look).

    it is quite different from the way we usually approach patients in that ‘the zone’ is spacious, non judgemental, allowing for complete freedom and control by the patient. As you comment it is necessary to explain about neurosignatures and emergent patterns before so permitting other thought processes to come to the fore. I also like to mention energy in my discussions as most people understand this at some level. Some patients get it immediately and feel these energy changes and see very quick results . Others take longer especially if there is entanglement of the neurosignatures for different aspects of the problem. How much someone has been protecting themselves in survival mode within the reptilian brain will always play a part in the letting go and changing the neuro matrix; how much they believe the neurosig is ‘them’. I would therefore disagree that the new emergent schemae always take a long time to appear, you would be surprised how quickly it is possible, the skill is in allowing the patient to find the one or two problems that are holding up the traffic from running smoothly again.
    I would also argue that digestion and tissue healing is far from linear !!!

    I have had and have some wonderful teachers that have taught me how to find the zone and look at the physical body from a different view point .

  8. Oophs, fogot to say how wonderful it is that you are including a module on emergence in your teaching programme. As you so rightly say, the fewer boundaries a therapist has the more the patient will benefit.

  9. Thanks all – I want to pick up on Alison’s comment about “digestion and tissue healing far from linear” and emphasise the spectrum. All processes and patterns will possess elements of emergent and linear contructions. At one end of the spectrum, something like consciousness or thought could be regarded as very emergent, and at the other end something like mitosis very linear. Both tissue healing and digestion have elements of both but they both possess a fundamental element of linear or sequential patterns in that A has to happen before B and C will happen. In the case of tissue healing – injury first, then swelling, then cell proliferation, then scar remodelling. An injured person “knows” and even sees the sequence. A single initiating (often blame) factor can often be identified. The pain experience however is far more emergent. If a person tries to understand their pain experience as linear with a singular cause , which is often the default mental framework, problems may follow.


  10. Thank you for clarifying the linear ,sequential process from the emergent ones. As you say tissue healing should be more linear but what then changes it to becoming more emergent when healing does not take place? Wouldn’t it be wonderful to find that answer?
    I would suggest that any event that the person perceives as a shock, no matter how small or great changes the energy/meaning of the situation for them.For example a lateral ligament sprain turning into CRPS following a perception that the stability of their life has altered for ever. In my experience this type of metaphor is revealed by the client when they are in ‘the zone’ . We know that the physical body is a medium through which we experience our world and when the internal does not match with the external the system malfunctions or comes to a halt.
    This is where the baking analogue is great but we must be careful in our enthusiasm not to talk/guide them into making a chocolate cake when they have their own deeper knowledge that a mudpie is what is needed ! The finished product they create must taste, smell, feel and look just right to them serving the purpose of creating order out of disorder.

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