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The pain-learning Catch 22

By Noigroup HQ Education for all 25 Jan 2018

YouTube: McGill Pain Questionnaire

(This is ‘The McGill Pain Questionnaire’ Installation from Eugenie Lee. Try this – put some headphones on and turn up the volume as you read the post. What happens to your concentration and ability to recall what you’re reading? Is there a metaphor embedded in a metaphor here?)

A classic Catch 22

The basic idea behind Explain Pain is that learning about pain helps people to hurt less. But, pain can significantly impact our ability to learn – it’s a classic ‘Catch 22’.

It’s not just that pain can be distracting – it can, but some of the same processes associated with persistent pain, such as alterations in neuroimmune and neuroendocrine function, can also directly affect our ability to form new synaptic connections, lay down new memories, learn and think (some of the usual suspects, such as proinflammatory cytokines IL-1 and IL-6 play a role, but that’s for another time). Additionally, many medications, including antidepressants and long-term opioids can have detrimental effects on memory and learning.

More a question to ask yourself

Question 3 in The Explain Pain Assessment* is all about respectfully teasing out whether the learner has any impairments in their ability to learn. You may have picked something up in the first two questions, but it’s worth exploring further. ‘How’s the ole memory?’ might be appropriate in some situations, but something more formal will be needed in others. It might be one question, or it might be multiple questions throughout your assessment that build a picture. It’s more a question that you ask yourself ‘Does the learner have an impaired ability to learn?’

Understanding the biology of pain and being aware that you are highly likely to find some learning difficulties in people with persistent pain states (taking a range of medications) should be an essential part of your planning for providing an Explain Pain intervention.

What have you found out there in the clinic? Comments and thoughts are welcome below.

– Noigroup
Knowledge driving health


* The Eight Great Questions in The Explain Pain Assessment come from Explain Pain Supercharged, available at (worldwide), and the NOI USNOI UK and NOI Europe book stores.












  1. It’s all about patience and peacefully revisiting the points you want to get across again and again and again……compassion, varying metaphors and humility a must……with time even the most “foggy” brain will change….

    1. I love the metaphor of ‘peacefully revisiting points’ combined with compassion and humility!!

  2. Kessels (2003) showed in consultations patients exhibit attentional narrowing and therefore find it difficult to retain information due to stress and high emotional levels. Also memory is affected if levels of stress are incongruent between the consultation and recall phases.
    We need to accept that for those with persistent pain we need at least 60 minutes in order for the patient to settle and have time to say everything they feel is important, or else to only gather data on the first consultation.
    I feel the difference between me as an explain pain practitioner today and 5-8 years ago is I feel far more in control of my knowledge and have higher confidence levels. This in turn (I hope!) has the effect of making the patient feel at ease which in turn switches down their stress and improves their learning and subsequent recall.
    Asking what they have taken from the consultation is also useful.

    1. Ah, but there’s the rub… 60 minutes per patient is unattainable for many therapists (but i do agree). But, I’ve also heard from some clever therapists who ask their patients to come in ‘early’ (20-30 minutes) – set them up in a very peaceful, seperate waiting/therapy space with some music/guided meditation or just quiet, soft light or candles etc, so that when the do ‘see’ the client they are relaxed and hopefully more receptive. And as far as the patient is concerned, the whole time including the ‘waiting’ was part of the appointment.

  3. Berna Lindfield

    Can you PLEASE provide more info (refs would be excellent) on the effect of persistent pain on learning.

  4. ellen barnett

    Agree with Lindfield, would like the ref on anti-depressants causing memory loss. Thanks.

  5. Renata Boyd

    My experience is that the stimulus of pain can be so strong with some persistent pain clients that there is no chance of them concentrating on learning anything and that includes receiving new information.
    Is it the opioids themselves which stop new learning? or the focus on the opoids from an addiction perspective that stop learning. I have heard a number of times, “I am not addicted to opioids but I am addicted to not having pain”

    1. Good questions Renata, i would hazard a guess that each of these factors play a role.

  6. Lisa Wishart

    From a patient/client perspective i was able to start living my life again after engaging in a lot of education regarding my pain. It definitely worked for me after a long process of not getting any information or mention of the term ‘chronic pain’. The first assessment i had with an amazing physio i recall asking her ‘can you help me’. She made eye contact with me and replied ‘yes i can’. The building of a relationship between the client and therapist allows for meaningful education to happen, and ensures continuity and consistency of information. Eye contact is so important, as is listening and picking up on cues that show anxiety and misunderstanding. These aspects helped me continue on with expanding my knowledge of my pain throughout the past 8 years. I hope this helps!

    1. Hi Lisa, thank you for sharing your experience – it’s invaluable to hear from people that have not only experienced life-altering persistent pain, but have found a way through it as well.

  7. Margaret Vandermost

    In our centre repetition is key, so patients are engaged with pain education from day 1, practitioners all “sing from the same hymn book” and we repeat many of the basic messages on a regular basis. We have lots of little sayings that are also repeated “know pain, know gain” etc. Over time it sticks and works concurrently with behavioural change which is encouraged even if the patients haven’t yet retained or gained an understanding of their pain.

    1. Thanks Margaret – it is so absolutely essential to have multi-profession support.

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