persistant pain

Persistent Pain

This is a guest blog written by Dave Renfrew (The Pain Weapon)

Pain Education and Exercise. Go together like a horse and carriage.

Doesn’t exactly rhyme, but we sort of get that this is a good idea, right?

The general premise has solid backing. Evidence is backing treatment to be heavily based on education and exercise, but our knowledge on effect, type, dose, pretty much everything is looser than an English football tour to Ibiza!

Plus, we have our lovely biases.

Empowering patients to be in control of their health is solid (Aussie slang for bloody good, also an Aussie slang). Exercise, in general, is solid. Increasing health literacy is solid. So all three pain treatment modalities are solid, especially because I think all of them are awesome.

This gives rise to 2 separate schools of thought

  1. This is bullshit – I can keep manipulating and massaging people in pain forever because you idiots can’t prove education and exercise does anything
  2. This is the way, praise be to Moseley, I can talk to people twice and I will have changed their lives.

But, it’s not really either, is it?

Let’s agree that education and exercise are a good idea. So how do you best deliver education and exercise to people in pain?

No idea!

Even before we get into what Neurophysiological Pain Education is, what about whether it’s even necessary that it’s Neurophysiological?

As described in the source article, it’s pretty heavy going. Ion gates, synapses, and excitatory chemicals, these words can cause the glazing over and rolling of eyes. Some people want to know about neuroscience nerdy stuff, most people don’t. They need to understand and re-conceptualise their pain. They don’t need to necessarily get a university degree in neuroscience.

Neurophysiology is similar across humans, but pain is not! It makes sense that pain education needs to be individualised, based on what and how the person wants to learn about it. So pain education is essential, but NPE may not be? It certainly doesn’t seem to add a huge treatment effect on top of what else you might do.

But, in our education of people on their pain, what is our aim? Are we trying to remove their pain instantly? That’s not going to be successful, no matter what you do.

Are we trying to improve their knowledge about the workings of their body and hopefully increase their ability to negotiate their lives in the future? Then any or all pain education is a good idea.

Humans have always used stories to convey meaning to each other. Conveying pain concepts to a patient is no different. Stories, analogies, and information presented in a way suited to the person is your best chance of changing people’s thought processes, activity and behaviour. You still have to understand the neuroscience yourself. The patient only needs to hear what they need to hear to change their BEHAVIOUR.

“Knowing cool shit is awesome, but if they do nothing with it then what is the point?”

Dave Renfrew

What about exercise?

What exercise is best for people in pain? No idea. How does exercise work for pain? Does it work? Well, looking at research, it doesn’t seem to work that well.

Study question/aim: Current review of concepts in musculoskeletal pain and the possible effects of painful vs. pain-free exercises.

Study type: Educational review

Topics and Summary of points:

  • Sensitisation – peripheral and central
  • Central sensitisation umbrella term for Allodynia, Hyperalgesia, Temporal Summation of Pain (TSP) and Diffuse noxious inhibitory control (DNIC)
  • Immune system – inflammatory immune response activated by various processes, detected by Toll-like receptors (TLR)s
  • Affective aspects – pain related fear and negative emotional states present in and affect pain states. All have a biological effect on the CNS and have prognostic/mediating factors as to presence or reduction.
  • CNS has maladaptive, pain related “memories”/”neurotags” because of correlation with pain episodes. Tissue stress and load become linked with threat and danger
  • Biomechanical effect of exercise doesn’t explain changes in pain. Common factors in all exercise has mediating factors for pain = Hard to research most effective exercise


  1. Pain related fear, kinesophobia, structural narratives are all challenged, force different thinking with painful, but safe, exercise
  2. Increased self efficacy – a positive prognostic indicator
  3. Exercise induced Hypoalgesia (EIH) – painful exercises have higher dose and response
  4. Immune response – regular exercise decreases risk of viral and bacterial infection – potentially resulting in improved immune function with exercise.

What can you do to weaponise yourself in treating persistent pain?

It’s probably the best thing available in a sea of shit and ineffective garbage. There are physiological effects of exercise, making people stronger, more mobile and durable. However, strong people can still be in pain. As Smith et al (2018) explore in their educational review, exercise, in general, produces system effects which may be involved in altering pain states, in the immune system and the production of endogenous opioids. Specifically, the effect may be on providing evidence of safety in positions, stressors or loads that are associated with danger and pain.

The tricky thing is, getting people to physically address neurological barriers is going to get a reaction – patients need to have some context, information, that this is ok.

Because the fact remains that there is a mountain of aspects we still do not know about how exercise actually works to reduce pain. This is, what the Smith et al (2018) review actually highlights. Why would moving about, potentially getting stronger, potentially unmasking previously ‘protected’ patterns reduce your pain? To become connected with the affective aspects of pain is a must when giving ‘exercise’ to your patient; stop thinking so clinically about what you are actually managing and consider these ‘higher-order’ effects.

The nervous system is set up for AVOIDANCE, at some point in order to progress they are going to have to expose the system to load, stress, movement. Getting comfortable making people do things that hurt is important. Therapists can’t be scared of pain – the patient already is. They have to hear a consistent message of support and encouragement.

Uncertainty with pain is a driver of fear for the person and for the therapist. But the fact that we don’t know can be exactly what you need to do the most beneficial thing you can for your patient. Get them to realise that they are in charge of their own outcome.

My favourite thing about all of this uncertainty is that there is every chance that you are the best possible person in the world to help the person currently sitting in front of you.

There are no gurus. There are no experts. There is a person in pain, there is you and what you know. WTF is a pain expert anyway?? That just means they are a little bit less lost in the jungle than you are.

If you are out in the Neuro-Endo-Immuniverse, zooming around in your X Wing, aware of all the fantastic possibility and endless combinations of situations, you can use an infinite number of things to be the weapon your patient needs.

But it’s about them. Education, Exercise, Exposure, Empowerment for the person in front of you. How are you going to relate to this person, how can you help them, how can you get them to understand the things they need to do to make a meaningful change in their lives?

It’s not a dichotomy of the proof of exercise or not, it’s the reason you do it and understanding that we still don’t have the answer why. At the end of the day, learning about pain, treating people with persistent pain comes down to a red pill/blue pill choice, as it does for the person in pain.

Avoid it, or Get Better at it.


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