Pain Education, No Script Provided with Monica Noy, episode 1

What if pain education got the fundamentals wrong by chasing tidy scripts instead of solid mechanisms? We sit down with researcher and educator Monica Noy to rethink how clinicians learn, reason, and communicate about pain. Rather than leaning on “explain pain” narratives and one-size-fits-all language, Monica anchors care in a clear premise: nociception is necessary—though not always sufficient—for pain. That single shift reframes assessment, reduces blame, and helps us speak to people with honesty and respect.

Across a candid, story-rich conversation, we explore why pain care remains under-taught across health professions despite being the top reason people seek MSK help. Monica traces the evolution of common teaching approaches, the biases that shaped them, and the real-world fallout when clinicians over-educate, over-promise, or quietly fault patients for not “thinking right.” We talk ethics, too: if pain is associated with actual or potential tissue damage, what does it mean to create pain during treatment? When does intensity cross into harm, and how do we decide with patients rather than for them?

You’ll hear a grounded way to use the biopsychosocial lens without turning it into a moving target that justifies endless chasing. We discuss definitions, semantics, and why shared language matters; how better mechanism literacy leads to fewer words and better questions; and what Monica’s new course, Pain Education, No Script Provided, offers clinicians who want to be less wrong and more helpful. Expect fewer scripts, more clarity, and a renewed respect for autonomy—yours and your patients’.

Enjoyed the conversation? Subscribe, share with a colleague who teaches or treats pain, and leave a review to help others find the show.

The Massage Science Podcast and my company, The Centre for Evidence-Based Education (The CEBE), are now official partners with Noterro.

Partnering with them feels like a natural alignment with our mission to support busy clinicians.

Get Noterro free for 44 days!
Noterro makes clinic management easy with scheduling, billing, and charting all in one place

Chapters

• 0:00 Meet Monica Noy And The Series
• 2:50 Monica’s Background And Research Work
• 7:30 The Case For A New Pain Course
• 11:40 Limits Of “Explain Pain”
• 18:30 Bias, Evidence, And Scripts
• 25:43 Nociception As Necessary For Pain
• 32:03 Grounding Clinical Reasoning In Physiology
• 37:08 Ethics: Education, Autonomy, Humility
• 43:23 Rethinking Patient Communication
• 49:53 Beyond Biopsychosocial Shortcuts
• 56:53 Practical Course Structure And Goals

Transcript

SPEAKER_00: 0:12

Hello everybody and welcome to another episode of Massage Science. I'm really excited about this, the first of seven episodes with the most amazing Monica Noy. We're gonna be discussing her new course that she created called Pain Education No Script Provided. And I'm so honored that she reached out to me a couple months ago to propose this idea, and how could I say no? So thank you, Monica, for being here. Tell us a little bit about yourself.

SPEAKER_01: 0:40

First, it's wonderful to be here, and I am glad that we have been able to get together and do this. I think we've known each other for a while now and tour with each other. So I'm very happy to see like everything put together. So this is great. This is what I can remember. My first sort of I don't know, there might have been on the podcast, but I can't remember. But sorry, what was your first question?

SPEAKER_00: 1:10

Who's Monica? Tell us some fun things about yourself.

SPEAKER_01: 1:13

Some fun things about myself. I'm just trying to figure that out. I don't know if there's any fun things. I can tell you a lot that sounds like I do a lot, but I don't know if it does. So I have a master's masters of science in rehabilitation. We did our masters at the same time, you're just across the country. I have a Bachelor of Science in Osteography from the British College of Osteopathic Medicine. I do have a diploma in osteography, but I was converted to the Bachelor of Science. I am a former massage therapist. I have that. I also have a Bachelor of Arts, but who doesn't? And and I have a I work one day week at a clinic up here in Chelvin. I'm a researcher, so I've done some more on the clinical professional commentary side of things rather than doing studies, although I've been involved in one Evans-based survey study, and I'm involved in a status osteopathy cross-country study right now, and that's with University of Quebec in Montreal. So I just am lucky to be one of the team members. And I teach at Sheridan at the honours bachelor degree in osteopathy, which I was part of setting up and had developed two new courses, of which one of them is philosophy and science of pain, and the other is critical thinking, and they both go together. And I've done other stuff. I like to garden, I play video games, I have an adorable kidney cat.

SPEAKER_00: 2:42

That's pretty.

SPEAKER_01: 2:49

Yes, those ones are no longer with us. They were, yeah, they all made it to their old age, and we gave them a lovely retirement home. But now we got a thanks to the cat distribution system, we have another one and a little tuxie. She's quite cute. She's perfect. So yeah, that's kind of me. Oh, yeah. I I like among several research committees in Canada and in Europe, and standards committees and various other things. And then I'm doing this con ed with you. So none of it pays very well, but it's all pretty interesting.

SPEAKER_00: 3:27

We're involved in a lot of I uh I feel important activities, things that are are there to make a change, to help clinicians learn better, think better, yeah.

SPEAKER_01: 3:41

I think that's a big part of it for sure, is the drive to be better is one of the one of the bigger drives that I have. And it's from an ethical, like a medical, ethical, philosophical perspective, that I think has been one of the big drives for this. And it's taken a while. It's taken a long time to get to where I am and to developing these courses. I was really lucky when Sheridan, I wrote about this. There's a paper in the International Journal of Osteopathic Medicine that I wrote about the two courses, but very lucky that when I was there during the setup, that I proposed these two new courses in Sheridan, didn't they go blink, and accepted these courses. And one of the a big impetus for this particular pain course was the knowledge gap that exists for healthcare providers who do not have enough knowledge of mechanisms and management of pain. And that's a documented knowledge gap for practitioners, but there's also a documented education gap for practitioners to be able to get that knowledge. And there isn't really a measurement tool for figuring out whether or not the knowledge we're providing actually has any benefit, not only for clinician knowledge, but ultimately for the person in pain. Those are all pretty big driving factors, I think, for uh getting these courses going.

SPEAKER_00: 5:24

And from what I've and from what I've seen, all the stuff that you've shared with me, the these courses are fantastic. And I there's a huge gap that is being filled or potentially being filled by what you are what you will be teaching and what you have created. Now, your courses that you that you're teaching at Sheridan, the course that you're gonna be doing through that through you and I are gonna be doing, or you're gonna be doing through through my company, is that course is based on some of the on some of the things that you're also teaching at Sheridan. Is that correct? So some of the stuff that you'll be teaching to practice practitioners through my platform, this is also stuff that's being taught at an entry-to-practice level at Sheridan. Is that correct?

SPEAKER_01: 6:06

One of the interesting things about Sheridan is that I think it's a first of its kind in that it is a 14-week pain course, which when we looked into the amount of education that occurs throughout the world for specifically pain, it's very limited. And there's not a lot of education that fills perhaps a whole semester, and then let alone being integrated necessarily into healthcare. And we see this across medicine, the muscular school of medicine, probably vets and nurses have more defined pain care, perhaps, than doctors or even MSK practitioners. Yeah, so it's that big knowledge gap that definitely exists. And it exists, it exists for me too. I didn't come about this on my own. We operated in the same circles on social media, and we came at this from very similar places where we were discussing it the other day about having exposure to pain, neuroscience education, and the explained pain phenomena that has become very entrenched in pain fields, and being slowly chipped away at in terms of becoming much more skeptical of that whole approach and starting to see that there are ways of going about this that are much more fundamentally and logically sound to be able to actually look at the mechanisms of pain and then be able to translate that to management in some more effective way than the kind of P ⁇ E type uh courses that are provided.

SPEAKER_00: 7:57

It's funny to think back when we when I when you and I first connected over social media, it was probably around maybe 2016, maybe 2017, somewhere around there. And yeah, we were very much at the same time we're asking some of the similar questions. And it was at the time I remember feeling very thankful and very happy to finally have connected with somebody that was having these same conversations or wanting to have these same conversations or asking these same questions. And almost 10 years ago, it is funny to see what a huge leap those conversations were from the previous ones and the questions you're asking, because it all went from this biomechanical, tissue-based dysfunction, lots of belief-based things, into another thing which seemed which is explained pain phenomena, which seemed like it was less wrong. But again, when 10 years goes by from that, you start to realize that no, that also had its own problems and had a lot of belief-based things and was based on a lot of how do we say not super robust science and based on some some self-referential science. Yeah.

SPEAKER_01: 9:16

A lot of kind of the idea was it was a hypothesis which the authors did do some research in, but a lot of that research was, I think, probably subject to a lot of design and report bias, because a lot of these people were invested in good outcomes for pain neuroscience education, or which the explained pain is part of. And what they provided, and one of the reasons why I titled this no script for what provided was they provide a script, they provide something that is easy, it's digestible, it comes with a way of talking to people about pain, and that makes it inviting for the therapist, and it makes it easier to understand. But it's a type of heuristic that when you look into it, you end up losing a lot of meaning and or assuming a lot of meaning that isn't really there. That was part of the problem. But I remember even when we were teaching some of these constructs, we were also questioning them in very similar ways. And we were we were very much on the same page with that kind of, oh, there's this, and we're like, Well, yeah, but there's also this. We'd both be questioning those constructs, even as we were like trying to present something that seemed reasonable and logical.

SPEAKER_00: 10:45

Yeah, yeah. Some of those conversations we had back then were fantastic, and the three or four times I came out there to Toronto to teach and hang out with you were those were really fantastic times. And I do admit now that the stuff I taught then was incomplete and there was full of errors, and so anybody that's listening is I took your course five, six years ago, and that's what you said. I was like, Yeah, I probably did say that. I I don't think I say those things as much anymore. I've definitely moved on from the explain pain stuff. I do still hold on to I understand the value of of education, people making sense of their of what they're experiencing, but I no longer believe from basically just from what I've read and just my experience and the way I think. I know I no longer think that's a the best approach or even always a good approach.

SPEAKER_01: 11:31

Yeah.

SPEAKER_00: 11:32

Yeah, and I think that's it's that's how it's sold. Because you mentioned that before that it was it created this kind of package, didn't it, of the explain pain where it's really when we think about it, that idea was no different than how every other single modality empire is. It was just its own modality empire that was not based on a acronymed technique that was supposed to solve all the world's problems, it was based on an acronymed educational strategy, which I guess could have been a technique that was supposed to solve all the world's problems. So when we take a step back, you think, yeah, it wasn't actually any different.

SPEAKER_01: 12:05

It wasn't. It was just it was packaged differently, it seemed to be more reasonable, it uh offered the therapist something neat in particular ways, some strategies in particular ways that they could take. But it didn't really make assumptions about the end result, it was making assumptions about the neuroscience, it was putting a particular perspective on the neuroscience that when you really looked into it didn't really hold true. And actually, if you look at some of the logical endpoints to those assumptions, can be quite detrimental to the person in pain because it's condescending and it is one of those things where we talk about the position that we come from that's very biomechanical, or it's very sort of dysfunction-oriented on a very physical level. And this was dysfunction-oriented, but just on a different level, on a kind of a mind or a thought process level. But it was the same approach. It's still therapist as expert, it's still at claiming to be patient-oriented, claiming to be person-centered, but at the same time incredibly therapist-centered, incredibly therapist as expert, incredibly, I'll tell you what you need to know. And leaving at the end part of things, leaving it very open for people to be blamed for their own pain because they didn't take on board the knowledge, or they weren't thinking about it right, or they weren't feeling about it, or there was something then fundamentally wrong with their thought process and therefore their bodily process. And that was the thing that I actually found the most objectionable about what was happening. And one of the questions I had of this particular perspective was please explain to me how a headache is a danger signal. And what is it a danger signal for? I've never actually had a reasonable response. Like I've never actually had, because I'm just like, I'm the kind of person who'll be like, oh great, I have brain cancer. Awesome. I'm gonna go, I'm gonna go there. I'm gonna go to the worst case scenario because someone's saying to me that's a danger signal, it's a threat that your body is providing pain or your brain's providing pain in order for to protect you against something. And okay, so what am I gonna do about this? I'm like, I'm gonna every time I get a headache, I'm gonna get it, go get a scan because that could be the tumor that's now stage four or whatever it might be.

SPEAKER_00: 14:55

And you can't think your way out of a tumor.

SPEAKER_01: 14:57

You can't think your way out of it, yeah. You can't uh yeah, reimagine your way or retrain. Retrain was the other thing. Yeah, retrain your so I had, yeah, I had a lot of fundamental problems with that. But I didn't come about questioning that myself. I was questioned. And the people who were doing the question thing, most people will probably know about, and you know about as well, which was uh John Quintner and Asaf Weissman. And their questioning on Facebook was very Socratic. It they didn't really offer a solution as much as they did question. And if you asked them to provide an explanation, they wouldn't provide the explanation, they would provide you with a resource that would enable you to then read and perhaps come up with an explanation of your own. So I did learn to engage with them in a particular way, which was more to ask the question, get the reference and resource, uh, try and figure it out, and then come back and say, okay, this is what I figured out. Am I on the right page? I'm on the right in the right place. So in that way, I started to think about things more. But basically, the reason I set this pain course up, apart from all of the other things where there's a knowledge gap and there's there were all these problems with the pain stuff that was out there, was that I needed to be able to make sense of what I was reading for my level of thinking, right? I'm not gonna, I'm not a neuroscientist. I'm I'm not I'm not necessarily gonna be under be able to understand all of that to an nth degree, but I needed to set it up in a way that I was able to then come to an understanding. And if I could do that in a way that I was able to understand, then perhaps others would also be able to understand those foundations and that that foundational thing. And so I've been following very much the blogs that ASEP has with pain lossophy does, and then the papers that are written with with relation to that and very interesting. Some of them are quite challenging, but at the same time have provided me with a perspective that makes a lot of sense. I have no script for it. I have a perspective that makes sense, and I can have a conversation with people about pain on a level that makes sense without having to explain it to them necessarily. But it harks back to that idea of the patient-centered and the person-centered and the listening, where it's like you're now seeing this person in front of you has pain and honoring their autonomy. It's not just having empathy, but it's actually honoring that this person has incredible amounts of autonomy and experience and expertise in that experience, and then placing your own expertise in relationship to that, as opposed to coming at that person with, let me tell you this is how it works. Which I have done.

SPEAKER_00: 18:19

Yes, guilty is charged here as well. And that's something that most of us I would say I don't want to say all, you always want to avoid you want to avoid saying always or never. But most of us, I would say the majority of us that took the explain pain, the pain or science education route would have easily done the over-explain, over-educate, thinking that that was something that people needed. And of course we remember our successes where it maybe it helps somebody, but we probably don't necessarily we have selective memories and in saying there's all those people that I probably really pissed off or I did nothing for, and I never saw them again. And I know I I will admit that I made those mistakes early on, and it was through the people that never came back that kind of left, and you got a bad vibe from them because you talked at them too much. That's where I started questioning. I didn't want to blame them. Because you can feel it. But you think, okay, well then I what did I do? And then I started reflecting on my own and having conversations with people like yourself and and others, and just and uh Saf and John and their stuff online, reading more into that and trying to make sense of it, really started to get me to question, okay, so what am I doing here? And what have I done? What have I done? I just I've had to pull away from that from that aspect, I think, as much as I can. But it's not it's hard. Anything is hard when you're challenging and you try to make sense of new information. Yeah, and that was 100% with those two two gentlemen and the their people, the papers they've written and the stuff they talk about. At first I remember hearing it thinking, what I don't understand what they're talking about. Yeah, it took a while and rereading and seeing them again and again before it finally started to make sense. And even now, I don't think it makes a lot of sense, but it makes more sense than it used to.

SPEAKER_01: 20:14

Yeah.

unknown: 20:15

Yeah.

SPEAKER_01: 20:15

It's true. And I think what the both of us have done in some way is dull back from some of the I think we pushed forward to a large degree when we first came across this stuff. And this is great. We need to tell everybody, and I still feel that way. Like people need to know. We need to have some way where people can be educated about pain in a reasonable manner. But I think what we both ended up doing was just dialing things back and slowing things down a little bit because there were so many changes right up front, whereas we did this, and then we're like, and then all of a sudden it's huh, whoops. And then you have to then dial yourself back from something because that's where you've gone. We both kind of went to a place where we're like, we're gonna pull back from this particular thing and blank and apologize for having dived into that way too quickly.

SPEAKER_00: 21:10

Yeah. And people trust you, they take your courses, they listen to you, they read your stuff, they listen to your podcast, and they trust you. And now, rather than just, oh yeah, you want to apologize, but it's hard to get in contact with everybody. But I try as much as I can now to say, this is what I used to teach, this is what I used to think, this is what I do now. If you heard something different from me before, I will say that was the best I knew at the time, but now we're moving forward. And I think that's something we all should be doing, we should be honest that way, and that should we should have that humility to say, you know what, this is what I used to think. It's a big gap that we see with a lot of the other courses out there on pain or treatment stuff, is it's the same thing for 30 years.

SPEAKER_01: 21:49

Yeah. And it's it and it doesn't invite self-reflection necessarily, and it doesn't invite you examining your own assumptions, and that's how we make changes. That's the that's that's what happens in the scientific method, where there's a built-in kind of check-in to see whether or not these assumptions make sense, and do you need to change anything going forward? And that's what self-reflection does as well, where if you're honest with yourself, and that can be difficult sometimes to get to that place where you're actually honest with yourself about what it is that you're thinking and about why you're thinking that way. And it's I believe this, why do you believe that? Where does that come from? Have you ever questioned why you believe that particular thing about pain? And when you question it, and if you see something that actually challenges your assumptions about it and your belief about it, it's there can be a big sort of defense mechanism that occurs. There's dissonance, people feel uncomfortable, and the easiest thing to do is sometimes double down and not actually represent with fairness, right? So it's finding a way to, I guess, straw man the other argument would be one way of doing it, where you actually just you don't represent that argument fairly, but that makes it much easier to then argue against. But if you were to represent that argument fairly, it would probably mean that you have to change something about what it is that you believe or what it is that you're thinking. Um, and that's harder. That takes a longer time.

SPEAKER_00: 23:35

Yeah, we have these beliefs, these feelings that are often associated with our identity.

SPEAKER_01: 23:40

Oh, yeah.

SPEAKER_00: 23:41

And how we view ourselves as a human or as a clinician and or as an educator, and when that gets challenged, it's easier to just push that away rather than to take that on and start questioning yourself, which is I think exactly what you were just saying.

SPEAKER_01: 23:56

Yeah, and but it is harder, it takes time.

SPEAKER_00: 24:00

Yeah, oh it takes a long time, it takes years. Yes, and even then you're still questioning stuff for sure. The one thing I guess that you we've you've given us a great overview of some of these key things. If you could summarize though about this course you created, what is the what's the kind of key two or three things that makes this different from other courses that are out there? Like what are the what how is it different?

SPEAKER_01: 25:11

Well, let me give you something where it's similar in one way, because it's coming from a particular perspective, but it's a very foundational perspective, meaning that it I'm not giving you a script, but it's a perspective where I'm just trying to find my kind of slide here on the perspective where here it is, where the fundamental perspective that underlies the course is that the construct of no susception is necessary, if not always sufficient for pain. So it's looking at the idea of necessary and sufficient conditions for certain manifestations of things. So no susception being a necessary condition and the necessary precondition for the sensation of pain, right? And for the perception when someone has that sensation and then a perception related to that, we can understand that if someone reports pain or is observed to be in pain, that the therapist at the baseline assumes that no susception has occurred sufficient to lead to a sensation. That's that's the fundamental underlying assumption of this particular course.

SPEAKER_00: 26:43

Yeah.

SPEAKER_01: 26:44

So that assumption is then set. So the first like deck is a context. So a little bit about the context of pain in Canada. We have the governor's written reports that show the education gap. The International Association for the Study of Pain has reports, and they did a declaration of Montreal that says pain care is a fundamental human right, but it's based on the idea that it's accessible by knowledgeable people. Right. So there's these huge kind of paradoxes that exist, not just within the definition of pain and some of the definitions related to that, but also within education and understanding of pain. And so that's one of the reasons for another reason for this.

SPEAKER_00: 27:37

Yeah, I and I I think that's sort of to just hit at some of those points there. The first one, obviously, that that really is important, and this is something that is probably not well understood across healthcare professions, is that no seception is necessary for the sensation with experience of pain and the experience of something that I've been teaching for the last couple years now is saying that if someone has pain we can s comfortably say that there's some no seception going on. There's no deception going on somewhere. But we may not always know why or why or why or why. And then trying to turn that into why does that matter? And what's the clinical application of that? And I'm not, I know what I say, but I want to hear what you have to say first, and then I'll let you know if I'm right or wrong, or if I agree or disagree, or if I do things differently.

SPEAKER_01: 28:32

Right. I think one of the one of the reasons for having this as a fundamental perspective of the course is that when you look at what is the sort of popular way of looking at pain, which is the pain neuroscience education, the sort of saying there was that no susception is neither necessary or sufficient for pain. But what that leads to is that this idea that there are other external things that you can then, for want of a better word, blame for a person's pain. And this fundamental perspective means that you ground that experience for that person in something physiological. So there's a physiological aspect that is there, and one that you don't necessarily have the privilege to observe. And this is one of the perhaps the problems with the definition because it's associated with tissue damage. And that's one of the one of the aspects of the definition is associated with tissue damage, but but certainly people report pain in the absence of what we can see as being tissue damage, right? Or what we can obviously observe as being tissue damage. And then this ends up becoming something where we start looking for other reasons. And this perspective means that we can look for reasons, but within a very logical and physiological sense. And that means that we're not then going to say, oh, this person's depressed. And we have this correlation, we have this association between depression and pain that's absolutely there. I'm not arguing against that. But we then don't say this person is depressed and has thoughts about these. Things and it is partly their thoughts that are causal of this sensation, and it just becomes a I'm not sure what the word is for it. It's it's a treadmill, it's something that is just cannot be beneficial for the person in pain to, and it's it if we go back to our biomechanical, our anatomical, you have a joint dysfunction, you have this, that's a cause of pain, you have this, that's a cause of pain, and we think of it as that really physical, your knees out of place or your hips out of place, or whatever it might be, and that's the cause of pain. It's a similar sort of thing. We're just reaching for all of these different aspects. I've observed something, therefore, I can attribute that to as a cause of pain. And when you can't observe it, then you're finding things that you can. You're finding a feeling, or you're finding some report that someone has given you about a death in the family, or something else that you can then say, oh, I can attribute this as causal for this person's experience. And it's quite frankly, about backwards, really. So I guess, did that answer the question? I don't know. I started to ramble, I think.

SPEAKER_00: 32:04

Yeah. Rambling is encouraged.

SPEAKER_01: 32:09

There was rambling.

SPEAKER_00: 32:12

What I liked, there's a lot of things I liked, but one thing I just I really wanted to just emphasize was the shift from that causal reasoning to something that is more the person's experience and understand and understanding and knowing that no cception is occurring and that's why they're in pain without knowing the cause of that no-seception. Because it, if we think, if we're always looking for causes, and we hear this all the time, don't we? The root cause. Come take my course and discover the root cause of pain or techniques. It just drives me absolutely crazy because anyone that says that is they're missing, they're they're missing the point.

SPEAKER_01: 32:50

Yeah. If someone says that in relation to pain, I'm just like, it's fairly clear they have a fundamental misunderstanding of mechanisms of pain.

SPEAKER_00: 33:01

Yes.

SPEAKER_01: 33:01

And but that's not, I'm not saying that's a problem that you know that that they're a problem. They're just a symptom of the larger lack of education that exists in pain. They're a symptom of the knowledge gap that exists in pain. And the way that that knowledge gap has been attempted to be filled with a whole bunch of different things. Right? We can basically attribute anything as a cause to pain. And that is just not helpful for the person who has pain.

SPEAKER_00: 33:32

Yeah. Yeah. And that's something I wanted to just emphasize too, is that I'm very critical of things because some of this information has been around for a long time. And people get upset with me because I they're like, You're too critical, and you got to give people a chance. I'm like, some of this information is 40 years old, but you've had your chance. And I've I'll admit that myself and people like myself that have been teaching are sometimes part of the problem too, but we're trying to be do different. And but the idea, and I think we said that there's a symptom of a bigger problem, people that are teaching stuff, because that knowledge gap is a huge problem. But the best thing we can do, though, with that knowledge gap is just to admit that it exists and try to fulfill it with something and try to fill it with something that is currently less wrong.

unknown: 34:17

Yeah.

SPEAKER_01: 34:18

And the we know now. This is yeah, this is the thing that is not well understood, and it's very hard to get people to understand. And that's one of the reasons for deck one, which is context of pain. It's what does it mean for to have one in four or one in five people who have chronic pain on like the economic and social burdens that exist and all of that kind of thing? And why do we have all of these supposedly amazing treatments for pain where people are saying, here, click this pen over the source of your source spot and it'll go away, or rub this cream, or have this treatment, or whatever it might be. And it hasn't moved the needle at all. The numbers for people with pain are predicted to rise. The Canadian reports predict that the numbers of people in chronic pain will continue to rise. And what we see with the research now, which is not being taken up as well, and that not admitting that we have these knowledge gaps in both practice knowledge, but also education knowledge and ability to measure that. So, what we see is I think I've lost my train of thought there. What was I saying? Like I keep moving from one thing to another. Let me think about that. No, it's gone.

SPEAKER_00: 35:42

I can't remember actually exactly what we were talking about that second, anyway. Listening to it, it was oh, we're talking about the knowledge gap, admitting the knowledge gap exists. There we go.

SPEAKER_01: 35:50

Admitting knowledge, yes. So that's what we were getting to. Is that is that's why the I had that context at the beginning, is that we have to understand that we don't know enough. And our explain pain courses or any other courses we might have done that have these kind of forays into this is a cause of pain or here's how to treat pain or whatever it might be. They're based on huge levels of assumption that we don't have a good grounding for in education. We don't have a good understanding in education that these make us reasonable, reasonably knowledgeable people about mechanisms of management of pain. So the documentation says we don't across the board have the knowledge in mechanisms of management of pain that we need to actually effectively treat people who have pain. And the numbers back that up.

SPEAKER_00: 36:51

Yeah, it's not just making it up, that's true. What are your thoughts about the reasons why in an entry to practice curriculum, doesn't matter of the you name the healthcare profession, why pain education is so poorly done or not done at all? When that's the number one reason why people come to see anybody in the MSK world is because they hurt.

SPEAKER_01: 37:17

Like 80% of the time it's like coming for pain.

SPEAKER_00: 37:20

So why is that not fundamental? What are your thoughts on that?

SPEAKER_01: 37:23

I think partly it's because the understanding of the mechanisms of pain has always been a bit of a challenge. And there's just been a lot of information over the years that has led to a lot of conflation around the topic. That is being cleared up much more now. It's like closing the gate after all of the horses have left the bar. So, you know, we have to get them back in and then close that gate. And I think that's part of what this is. It's an awful back from all of these different causal explanations that we've had because we didn't have the mechanistic understanding and knowledge. And it perhaps it was just that it's so hard to translate. If I'm saying no script available or no script given, or whatever it might be, I can't provide you with a way of talking about this to people. What I can hopefully provide you with is an understanding of the mechanisms that are occurring and a way of assessing what mechanisms may be occurring in any given presentation. And then that gets translated to some sort of management aspect, and we'd have to look at that for a musculoskeleteal setting, but that wouldn't just be musculoskeleteal, right? There's there would be a medical management as well.

SPEAKER_00: 39:03

Yeah, so the understand the more a clinician understands no suception and they understand the ideas of pain or the experience of the individual experience of pain, as much as we can understand it from a outside of observer.

SPEAKER_01: 39:24

Like not a neuroscience perspective, right?

SPEAKER_00: 39:26

Yeah, but the more we understand it, do you I feel, and maybe my bias is right or wrong, that the more we understand about it, the better we can be as clinicians, because it really shapes how we think, which shapes how we communicate, which I feel shapes our expectations as well as the expectations of the person who's coming to see us for help. Would you agree with that or would you expand on that?

SPEAKER_01: 39:50

I would say so. I think the more that I know and the more I understand, the less I talk about it to patients. I talk all the time. Who am I kidding? But but the less I talk about it to patients, I don't try and explain their pain to them. That's just why would I do that? Because they provide a lot of the information that allows me to make some sort of assessment as to what I think might be going on a no susception level, and also what that means on a sensitization level and what that means for what we consider to be tissue damage and the idea that mousseception is sufficient. And if there is an association with tissue damage, it's related perhaps to that sensitivity, that low-level CRP kind of thing that can occur in illness label chronic pain situations. So you start to get a little bit more of an understanding of what it means when people have inflammation and what that means for nosoception, just what inflammation means. And I think of it like I don't know more than a general level of how the sort of specialized nervous system for sight works or for hearing, or a bit more for touch, hopefully, because that's clear is what we do. But we have a similar specialized nervous apparatus for pain. So knowing that we have that, I don't necessarily need to have an in-depth knowledge of how that apparatus works in the minutiae, but an understanding of that knowledge that there is a there's a sort of a mechanism that occurs when someone reports pain, that we have a mechanistic process in relation to that, that it'll ground our thinking, it'll ground our understanding in reality. And I think that's part of the big sort of drive is that everything that we see around pain, when we see all these kind of causal mechanisms, it's outside of reality a lot of the time in terms of a mechanistic explanation. And so we're leaping, we're making these giant leaps, giant sort of assumptions about what this person's going through and about how we can then use our expertise or I would say pseudo-expertise for a lot of it to help them. And we may eat we may just as equally uh cause harm in most situations.

SPEAKER_00: 42:46

Oh, for sure. Yeah, I would agree with that too. You mentioned the grounded in reality, and that is something that listeners or people that are gonna take this course in the future will hopefully really get from it is understanding pain that is no deception, that is and mechanisms involved that are grounded in reality, not based on beliefs or based on ideas that are un unchallenged. Because I know also in the first part of the course or part one, we haven't really talked too much. We are talking about the course without giving away too much. We are talking a bit.

SPEAKER_01: 43:24

Well, hopefully go into a little bit more depth. Who knows? We might just make one podcast.

SPEAKER_00: 43:30

No, this is all just part one. The yeah, the grounded in reality, and then the understanding that yeah, the differ different things are involved. But you mentioned that the there's human rights, there's the and then and there's these kind of ethical obligations.

SPEAKER_01: 43:51

I was just looking at that night actually for ethical challenges, yes.

SPEAKER_00: 43:55

Ethical challenges and for people that are listening, that is something that they really should stop and reflect on. I highly encourage to is that if we're treating people who have pain and we're doing it based on ideas that are not grounded in reality from an ethical that's an ethical challenge.

SPEAKER_01: 44:20

Well, that's a really fuzzy, yeah, fuzzy ethical area.

SPEAKER_00: 44:25

Yeah.

SPEAKER_01: 44:25

And we talked about that question of whether it's ethically reasonable for you to deliberately cause someone pain during a musculoskeletal treatment. Because if we look at the definition of pain as associated as it is right now with tissue damage, at what point in time are you causing tissue damage? Because if someone's reporting pain, it's associated with actual or potential tissue damage. And if we look at the foundation or the fundamental perspective of gnosis is necessary, if not always sufficient for pain, then you are impacting nosoceptors in order to provide this sensation which is associated with actual potential tissue damage. So, yeah, from an ethical perspective, that's pretty challenging.

SPEAKER_00: 45:31

For sure. Particularly for those people that feel they need to hurt or they need to experience pain or they want to experience the pain, or a therapist who says, I need to hurt you to help you.

SPEAKER_01: 45:40

Yes, pain treats pain or something along those lines. Yeah. It just feels better afterwards because someone stopped hurting you.

SPEAKER_00: 45:48

Yeah.

SPEAKER_01: 45:49

And there's there's other kind of mechanisms, chemical mechanisms that may actually mean that you temporarily feel a bit better.

SPEAKER_00: 45:58

Yeah.

SPEAKER_01: 45:59

But yeah, it's an interesting ethical question.

SPEAKER_00: 46:02

Yeah. Yeah, something maybe we'll we could I feel like we could talk about that for another hour, but maybe we'll talk a little bit later. Yeah.

SPEAKER_02: 46:10

Yeah.

SPEAKER_00: 46:10

Just because you mentioned the definition of pain, I just wanted to read it out here just for people listening, because I would assume that not everybody has it memorized. So pain, according to the International Association for the Study of Pain, is an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage. And that was updated, I believe, in 2020. And it was for the previous 41 years, it had a slightly different something like an unpleasant sensory and emotional experience associated with actual or potential tissue damage, I believe.

SPEAKER_01: 46:45

And report it was like and reported as such or something along.

SPEAKER_00: 46:49

Yeah. So this one's changed. I think the key thing with this is it was changed to resembling that associated with.

SPEAKER_01: 46:54

Yeah. So it didn't rely on reporting, it could be nonverbal as well.

SPEAKER_00: 46:59

Non-verbal. I think that was one of the key. But then the new one they add those six kind of sub points, whatever, about it.

SPEAKER_02: 47:07

Yeah.

SPEAKER_00: 47:08

And that's all stuff I know that is covered in the first part of the course, I believe, in the first.

SPEAKER_01: 47:14

Yeah. One of the things that this course doesn't go into a lot is is biosychosocial, apart from looking at more looking at it more on a I guess a critique of that understanding. And I guess asking questions of an internal critique of people's understanding of biosychosocial. It's one of those words that gets really thrown around. It's a heuristic, basically, for learning that has meant from what I can see in pain management, given that we don't know enough, it's one of those heuristics that has meant that many assumptions are being made about what pain is. It's one of those huge conflations that exist within pain care. And a lot of those conflations are quite well documented.

SPEAKER_00: 48:12

Yeah, and bisexual is a term that it is common in the lexicon of the MSK world or of the healthcare world, but it's often used as just another tool to explain away or to blame why someone hurts. And you mentioned that earlier about the relationship between depression and pain. It exists. But people are often said, Oh, if you weren't depressed, then your pain wouldn't that's causing your pain.

SPEAKER_01: 48:42

But I think or it's making it worse or whatever.

SPEAKER_00: 48:45

And the problem that we have with the biopsychosocial is that it often it gets segmented into oh, it's this thing that's causing your pain, is your stress, or you're not sleeping, or you have these negative self-thoughts, or you hate your job, whatever. It gets and those things could all be part of things that could be sensitized.

SPEAKER_01: 49:04

They can definitely be aspects about the condition of being depressed that would have some impact on a sensitized noseceptic apparatus. 100%. I'm not arguing that. But yeah, one of the whole things is we're dealing with people on a one-to-one basis, and we only get the information that they tell us.

SPEAKER_00: 49:28

Yeah.

SPEAKER_01: 49:29

So if we're making an assumption that the one thing or the two things that they've told us about the stressful aspects in their lives are the keys to their ongoing pain condition, we've just done them a huge disservice because we're cherry-picking and not, and that's where we stop. We stop as oh, it's this thing. I can treat this thing by retraining or education or something or explaining their pain to them or whatever it might be. And we might have missed like a whole mess of things that are occurring in these people's lives that all come together to be part of their picture that we're not privy to. The assumption is that we shouldn't be. We don't know these people, they don't know us, right? So we're getting certain we're coming to us for a particular reason. And for us to go outside of that scope or reason is again another ethical challenge. We're gonna have to get into this.

SPEAKER_00: 50:37

Oh, much more to say. Oh, yeah, I know for sure. One of the reasons I wanted to bring up the biopsychosocial was because of how it can often be used as a way, as a rather than blaming tissue or joints or posture, it can be used to blame other things. And then the problem is what happens is the person who's experiencing or is living with pain, if what happens if those other things in their life are dealt with?

SPEAKER_01: 51:08

Right, and they still have pain.

SPEAKER_00: 51:10

And they still have pain. It's no different than saying, Oh, you're you've got this anteriorly rotated hip, and it's causing this left thing here, and this is blah blah blah, and this is tight, and this is loose, and this is long, whatever, and then the person goes and fixes all those things, you still have pain. Well then where you're left with, you're just left searching for another causal.

SPEAKER_01: 51:28

I think the biopsychosocial, this idea that you have the biological, the psychological, the social the social, which is just like not being a human, but when you put it in that way, you now have a lot of outs because perhaps it's not biological, it's psychological. We deal with the psychological, oh, maybe there's also something biological. Do you know what I mean? It's like you can weave in and out of all these things. It's like we could maybe have more of this over here and more of that over there. So you again, you may never get to a point where you actually have a you help someone because there's always something in the course of being a human being that you can then choose to attribute pain to. If pain is a biased psychosocial phenomenon, you've just got like massive excuse to just treat for as many weeks as you possibly want for all sorts of different reasons.

SPEAKER_00: 52:30

Yeah, because then there's always something to chase.

SPEAKER_01: 52:32

There's always something to chase.

SPEAKER_00: 52:33

Always something to chase, always something affects you.

SPEAKER_01: 52:35

Always something to blame. Yeah. Whereas this for this is the fundamental, this fundamental perspective of no susception being necessary for pain, it doesn't necessarily remove anything else that's going on. It's simply a grounding factor. Like we know what a no-sceptor is. It's been fairly common knowledge that there's a no-sceptive apparatus, that is a thing that has been talked about a lot longer. It makes sense. We have this sensation, we know how these neurons work, we understand what activates them, we understand those sort of basic level of things. So it allows us to have this kind of. I I we'll see. I won't use the word because I'm I wrote a paper, so we'll see what happens, but it allows us to have this foundation, right? That is again grounded in reality, in physiology, in neurology. It's not controversial, it makes sense, it has documentation behind it. A lot of the science behind it supports this. We're not talking about something that we have to make massive assumptions about.

SPEAKER_00: 53:55

I love that. I think we can almost just leave that there for today's episode. The what we're gonna do, we just we didn't really say too much at the beginning, is that we're gonna do six episodes. We're gonna talk about all the different sections of the course. The first one's more about context and it's about obligations, and it's about and we'll get more into that, I think more into the what it means on an ethical obligation level as well. So yeah, I think we'll explore that in in in the next episode and then more to come. That was fantastic, Monica. I really enjoyed that. That time flew by quick. I think we did questions, and I don't know if we gave many answers, but that's part of the purpose, I think, of this course that you're gonna be doing is it's gonna be asking more questions and providing answers and getting people to think differently. But hopefully by the time they're done, the six module program, which is also gonna include three live online via Zoom sessions for people to try and put this all together, and you're gonna provide papers to read and questions to think of. And we'll I can put together maybe even a little workbook that we can I can put together for everybody so they can make their notes in and do their work in. I think it's gonna be a good, not good, it's gonna be a fantastic program and project that I think is gonna hopefully start people going down the a better way for thinking about campaign management.

SPEAKER_01: 55:16

And I think if people wanted to start, they could go to the ISP and just peruse through the terminology and get really familiar with some of that, but also understand that terminology is consensus, but not concrete. There are proposals to change, things have been added. So as new knowledge comes about, we get new understanding of things and things change. So hold on to definitions lightly, but also they constitute our semantics at this point in time, and semantics are meaning, and we need to make sure that we're talking about the same thing.

SPEAKER_00: 55:59

Love it. Well, thank you very much for that, Monica, and we'll be back soon.

SPEAKER_02: 56:03

Amazing.

SPEAKER_00: 56:04

Thank you for listening. Pain Education, no script provided, is now available for purchase on my website, the CEPE.com. To listen to more of these episodes, please subscribe on your favorite podcast network. If you enjoyed this episode, please like and share to your favorite social media platform. If you'd like to connect with me, I can be reached to my website or send me a DM through either Facebook or Instagram at EricPurfass RMT. If you want to support my podcast, please consider making a small donation. This can be done by clicking on the support button or heading over to buymeacoffee.com slash hello.