Pain Education, No Script Provided Ep 6, Conflation and Semantics

We rethink pain from the ground up with Monica Noy, separating nociception from pain and showing how sloppy language and seductive stories distort care. We examine multiple modes of nociceptive activation, challenge “root cause” thinking, and push for ethical, precise explanations that validate lived experience.

• nociception as necessary for pain, not equivalent to pain
• immune, neuroinflammatory, cellular, and prolonged stress pathways activating nociception
• the nail-in-the-boot anecdote clarified and deconflated
• risks of guru narratives and circular brain-first explanations
• the pitfalls of “root cause” and regional interdependence
• pain-driven movement changes versus movement as cause
• clinical descriptors as mechanisms of nociception, not pain types
• social determinants as context, not convenient causal levers
• semantics as shared meaning that improves assessment and care

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Chapters

• 0:00 Setting The Stage With Monica Noy
• 3:40 Updating Teaching And The Social Determinants
• 7:40 Looking Upstream: Context Before ACEs
• 11:35 Today’s Plan: Nociception And Language
• 15:20 Many Modes Of Nociceptive Activation
• 22:45 Stress, Sickness, And Prolonged Responses
• 27:58 The Nail-In-The-Boot Story Deconstructed
• 36:03 Bias, Gurus, And Evidence Gaps
• 37:56 [Ad] Courageous Alignment3
• 38:42 (Cont.) Bias, Gurus, And Evidence Gaps
• 41:43 “Root Cause” And Infinite Regress
• 48:53 Regional Interdependence Versus Pain-Driven Change
• 54:08 Semantics Matter: Pain vs Nociception

Transcript

Eric: 0:13

Hello and welcome to the Massage Science Podcast. My name is Eric Purves. I'm a course creator, educator, researcher, RMT, and advocate for evidence-based care. Today is episode six of my seven-episode series with Monica Noy. In today's episode, we have a discussion about peripheral no-susceptive activation and the problems with conflation and semantics in pain medicine and pain research. Thank you for being here, and we hope you enjoy this episode. Hello, everybody, and welcome to episode six, Pain Education No Script Provided with Monica Noy. These have been so much fun, Monica. I've really enjoyed these, so thank you for being here. Again.

Monica: 0:50

They have been they have been very fun. I quite look forward to them. And this is where we're going. It's great to actually talk about these things and be able to to nut them out and discuss them. Yeah, it's been terrific.

Eric: 1:04

I have it uh marked in my calendar and have it in like big, like bright colors so I can see it. And I always add next I always add time afterwards because it's really like, oh yeah, we're gonna be an hour, but we never start until 20 minutes or so.

Monica: 1:17

Fine.

Eric: 1:18

Before we're supposed to, and then we chat longer and then we chat after. And so it's been great. So I've really gotten a lot of these, and I hopefully the listeners will as well. And hopefully this will spark some interest in the course. Upon recording this, I'm actually teaching a little webinar tomorrow on chronic pain, or it's just an introduction to pain. Right. It's funny, I hadn't done that one in a while. And as I was preparing for it, as I usually do, always do, I should say, just to make sure that there's things I want to remove and things I want to add. And I was doing that the other day, and I was happy and sad at the same time. I was happy that I had a lot of stuff and in terms of references and things that you have brought that I was like, oh, okay. I had this in here last year or earlier this year when I did it, which was great. But then there was some other stuff in there, and I thought, ooh, yeah, I should remove that. I'm gonna fill that with because there's some stuff there that was incomplete or some of the more darcy. Yeah, some of the stuff that I just was I don't feel so comfortable talking about the stuff anymore. And a lot of the stuff was the really I used to talk a lot more about the like the neurophysiology and then moved away from it, but I felt like I filled it in with this overly simplistic explanation, which trying to make it so people understood.

Monica: 2:39

But then I thought that's just when I reflected on it, it made me realize that the way I was presenting it could probably be taken in a way that I didn't want it to be, and especially when people are coming from a place where they already have some preconceived notions about what pain is based on the kind of popularity of things that are out at the moment.

Eric: 3:08

Yeah, that's what I thought was yeah, that I started thinking about that. So, anyway, I we'll see how it goes tomorrow. I I've made some changes and not too many things because I didn't want to reinvent the wheel, but always up.

Monica: 3:19

Yeah, steal anything you like from here because again, it's not proprietary information, I just put it together in a particular way.

Eric: 3:28

The one thing that I did add, which I didn't have before, and this was from the reason I changed this was because of some of the conversation. I can't remember, it was episode one or two that we did. We talked about the social determinants of health and how psychosocial, like social determinants often just gets bundled into that.

Monica: 3:43

Yeah, yeah.

Eric: 3:45

And so I made sure to take uh some of the quotes from one or two of the papers that you had shared. I put that in there, which I thought was great because I felt it made that section more robust.

Monica: 3:58

Yeah.

Eric: 3:58

Just talking about gender and sex differences and racism and yeah, those socioeconomics and poverty, just to mention that. Because before I would say, Oh, yeah, social factors, and I was just gonna leave it. But what's that mean?

Monica: 4:09

It was too yeah, too vague. I mean, and and that would be the thing I remember when people would say, Oh, psychosocial factors, and I'd just be like, what does that actually mean? Especially on the social part of things, that was something that I was very vague on for a while. And so d delving into that is really being helpful. And it's a it is a bit of a different mindset. It is more of a public health kind of thought process and mindset, but it's really important. There was a study I was flicking through, might have been LinkedIn. There was a study that was basically relating some social determinants of health, some adverse events, ACEs or whatever, to chronic pain or within people over 50. And I was just looking at the study and I was thinking to myself, like, where did we start? It's like the before those ACEs come along, before that person was subject to the trauma and they categorized some of the levels of trauma or areas of trauma. And I'm like, before that came along, where were those those social determinants, those because they're saying it leads to problems in social levels, and that then leads to health disparities and whatever. And it's did we start off with disparities before that even came along? So I'm like, it's interesting because it was a study that was looked at the end result of something, and it's but we forgot the kind of beginning. How did we get to those adverse events? Probably those similar discrepancies were there to some degree.

Eric: 5:55

It's like a cycle rather than a they weren't measured or assessed, they just looked at the yeah.

Monica: 6:00

It was, it was yeah, it was a snapshot of that event happened, and then we go for outcome after a certain age or whatever. And it's oh, but before the event happened, before the childhood trauma, you probably have those same sort of social discrepancies that were there. And we could maybe just go back infinitely in terms of and what led to that, and what led to that, and what led to that. So that's kind of something to think about as well. When I see something like that, I'm like, but how did that adverse what was the context in which the adverse events were experienced? Anyway, that's just me going backwards.

Eric: 6:47

Those are important questions to ask, though. I I think that if we are looking at research or reading anything, it's important to ask those questions.

Monica: 7:00

Yeah, to start to think about it because it's like making this causal association. And the context is so much larger than that.

Eric: 7:09

Yes, it's much it's yeah, it's not as simple as people want it to be. Today's episode, we'll go back a little bit to some of the modes of no-seceptive activation.

Speaker 2: 7:21

Yeah.

Eric: 7:22

We're gonna we're gonna talk about language in pain literature or language in pain medicine, and then you've got that's the plan that we may or may not follow. Yeah, so we'll just kind of say this is the table of contents, but you may get there and it may not exist. And we'll but we'll try to do you have a lot of great things to talk about with the conflation in the words of languages and how that's important. Why it's important, because I think one of the things I hear, I don't think one of the things I hear I've heard over the years is oh, you're just arguing semantics. And that is usually comes from someone's place of not really appreciating, understanding why we need common language.

Monica: 8:08

And yeah, that annoys me.

Eric: 8:10

Yeah.

Monica: 8:10

When I hear because I'm like, when I looked it up, I'm like, oh, semantics is the study of meaning. That's really important. So it's if we don't have that shared understanding, we are very lost in terms of where it is what it is that we're talking about. Yeah.

Eric: 8:32

So we'll try and get there today. But let's start like last time, I think we were talking, uh, we talked about the different ways of seceptive activation and no seceptive activity, you talked about some of the mechanistic descriptors that were there. Yeah. We touched a little bit on neuroinflammation and the neuroimmune crosstalk. Did you have anything more to those different modes of noceptive activation that you wanted to address?

Monica: 9:03

Yeah, so I think one of the reasons for actually addressing those, and I remember myself when I was introduced to this understanding, is that we often tend to have this kind of very simplistic understanding of tissue damage, no susception pain.

unknown: 9:21

Right.

Monica: 9:21

So we understand that's occurring when someone sprains an ankle, what that looks like, does the healing process. And that would get translated, I think, to some degree to everything. So looking at those different kinds of ways in which nosoceptors can be activated allows you to understand that we don't need to see tissue damage or even potential tissue damage. To know that there is the ability for no susception to be occurring. We don't have to be able to see it. It does have to be visual for us to know that there are several different ways in which no susception can be activated. And it relates to several different systems throughout the body. So the neuroinflammation and the neuroimmune crosstalk. So we're talking about the immune system, we're talking about a specific kind of inflammation, there's autoimmune, what's called autoantibodies that have particular effects on peripheral nervous system. There's cell communication with what's called, I get this wrong all the time, pexosomes. I believe that's correct. And that has both peripheral and central effects. And then there's stress responses. So stress gets used as a really big one. It's like stress and pain. But definitely there's the correlation, but there are there are responses. So stress responses, like hormonal responses, various kind of physiological responses that have central and peripheral effects on the no-susceptive apparatus. So there's four, and we haven't even got to the one we know about, which is the one that we assume is happening, that there's some sort of peripheral activation. Someone comes in with joint pain, we think there's something that's happening at the joint. Right. But there are so many different ways in which nosusception can be activated. And it may not necessarily be by a noxious stimuli that we are familiar with. So when that was presented to me, it was like one of those light bulb moments where it's, oh, actually, there's a it's it's like the concept of inflammation, where inflammation is has many different aspects to it depending on the kind of condition that's going on. So we can have discrete inflammation, we can have inflammation associated with healing, we can have inflammation that has no apparent purpose, right? That has to do with some sort of genetic dysfunction or some other kind of predisposition to an autoimmune component, the immune effects. So it's a similar sort of thing with this, where this all goes hand in hand, where we have all of these different ways in which no susception can be activated. Now, when we go back to what the basis of this course is, we're going back to that no susception is necessary for pain. But that's your bottom line, that's your kind of baseline understanding. And if we have this really simplistic notion of what it means to activate no susception, then of course it makes sense that you're like, well, this isn't sufficient. Right? Because this person's not, this person doesn't present as though they have something that would activate no susception. But we can get into stress and sickness responses, cellular insults, a whole variety of different ways in which the cells communicate, the bidirectional communication, and we are talking about many different ways in which no susception can be activated. We don't have to see it. Or even necessarily be aware of it. And the bottom assumption is it's happening.

Eric: 13:32

Yes, the assumption is it's happening, but we don't have to see it.

Monica: 13:35

And when someone reports pain, we think no susception has occurred sufficient to create that sensation.

Eric: 13:46

And the pain has to be is a self-reported thing. Yeah. Unless they tell us.

Monica: 13:51

Yeah, or it's visually you can see, and there's something that you observed that would indicate that person is having discomfort or pain.

Eric: 14:00

Yeah, I shouldn't say I I should be careful because they don't have to communicate it verbally in order for pain. And that's a thing that I know is was added to the last update with the ISP definition.

Monica: 14:12

Yeah.

Eric: 14:15

Yeah, to address that, yeah. What I love this stuff because I think this is so fundamentally important for anyone in MSK care or health care to understand. Because this to me really seems to provide a lot more explanation and I would say validation for those people that live with persistent pain, but there's nothing wrong with them, is what they get told, because they can't find anything, because you can't find a perver a peripheral activated no deceptive driver or no noxious stimuli.

Monica: 14:49

Yeah.

Eric: 14:50

And what if we understand that there's all these other things that happen that to me just seems okay. So it's it gives us information that says there's stuff that happens that we can't see.

Monica: 15:08

And this goes back to the notion of the no-susceptive apparatus.

Speaker 2: 15:12

Yes.

Monica: 15:12

Where we're not talking about just a bunch of no susceptors. This is a in and of itself a complex kind of, I don't want to say system, because that's not quite right, but there is this apparatus that interacts in various ways, cellular at cellular level, with other components and interactions within the body.

Eric: 15:33

And whereas, say there's you've mentioned five of these modes of no septive activation, really the one that the only one that we get ever any information about it in school is peripheral. Or anybody like we talked about many times, the knowledge gap. All of us that are helping people with pain, we really get one, so we get 20% of the information. And even then, there's a lot of conflation that which we'll talk about, the things that are associated or not associated with some of those peripheral drivers.

Monica: 16:04

Yeah. Yeah. And this was one of the things where, yeah, but that was one of the reasons that when it was introduced to me, I'm like, oh, my understanding of no susceptive activation was so limited that it allowed me to then be okay with when someone came along and said there are uh psychosocial factors. Now, if we look at something like stress response via hormones that have central and peripheral effects, we can make sense of that. But we can't measurably, we can't necessarily measurably make sense of that. These stress responses tend to be fairly significant. So it's not a panic attack. That's not this, that's not a there was there was actually research I read on that, which was that the stress response we're talking about is prolonged. This is prolonged, and there are multiple factors. These are things that you can tick off. There's an illness response that generally goes with that. This is not something where someone has short-term panic. This is not what we're talking about. Let's just go back to the workman who stepped on a nail.

Eric: 17:22

Oh, yeah, that classic.

Monica: 17:23

Right? Just in terms of that, but the amount of negotiation, like mental negotiation around how psychosocial factors led to this person's real imaginary pain, was really significant. And the case study was completely misread. And there were assumptions made about it that were unrealistic, but B, it completely negated this idea that that no suff no susception was necessary. And the other thing it did was what was I trying to say? Oh, yeah, it ignored peripheral activation one, which would have actually been the easiest one. It's the one we knew about, which would have been the easiest one to explain. Anyway, and there was something else, and now I can't remember. But but yeah, it was very problematic in the way that became an example of pain without no susception and had been used as an example of pain without no susception. Where clearly that was when you just go to it on an Ockham's razor level, of could this be an example of pain with no susception or pain without no susception? It's simple to explain the fact that there is peripheral activation by noxious stimuli.

Eric: 18:48

And just for people that are listening, if they're not familiar with the nail in the boot story, uh, very quickly, a worker stepped on a nail, it went, pierced the sole of his boot, went between his bows, and up to the boot. Yeah, and up through the boot, and and the nail, the steel cap.

Monica: 19:09

It was a steel cap, so the nail was sitting up against the steel cap.

Eric: 19:14

Yes.

Monica: 19:15

And then the person was taken to an emergency department, sedated with fentanyl and my dazzolan, I think it was. They took the boot off, and there was a quote unquote miraculous cure in that there was no damage. So the several things that happened with that is we know nothing about the worker, other than when they tried to move, like the slightest movement apparently caused him pain. That was the report. It was a small report from a it was a very small report. It was a paragraph and a picture from a journal in 1995 that was from an emergency medicine department. So it was a fun story. And what was conflated there was the miraculous cure, which was from an emergency department, there was no damage to the foot. The pain, the nail had not penetrated the foot. So in an emergency department, you're sedated, we're removing the boot because we might have to do surgery. Right? Because at this point in time, you could have a nail sticking into your foot. Into your foot. From a case report perspective, very brief detail. The miraculous core was not pain. The guy was sedated. There were all these stories about, oh, his pain miraculously went away. Guy was unconscious. So, you know, there's no way he's looking at this boot coming off and this nail being between his toes, and he's, oh my God, all the pain's gone away. There are all these different reports about all this sort of thing. And when you drill down to what the case study is, there's none of that information in there. We have no knowledge of the builder. We have no knowledge of the context in which he stepped on the boot, on the nail. We have no knowledge of his work situation. We really have no knowledge of how he expressed pain. Yeah, none of that. We know he was sedated. We know that took the boot off. There was the we know that the nail had not penetrated his foot. Lucky.

Eric: 21:36

Lucky, yeah, lucky guy. Yet for probably close to a decade or longer, that story was still told in numerous pain science courses and conferences as and used as an example. And I like to think that we still is. Is it still? Okay. I've heard time, but I still like to think, I like to think now that we know enough to think twice when those things come and say, hey, maybe there's more to it. Can we prove this theory wrong?

Monica: 22:08

I think part of the problem is, I think part of the problem to begin with was not even proving the theory wrong. It was like recognizing where your bias is coming from.

Speaker 2: 22:18

That's what I'm saying.

Monica: 22:20

So the people who are reading this had a bias related to pain, and they read it through that filter. When you take that filter away, it's a fun story that has no real meaning with relation to pain. It was an interesting anecdote from an emergency department. That was literally it. And the and all of the kind of machinations related to the pain were added post hoc in order to justify the this idea that what that story was about was pain.

Eric: 23:03

Yeah, we could go for dozens of examples. I'm sure because I can think of a few other quickly off the top of my head, uh, stories that were told by very charismatic pain science educators, whose names we will not throw under the bus. People that would tell these stories, and then you would go and look for the research or the reference, and that they would where it came from. And more often than not, these were stories without like it was not a uh it wasn't like a large study.

Monica: 23:41

Yeah, it was elaborations.

Eric: 23:44

There's a lab and a lot of them were elaborations or and assumptions, assumptions, and you realize, okay, so there might not be as much to this as but you tell a really great story, and of course that's charismatic. And I remember early days in my pain science journey. I remember someone who I think is still doing a great job, and he said, Be careful of the pain science guru because they're gonna be just as bad as the manual therapy or the exercise guru that that you may have liked before.

Monica: 24:22

Yeah, just a slightly different type.

Eric: 24:25

Yeah, and that's stuck with me. I and I'll admit, I'll admit my own faults. You do kind of lean towards one way because you like how that sounds and it tends to make sense. I think we've talked about that before. But anybody listening to this, hopefully you'll hear us talk about these stories, and you and maybe these resonate with you. But I think the same thing is that we just have to be careful about what do we believe. Yeah, what are our assumptions, what are our biases, because it's so easy to fool yourself.

Monica: 24:57

Yes, yeah, especially when when looking, we're coming from helping professions where we want to help people and we're being offered tools in order to do that, and they're come they and they come wrapped in a bow. We just have to hand over the check. Yeah, so it's very interesting because what I did realize doing all of this and having the questions thrown at me that were thrown at me, and perhaps having the disposition that I have to try and answer them, this has been a lot of work. And I don't have a neuroscience degree, so when we're talking about these kinds of modes of activation of nocerception, my understanding, I read the research and I try and summarize what that means, but I'm not expecting anyone to have the to be able to explain it on a neuroscience level or a physiological level in any way. The goal of this is to understand that these things occur and that we don't have a measurement tool for them, though we might be able to make a reasonable and even a sound assumption that these things may be activating depending on what the purpose is, what the person is presenting with. So some of those symptoms might give us some indication that there are particular mechanisms at play. And that's where we get to those clinical descriptors of no susceptible, neuropathic, and nosoplastic. Same sort of a thing.

Eric: 27:21

If someone's watching or listening to this not in order, go back to the previous episode when we talk about those different mechanisms.

Monica: 27:29

Yeah. Just go back. But that's that's partly, of course, what the course is offering. Is not like I will present some research with relation to this. And we start to see, and I've started to see now that I know about this when I look at research, I can start to see where those threads go through different kinds of research where I'm like, oh, this person is actually also documenting this aspect of no susception and what is occurring here. But that's the goal is not for you to be for someone to be so up to date with research that they understand all of the nuances. It's just to understand that the nuances are there and that before you make an assumption that the person said to me that they were stressed or whatever it is, and then you make this assumption that is one of their factors related to their pain, that you understand that there is that no susception underlines this sensation. Absolutely necessary for this sensation.

Eric: 28:42

That's a very writing theme. No susception is necessary, if not always sufficient for pain. Yes. Which I don't think we can say that enough. I think that's something we really just need to just take that in and just make it part of the.

Monica: 28:56

Yeah, because I think what the popular thing was no susception. I remember this, no susception is neither necessary or sufficient for pain. And that was, I think that is very problematic to think about if we take a if we if we take a component out, partly because it leaves the category of what are the factors related to pain? It's just blows it wide open. There's no foundation anymore. There's not there's nothing in which anything can be in that category at any given time, or not. Because there's nothing, everything's contingent, which makes it very difficult. Like, how are we how would we ever measure anything about pain or understand anything about pain if literally everything is contingent?

Eric: 29:48

You can't. You can't. Let's take this premise here of deception is necessary if not always sufficient for pain. And we talked about these five modes of no-deceptive activation. And let's talk about let's relate this into a term that I know we both hate, which is the root cause of pain. Right. What's your gut reaction when you hear someone say root cause of pain?

Monica: 30:14

In terms of how I was educated with that term, it again, it's one of those category error things where it's like it could be literally anything. Because there's nothing that's it's there's nothing that's necessary. It's supposed to be a necessary component in and of itself. If you if it's the root cause, it's supposed to be the necessary cause. It would have to be necessary. So if someone has pain, let's say you I always go back to spraining an ankle, mostly because that's what I do and I'm dealing with one right now. But but if you go back to something like that, what is the root cause of spraining, of the pain that you feel from a sprained ankle? This might be easier to understand because then we would think, oh, maybe that's that is peripheral activation. There's a noxious stimuli, there's been tissue damage, there's been mechanical damage, whatever it might be. But what if the healing takes a little bit longer? Right? And maybe it's a year and you still have ankle pain, and maybe you've got some hip pain. And then what is the root cause? What's the root cause for the hip pain then? And now maybe that's because of your ankle, and or there was some other thing that came along. You had a kid, and then so literally the causes we could just roam around the body and the person's life and start to pick a few things that we could then attribute to being causal for that issue. So if people wanted to narrow that down, and instead of saying root cause, we could actually say what is the necessary cause for pain. The necessary cause would be no susception. We could if people really wanted to use root cause, sure, but really more appropriate would be ness would be necessary.

Eric: 32:30

Oftentimes root cause is used to say like you can assess or diagnose or find the specific joint or tissue or thing that's not moving properly, whatever might be, and then you target that, and then the person's pain is supposed to go away. And then when I hear root cause, that's what I think of as someone being like, oh, you just gotta you gotta do this thing, and this is gonna fix it.

Monica: 32:55

Because you're not your elbow's not, so you have pain, but your elbow's not moving properly. So if we get your elbow moving properly, then you won't have pain, and therefore the not moving properly was the root cause for the pain.

Eric: 33:11

But then what you're and then to follow this kind of line of thinking though is what if you get your elbow moving again and you still have pain there? Then we're gonna find another root cause, or maybe it's because of a tendon, or maybe it's because of some adhesion, or maybe it's because uh whatever, and you can just like you said before, like it just never ends.

Monica: 33:29

Yeah, it doesn't have to end, no, it doesn't happen.

Eric: 33:33

We can just go on, and this happens with people all the time that live with persistent pain is they get told that it's all this different, this is the causative thing, and it's and partly because with chronic pain as well, and it's the long term, you'll often get shifting.

Monica: 33:50

You'll get people who have like pain here one day, pain here the next day. Maybe there'll be some consistent things as well. But when you're talking about a central change, let's say there is an alteration of the no-susceptive apparatus from the central levels, brain and spinal cord, where's your root cause then? Because now you have pain in a joint, but it's because the messaging is problematic, not because the joint is.

Eric: 34:20

And you could do all the things in the world you want to that joint, and it might still be painful.

Monica: 34:27

Yeah, exactly. And then it'll be that person's fault for not being strong enough or not doing the movement properly, or something along those lines.

Eric: 34:39

Yeah, and uh, this is hopefully people as it when they take the course and also from listening to this, they'll start to realize the errors or the problems with that way of thinking because it you really don't have an end.

Monica: 34:52

No, you can just it's an infinite regress for anything that you would like to what caused that, and what caused that, and what caused that.

unknown: 35:01

Yeah.

Eric: 35:01

Yeah, and this comes down to that whole and you see this in the one that drives me the most bonkers in the MSK world is the whole kind of regional interdependence thing where your your baby toe is sprained, so it throws off your knee and it shows off your hip, which shows off your back, and then you're you have left subocipital pain because you stubbed your right baby toe or something and it's very complex.

Monica: 35:23

Yes. And but it totally makes sense that if you are looping, yeah, you're going to be using your joints and muscles somewhat differently while you're looping, and that you may end up having discomfort or pain because of that. So you get that there could be definitely a chain reaction that occurs, but that's going to be more of a functional kind of issue than it is anything else that will probably be resolved when you're not limping anymore or when you can walk better.

Eric: 35:59

And that's the way I always have teach it, and is that we see that kind of line of thinking, but it's usually those changes that you see in movement, whatever, or postures or mechanics, whatever, are because you hurt. Right. It's you're flipping the you're flipping the script on that.

Monica: 36:19

Yeah, it's a cat before the horse kind of thing. Yeah, yeah. It's like you hurt and therefore, or it's yeah, because people have pain, and then they're often they can. I remember doing this myself where it's like someone will come in with hip pain, and you will see some asymmetry in the hip. And then you'll be like, oh, it's because your right hip is elevated and rotated. And then I started thinking maybe it's elevated and rotated because you have pain.

unknown: 36:53

Yeah.

Monica: 36:54

And you're holding in a particular way because of that pain. There's some other reaction that's going on because you're trying to avoid having pain. Yeah, so I do remember that, and that's how we do it. We're we're like you have pain, therefore, yeah, that's that root cause thing when we get back to it as well.

Eric: 37:52

It's leads us thinking a stray.

Monica: 37:58

Yeah, interesting.

Eric: 38:01

Let's talk because I know we're gonna run out of time. We always do. Let's talk about language and the importance of language in pain literature or pain medicine. And we've hinted before, or we've talked about before about why matters, because then we don't really know what the heck we're talking about. How do you see this impacting patient care?

Monica: 38:25

I think a big part of it is that semantics matter, number one. And semantics being meaning, having a shared meaning makes a big difference in terms of our understanding of the language that we're using. And some of this comes down to so I'm talking about the course that has a foundational basis where no susception is necessary for pain. And one of the big misunderstandings that come from this is that people think that is conflating no susception and pain. And the conflation of no susception and pain is a very big problem because it occurs all the time. And it occurs in clinic, in research, in education, in just discussing pain, it occurs quite frequently. So it becomes very problematic. But these two things are very different. And because I say that nose deception is necessary for pain, it's I can't be saying they're the same thing because I'm saying one is necessary for the other. So I'm using this terminology as in these are distinct from one another, but you need one in order to have the other. But that doesn't mean that you know that A equals B, that or A plus B equals C, or whatever the formula might be. Pain is how we use it, it gets used so often, but let's talk about it just on a sort of a meaning level so we have a shared understanding. As an it's an individual experience, we need to be conscious to some degree. Certainly, they're if someone's unconscious and there's a level at which they're moving that it seems that they're painful because something is going on that might also be some level of awareness. They're not brain-dead, let me put it that way. Sensory, it's a sensation, and it can be reported by or observed in the person that's experiencing it. And no susception is a neural process, it's translation and encoding of information. It doesn't require you to be conscious, to have no susception. It's a chemical, it's electrical, it's part of the nervous system, right? Part of the process of the nervous. These two things are quite different, but in order to have that sensation, you require process of the nervous system to process some form of signaling to come up with that sensation of pain. That's where these two things are both different and in no way equivalent. Does that make sense?

Eric: 41:13

I understand.

Monica: 41:15

Yeah, so they get used very interchangeably in a lot of different ways. And when we're talking about semantics, and people are like, oh, it's just semantics. Actually, the semantics in pain research is very important because it changes meaning. If what if I say no susception and you have a different meaning in your head than the one that I do, we're talking about a completely different matter. There are some errors that occur in pain medicine, some specific sort of language errors that occur in pain medicine. And that has actually been studied in a couple of different ways. And the main errors that one particular paper found, let me have a look at the pain at the paper. Let me have a look at the pain. Just again. And then also the conflation of pain and no susception. I these authors expected that pain as a thing was going to be, no, conflation of pain and no superson was going to be bigger, but I think it was pain as a thing that ended up being a bit more robust. And these are the shortcuts that get used when people talk about pain. And they talk about pain as being transmitted. So this is when no susception and pain get conflated. When someone calls it pain fibers, remember we had this pain fibers and no susceptible fibers were conflated. I think it was Patrick and Wall or something had a quote with relation to that. Let me find that quote. The labeling of no susceptors as pain fibers was not an admiral simplification, but an unfortunate trivialization. This was a thing. Once we understand that that conflation is there, though, that makes a big difference because then we can start to under see understand if this is a language issue, did someone just use the wrong language in place of no susceptor, but the meaning stays the same? Or is this a meaning issue where people are using the language incorrectly to say that pain is a thing, that it is produced in a particular way, that it is transmitted in a particular way. So that becomes part of the big problem. And so when we start to see that those issues, and all of the papers that these people looked at, these authors looked at, all of them contained at least one error. Like one error, and many of them are more than one error. So if we're not talking about the same thing, that's a major problem. If we're linking pain, and this is where some of the popular pain theories that are out there with regard to pain neuroscience education often conflates pain and no susception and gives pain purpose and has it doing things that, or has the even has the brain doing things that really is a construct of the human being. So this is what happens is that we've got education that then is based on confounds of meaning. And then that is really a huge problem for the person who has pain more than anything else.

Eric: 45:36

And would it have a problem for them just because the treatments that they would be given or they would be offered?

Monica: 45:42

Yeah, so some of it is the treatments that they're given. Because if pain can be transmitted through or produced in particular ways, I think the brain one is the biggest thing. Often brain gets used. The brain produces pain based on based on level of threat or something along those lines, where once the once all of those elements have been assessed, then the brain will produce pain. Then there's a lot of holes in that, just in terms of the kind of logical questions you could ask as to why pain would be the thing it produced in response to threat. That then becomes a bit of an issue. But then the brain is making decisions as well. So there's this language where the brain decides. Now that might be language where that's used erroneously in trying to understand, trying to get people to understand the central nervous system has a level of processing. But once you start to add those, that kind of language, the brain decides, the brain makes, the brain produces, then you start to concretize pain. Now pain is a thing that the brain has made.

Eric: 47:03

And then the treatment or the solution to that would be just train the brain to not do that anymore. Unthink it.

Monica: 47:14

Make it do things differently. Doing things differently might be thinking that, oh, you have to think about this differently. Or maybe if I give you knowledge that you are thinking this way about pain and you can start to think this way about it, that will change how you feel. That will change the sensation. Because it's because if it's your brain that's making it, then it's your brain that is the problem.

Eric: 47:43

So fix the brain.

Monica: 47:45

Fix the brain. And we're not doing that with neurosurgery because that's like out of our scope.

unknown: 47:51

Yeah.

Eric: 47:53

But psychology is also out of our scope. Hobotomy would work really well.

unknown: 47:57

Yeah.

Monica: 47:58

But psychology is also out of our scope.

Eric: 48:00

But it's that's such an important distinction, though, too, because that was a big idea. And I remember myself jumping on that idea, it's like, oh, this is different. Okay, this is a thing. Right? This it's this is this gives us something else to think about.

unknown: 48:13

Yeah.

Eric: 48:15

But then when yeah, if you look at the research on it, it is not good.

unknown: 48:19

Yeah.

Monica: 48:19

And no, the research is often self-referential for one, but isn't it's like any other musculoskeletal research, like none of it is groundbreaking in terms of we have this thing that is the most amazing kind of like treatment ever. It's definitely marketed as that. It's marketed as something that will be incredibly beneficial without really much regard to uh how it can not be beneficial.

Eric: 48:52

Because there was a study that came out, was it this year or last year, recently, about people that live with pain, how they feel about that kind of messaging, and it wasn't supportive either.

Monica: 49:04

No, exactly. And it didn't change pain.

Eric: 49:07

It did change pain, yeah.

Monica: 49:08

Yeah, so there was it was like these things didn't make differences on that kind of outcome level that you were looking at, which we already know. The numbers haven't really changed, the costs haven't really changed, but we're kind of stuck. We're mired in this. It's like in musculoskeletal professions, we get we've been stuck in this must in this biomechanical thing where it's oh, it's their rotating L5 and their elevated left iliac and their key cuboid bone and some other kind of element or lesion or some postural thing or whatever it might be. These are all causes of pain. These are all causes of dysfunction that we have conveniently hooked onto because we're able to feel a restriction, or the person can report pain when we manipulate them, or whatever it might be. And it's the same. It just is a different target, but it's the same treadmill. It's the same thing where it's just, oh no, this is the problem. And ultimately, the problem is of the person. It's like whether it's their posture, or whether it's their upslip, or whether it's their rotated vertebrae, or whether it's their footbone that needs adjusting, or whether it's their thought process, or whether it's their stress levels, or whether it's their social situation, it's like it's their fault, or at least it's their. Ultimately, they have to do something about it in order to change anything. Whether that be pay money to go and get something adjusted or get richer, I don't know. A bunch of different things. But ultimately, that person then supposedly has to go and do something about it. And then if they don't, we can then say, I did um, I did my best. I educated you, I gave you all the things.

Eric: 51:18

And now it's on to you to figure it out. One last thing, and maybe because we're gonna do a bonus episode, because we said we're gonna do six, so just people are listening to the bar, we're gonna do a seventh episode.

Monica: 51:30

Yeah, because we have to get to the making a pain assessment thing. Making a pain assessment.

Eric: 51:34

We haven't got there yet. And but for today, just one thing I thought would be worth touching on was you said about those themes that came up, the confounding in the pain literature, and you said the thing that was the most I can't remember what the words you were you used were, but the most impactful, or the one that was created the most notice was pain being labeled as a thing. Can you talk about that for a bit more? About what does that mean and why pain being conceptualized as a thing is incorrect.

Monica: 52:09

Because it means that what it means that then the brain is able to produce it, right? That fibers are able to transmit it, that you have something that is external to you that can be moved through you and somehow not only external to you, so pain is transmitted to the bro spinal cord and brain, where the brain makes a decision to then make pain or to produce pain. The whole thing is it's it's circular, but just wrong on on just that kind of level. How do you transmit something that then you also produce? Like, what's the point if you're transmitting pain in order to but you're producing pain? So that doesn't make sense on a particular level, but you can't do it unless pain has some form of physical component to it, electrical, chemical, something that can be transmitted through a nerve fiber, something that goes from that has a physical component that can go from the noxious stimuli into the nerve fibers to be transmitted in order to that the brain can then decide to make more of it. It's a bit of a fundamental error in the understanding of what it means to have pain fibers or pain pathways, right? Where when we're talking about something like that, we're talking really about no susception. And so that's where again that conflation comes in.

Eric: 54:04

That's what I say, yeah, where the conflations that makes sense. And so thanks for going talking about that a bit more. Just because it's something that you see and hear often is the idea that pain is is the thing, and pain isn't a thing, because a thing is like an object.

Monica: 54:20

It's a yes, it's it has objective. Yeah, it has properties, it's like physical properties, yeah. Which it doesn't, it's a sensation, it is a sensory element that then along with everything else, people have perceptions of how they present with it or deal with it, or maybe why they have it. But it goes back to some of the other conflations that we see, which is a stimulus. So people will call it a painful stimulus, which again goes back to this idea that perhaps pain is being transmitted in some way. Because you start with it. You're starting with this stimulus that's that has this sensation already. Whereas the stimulus would be the noxious stimulus, which would be it's a noxious stimulus, but that painful stimulus goes through pain fibers and is part of a pain system, right? So it's a part of this system of pain, which it should be appropriate again, should be no susceptible. But then you get pain sensitivity, which makes sense because you have pain everything else. Even ISP isn't immune to some of the category errors that are there. So when we talk about, we talked about the clinical descriptors like no susceptive pain, neuropathic pain, nosoplastic pain, they're not types of pain. They are mechanisms, uh, they're descriptive mechanisms or ways of describing a possible mechanism of no susception.

Eric: 55:56

To be correct, they would be mechanisms of no susception.

Monica: 56:01

Yeah, or hypothesized mechanisms.

Eric: 56:03

Hypothesized mechanisms. Hurts the brain a bit to think about all this stuff and to work through it, but uh extremely valuable.

Monica: 56:11

Yeah, and it's unless we start to think about it, like even just talking to you then about when you have pain being transmitted through when you have a painful stimulus, so you've got pain already being transmitted through pain fibers, and the pain itself is going through these pain fibers to the brain, which then produces pain, you can start to see where this doesn't make sense, where there's a huge disconnect here that then, like when we get to the end portion of things, we just have this, we have this really problematic kind of circular way in which we're thinking that has no real beginning or end kind of thing. When we put the foundation down, when we say that no susception is necessary for pain, then we understand when someone says pain, that we understand that no susception has occurred sufficiently to have that sensation or that observation. Makes it much more simple and stops us from making massive assumptions about causes of pain. We can still go there, like we still will because we're that's the nature of things, but we will be less likely to make especially psychosocial assumptions. Not that, and I want to make this clear, psychosocial barriers to health and recovery matter, and they are part and parcel of the person who comes in to see us, but unless we know everything that operates that every context in which they operate, for us to pick any of those factors out as in any way causal or in any way significant in contribution, so that we can then develop a treatment in order to target that's ethically we've gone below a reasonable ethical standard at that point.

Eric: 58:21

I think we'll finish up there.

Monica: 58:24

Sure.

Eric: 58:25

I think that's a good feels like a good stop point. Next time we will talk about the making a pain assessment and whatever else from mind. And we will that'll wrap up this series. Maybe we can bring a special guest on. We were talking about maybe.

Monica: 58:42

Yeah, I can hit SF up and see if you'd like to draw.

Eric: 58:46

Come on and hear what he has to say.

Monica: 58:48

If not, that's okay too, but it'll be and then we'll have to change everything again.

Eric: 58:54

Maybe hearing his perspective on a bunch of stuff from somebody who is very has a lot of strong, uh informed evidence.

Monica: 59:05

Yeah, certainly things to certainly things that would get us thinking for sure. Like a lot of what this is based on is very much the questioning that comes from Cohen and Quintner and ASAF and colleagues in that line of thinking. And they present some logical arguments as well for particular things like paradoxes that are within the definition of pain and no susception, which again is super interesting. And this is where it's led me, where it's like, I do not want to go to the place where I'm jumping into these massive conclusions about who this person in front of me is, and then possibly ignoring the information that is actually in front of me, where I may actually be able to have a hand in perhaps helping relieve something that's going on. And if we go back to the boot in the nail story, that's exactly that. It's like you have a paragraph that has salient details, and there's a lot that's missing. And the only thing that you really have in front of you, like your response, your first responsibility is to understand what's in front of you before you actually leak off and assume that there's all these things that are going on. Now we can end.

Eric: 1:00:35

Thank you for listening. If you want to learn more about this topic, Pain Education No Script Provided is a self-directed course which is now available for purchase on my website, the CEBE.com. Please subscribe so you can be the first to listen to new episodes. If you enjoyed this episode, share to your favorite social media platforms. To connect with me, I can be reached to my website, thece.com, or send me a DM through Instagram at Eric underscore pervis underscore C E B E, or you can find me on Facebook at Eric Pervis RMT. If you'd like to financially support my podcast, please consider making a small donation. This can be done by clicking on the support button or heading over to buy meacoffee.comslash helloob.