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All your pain questions, answered.

Written by FXNL Staff
May 6, 2018

You asked, they answered!

Three top pain scientists – Prof Lorimer Moseley, Dr. Tasha Stanton, Dr. David Butler – answer your burning questions about pain science. This episode is live from the Pain Revolution event in Australia.

You can watch the video for a collection of the top questions from this interview.

If you like this, be sure to subscribe to FUNCTIONAL F1RST on Apple PodcastsGoogle Play, Overcast or other podcast apps.


Katie Yamamoto [KY]: This is episode 22 of Functional First podcast. I’m Katie Yamamoto from Functional Media and today we’re in Australia, traveling with the Pain Revolution. We’re joined by three pain experts, Dr. David Butler, Dr. Tasha Stanten and Professor Lorimer Moseley who will be answering your submitted questions.

Dr. David Butler [DB]: What is pain?

Instead of going through all these definitions that have been put out there, why not try something which is really simple and clinical? We will have pain when our brains weigh the world, everything going on outside and inside and makes incredible judgment that there’s more danger than safety.

Equally, we will not have pain when our brains weigh the world and judge that there’s more safety in there than danger. Great question but the key thing is, danger and safety hides in hard to find places and when you can grasp how important context is and how important distributed processing is, you’ll realize that many, many, many things out there can have an influence on pain, both send it up and down.

DB: What do you say to a patient who says “So, it’s just in my head?”

Well I’ve got to tell you sometimes, when your clinical interaction skills are good enough and powerful enough you can say “Right on, you’ve got it” but of course, it’s much bigger than that. I would say “No, it’s never just in your head. It’s in your body, it’s in your life and yeah, the brain may well be boss but it’s much, much bigger than in your head.” And I think I’d probably apologize if some health professional out there has told a patient “It’s just all in your head” I’d apologize on behalf of the health professions for being just a little bit out of date.

DB: How can we change peoples general knowledge before they become patients about pain and pain management?

Look, that’s a really, really good question and if I reflect on my clinical life, I would have to say that the ideal way to deal with this massive expensive and horrible epidemic in society is to pre-empt it. And that means going into schools, going into sporting clubs, going to parents and teaching them about pain, before they get a problem.

If somebody was doing some research out there, I reckon you could go to a sporting club and go in and give maybe two by 20 minutes with a bit of a follow up and a few multi media links, you could go in and teach these people about pain and I reckon there’d be far less issues with return to field or pain problems later. But research has to go there yet, but yes, let’s go young, let’s teach it in the schools and the sporting clubs.

DB: What metaphors and analogies do you use with your patients?

And the answer is I don’t think I use anything else but I use metaphors and analogies all the time and part of this is also in a diagnostic sense. Looking for the kind of metaphors patients are using and making a judgment on whether we need to try and shift that. A couple of key examples there is when somebody uses metaphors that suggest invasion of the body, “it’s like a knife in me, something is degenerated inside, it’s burning inside.” We try and give them alternative language.

Other key metaphors we use are when people use language to try and grasp a chronic pain state that they don’t have language for. So we see things like, “It comes out of the blue, I’m falling apart at the seams, I’m feeling fragile today” and if you look at those three examples, the people are trying to link pain to something objective. Fragile to glass, blue to the sky, seams to clothing. These people are really asking for some form of grounding of their particular problem. So yes, I use them all the time, develop them all the time, try to get a store of metaphors that I can use in the clinic all the time. Simply said, I have a belief that offering a patient optimal linguistic expression, is as important as helping them to optimal motor expression.

DB: How much is it possible to deliver in a 20 minute educational intervention?

And the answer is heaps. Hardly a health professional out there is offering patients, clients a 20 minute intervention. But you could prioritize it and critically it is to make an assessment of that persons particular needs. It’s not delivering education as just the same story to everybody, it’s going in and making it an interactive thing with patients. Picking and identifying what you believe, what they believe are the critical target concepts that need addressing. So yes, you can do it. And just one other comment, if you could follow it up with just one contact after, a phone call, an email, what you delivered will be far more powered up. So go for it.

DB: What are some of the great advances in pain sciences now that will have an impact in the future?

And for me this comes down to one major thing, and this comes from the many domains of pain sciences. It’s for me now, to be confident to say to a patient or a client that it’s not just all about management, that treatment is on the cards and that cure is on the cards for some. I’m not saying it’s easy, it can be bloody hard. But for me to be able to say that, that comes from a knowledge of basic sciences of bioplasticity but increasingly now, 20 plus well done randomized clinical trials that show that effective education, combined with quality movement change can make a huge difference.

Dr. Tasha Stanton [TS]: What is one piece of advice you would give to someone suffering from persistent pain?

I think I probably have a couple of pieces of advice I’d like to give but I think if I had to choose one I would probably say, find a clinician that listens. Find a clinician that is happy to hear your whole story and is happy to explore some of the history that you’ve had and can give you some help and addressing different situations and how you might be able to cope in those situations.

Because I think one of the hardest things is when you actually have chronic pain is getting someone that is helping you to explore ways that you might be able to go forward and ways that you might be able to cope in your individual situation and if you can’t find that person, ask around as much as you can.

TS: Those of us in the profession like to dig deep in the science and research. But what the overall public is interested in is far more practical. What can we do? Data alone hasn’t convinced many, how can we better explain what’s going on in a simple and understandable way?

Well first of all GetPT1st, I think you hit the nail straight on the head in the fact that often times we have good evidence in terms of data and science for things but it doesn’t get taken up in a practical manner or in clinical practice. So I think one of the hardest things from that is that in order to translate some of our science, we have to think of ways that we can actually create simple explanations for people but also what can be quite powerful is creating metaphors, so that they understand is what we’re doing is trying to treat something different.

I think when we look at some of the pain science work, there has been a fair bit of attempt to try make an use metaphors to help convey different concepts so I guess I would say, one example might be when patients are experiencing pain with certain things and they don’t quite understand why, we might talk about well it wouldn’t make very much sense. Say, pain is like an alarm system, so if the alarm system is set way too high, tiny little things will activate it and it will go off.

But the trouble isn’t with how the alarm system is in the car, it’s actually with the sensitivity with the alarm system itself and that’s similar to what’s going on with this person that has chronic back pain. It’s not the problem of the back itself but its the problem with the sensitivity with that system and I think if we can take these messages and actually go to the public with them, that actually becomes a way where we can go from the ground up.

Because what we found is actually going and trying to implement changes in practice as we go from the top down is doesn’t always work. But if the patients are asking for it and want it, that’s often times how things can change.

TS: What are some exciting new advances in pain science that you think will impact clinical practice in the near future?

In the near future, that gets a bit harder. What I think probably will be some of the biggest differences is some of the information that is actually coming from the learning field and so how we associate things and how we learn that some things are dangerous and how we learn that some things are safe. Because right now, for example when we look at pain education we’re trying to on a cognitive level, change those danger and safety understandings.

But if we start to understand a bit better how we might be able to extinguish some of these pairings of danger and safety, or lets say movement and danger in patients that do have pain, then that actually opens up a whole new realm and I guess where I get excited is at a cognitive level we can actually work with patients to understand this is what pain is all about. When you feel pain when you’re doing movement, it isn’t that you’re damaging something further, what it actually is is your system is sensitive and it’s protecting you.
If they have that understanding and then we do some of the exposure type paradymes and we have people actually doing the tasks that they were at one point scared of because of pain, I think that could be incredibly powerful and to date we really haven’t done that.

TS: What are the biggest barriers in making physio and pain management move forward?

I think there’s probably a couple, there’s definitely couple. I think one of the challenges, is a very practical challenge. If we think of people going into a private clinic, you can only actually have them come in for so long in terms of a clinical appointment. And a lot of the things in terms of pain management, we know that explaining the neurophysiology of pain to someone takes time.

We can’t rush that, it’s a conceptual change. It’s trying to institute differences in how people understand a most basic sensation that is scary, pain. So I think almost policy changes become important so that we can actually then be able to provide those sessions to people and they’re covered they’re not having to pay extra for them. I think that’s a big deal. But I think it’s also engaging the community of physiotherapists and understanding that actually a lot of this information can relate to the treatments that they’re already using.

I think that’s where various groups going forward and trying to collaborate with different areas is really important.

TS: How do you see the role of manual therapy in both acute and persistent pain assuming an ethical and accurate explanation as opposed to a PSB model approach?

This is a hard question because if we look to some of the clinical evidence it suggests that often times manual therapy as a single treatment may not have long term efficacy or effectiveness in terms of positive outcomes for people. In acute pain there’s a little bit more evidence to suggest that it may be beneficial in some conditions.
So for example, conditions such as chronic back pain. We look at some of the manipulative clinical prediction rules in that area. So I think if there is evidence from larger trials to suggest that it works then I think we’re quite comfortable in saying “This is great, this is something that showed in these people it was good”.

In persistent pain I think it becomes a little bit more difficult because it’s not been shown to have long term outcomes. I think actually how we might see it as a role, we know that numerous treatments might help us feel better in the shorter term. And these things are actually really important in terms of making us feel better and making us enjoy that day more. While you’re not promising them that this treatment is going to change nor cure them, if you’re combining it as part of a multi module treatment then I think including and explaining that this has been shown to have shorter term outcomes, I don’t think that is a problem from an ethical standard at all. I do think that still encapsulates and accurate explanation.

TS: What is the most effective way to implement a pain science approach in Complex Regional Pain Syndrome, CRPS, and how should medications be used in implementation?

This one is a great question and part of it is determined by the stage at which it’s at. So there’s some work coming out of some of the clinicians that are working in Melbourne, that are trying to capture people early. So they’re trying to capture them within three months after having a wrist fracture and looking at people that have quite high pain levels, are quite fearful and quite anxious.

What they’re showing is actually instituting things like, graded motor imagery. Actually they’re looking at a sensory paradigm of that, that hopefully would be out soon, has been shown to be in some of their pilot data to be helpful. So I think in that case, its probably working quite hard to do your best to keep them moving while not completely flaring up what’s going on in terms of pain and that may be instituting things such as left right judgements, imagining movements and then also using mirror therapy.

In terms of how should medications be used, I think it’s probably a good idea that in this case we’re working within teams, multimodal teams because, for Complex Regional Pain Syndrome many times we’re looking at numerous approaches. So using medications in conjunction with different brain based approaches and with the aim to reduce pain and improve function. Also as they’re beginning to improve, reduce that medication use.
In people with Chronic Complex Regional Pain Syndrome, that does get to be a more resistant and tougher population. In this population it tends to be taking a bit longer with some of the stages that we have with things like graded motor imagery but also I think it’s really critical and probably for both populations but particularly when they’re chronic, but having an explanation of pain and what we understand from modern pain neuro science is essential.

Because they may not understand, well certainly they most don’t understand why on earth is this pain so bad and especially if I seem to have done such a little thing to hurt myself, might have just bumped your hand or perhaps broke a wrist. But I think with that it’s really important to combine those two things because what we’re finding with graded motor imagery, they did a clinical audit on the data and the effectiveness of it wasn’t as good.
We didn’t see as good clinical results as compared to the clinical trials that were run and we think that part of that is actually due to differences in dosage. Because the challenges with graded motor imagery is it’s a massive dosage. It’s five minutes every waking hour and if you don’t have the buy in then I think that’s a real challenge and I think actually educating people on pain and the neuro biology behind it helps to get that buy in.

TS: What can you tell us about pain thresholds? Could a pain threshold be more about coping, pain tolerance, or is there an actual inter individual difference on a neurological level such as our perception or even a nociceptor level?

So that question combines actually quite a few different concepts. So we do know that your pain thresholds can be modulated by various things. So one example is actually even changing your own perceived size of your body. So making your hand look bigger actually increases your pain threshold so it makes you less sensitive to that noctious stimuli. I think the second bit of the question asking me to in coping and pain tolerance, there’s more evidence to suggest that having effective coping strategies will increase your tolerance to pain, you’re better at tolerating it.

But there’s not very much evidence that your coping strategies will change pain thresholds. In terms of interindividual difference, well we do know for example there’s difference in nociceptor density around our body. So different areas are more sensitive. So right within an individual actually, you’ll have differences as we well know in pain threshold. So it may well be that actually for different people, there’s differences in the amount of nociceptors they literally have in a different area.

We do see that there’s differences between genders, so it tends to be that females tend to be more sensitive to noxious information or input. So I think there is good evidence to suggest there’s actually interindividual differences in pain thresholds and it’s not related to necessarily how tough you are, it’s related to the functioning of your neurological system. Pain tolerance I think you may be able to make a slightly different argument in that coping strategies and your motivation to hold out can probably make more of a difference.

TS: Does the health industry need to change the way it understands and treats pain? If yes, what are your suggestions?

Well my answer to that question is a resounding yes and I think some of the way it needs to really change is move away from this solely biomechanical understanding of pain. That’s hard because that’s what we’ve learned growing up because when something hurts, we’ve injured it.

And yet the vast majority of pain science knowledge and literature suggests that’s indeed not the case. There’s many things that modulate and contribute to our pain experience. I think one of things that is really good way to look at doing this is to start to give a little bit more than just lip service to psycho-social factors. So we think about asking people about “What is your social environment? What are your support networks? What do you feel? Do you feel anxious?”

Its one thing to ask people about that within an objective interview, but its another thing to actually help explain to them, “Look actually when this happens this is the way that your system reacts” and if we give them that understanding and that knowledge that can change the way that they react and understand their condition in the future. Because knowledge changes our perception. I give an example that you’ll see in some explain pain books is that if you are home alone at night, all by yourself and you hear a scary noise outside, something rattling, if you have the knowledge that you just ordered pizza you think very differently about that noise than if you didn’t.

Because then it might be an intruder. And it’s the same way I think with people that have pain. If they have an understanding that they have a dynamic bioplastic system that can change and it can turn the volume up in terms of danger detection, then they can understand why sometimes they’re in a situation where they don’t have enough money for bills this month, they have a kid that got in trouble at school, then it makes more sense why they might experience more pain that day because the volume knob of their system is turned up.

So I think knowledge is incredibly empowering because the health industry needs to start to understand and promote the fact that education in and of itself is a treatment for pain.

TS: With this bio psychosocial model and often this focus on psychological or social factors, where does this bio fit in to all of this? Where does it actually come in to play or do we think about these things very separately?

It’s interesting because I actually don’t think we can even separate them. I think sometimes separating them is part of the problem because the bio underlies psycho, it underlies social, if you’re feeling stressed, if you’re feeling anxious there are biological processes behind why you’re feeling that and then there’s also biological processes that then contribute to them further.

There’s a fascinating study that was looking at if you remove afferent input from the face, so people that get Botox and then unable to make a grimace, they have been studied and shown they can’t get as angry because you get feedback from your facial muscles of a grimace. So I think with even things like anxiety, often times for example, as we get anxious, as we get nervous, we’re starting often to get tension in the shoulders. So we have this biological afferent feedback and going back and sustaining this state.
I think we also know that psychological states, such as anxiety or fear, change the sensitivity itself of our system, of our nociceptive system. Meaning then that what’s actually going on is potentially the message itself, that danger message itself that’s getting up to the brain has changed, it has actually changed because what we’ve done is we’ve had this psychological state modulate our own system. I think that’s where the power of bioplasticity is actually so huge.

Prof Lorimer Moseley [LM]: How do you explain pain to an uneducated patient who thinks treatment is a quick fix?

Great question Karla, my challenge is breaking down information simply enough for such patients to understand, that’s my challenge too. I think that any patient that wants a quick fix, it’s difficult to present a whole new way of understanding the situation.

I feel like the answer to that question is probably a room full of people for a couple of days. But the principles that I would apply are the same principles that we apply to anyone for whom we would like them to think differently about their pain. I guess those principles are to absolutely respect the resources the patient has, to remember they might be uneducated but that doesn’t mean they can’t learn. The challenge that we have as deliverers of content in way that actually changes knowledge and changes beliefs, because I think that’s what we’re in. We’re in belief revision game as a way to get behavioral change.

I think we need to foster our skills of articulating things clearly without judgment but also acknowledging things take time and there are a lot of principles of teaching things that I would apply to that which would take us days to walk through. That’s a really tough question for me to have a short answer to.

LM: What changes do you think health care professionals need to institute in the treatment of acute pain in order to help prevent transition to chronic pain states?

Wow, I think about this a lot Alex, and in my role in the University of South Australia I’m chair of physiotherapy so part of my role is to work with the clinical education and the lecturing teams on a cognitive culture.

The thing that I’m working hard on there is to shift the idea, particularly in musculoskeletal physiotherapy, to shift the idea of us being pathology detectors and correctors, to us being facilitators of recovery. And I think we have a great skill set to detect when things are truly structurally out but we have to be really honest in appraising the value and validity of those tests and I thin our mindset should always be, how do I facilitate recovery rather than what can I detect that’s wrong and try and correct it.

I think that’s a subtle but really important difference. That’s how I think health care professionals could change and I guess it’s almost like remember healing is an irresistible force for too long we’ve just got in the way of it, I think. And learning is an irresistible force and I think for too long we’ve facilitated learning of things that are not helpful.

LM: What is your go to one liner for explaining central sensitization to your chronic pain patient?

I don’t have a go to one liner, sorry to disappoint you on that. I rely on a lot of metaphors such as magnifying glass turning up the danger message in the spinal cord, putting in 1D in the periphery but getting 4D’s for danger going to the brain. I rely a lot on metaphor and drawing pictures but I don’t have a one liner. The general concept of which central sensitization is a part is the idea of the expanding buffer.

That is a one liner that I use a lot in all of my interactions but more importantly that I see really good clinicians using. Remember I’m only a clinician for four hours a week but in my experience of explaining pain, the idea of a buffer and the buffer getting bigger. The protective buffer getting bigger. Central sensitization is one contributor to that, it’s not the only contributor, but that would be the one liner that keeps coming up. You’ve got a bigger buffer, you’re protected.

LM: How do you explain this on day one without losing the patient?

Well I think this is not a particularly difficult concept if we think about it. How do we do it without losing the patient? I think the key there is not in what I say, I think they key is in the engagement and in the pervasiveness of respect and trust and acknowledging if they’re having a hard time with a concept. But also finding that balance between presenting the conflict in their own idea set.

So you could for example, feedback to this person, three weeks ago when you did that task it hurt this much and now you’re saying doing less of that task hurts more? So do you think there’s more loading on your tissues now than they were doing the same thing three weeks ago? Normally I would expect the answer of that to that to be no. Say so something is making you more protective than you were three weeks ago, something in your system. Now that could easily be a change in the way the relaxation in the spinal cord is working. So that might be an example of providing a little bit of conflict to the current idea set and an astute, respectful suggestion of an explanation of that. I hope that made sense.

LM: The toughest assignment so far of this weeks Pain Revolution – explain Fibromyalgia.

Fibromyalgia means pain in muscles and other connective tissue, how’s that? I hope that’s satisfying. I don’t understand Fibromyalgia biology well enough to explain in and I would argue that no one on the planet does. What we really do know about Fibromyalgia is that they do have a pattern of pain across their body, that they get a lot of fatigue, they get the Fibro fog, that there are changes in the profile of nociceptors in some locations. There are differences in the way their brain works in response to stimuli, they process even auditory stimuli in a different way.

Keep an eye out for Carolyn Berryman’s work, she’s doing great work in this space. The only way that I would be comfortable explaining Fibromyalgia is to say Fibromyalgia is a persistent pain state with multiple contributions to multiple domains, that is well and truly over protective. I know that’s not very satisfying, but that reflects our current understanding of the biology. I’m sorry to disappoint you on that Benjamin.

LM: How do stress and emotion contribute to pain manifestation at different sites?

So I’m not sure if this question is referring to the possibility of having pain emerge at two different sites because of stress and emotion or whether its a question of how does stress and emotion affect pain in multiple sites?

So if I think about what I think stress is, I think stress is what happens in any system when the capacity to meet the demand is getting pushed. The feeling of stress, of being stressed, of being anxious I think that the feeling itself is at the end game of a processing change. I would put pain at the end game of a processing chain and fatigue, the feelings of those things. In that sense, I think that they modulate pain through a indirect circuit because when you’re anxious you behave differently and that different behavior may affect nociceptive input, or other inputs. But the physiology that underpins stress and other emotions, for example a change in pituitary access, so a change in autonomic regulation and endocrine regulation.

The molecules that those systems use to effect their response also activate sensitized nociceptors, change the synaptic efficacy in nociceptic pathways and also modulate brain cells that are also contributing to pain so there are multiple mechanisms by which different stresses and different emotions will also involve changes in pain. Sometimes it can be inhibitory.

Yesterday I had to dig really deep on the bike, really deep. I was close to red lining for about four hours and with 50 kilometers to go I was unsure I was going to make it. I had to dig very deep and that started to become distressing for me. In hindsight, the distress or the stress of that was the winner out of my brain. My wrist which has been sore for a few days stopped hurting in retrospect. I didn’t really have much burn in my legs, there was another thing, a whole body survival thing. So it’s not that those stresses and negative emotions always facilitate pain. It’s all about influence inside the brain and if I think whatever influences consistent with needing to protect a painful body part or multiple painful body parts, then those body parts will be more painful when that cue is present.

LM: Mindfulness, how can it be used to work with peoples pain management and perception?

I think it can but I am not the guy to answer that question. I can just tell you my understanding of the evidence is that some mindfulness techniques offer pain relief in the moment and may offer some sustained benefit on pain and disability outcomes. The way that mindfulness works is yet to be unraveled from a pain perspective I think, biologically.
Candidate mechanisms are a reduction in HPA access, so you have a general toning down of the protective set point. If you want to learn about protective set point, go to Explain Pain Supercharged and if you buy that, I get money, so you should do that. So does David Butler. Mindfulness may also work by reinstating normal intracortical inhibitory mechanisms and when we lose them we think that the loss of normal intracortical inhibition normally increases pain.

So mindfulness, particularly focusing on bodily parts, may very well address that a little bit. But I think the evidence also says that mindfulness training is going to be far less successful if people don’t understand why it’s a sensible thing to do and I would say that for all psychological therapies for pain. Unless people realize that the biological reality is that psychological strategies that we all have can turn pain up or down, can make things better or worse. If people don’t realize that, the idea of doing mindfulness is daft to me, I think. And our data suggests it’s daft to anyone in pain which is why I get so excited about explaining to them the fearful and wonderful complexity of their biology and why psychological therapies are sensible to do with persistent pain.

LM: I want to hear the answer on a question asked by Mick Thacker. “If pain is a perception, then how does the neurophysiology involve go on to become a higher centered cognitive function?”

I don’t really know how to answer that question which is not unusual for something from Mick because Mick lives at a higher plane to the rest of us with his cognitive processing. But if I have a stab at what I think this means, I’m going to re word it. If pain is a perception, how does it become a higher centered cognitive function? Because if it’s a perception it must involve neuro physiology. I presume we would say that.

I always get tangled up in the use of words like perception and sensation because they mean different things in different communities. So I’m going to change the question again to, if pain is a feeling, how does it become a high centered cognitive function? On my third attempt, I can answer it. But let me think about, I’m not sure it is a higher centered cognitive function. I think the question is making an assumption that’s not verified. So I reject the question. Maybe the question is, is pain a higher centered cognitive function and what other higher cognitive functions do we have? I presume we have metacognition is a higher cognitive function or arithmetic.

Pain is fundamentally different to those things, I would say that pain is better classified as a survival feeling. I get hammered a bit about using feeling as a definition of pain but that’s what it really feels like. But if i was to categorize pain with hunger, which is what Pat Wall suggested to me a long time ago. I know Mick has had a lot to do with Pat Wall and will understand that.

First, maybe last but that’s a bit different. Air hunger, so that sense of breathlessness that we get. Pain, itch, I don’t think they’re higher centered cognitive functions. So I’m going to change it a fourth time. If pain is a feeling, then how does neuro physiology become a feeling? And I don’t know. I have no idea how anything that we feel or how the brain produces anything. I know people are working on models for that and I guess I’m in an active process of working on my own model for that but I don’t know how it works.
When we solve that, when we solve how consciousness emerges then that’s going to be bigger than discovering DNA, I reckon. Maybe we’ll never get there, I don’t know. I think we probably will but I think it will be a whole new way of thinking that we don’t recognize a the moment. It will be on my lifetime and certainly my capacity to generate it. But I love the question thanks Christian for bring Mick’s typically penetrative question to my attention.

LM: Children who fall over in the playground experience a broad range of responses from their parents, ranging from a toughen up indifference right through to overt and excessive concern. How might these parental responses among others within a family, shape a developing child’s ongoing pain experience that might persist in adulthood?

Great question, I’m not the best person to answer that one. There are people studying how parental responses to children’s pain affects subsequent pain experiences. The people I think involved in that are Dr. Melanie Noel, who’s in Calgary. I think Christine Chambers, there are others, look those people up. From my perspective as someone who tries to understand how the brain does stuff, how neural networks form, what are the principles that determine the ultimate output of a series of neural networks. I would say the impact of a parents response to my injury if I’m the child, will be highly informative would be highly influential on what my brain produces.

I’ve got a great experience as a parent where I came home from work one day. I was living and working in England and on the three days of summer we had one year I came home and my son Henry saw me coming and ran, dad’s home from work, he would have two and a half maybe, three years old. Someone had moved a table into the corridor and Henry ran straight into the table and hit it full bore, his legs went out in front of him and he fell on his backside and he was sitting there and I could see the lump growing on his forehead. And I’m a pain scientist so I didn’t want to give him any cues, so I just sat and stared at him and Henry was looking at me and his facial expression was suggesting he was thinking, “What’s wrong with dad?” And then he kept running and we kicked a ball around in the backyard for a while.

He showed no sign that he was in pain meanwhile his sister and my wife are on the couch and clearly concerned and upset about what had happened to Henry. So it wasn’t a trivial event. I’m not saying that we should not give any feedback to children when they’re injured because I think that how’s they learn. It would be very interesting to know what sort of responses children who have, you’d never do this study, but children who have been denied all social contact have as adults, what’s their response to a noxious trigger?
I imagine it would be a questionably appropriate one. It might be massive, it might be very small, I don’t know. Social learning I think is critical in pain, absolutely critical. So yes, as parents we will have an affect I think on the pain system of our children. We’re just on effect on it but we do have an effect.

LM: Medicinal marijuana for pain, have any of you studied cannabinoid receptor anatomy and physiology or anandamide physiology and their role in pain?

That’s an easy one to answer, no. But, I’d love to offer another reflection on medicinal marijuana from a perspective of an Australian where medicinal marijuana I think has just been legalized. It has, it certainly has in my state. I think it’s really intriguing. Its almost a case of political cannabis rather than medicinal cannabis.

We just don’t have the data to support introduction to this, in my view. But it’s coming in and it’s very fashionable and I really hope we don’t realize in 10 years that it’s opioids too or something like that. So that’s a little political perspective I have. The fact that we’ve got no idea what doses people are giving themselves according to method of giving I, preparation or temperature it’s at, whether it’s in a cookie to it’s smoked. These things, we’ve got no idea of the dose, we’ve got no idea of how quickly it’s processed in the body. So we can be prescribing these things with any accuracy.

I think that’s a potentially dangerous situation. I’m not saying we shouldn’t have it, I’m just saying we need to understand it better before everyone starts using it for medicinal purposes. That’s my little political soap box rave. Thanks.

KY: A special thanks to Trust Me I’m a Physio Therapist, Physio Tutors, Re-Thinking Physiotherapy, GetPT1st, Info Physiotherapy and Exploring Pain Science for contributing their questions. If you’re enjoying this podcast, please subscribe and like us on iTunes.

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