Explain Pain is by far the most popular and origninla ‘brand’ of pain neurophysiology education, and it includes a book that has become the pseudo-text for all physiotherapists who a treat pain. “Explain Pain” has become an empire and spawned seminars, webinars and range of supporting books. It is an industry unto itself.
“Explain Pain” was written by David Butler and Lorimer Moseley and promoted by the NOIGroup. It is a very expensive book, and is a best seller. It has clearly made its authors a lot of money…
I was warned a very long time ago by my very astute GP that if someone is selling a book, don’t trust what they have to say because they are trying to sell books, not help people and people will say anything to make money.
“Chances are it’s full of shite” were his exact words. Back then, I was a committed hippy chick who, while not quite into balancing my chakras and astral travelling, definately was into natural therapies. And exercise. Exercise was always my answer to everything. So I disbelieved him. I told him that sounded a bit harsh while internally thinking that he was only saying this because he didn’t want to prescribe the testosterone for severe PMS that I was asking for.
However. This has turned out to be exceptionally good advice, because a LOT of people are selling a LOT of books on pain neuroscience education, and the evidence does NOT stack up. Especially the The Most Famous Book Of All – Explain Pain by David Butler and Lorimer Moseley.
I have listened to many, many podcasts with Lorimer Moseley and David Butler and they repeatedly say that “Pain is a danger signal. If the brain decides that you need protecting, there will be pain. When the brain decides you no longer in danger, then the pain will go away. This is the basis of “Explain Pain” and its utter rubbish. Its a great little theory, and you can create some really cute metaphors and fun stories around it. AND develop a very fun seminar that has more in common with a motivational speaker or a stand-up comedian than your typical physiotherapy conference on chronic pain.
The thing is, do you take your health advice from a stand-up comedian? No, me neither.
“But they evidence!” you say.
I have recently read the full second edition of “Explain Pain”. Previously, I’ve only seen bits and pices of it, and watched the youtubes and the snippets. TO be honest I found it all extremely patronising and aimed at toddler level understanding. All the talk “DIMS and SIMS” was daft, and only a child would find that engaging. (Ok, clearly I’m wrong, millions disagree ith me, but I thkn there are a few really good reasons for that, which I’ll go into later. )
For right now? I’m looking at the evidence. The evidence that these two men have used to build lucrative careers. And I’m pretty horrified at what I’m finding.
In the first few pages of “Explain Pain” the authors state”
There are many myths, misunderstandings and unnecessary fears aboutreferences 1-12
pain. Most people, including many health professionals, do not have a
modern understanding of pain. This is disappointing because we know that
understanding pain helps you to deal with it effectively. Here are two
important things we now know about explaining pain: the biology of pain
can be easily understood by men and women in the street, and
understanding pain biology changes the way people think about pain,
reduces its threat value and improves their management of it.
They are very clearly saying that understanding pain neurophysiology reduces the threat value and thereby reduces the pain itself. They have stated many times that pain can be reduced just by learning about it. I dispute this. It is utter hogwash and makes NO sense. Not scientific sense and not common sense. It does not correlate to my life experiences, it’s like saying I need to know how an internal combustion engine works to drive my car. Clearly, I don’t. ANd clearly, when I learned all about pain neuroscience and how pain works ‘in the brain’ it did absolyutey nOTHING to reduce my pain.
When I expressed this basic truth to my physiotherapist, she was quite horrified. And told me I must not have understood! Because no way is “Explain Pain” wrong. And no way did she teach it wrong. So…clealry…It must be me. I must be wrong.
What followed was victim blaming and gaslighting. I know ‘gaslighting’ is a horribly overused phrase these days. But when multiple health professionals try to tell you that you’re nuts because your pain didn’t decrease just because you learned a new concept, whelp, that qualifies.
I cannot understand why so many people chose to believe this with zero evidence. Chose to spend upwards of $80 to buy the book. And then chose to make “Explain Pain” the centrepiece of their therapeutic pain management plans. Even later, when many patients are pissed off and telling their physio that this stuff doesn’t work, htey keep at it. They have to, they bought the lie and admitting it would be admitting they were wrong. Impossible!
Actually, I can understand in part. Dr Lorimer Mosely is a talented presenter. He’s a showman. Hes charismatic, entertation. All the other conferences have speakers who are droning an a monotone at a lecture struggling to use the power point presentation. He was not so much a breath of fresh air as a full on tropical cyclone and people remembered WHAT he said because they have fun learning it.
What they didn’t do is check the facts. Check the evidence. Cos it’s all there in the book, I think 163 references to scientific studies that back their claims.
But what does the evidence say? You might be surprised.
So here it is, folks. Here’s the ‘evidence. From a non-scientist. A layman. And worst of all, a chronic pain patient! Yes, i have a vested interest. No, not the same vested interest that the authors have – they got paid a mint. Me? I’m spending my time reading through al this stuff for no money. When I should be trying to make money. you see I am disabled. I can’t get a ‘real’ job, so I run my own business. It takes a LOT of work and makes a tiny bit of money. MY kids and I live well under the poverty line. Well under.
But I am angry. I am sick of being treated like I’m the problem, when in fact, Dr Moseley and Dr Butler have performed the swindle of the century. THey’ve gotten rich and I’ve paid out a fortune tyring to get physiotherapy help. And instead getting told “No wonder you’re in pain, your attitude is all wrong!” And there was I thining it was the compresed nerve at L5/S1, so compressed that my left leg is partially paralyse and I have no calf muscle function. Then ther’s the inflammatory arthritis, and then there’s the peripheral neuropathy climbing every higher. And the funny thing is, the really funny thing, is that i went to physiotherapy for muscle weakness. Chronci pain is obviulsky part of my history, but as soon as I mentioned pain, five phsyiotherapists we unable to focus on my patholgoical and progessive muscle weakness (myositis) and focussed instead of ‘educating’ me about my chronic pain. IN the fervent belief that sitting htere talking at my (while the clock is ticking for 20 minutes) will relieve my pain. And then have the hide to charge me $100 for that 20 minutes.
I got to speak for two minutes. As soon as I said “pain” that was it. My fate was sealed. forget the muscle weakness, lets cure your pain! And after two minutes, they all felt they knew exactly who I was, what kind of person, and ofcourse how to help.
they decided, thanks to Drs Moseley and Butler that I must be highly anxious, that I must be fear avoidant, and that I must catastrophise. LIke, a LOT.
IN truth, I am hghly motivated and determined. I exercise most days, despite being in signiiddant pain. Anything up to an 8 out of 10 and i exercise. at an 8 I’ll do stretches. a 9 necesitiates lying down, and a 10 is dead on my scale.
I have never become deconditioned. I am not afraid of pain. I accept that I need to move my body to retain my strength. I do not avoid that pain because I know it is unavoidable.
Apparently ‘my attitude’ means that I will always be in pain. Psssszzzzzt!
Imagine being a highly motivated, determined, self-efficient person who manages not only their pain, but their entire life rather exceptionally well. Instead of receiving kudos, I receive what I find to be the insulting diagnosis of ‘uneducated, timid, with maladaptive coping skills’. And on what do they base this ‘diagnosis’ on? The mere fact that I have chronic pan. THAt fact an that fact alone tells them this.
But they are wrong. And because they are wrong, they are giving me the wrong treatment. So I am paying out the wazoo for a treatment that will never help me. They are doing fine, they are getting paid. And when I tell them that “Explain Pain” does not reduce my pain, they flat out do not believe me. And their disbelief comes in many flavours from “ok, let’s try again, from the top” to ‘you WANT to stay in pain!”
Yeah…No I don’t. But I have been in pain for almost 20 years, and that pain has been severe for 10 years and it has been severe for at least part of every, single day for around six years now. I rather think that reading a book is not the way to reduce my pain. I will stick to the exercise and the opioids thanks, to maximise my changes of having at least a partially functional, and not constant misery, life.
But back to the evidence. There are actually 163 references to scientific papers that ‘prove’ what they are saying is true, but in that first part of the book, they reference nos 1-12 as evidence that educating people about pain reduces that pain. So these are those first 12 references:
- Moseley, G.L. et al. (2002) A randomized controlled
trial of intensive neurophysiology education in
chronic low back pain. Clin J Pain 20: 324-330.
- Moseley, G.L. (2002) Combined physiotherapy and
education is effective for chronic low back pain.
A randomised controlled trial. Aus J Physioth
- Moseley, G.L. (2003) Joining forces – combining
cognition-targeted motor control training with
group or individual pain physiology education: a
successful treatment for chronic low back pain. J
Man Manip Therap 11: 88-94.
- Moseley, G.L. (2003) Unravelling the barriers to
reconceptualisation of the problem in chronic pain:
the actual and perceived ability of patients and
health professionals to understand the
neurophysiology. J Pain 4: 184-189.
- Moseley, G.L. (2004) Evidence for a direct
relationship between cognitive and physical change
during an education intervention in people with
chronic low back pain. Eur J Pain 8: 39-45.
- Moseley, G.L. (2004) Imagined movements cause
pain and swelling in a patient with complex
regional pain syndrome. Neurology 62: 1644.
- Moseley, G.L. (2007) Painful Yarns. Metaphors and
stories to help understand the biology of pain.
Canberra, Dancing Giraffe Press.
- Moseley, G.L. (2007) Reconceptualising pain
according to its underlying biology. Physical
Therapy Reviews 12: 169-178.
- Meeus, M.J. et al. (2010) Pain physiology education
improves pain beliefs in patients with chronic fatigue
syndrome compared with pacing and selfmanagement education: a double-blind randomized
controlled trial. Arch Phys Med Rehabil 91: 1153-
- Clarke, C.L. et al. (2011) Pain neurophysiology
education for the management of individuals with
chronic low back pain: systematic review and metaanalysis. Man Ther 16: 544-549.
- Louw, A. et al. (2011) The effect of neuroscience
eEducation on pain, disability, anxiety, and stress
in chronic musculoskeletal pain. Archives of
Physical Medicine and Rehabilitation 92: 2041-
- Nijs, J. et al. (2011) Pain neurophysiology
education improves cognitions, pain thresholds,
and movement performance in people with chronic
whiplash: A pilot study. Journal of Rehabilitation
Research and Development 48: 43-57.