The Thinking Practitioner Podcast:

Episode 111: How Bodyworkers Can Explain Pain (with Lorimer Moseley)

Key Points in the Podcast

• Introduction to The Thinking Practitioner Podcast (0:00)  
• Sponsorship by Books of Discovery (1:30)
• Introduction of Lorimer Moseley (3:00) 
• Lorimer Moseley's TEDx talk and its impact (6:00)
• Description of pain to those experiencing chronic pain (9:00)
• Historical context of pain education (13:00)
• Three historical phases of pain education evolution:  (15:30)
  1. ancient pain education, 
  2. old school pain education, and 
  3. current pain science education
• Four essential pain facts: (19:30)

1. pain protects us and promotes healing, 
2. persistent pain is also a protective function, 
3. many factors can influence pain, and 
4. therefore, there are many ways to reduce pain and recover. 

• Challenges of explaining complex concepts in a short period of time (26:00)
• Importance of validation and empathy in pain education (30:30)
• Role of optimism and encouragement in pain education (34:30)
• Lorimer Moseley's upcoming courses in North America (39:00)
• Sponsorship by ABMP (42:00)
• Closing remarks and contact information (43:30)

Transcript

Whitney Lowe:

And welcome to The Thinking Practitioner where Books of Discovery has been a part of the massage therapy and bodywork world for over 25 years. Nearly 3,000 schools around the globe teach with their textbooks, eTextbooks, and Digital Resources. Books of Discovery likes to say learning adventures start here, and they find that same spirit here on The Thinking Practitioner Podcast. And they're proud to support our work, knowing we share the mission to bring the massage and bodywork community thought-provoking and enlivening content that advances our profession.

Til Luchau:

Instructors of Manual Therapy education programs can request complimentary copies of Books of Discoveries textbooks to review for use in their programs. Please reach out at booksofdiscovery.com. Listeners, that's you, can explore their collection of leading learning resources from anatomy, pathology, kinesiology, physiology, ethics, and business mastery at booksofdiscovery.com, where thinking practitioner listeners save 15% by entering, thinking, at checkout. Lorimer Mosley, thank you so much for joining us here today.

Lorimer Moseley:

Thanks so much for having me here today.

Til Luchau:

I'm going to do my best to introduce you, although you in my mind, clearly need no introduction at all. You are a Bradley Distinguished professor at the University of South Australia, and I had to look up AO, this is your title. And you were in 2020, made an Officer of the Order of Australia for “distinguished service to medical research and science communication, to education, to the study of pain and its management, and to physiotherapy, to humanity at large.” I think that's rather well said honestly, because you have-

Lorimer Moseley:

you have too.

Til Luchau:

You have made an enormous contribution to our field, and I actually did meet one person who hadn't heard of you in our social media post where I put it out there, "I'm talking to Lorimer Moseley, what do you want me to ask?" And someone posted back, "Hey, I haven't heard of him. That's interesting. Who is he?" I was like, "What? You don't know Lorimer Moseley?"

Lorimer Moseley:

Most people I met have never heard of me, so that's not surprising.

Til Luchau:

What I did was I sent her, I hope you don't mind, I sent her the link to your TEDx talk you gave about 12 years ago, why things hurt, and it has at this point, I saw that it has over 1.3 million views. And I think it honestly helped to catalyze that conversation that you were a part of, and especially the attention that got, helped to catalyze really profound changes in how pain is conceptualized in our field and hands-on therapy, and was a part of many of the discussions that came out about a pain and where it fits and how we might or might not help.

Lorimer Moseley:

Yeah. Cool.

Til Luchau:

So I'm looking forward to hearing, yeah, what might've changed in your thinking for these last dozen years or what's still useful. But anyway, this person that hadn't heard of you, she came back after watching that, and she said something interesting. She says, "Okay, I got a question for him." She said, "Have you been able to describe pain to those experiencing chronic pain in a way that helps them? And if so, how would you word it simply so that practitioners might be able to help their clients and patients?" So I think-

Lorimer Moseley:

What an outstanding start, right?

Til Luchau:

Yeah.

Lorimer Moseley:

That question could also, it would've been the same question if she had have said, "What have you been doing for the last 20 years?" Because can we describe, there was a few things in that. Do you want me to respond to that now?

Til Luchau:

Well, yeah, I mean maybe especially with how-

Lorimer Moseley:

Do you want me to kick off?

Til Luchau:

... sure, how you got started, how you got there, and then we'll walk through some of those specifics, like what do we know, what's changed, and especially what can we do?

Lorimer Moseley:

Yeah, cool. I guess, that's where we're all heading, isn't that, how can we promote better consumer outcomes ultimately, or maybe not even consumers. Ultimately, how can we improve human lives, is probably where we're all heading. I wonder if it might be helpful to, as briefly as I can, give some historical context to the TEDx talk.

Til Luchau:

Yeah, that would be great.

Lorimer Moseley:

So my own interest in this, I guess, was ultimately ignited through a lived experience of having back pain for a long time, consequent to a football injury. And that really changed the course of my life, but it wasn't for 10 years until I really discovered research. So I've been a physiotherapist for eight years before I almost accidentally became a PhD student, and then discovered the synergy between that work, research, my own character, and things that fascinate me. I'm an explorer by nature, and I'm fascinated by humans. And when you combine those two things into some sort of matchmaking device, I'm sure it would spit out, you should become a clinical neuroscientist, which is what I became. But I guess, the clinical experience...

I've had this lived experience of feeling, during my training as a physiotherapist, I was in a lot of bother with this back pain for years. And I would go to the biology and neuroscience and even biomechanics lectures and get so excited, really unusually excited about how wonderful and complex and amazing we are, and animals in general are. I mean, I love David Attenborough. I'm one of those guys, right?

Til Luchau:

Yeah.

Lorimer Moseley:

And then I'll go into the clinical classes and be confused, because what I was learning in the more science-based classes, just full of hope, full of opportunity, full of the opportunity for personal innovation, which wasn't penetrating the clinical classes. And so even as I was training, I was thinking, this is a bit confusing. So what hope is there for people like me if we're not embracing and trying to work with all this magic that we've got inside ourselves? That was an experience that I had from that lived experience perspective.

And then I became a physio, and my own journey was one of almost not applying the clinical stuff and just getting off on the science and personal experimentation, and slowly recovered. And as a clinical physiotherapist, the next important thing for me was discovering that people would come in for treatment, and I felt like, I've got nothing for you. My clinical skills, I can't help you, and this is why. And I've always been a stickler for authenticity, telling the truth. And I would say, "This is why I think I can't help you." And it would always be an account of my understanding of the science underpinning their experience.

What I started to notice clinically, is that people would come back after a session where I just spent the time trying to help them understand how I understood the science of this. And they'd come back and they'd say, "Yeah, look, I'm definitely feeling a bit better. Can we just do more of the same?" And I would say, "But we didn't do anything." "Yeah, yeah, no, you know how..." And then they'd ask me something about what they'd learned, and how you were talking about that truck driver, the metaphors that I was using to explain things.

And then, as someone who has, since my favorite teacher at school, when I get into playing football, I was in hospital and my favorite teacher at school brought me science books, Charles Darwin's Advice to Young Scientists, and Thomas Kuhn, The Structure of Scientific Revolution. And I love science. I am a card carrying believer that the scientific method is the best method. It's not the only method, it's the best method we have for knowledge progression.

So here I was, observing this thing in patients, loving science, and I thought, "Righto, let's see if this is real," because this could just be my bias. I like to hear the things that I already believe in. So we did a couple of clinical trials of what happens when you intentionally explain to people in a way that you hope they understand as well as you can, how pain works and how chronic pain works, and why the treatments and the approaches that might not seem immediately intuitive, are actually the best ones.

So we did a couple of clinical trials, and they showed important effects, and that was towards the beginning of my research life. And then I learned how to do research properly, blah, blah, blah. Fast-forward to 2011 or '12 or whenever it was when I was riding my scooter to work in the middle of November, which is the mustache growing fundraiser usually for men's health. Do you have that? It's called Movember.

Til Luchau:

It's good we talked. We should.

Lorimer Moseley:

It's a play on November and it's Movember, and you'd grow a mustache and you get sponsored to grow a mustache. And I thought, I'm going to grow a truck driver's mustache. So for you guys, it'd probably be a lorry driver. Is that what you call them? Anyway.

Til Luchau:

No, we call them trucks.

Lorimer Moseley:

A big trucker. The mustache style is called a trucker. It comes across the top of your lip and then down by the side of your chin. And I was halfway through growing this, there's a fundraiser for men's health, and I got a phone call on the way to work from the people running TEDx in Adelaide saying, "Our main speaker has just been in the car accident. We've got to fill the slot, can you come?" So I got on the phone to my PA and said, "Can you just grab a talk off my hard drive and send it to these people?" And I just changed my direction and turned up to give that TEDx talk. And I agree to I think that, that talk was received very well. And I think primarily by a massive number of, not massive, I don't want to overplay this at all, but by a significant-

Til Luchau:

We're talking Taylor Swift scale audiences here. Go ahead, yes.

Lorimer Moseley:

Oh gee, wouldn't that be great though in pain science if we had Taylor Swift singing a song?

Til Luchau:

Yeah.

Lorimer Moseley:

Actually that's what anyone out there who knows Tay-Tay, get in touch and say, you can transform humanity here by getting this information out.

Til Luchau:

There you go.

Lorimer Moseley:

We'll get back to that, because I believe that might be true. Anyway, I think there were a significant number of health professionals who were in a similar place to me in struggling to get across the fearful and wonderful complexity of how pain works in the human, in a way that was enabling and empowering for their clients. And I'd already been doing that for 15 years, and a lot of that clinically, I mean the number of times I've told that snake bite story, whoa, I could go to sleep and tell you word for word that snake bite story, because I did it every day, sometimes twice a day for years with groups of patients. And you work out what lands and what doesn't. But then to fast-forward to that ultimate question, that's the background of the TEDx talk, which I agree it's had a lot of views, but it's on loop in hospital waiting rooms and pain management programs. None of that's, they're not as counted, but it is a really useful conversation starter.

But I think among the things that we've learned since then, it is a long time ago, one of them is, that was a really naive position that I was in. I was in a really naive position with respect to learning educational strategies, conceptual change strategies, and some of what was in that TEDx talk, really the core-

Til Luchau:

Yeah.

Lorimer Moseley:

Yeah, yeah, it was really the core of that explained pain stuff. And probably eight years before that talk, David Butler and I had written Explain Pain, and I think that was a significant... Sorry, I've got my phone ringing there. That was a significant... Let me do not disturb myself, Explain Pain was quite a significant contribution as far as also opening up that conversation. But we've realized since then, in clinical trials and mainly in real world data from 1,500 people, that conventional way of explaining pain, that didactic, we did it in the clinical trials early on, and there are now 70 clinical trials that include that didactic pain education as part or entirety of the treatment, and they consistently show a small effect across the group.

But our real world data show quite clearly that we are only getting conceptual change or getting some degree of understanding with that approach. We're only getting understanding in 50% of people, and this is with good educators really intensely doing it, using that approach that we pioneered 20 years ago, 25 years ago. So the real world data show that we're not very good at educating people about pain. Me, the way that I was doing it and the way that it's done clinically as a real intentional thing, is not very effective, but in the people... So that's the bad news. The good news, and this is what's motivated a real shift in our research in the last six or seven years, the good news is that when people understand, so when our education is good enough and they understand, the outcomes are way better than we ever thought they could be, transformative outcomes.

We've got data showing that in that 50% of people for whom education is effective, the majority are becoming close to pain-free a year later, and these are people with years of chronic pain. So that real world data combined with all this clinical trial data, and now our group and others are really interrogating with patients and clinicians, what's the best bits, how do we get this across, all that. I have way more oomph for the statement, we can prioritize giving people the resources to master their situation. And those resources are about understanding for enablement and empowerment, and I like to say for excitement about the potential transformation of their pain system over time. Anyway, all that to say education now looks very different from what it looked like when that TEDx talk was produced in content and in delivery.

Whitney Lowe:

Yeah. And you may have hit on this, but I did pick up in one of your podcasts, and by the way, for those who aren't aware, you have a wonderful podcast out there, Lorimer Moseley Podcast is its name, right?

Lorimer Moseley:

I think it's called Pain Matters, and thanks for the compliment, Whitney. I've listened to one and I cringed with it. Anyway.

Whitney Lowe:

Yeah. We all do when we listen to our own stuff there, but it's really good and very informative. But in one of those you had talked about there being some different phases of the pain science education process that we've moved through over the course of the years. And I was wondering, can you briefly summarize where you see that? I know you've talked about that a little bit, but maybe just a brief summary of that.

Lorimer Moseley:

Yeah, sure. I think it's really important actually. I would split patient or consumer or general public facing pain education into three phases now. One I would call ancient pain education, and that's what was around up until, we're still around in some places, but that was the only thing around until around the turn of the century. And that was covered broadly by concepts like back school with a lot of stuff around anatomy, physiology, lifting, ergonomics, posture, all that sort of stuff. And then some pretty rudimentary advice on pacing, relaxation, things like that, with no attempt to give people an understanding of why these things might be important. Just, this is what you should do, advice or this is how the invertible disc works. Unfortunately, even the content of that wasn't how the invertible disc works. No one thought to mention that it's not a disc, nor that it can ever possibly slip.

But nonetheless, we could go on about that for years. So ancient pain education was really about structure and behavior. Then I would say, along came what is widely known and now the dominant component of pain education, I think. We would call it pain neuroscience education. That is the name that became popular for, I guess what we started with these clinical trials in the early 2000s we called explain pain or therapeutic neuroscience education or something like that. I think our first paper is called Intensive Education on the Neurophysiology of Pain, that sort of stuff. That's that didactic model that I would now call old school pain education. So we've got ancient, we've got old school, but all of the clinical trials around pain neuroscience education are old school pain education. The meta-analysis clearly show that, that's got small effect sizes, but they're significantly clinically important.

So I would say, old school pain education is, in quotation marks, good. It's not very good or excellent, but it's better than useless. And then I would describe the new wave of pain education, and I'm part of an international collaboration called the PETAL Collaboration. PETAL stands for Pain Education Team of Absolute Legends. And we, as a collective, we thought we need to differentiate the current pain education strategy from pain neuroscience education, because it's a different format, it's a modified content, it's a broader content, because it's across the sciences, not just neuroscience. It's delivered differently. So we called that pain science education, and that phrase is already being adopted, but unfortunately it's being adopted to retrofit what is actually old school pain education. So I prefer this idea of ancient pain education. No one should be doing that. The evidence says this is worse than useless.

Old school pain education, it's good, it's didactic, it's that classic pain neuroscience education. And then I would say pain education 2.0 or modern, but what we're calling is pain science education, which is incorporating the stuff we're learning about the best content, the strategies by which to get it across, and the ways we can integrate it with other models of care. For example, bodywork. How do you integrate that? What are the principles of delivery? How do we evaluate what are the easy wins? What are the mistakes that most people make that are probably making things harder? Does that work, Whitney? Does that cover?

Whitney Lowe:

Yeah, absolutely. Yeah, that gives a good encapsulation of the different phases of where we're at there.

Til Luchau:

And your final phrases there are the teaser. We are curious about what does work, about how what you've learned in your 30 years or so of pain science education could be relevant to our practice. I mean, I think most body workers don't think of themselves as educators per se, and I wonder if it would be useful to get a picture of some of the essential elements of what you consider education when you do that, so that we can look and see what can we learn from you in our field?

Lorimer Moseley:

Cool. Well, I guess my first response to that is, education is a pretty broad thing, and I think there would be some pretty compelling arguments that even without speaking, without any conversation, body workers are educating by virtue of the fact that they're delivering stimuli and within certain conjured contexts and frames of working and things like that. So they're changing the way the person in front of them, or from a scientist perspective, the way the organism stores data and uses that data for future decision making. So in some way, education is really broad, but if we do confine it to that more conventional idea of targeted learning objectives, I would say if there's a conversation happening anywhere during the interaction or before the interaction or after the interaction, it's an opportunity for education. So in answer to your question, Til, I think I would divide what we've learned over the last six or seven years primarily into what we've learned about content, and what we've learned about delivery. And as far as content is concerned, we have done a lot of work mining the wisdom of people with chronic pain who have now recovered.

So we've got data from hundreds of people who were in trouble for months and usually years with chronic pain, and they recovered. And we asked them, how'd you do it? What was important? What were the main things that you learned that enabled you and empowered you to recover? And that's been an incredibly fruitful research line when we're publishing that data now, we publish a lot of that data. And I can summarize all of that process, heaps of work over a decade, but the content that we're at that I would say is almost the minimal education curriculum in a therapeutic encounter with someone with chronic pain. And I would probably go pain, someone with pain, and it wouldn't be a big nudge to say, any therapeutic encounter, full stop.

And so we've come up with four what we call now, because consumers have told us to call it this, the essential pain facts. So there are four essential pain facts that I think every body worker should have in mind when they're having a conversation, when they're in a relationship with someone. And those essential pain facts are, number one, pain protects us and promotes healing. And that might not sound very striking, but I would encourage everyone to think carefully about how that aligns with their current understanding of pain. Because most people, when they think of pain, they would more readily say, pain detects pathology or detects danger, but that's not how pain works. I could argue this in any context that the evidence that pain detects damage, is very, very poor. In fact, I would say it's absent. The evidence that pain occurs in order to prevent damage, is very compelling.

Til Luchau:

This is the radical central thought. I think your TEDx talk, or much of the debates that came out at that period of time were about is, decoupling pain from damage opens up all kinds of possibilities and raises all sorts of questions.

Lorimer Moseley:

Yeah, yeah, I agree. I agree. And it presents so many opportunities for intervention if we really embrace that. So anyway, pain protects us and promotes healing, and within that are concepts like peripheral sensitization in the presence of injury or inflammation, the interpretation of a flare up, for example, all that sort of stuff. The second essential pain fact is that persistent pain over protects us and prevents recovery. Tied up in that are a whole lot of principles like central sensitization or what the peak body would now call nociplastic pain, stuff like that. The lived experience of anyone who's had pain on most days for more than a few months, like it or not, the system is winding up. And it's an inbuilt property of animals is that repeated protection. The protective systems get better at doing what they're doing. That's bioplasticity or neuroplasticity across systems. The third piece of-

Til Luchau:

I have the feeling... Sorry, I have a feeling you said something really important, I want to make sure I get my head around it. You're saying that ongoing pain is also protective, that it's the system winding up in a way, learning?

Lorimer Moseley:

Yeah, I think so.

Til Luchau:

Did I get that right?

Lorimer Moseley:

Yeah. Yeah. And I would say, because of the way that neuroimmune networks, and I guess more specifically synapses work, neuron to neuron and neuron to immune cell synapses, the way that they work at a cellular level means that the more often we produce pain, as an organism, the lower the threshold to produce it will become, because our system learns how to do it better. And so then we have a situation that clinically we call allodynia and hyperalgesia, but neurophysiologically, we call it a reduction in postsynaptic membrane excitability. In clinical terms, in the consumer's words, we call it pain system hypersensitivity. So it's assisting pain.

Til Luchau:

It's often talked about as the pain system going wrong or somehow getting stuck in a state that it shouldn't, in quotes, be in. But you've reframed that, you're saying it's actually also learning and protecting?

Lorimer Moseley:

Absolutely. Yeah, yeah. Yeah, I'm emphatic on that. I think it's not going wrong. This is how it works and it works like this in all of us. The speed with which it adapts will vary a lot between individuals because of lots of reasons. But I will often find myself saying to people challenged by chronic pain that this is a normal response to an abnormal set of circumstances. So in my view, it's not the pain system going wrong, and it would be a healthy debate that I would be engaged with with other people I have a deep respect for who would say it is the pain system going wrong. I don't conceptualize it like that. I feel like it's doing something pretty predictable based on biological principles. And in a way it's a moot point, because the outcome is not helpful. People are protected from doing things they actually need to do to fully recover, because it hurts. And it makes a lot of sense to if it hurts to bend over, don't bend over.

That's why pain is so effective, because it stops you doing things that the system believes is dangerous. The problem is that the the threshold for what is dangerous has reduced so much. That's how with all these consumer focused research, we capture that with persisting pain is overprotective and prevents recovery.

The third essential pain fact is that many factors influence pain. It's a simple one. It will be very intuitive to anyone in doing body work, because we know that. You can see how many factors in people's lives affect their pain, their fatigue, their activation muscles what we might feel is tightness or stiffness, or what they might experience as stiffness or tightness, many factors influence that. So that's a pretty easy one for a lot of health professionals who work with people with chronic pain to get their head around.

And the fourth essential pain fact comes off the third one and it starts with, therefore there are many ways to reduce pain and to slowly, and there's two ways we could say this, and to slowly recover, or to slowly retrain the pain system back to normal protective settings. And they're the four essential pain facts.

That doesn't mean that, that's all we want to get across, but I think anyone working in a relationship with someone challenged by or at risk of chronic pain, should be aware of the essential pain facts and how they can communicate those essential pain facts within the context of that relationship.

Til, you said the teaser, how do we integrate that? I think we can integrate it in many ways from having ready a whole lot of resources that we can refer our patients to, not just the TEDx Talk, but where one group who's developing those resources that are freely available online as a rule or in book form, that people usually have to buy, or there are apps that are doing stuff now, although the best evidence on apps is that retention is on average about four days or something like that. So one is having the resources. So your myotherapists, end of the session, that was interesting how after I did this, whatever it was that I did, you were able to move more freely.

The most obvious explanation for that is that we've adjusted, we've had some effect on your nervous system or your immune system, and just wait for the response. Because what you'll probably see is something a bit like, I don't know if people will be seeing this, but you could quote subtitles on the television, Lorimer adopts a confused face, and then there's the opportunity. Oh, yeah, it's surprising, isn't it? But when I do that, a whole lot of messages into your nervous system, and now your brain has changed the way it's turning on muscles. That's amazing, isn't it? If you want to learn more about that, there's a great resource, there's this great TED Talk, or there's this great video, or here and here's the little business card with a QR code or whatever it is that you choose to give them.

But my view is that we have all that ready, cataloged. And as I'm saying this, I'm thinking maybe we should convince some commercial entity to make a whole lot a catalog with QR codes for the best resources out there at the moment or something like that.

Til Luchau:

That's a great idea. Yeah.

Lorimer Moseley:

So that's one thing. The next way is, in the conversation to just remind people that pain is protective, for example, and how many opportunities do you have when people flinch and they say, "Well, that hurts." And our response might be, "Oh yeah, you've got a knot there, or that's a trigger point," or whatever. What if our response was, "Okay, so your system's really protecting you from this part." Just a little message.

Til Luchau:

Yeah.

Lorimer Moseley:

That's interesting.

Til Luchau:

A subtle reframe, a different possible explanation that might open some possibilities.

Lorimer Moseley:

Yeah. Yeah, and I guess the easiest practical response to this bucket load of research from the perspective of body workers, I think any clinician, is to just hold up your explanations and your responses to what people say, to the essential pain tracks. Do they fit? And if they don't fit, change what you say so that they fit, because the data strongly suggests that you can be part of a transformation by promoting a more contemporary understanding of how pain works.

Whitney Lowe:

Yeah. One of the things as we're talking about this education end of things that was a burning question for me I really wanted to ask, because as an educator, I'm aware that the less time that you have to explain a concept, the better the teacher needs to be in order to make that understandable. And I'm thinking about our clinicians who have such a very short period of time to explain things to the clients and the patients that they're working with. If you have any suggestions, how does one get much, much better at that little educational piece of getting complex things across to people about neurophysiology in just a very short period of time, especially to somebody who knows nothing about it to begin with.

Lorimer Moseley:

Yeah, that's such an important acknowledgement, I think, Whitney, and target. And I guess my response to that would be, take the pressure off ourselves. We don't have to take people through a year's worth of neurophysiology each session. One of the advantages of the work that people like massage, osteo, physical therapists, myotherapists' role is, that one of the advantages is often a relationship, and we can be patient about getting people about conveying an understanding of this stuff. So I don't think we need to be in a hurry. We need to be honest.

But I guess the more practical answer to that question, from my perspective, is to always be dangling the hooks, because we know that learning is most effective if it's active, if someone's doing something to learn. So that's one of the mistakes that I made. And I think unfortunately, I've influenced a field who are all making this mistake that we try and just force data on people, and that can make us feel really, really good about what we're doing. It certainly had that effect on me. I thought, "Oh yeah, look, I'm explaining this, blah, blah, blah." I've had a couple of key moments where I've realized, "Oh, shit, that wasn't anywhere near as good for them as it was for me." So I guess we are always thinking about, how do we dangle something. So we don't have much time, and we're thinking, "Oh gee, I want to get across essential pain fact one." Where I would start would be to try and evoke a question, the answer to which is your learning objective.

And that can be hard, but you get better at it with practice. And anyone listening, remember the first time you felt a neck and you thought, "Hang on, this person's got no vertebrae," because it was so unfamiliar under your fingers. And then slowly over time you learn how to feel things and you can become very nuanced in what you're feeling, and you get better at it. Well, it's exactly the same with education. You practice it, you have your failures, and I think it's easier to have the failures when you get the question wrong, than when you blurt out something that actually disrupts their trajectory in the wrong direction. Or you get this posture, for those of you who can't see me, it's the alarm, I stand with arms crossed. We call that the fuck-off posture, when you want to get this data out, but what they hear is, I don't believe you. And I think this is all in your head, and that is the worst message.

Til Luchau:

But that's the takeaway that people could take is that you're being told it's all in their head. Yeah. And there's this persistent narrative that I hear in conversations with body workers or with educators that pain science is difficult, or pain science is complicated, or that we need a lot of time to get it across, or that people don't understand the data. And I question all those myself, because I think you've given us some essential, you said, pain facts or essential concepts, that simply open up possibilities for people that began to open up some other ideas and other avenues.

Lorimer Moseley:

Yeah, but I'd love to respond to that, Til, because I think it is really well evidenced that pain science is difficult. In our clinical trials when we do treatments, we look at mediation analysis. So mediation analysis are using assessments to work out why there was a reduction in pain or a reduction in disability and to look at when things happen. And our mediation analysis, not just our own group, but anyone doing high quality clinical trials in this area, when they look at the question, how does it work, the answer is consistently, it works through learning about pain, reconceptualizing your understanding of pain. So in one source of data, the empirical data is saying education is key to the best treatments we have. We also ask patients who are involved in these trials, and the health professionals who are delivering treatments, about their experiences of this. And stand out, the most difficult thing for the health professionals, pain education. Most difficult thing for the patients, pain education.

So what you've observed there, Til, and you have these conversations, I guess I want to reassure anyone who's thought those things, to say, yeah, you're in the majority in thinking those things. It is difficult. And even though we have managed to funnel this stuff down to, okay, here are four essential pain facts, plain language, it's still difficult. And I think our ability to convey the understanding of these things to people with whom we're in relationships, will be better the more we understand it ourselves. So I guess my challenge, and I would go so far as to say I believe, in the face of the evidence, the responsibility that all these people you're having these conversations with now have is to understand as much as you can.

I know it's hard, but that's your job. That's my feeling about it. Learn about it, understand, but don't feel like you're the only one who's finding it difficult. Don't feel like you're the only one who sees conflict between something you learn and something you thought was true beforehand. Don't feel like you're alone in really wrestling with some of the implications of this for you as a body worker or as a person.

But at the same time, I would say celebrate that internal conflict and that dissonance, because that is learning that what's happening inside you is a change in how your brain is processing information towards what the scientific method tells us is most likely true at the moment. And they'll keep moving, because that's science. But in a way, I mean, one of my responses to those conversations, I always have two responses. I'm so empathic. I think, yeah, this is hard. This is a nuisance. People are so much more complex than we'd like them to be. Wouldn't it be great if this person was actually just a trigger point? Wouldn't that be great? I could just fix them. But they're not, humans are complex. We're in complex relationships. They have complex context. But I guess the other hat that I wear is, but you are in the bed. You've made this bed. You've got to do this, because that's your job. You have a responsibility to people to be good at it.

Til Luchau:

Yeah. I'm thinking your pragmatism here, your realistic description of the difficulties there must have a parallel to how we talk with patients and clients too about pain, and it isn't-

Lorimer Moseley:

Absolutely. Yeah.

Til Luchau:

Can you say something about the role of optimism or encouragement, where is that helpful, where that might not be helpful, those kinds of things?

Lorimer Moseley:

Yeah. I think one thing that we are gaining a deeper and deeper respect for is the critical role of validation within an educational context. And whenever I've been maybe doing a course or talking to students, people say, "So if there's one thing I have to do differently or one thing I have to make sure I do, what is it?" And for me, it's never about pain science education. It's always about, you got to respect the person in front of you. And I think you have to do your best to metaphorically sit on that bench of whatever shit they're in, alongside them and understand what it's feeling like and what it looks like here. Because I think with respect and empathy and kindness, we can then, if that's the platform, I think we can build on challenging conversations, and I guess calling people on things and presenting, potentially confronting scientifically-based evidence.

But how do we capture that as a way to operationalize or make it happen? I think validation, being great at validation is important. And one of the people in our research group, Sarah Wallwork, is working with Mel Noel from Canada on validation, particularly around children. But in the therapeutic encounter, we tend to validate not the feeling, but the possible explanation for the feeling. And people are very good at validating. Health professionals are very good at validating, but what we find is that if someone says, "Oh, I've got the worst back pain ever after I picked up that box." And they'll say, "Yeah, that's a heavy box." Or, "Yeah, I mean the scan's, it's horrible, isn't it?" But that's not what someone's experiencing. I think, to validate their experience is, "Yeah, it looks like you're in brutal pain. That must be horrible." You validate the experience. I think that-

Til Luchau:

The experience as opposed to the explanation or the mechanism.

Lorimer Moseley:

Yeah, particularly when the explanation's probably wrong. How many times did we hear about surgeons who say, "Well, it was the messiest knee I've ever seen. No wonder you were in a lot of pain." The first bit from that catastrophization and the savior complex for the surgeon. So the role of that-

Til Luchau:

We get that as body workers too. We have the stuff body workers say that probably isn't helpful to hear as a client. But you were going to say?

Lorimer Moseley:

Physios are the same, health professionals are the same. We like to just slip in little reminders of our own expertise and how important we are for someone else's life. The last physio must have missed that, but I'm very experienced with hamstrings, will be deep. But the question about optimism, I think, I guess I come back to that idea of respect, empathy, and kindness, because optimism is great, but if we're not reading the room, it can be very invalidating, because it can come across as, "Don't be worried." "Well, I'm worried." "Yeah, but think on the positive. You're not in Syria." That's not a very validating, I think, but it's optimistic. I think that it's challenging for us to find the balance, and I'm not the truth sheriff on this stuff. I fully respect the challenge of getting it right, but almost everyone listening will have decades left to get it right. Just keep getting better, that's what I would say.

Til Luchau:

That's great. Well, I want to respect your time, and I really appreciate what you've shared with us. Thoughts you'd like to end us on?

Lorimer Moseley:

I think that the underlying science of how the human works, presents to us a massive breadth and depth of opportunity to improve someone else's life. But I think we have a responsibility both to understand it as well as we can, and the data say, when we do that, the clinical outcomes of our patients will be better, but also to be very self-reflective in the moment to do all the stuff we're wanting our patients to do, to hold up our experiences against the best available evidence, to be courageous, to almost chase failure in order to improve, all that stuff. But at the same time, you ask a question like that, and I think, no, look, we're all just trying to do our best.

Whitney Lowe:

That's all we can do, I think, at a certain point. Yeah.

Til Luchau:

That's right, yeah. And I want to thank you personally for being a model of that. What you're describing there, the perseverance, but also the humility with which I know you've spoken very openly about the limitations and the challenges around this path you're on as well. It's a great model for us all.

Lorimer Moseley:

Thanks, Til.

Til Luchau:

You're coming to North America this year. How can people find out more about that or about your work?

Lorimer Moseley:

Wow, I'm coming to North America. I'm so excited. I haven't been to North America for five years. And oh yeah, the change in, well, the stuff I've learned in the last five years is really exciting to me, and I think it presents exciting new opportunities. So I'll be running three, two day courses in North America, all about how to put pain science into practice. All health professionals, we often get a few consumers, but we're really targeting health professionals. Your guys would be perfect. The way to find out about it is to go to noigroup.com and look under courses. They're going to be hosting.

Til Luchau:

Put this in the show notes, Noi, N-O-I group.com.

Lorimer Moseley:

Yeah.

Til Luchau:

Check it out for the schedule. The way to take part in that, whether you're in North America or beyond, I know there's lots of other resources there as well.

Lorimer Moseley:

Yeah, yeah. And the other website is painrevolution.org. It's a charity that I started in 2017, 2018. Resources, but always changing, always trying to provide better stuff, lots fact sheets in lots of languages. Check it out there. If the language that you wanted in is not there, then get in touch and help us translate it, that sort of stuff. North America is Vancouver, San Fran and New York City.

Til Luchau:

That's where you're stopping off.

Lorimer Moseley:

Okay. So great to chat with you guys. Congratulations on what you do. And yeah, it's tops, really enjoyed it.

Whitney Lowe:

Yeah. Well, thank you so much for everything that you've contributed and wonderful contributions to all of these fields of pain management, and especially for us in the manual therapy world. We certainly take great inspiration from everything that you've done, so thanks so much for sharing that with us.

Lorimer Moseley:

Thanks, Whitney. No, I appreciate it. Fantastic.

Til Luchau:

We'll do our sponsor rollout and then close up for the day. The Thinking Practitioner Podcast is supported by ABMP, Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners, like you, a package, including individual liability insurance, free continuing education, and quick reference apps, online scheduling and payments with Pocket Suite, and much more.

Whitney Lowe:

And ABMPs CE courses, podcast and Massage and Bodywork Magazine always feature expert voices and new perspectives in the profession, including from Till and myself. Thinking practitioner listeners can save on joining ABMP at abmp.com/thinking. So thank you to all of our listeners, and also to you, Lorimer, as our guest today. You can stop by our sites for the video, show notes, and any extras. You can find that on my site at the academyofclinicalmassage.com, and Til, where can they find that with you?

Til Luchau:

My site, advanced-trainings.com.

Whitney Lowe:

And if you've got comments or questions or things you'd like to hear us talk about, you can record a short voice memo on your phone and email it to us at info@thethinkingpractitioner.com or look for us on social media. I'm @WhitneyLowe, under my name there, and Til, people, where they can find you?

Til Luchau:

Under my name, TilLuchau. Please rate us on Apple Podcast as it really does help other people find the show. And you can also hear us on Spotify, Stitch, or Podbean, or wherever else you listen. Please do share the word, tell a friend. Thanks again Lorimer and Whitney, such a great conversation with you today.

Whitney Lowe:

Sounds good. We'll see you in the next one.

Lorimer Moseley:

See you later.

Whitney Lowe:

Okay.