Important criticisms and limitations
Treating pain involves making decisions based on the ideas that are most likely to be correct, while considering and protecting against the risk that we have got it wrong. To achieve this it helps to think clearly and be aware of our assumptions.
In 2019, we wrote a book called Permission to Move. Looking back, many of the core ideas hold true. Permission to Move was written as a guide for clinicians, and we suggested that pain recovery should begin by asking a critical question: is this person Safe to Move? This approach encouraged health professionals to consider not only the risk of activity, but also the risk of inactivity. We called the answer to this question a constructive diagnosis.
Once a constructive diagnosis was made, clinicians would then communicate this to the person, and then act. This led to a three step process: establish, communicate and act on the knowledge that a patient is safe to move. It was deliberately simple, and aimed to offer a fresh, pragmatic approach to pain treatment. But its simplicity also meant that it didn’t fully capture the complexity of pain. It was helpful, but incomplete.
Pain is influenced by a wide range of contributing factors that span multiple body systems. Each person’s pain is unique, and so are the solutions. This book offers a more detailed approach. It unpacks the complexity of pain using models and tools that visualise problems across domains. It helps each reader represent their own pain, and then build an individual approach based on their unique set of problems. It is general, adaptable and designed to grow.
That said, this work too will have flaws. Here are some potential criticisms for you to be aware of, as well as our responses:
1. Where's the evidence?
Fair question. There are no large, definitive randomised controlled trials proving that our approach works for most people, most of the time. But a growing body of evidence suggests that it can help. Learning about pain can reduce pain-related disability and increase a person’s sense of control. In some cases, education alone can reduce pain.
But we don’t think education is enough. Our approach is multimodal. While this book uses pain biology as a lens to view the problem, we are not tied to it. We integrate the best bits from the traditional biomedical model, and encourage people to identify and treat pain related problems - as guided by the evidence. But we are also aware of the fact that pain is not just pathology. Our treatment integrates exercise, education, psychology, general health, and lifestyle change. This reflects current best-practice guidelines, and aligns with the biology of how pain works.
2. You overstate pain science, and understate pathology
Some readers may argue that we put too much emphasis on pain biology - and not enough on mechanisms like nociception, injury, inflammation, and disease.
While this criticism is accurate for some resources about pain, our work has always emphasised the importance of accurate diagnosis. We know that pain is not a reliable measure of damage, but this does not mean that having pain means there is no damage. This is why we complete a thorough diagnostic and screening process before taking new action.
Still, for many people with chronic pain the safest path is not to avoid pain. Our approach tries to balance the risk of activity, with the risk of inactivity. In most cases, we suggest a a gradual return to things that hurt. By doing more, we trigger adaptations throughout the body which increase the capacity for load. This process is measured, gradual and individualised. It is always informed by the underlying biology of both the primary problem, and the secondary effects of pain.
But we always think that your understanding matters. This is because our ideas about pain can become barriers to actions, and sometimes these actions are necessary for recovery. This is why education matters. Learning is not a soft skill, it is an essential part of our approach.
We use Albert Bandura’s self-efficacy theory to support this process. This follows a three step process:
Verbal persuasion, i.e. learning about pain
Vicarious experience, i.e. hearing stories of others
Mastery experience, i.e. doing new things.
We also offer tools for retraining the body’s sensory system, so that the same input leads to less pain. These strategies rely on ideas such as the neuromatrix theory, neuroplasticity, predictive processing, and classical conditioning - as well as the biopsychosocial model and the anti-fragile principle.
By considering a wide range of factors, including both the primary problem and secondary effects, we believe that this approach offers a balanced approach to the complex problems associated with chronic pain.
3. Learning about pain feels like a distraction from real treatment
If you’ve lived with pain for a long time, then it might feel like you already know enough about it. But knowing how pain feels is different to knowing how pain works.
The good news is that learning about pain can change how you respond to it - and it can even change how pain feels.
Learning doesn’t mean going back to school or cramming information, and it isn’t about perfection. It’s about challenging your assumptions and exploring what it means if these ideas are correct.
For most people, recovering from long term pain means taking a different approach. Learning about pain can help you to find the potential for recovery, and identify new targets for change.
4. I get what you’re saying, but I have a real problem causing real pain
Most people we work with have a physical diagnosis: a disc bulge, a tendon tear, osteoarthritis. Others have widespread pain that doesn’t map clearly to a known problem.
But all pain - no matter the cause - shares a common biology. We know that there is no “right” amount of pain for a particualr problem - it is always possible for the same problem to cause more or less pain. An interesting way to understand this is to ask yourself if it is possible to make your pain worse.
If stress, fatigue, worry or uncertainty make your pain worse, then you already know that pain can be influenced by more than just the physical problem. And if these things can make pain worse, they can also make it less worse.
This approach is not about ignoring the primary problem. It is about organising your approach to the problem in a way that aligns with the biology of how pain works. Each person’s pain involves secondary effects that contribute to the problem. By treating those factors as well as the primary problem, you give yourself the best chance at recovery.
5. My healthcare provider knows what’s causing my pain, yet your book talks about uncertainty
While some tests - like x-ray and MRI scans - are good at identifying problems in the body, the only test for pain is to ask a person whether they feel it. Your health professional may be able to tell you what is happening inside your body, but this is not the same as telling you why you have pain.
Pain and injury are so closely aligned that it is easy to think of them as the same thing. But the longer pain persists, the more this starts to fall apart. We know that many people show findings like disc bulges and arthritis on MRI, but have no pain. In the same way, people will often experience pain even though there is no obvious problem in the underlying body area. Pain and injury are always different things.
Persistent pain is linked to widespread changes across multiple body systems, including the nervous system and the immune system. These changes, such as central sensitisation, make your body more sensitive over time. But they are also hard to measure. There are other changes, too. We can never understand the full picture.
This is why we are cautious about locking in a specific cause for a person’s pain. Instead, we prefer to look at pain as a problem of problems. Lots of things contribute to pain, which means that lots of things can be used to improve it.
If your healthcare provider has identified a particular problem, then this may explain part of your pain - but likely not all of it. Learning more about pain biology helps uncover patterns and feedback loops that keep pain going. Once these are identified, we can take simple actions to reduce their effects.
This is about looking at the problem in new ways to make sure that you are doing everything possible to solve the problem.
The good news is this: The processes that maintain chronic pain can always be shifted. If pain was just a readout of damage, then recovery would only be possible if that damage could be fixed. But pain is shaped by your whole system, and that system is always changing.
So while one person might say that they have identified the cause of your pain, we’re more likely to say that we have identified the causes.
Where We Stand Now
We don’t have a single solution for chronic pain. No one does. But we believe that this approach is both sensible and doable. It’s grounded in science, tested in practice, and designed to evolve.