Key Point 

• We can help clients understand that pain indicates protection rather than damage.

Professor G. Lorimer Moseley is one of the world’s leading researchers in pain science, and his book Explain Pain (co-authored with David Butler) has influenced how massage therapists are being educated about pain in programs around the world. Whitney Lowe and I spoke with him recently about how hands-on bodyworkers might best understand and utilize his findings. This excerpt from our longer conversation (which you can listen to as Episode 111 of The Thinking Practitioner podcast) has been edited for clarity. 

Til Luchau: Lorimer Moseley, I’m going to do my best to introduce you, although in my mind, you clearly need no introduction. You are a Bradley Distinguished Professor at the University of South Australia and, in 2020, were 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 because you have made an enormous contribution to our field and others. 

Lorimer Moseley: Thank you, Til. 

TL: I actually met a person who hadn’t heard of you in a social media post where I asked, “I’m talking to Lorimer Moseley; what do you want me to ask?” Someone messaged back, “Hey, I haven’t heard of him. That’s interesting. Who is he?” I was like, “What? You don’t know Lorimer Moseley?” 

LM: Most people I meet have never heard of me, so that’s not surprising. 

TL: I sent her the link to the TEDx Talk (“Why Things Hurt”) you gave about 12 years ago, which at this point has over 1.3 million views. Honestly, I think it helped catalyze profound changes in how pain is conceptualized in our field of hands-on therapy; it was a part of many of the discussions about pain and how we might or might not help. She came back after watching that and said, “OK, I have a question for him.” She asked, “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 practitioners might be able to help their clients and patients?”  

LM: What an outstanding start, right? It would’ve been the same question if she had said, “What have you been doing for the last 20 years?” 

Well, I guess my first response to that is: Education is a pretty broad thing. I think there would be some pretty compelling arguments that even without speaking, without any conversation, bodyworkers are educating by virtue of the fact they’re delivering stimuli within certain conjured contexts and frames of working. So, they’re changing the way the person in front of them stores data and uses that data for future decision-making. I would say, if there’s a conversation happening anywhere during the interaction, before the interaction, or after the interaction, it’s an opportunity for education. So, in answer to your question, 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. 

As far as content is concerned, we’ve done a lot of work mining the wisdom of people with chronic pain who have now recovered. We asked them, “How’d you do it? What was important? What were the main things you learned that enabled you and empowered you to recover?” And that’s been an incredibly fruitful research line. So, we’ve come up with four essential pain facts I think every bodyworker should know. 

Essential Pain Fact No. 1

First, pain protects us and promotes healing. That might not sound very striking, but I would encourage everyone to think carefully about how that aligns with their understanding of pain. Because most people, when they think of pain, would more readily say “pain detects pathology or detects damage,” but that’s not how pain works. I could argue this in any context, that the evidence that pain detects damage is very poor. In fact, I would say it’s absent. The evidence that pain occurs in order to prevent damage is very compelling. 

TL: This is the radical central thought. I think your TEDx Talk was about how decoupling pain from damage opens all kinds of possibilities and raises all sorts of questions.

LM: 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 and the interpretation of a flare-up, for example.

Essential Pain Fact No. 2 

The second essential pain fact is persistent pain overprotects us and prevents recovery. Tied up in that are a lot of principles like central sensitization or what we would now call nociplastic pain. The lived experience of anyone who’s had pain on most days for more than a few months, like it or not, is that the system is winding up. And 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.  

TL: You’re saying that ongoing pain is also protective, that it’s the system winding up and, in a way, learning. 

LM: Yes. And I would say, because of the way that neuroimmune networks, and I guess more specifically neuron-to-neuron and neuron-to-immune cell synapses, work at a cellular level means 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. 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. 

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

LM: Absolutely. Yes, 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 for many 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. In my view, it’s not the pain system going wrong, and it would be a healthy debate with other people I have a deep respect for who 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 that if it hurts to bend over, don’t bend over.

That’s why pain is so effective, because it stops you from doing things that the system believes are dangerous. The problem is that the threshold for what is dangerous has been reduced so much. 

Essential Pain Fact No. 3 

The third essential pain fact is that many factors influence pain. This will be intuitive to anyone doing bodywork, because we know that. You can see how many factors in people’s lives affect their pain: their fatigue, their activation in muscles that we might feel as tightness or stiffness. 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.

Essential Pain Fact No. 4

The fourth essential pain fact is there are many ways to reduce pain and to slowly recover, or to slowly retrain the pain system back to normal, protective settings.

Communicating the Pain

So those are the four essential pain facts. That doesn’t mean 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 within the context of that relationship.

I think we can integrate these essential pain facts in many ways, like having a whole lot of resources that we can refer our patients to (not just the TEDx Talk, but resources that are freely available online or in book form).

So, your myotherapists might say at the end of the session, “That was interesting how, after I did this, you were able to move more freely. The most obvious explanation for that is that we’ve had some effect on your nervous system or your immune system,” and then just wait for their response. Because what you’ll probably see is something a bit like a confused face. And then there’s the opportunity to say something like, “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—have changed the way they’re 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 TEDx Talk, or there’s this great video, or here’s the little business card with a QR code,” or whatever it is you choose to give them.

Another way is to remind people that pain is protective. For example, 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, “OK, so your system’s really protecting you from this part”? Just a little message. 

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

LM: Yes, and I guess the easiest practical response to this research from the perspective of bodyworkers is to hold up your explanations and your responses to what people say to the essential pain facts. Do they fit? And if they don’t fit, change what you say so that they do fit, because the data strongly suggests you can be part of a transformation by promoting a more contemporary understanding of how pain works.