What Most Clinicians Get Wrong About Pain Science Education #1

If you look at the evidence...you'll find there isn't much

One of the most common statements you’ll hear in pain education is this:

“The brain produces pain.”

That statement is true.

But somewhere along the way, it became transformed into something very different:

“The brain can produce pain without ongoing nociception.”

That is an extraordinary claim.

And extraordinary claims require extraordinary evidence.

The problem is that the evidence was never there.

Asaf Weissman and colleagues recently examined one of the central assumptions underpinning modern pain neuroscience - that pain can occur in the complete absence of nociception. What they found was not a strong body of experimental evidence, but something much more troubling.

Here’s the paper: Adieu to an aphorism: why nociception is necessary for pain

The literature repeatedly cited itself.

One paper would make the claim and cite another paper. Follow that citation, and it either didn’t support the claim being made, or it simply referred to another paper by the same group. Eventually the trail looped back to the original assumption.

A self-referencing circle.

An idea treated as fact because it had been repeated often enough. A literal game of chinese whispers…with pain patient’s lives on the line.

That’s not how science is supposed to work.

This matters because an entire philosophy of pain treatment has been built on that assumption.

Pain neuroscience education teaches that if people truly understand pain, they can reduce or even eliminate persistent pain by changing how their brain interprets danger.

It sounds appealing. It even sounds simple! Elegant…

But where is the evidence that someone with severe pathological pain from an active disease or injury can simply learn enough pain science to override it indefinitely?

There isn’t any.

Those who promote pain science education often point to battlefield stories.

A soldier loses a limb yet continues fighting, only feeling pain later.

Those stories are real.

But they do not demonstrate that the brain can switch off pain permanently. The brain can override the pain, but only very temporarily.

And they do not demonstrate that education about pain changes pain.

They demonstrate something we have always known: under extreme circumstances, shock, adrenaline and survival responses can temporarily suppress pain.

Temporarily.

When the danger passes, the pain returns.

The soldier doesn’t stay pain-free because they understood neuroscience.

They collapse.

They require medical treatment.

That’s a completely different phenomenon.

Yes, the brain can modulate pain.

Yes, attention, emotion, stress and expectation influence the pain experience.

None of that is in question.

But modulation is not elimination.

And temporary suppression is not permanent resolution.

And none of it demonstrates that severe pain arising from ongoing disease or tissue pathology can be switched off simply by thinking differently.

Yet that is what pain science education teaches. That is what pain science education expects patients to be able to do. That’s what clinicians expect patients to be able to learn to do…without any evidence that anyone has ever managed to do this.

There is not one shred of evidence that the brain can override pain from injury or disease, at will, long term. By learning about pain, or any other method, for that matter.

Yet clinicians believe that it can. They have been taught that it can. And when people cannot...it’s clearly their own fault!

When pain neuroscience education promises more than the evidence supports, patients inevitably blame themselves when it doesn’t work.

“If I still hurt, I must not understand it.”

“I must not be trying hard enough.”

“I must not be good enough.”

And often, clinicians blame the patient as well.

Obviously, it’s not the clinician’s fault, they explained pain.

Obviously, it’s not the intervention’s fault. The evidence…

And, very often, clinicians judge patients who say that pain neuroscience education does nothing for their pain. All the while not realising that there is zero evidence that it could reduce their chronic secondary pain in the first place.

Wrong patient. Wrong treatment. Wrong time.

And a complete lack of understanding, on the clinician’s part, of what pain IS. And how pain neuroscience actually works. Or doesn’t.

Not one study, controversial or otherwise, shows that pain neuroscience education can reduce chronic secondary pain. I’ve yet to find a study on pain science education that includes people with chronic secondary pain. They are always excluded from the study. And this is always in the small print, hidden away, when it should be listed first in the ‘Limitations’ section.

That’s why and how the Moseley’s of the world erased chronic secondary pain from the narrative. Shoved people with pathological pain under the rug. Ignored, abandoned, left to suffer.

Chronic secondary pain is caused by nociception. Not by the brain alone. And the brain cannot override pain caused by serious injury or disease, indefinitely. Not with education. Not with anything.

The brain can only be ‘retrained’ in chronic primary pain, where there NO explanatory pathology. Where the pain is caused by psychosocial factors.

Funny that Moseley neglected to make that point, in all his thousands of podcasts and seminars and webinars. Such an important point to make. Can’t imagine why he would exclude that information.

Pain neuroscience has taught us many valuable things about how the nervous system processes pain.

But it should never have been used to imply that understanding pain is, by itself, a substitute for treating the underlying source of nociception. Or that this is even possible.

Those are two very different ideas.

Only one is supported by evidence.