Pain Education, No Script Provided, ep 2. Pain and Nociception

We question whether it is ethical to cause pain during manual therapy and unpack what nociception, tissue insult, and consent truly mean. We challenge heuristics like no pain, no gain and ground decision-making in evidence, context, and patient autonomy.

• defining pain and nociception as signals of actual or potential tissue damage

• challenging bruising and discomfort as therapeutic proof

• critiquing hurt does not equal harm as a blanket rule

• considering acute movement without adding insult<br>• separating clinical experience from mechanisms

• identifying knowledge gaps and outcome bias

• using informed consent beyond a checklist

• acknowledging identity, change, and humility in practice

• recognizing social determinants and inequities in pain care

Pain Education NoScript Provided is now available for purchase on my website, the CEBE.com

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Chapters

• 0:00 Welcome And Series Setup
• 1:02 Is It Ever Ethical To Hurt?
• 4:30 Pain Definitions And Nociception
• 9:35 Bruising, Tissue Insult, And Consent
• 15:13 Hurt Versus Harm Heuristics
• 20:13 Acute Pain, Movement, And Caution
• 26:03 Knowledge Gaps And Overconfidence
• 31:53 Belief, Evidence, And Justification
• 38:13 Identity, Outcomes, And Bias
• 45:03 Changing Practice And Letting Go
• 51:53 Categories Of Pain And Limits

Transcript

Eric: 0:12

Hello and welcome to the Massage Science Podcast. My name is Eric Pervis. I'm an RMT, course creator, educator, researcher, and advocate for evidence-based care. Today is episode 2 of my seven-episode series with Monica Noy. In this episode, we discuss more of her course content, including important knowledge gaps, definitions, and social determinants of health. Monica's new course, which is the first of its kind, Pain Education NoScript Provided, is now available for purchase on my website, the CEBE.com. Thank you for being here, and we hope you enjoy this episode. Part two, I'm excited. Last week's episode I thought was really great. We had a great conversation. It was a whole week ago. I can't remember what we talked about, but something about pain? Something about pain. It was fantastic. And one of the things that I wanted to start this conversation off with today was something we briefly touched on last week, and it's something that I touched on in a webinar that I was delivering last night about the question of is it ever ethical to try to hurt someone?

unknown: 1:22

Right.

Eric: 1:23

When so we the we are delivering a treatment or an intervention. What are your thoughts about that?

Monica: 1:31

It's a really challenging question because I think that one of the things that has been accepted in manual therapies is that it's therapeutic treatment is going to be uncomfortable. Right? That we are that we it that it's okay for us to cause discomfort because ultimately we're helping. And then you'll hear that being said vibaticians is better. So on an ethical level, it's like when we look at when we start looking at what is involved, the neurophysiological aspects of pain and what that actually means when someone's saying that they feel then what that means is that we are that we have then deliberately, it's like during treatment, that we are deliberately activated. Sufficient to cause that signaling to reach the person's awareness through the peripheral and central nervous system. And no susceptors as part of that apparatus related to the sensation of pain, that means that we're actually engaging a sensory element that is related to tissue damage or damage of some. And that's what we're looking at with the current definition of pain. We're looking at that association between tissue damage. And then so the challenge is if we're causing someone's pain, at what level do we know or not know that we have caused actual tissue damage? In which case, like on a black and white level, so whether or not they feel better afterwards may simply be because we took our hands off and we stopped causing them tissue damage. So ethnically, it's it's really it's quite an interesting thing to think about on a manual therapy level. On a surgical level, maybe that's something different. Surgery is an absolute insult onto the tissues. Tissue damage is being caused. That is the consent that you go in with. I mean you someone's cutting into you. Like that's an absolute thing that's happening. We don't have anywhere near that level of uh consent that we're giving people about causing them pain if we're causing them pain on a pain for sound. We've never got that consent to say we might possibly be caused of tissue damage. It's just me like doing the jud ja generation.

Eric: 4:32

And that is part of the dilemma, uh, from what I understand, is that because the definition is actual or potential tissue damage with the definition of pain, and also the definition of breaking at pain from uh we know that no susception is involved in pain. And I know the ISP has a nosyceptive pain definition as well, which says that pain arises from actual or threatened damage to non-neural tissue and is due to the activation of nosyceptors.

unknown: 5:00

Yeah.

Eric: 5:01

It's got that actual or threatened or actual or potential, it's it's a very similar overlap. So, by the definition, we don't know, is what you're saying, whether or not we're doing tissue damage or not. All we know is that we're activating, we're adding enough noxious stimuli into their apparatus that they're becoming aware of it, but we don't know through our touch if what it's actually.

unknown: 5:29

Where does potential yeah, where does potential become actual? Yeah, that's so if you're putting pressure on someone and that's pressure enough for them to report to you that that hurts, like where was that line between potential or actual? And we know in manual therapy that bruises have been created, like after manual therapy, that people sometimes actually work to create those bruises, and that that is actual tissue damage, that is a evidence of actual tissue damage. So for us to then say that that is therapeutic is like that we can't have that ethical situation both ways. You either have to have a stance in it, or you are you or you're okay with potentially causing some tissue damage or causing someone actual potential tissue damage if it leads to them reporting pain to you with what you're doing. As a manual therapist, if you're okay with that to me, that's possibly ethically reprehensible, right? Like when you you're you're getting into a place now where you're okay with doing because it's not at the same level as say a surgeon or someone who's doing something, even like a PRP injection or something along those lines. The description for that is we are actually irritating the hell out of you for these reasons. This is what this injection is doing, or this is what this surgery is doing. We're removing something, changing something, we're cutting through skin. So all of that is within the description of it, within the consent process. On a manual or physical therapy level, we don't have that same level of consent. We don't have that same ability to describe what it is that we're doing and to actually say, yeah, no, we're gonna give you painkillers after this because it's gonna hurt like health, because you're gonna go through healing.

Eric: 7:48

I would like to say it was rare, but I've heard many, many stories from other therapists over the years of teaching and working in the profession, as well as stories from patients when I was working full-time in the public, was that a lot of people that took ibuprofen or Tylenol before treatment or right after a treatment, but many people said that they would take them before many people, therapists, I know we can't prescribe drugs, but would tell me that like they're oh yeah, I always patients, they all I have all these patients and they take these drugs before they come in because they don't want to feel the pain because they have the expectation that the treatment's gonna hurt. And then if they don't feel the pain, then they're the therapist is gonna be able to do better work in air.

unknown: 8:29

Or to create more damage.

Eric: 8:33

And that mindset is and that belief system is so common in our profession and in culture and society here. And I'd like to say outside of North America, it probably is too, for here in Canada and where we are for sure. That's that belief that it needs to hurt to help, or the no pain, the no gain. If it's hurting, it's it's helping. That aggressive technique is supposed to be a better technique.

unknown: 9:00

And or even this, even this sort of notion that we have of that hurt doesn't equal hurt.

Eric: 9:07

Yeah.

unknown: 9:08

Like that that's a big one that that occurs now with some of the pain education stuff, where it's like, oh no, just because you're hurting, it doesn't mean that you're harming yourself. Whereas, in fact, if it hurts, and if we go by the definition of pain, then you cannot absolutely say that you are not being harmed or that there is not some harm occurring. Is it ultimately detrimental to you on a larger scale? Maybe not. But is it ultimately helpful? We don't necessarily know that either, right? We can't actually say, yeah, we're gonna we're gonna give you an exercise that's gonna hurt work through the pain because you'll be better afterwards. You may be better despite that, or it may take longer to be better because yeah, you've added some things onto that. We can give whatever twine the longer we want. So it's gonna take longer than you expect. Because someone's actually undergoing more damage.

Eric: 10:16

Yeah, and that's such interesting point. There's two things there. So one that I wanted to hit on was one was yeah, the hurt doesn't equal harm, and that's a very common explain pain type of thing. And there's a part of that that I like and agree with, and there's a part of that that I don't. I'm kind of torn between that because I find in my own personal experience, my clinical experience, is having people say, hey, you know what, this might hurt a little bit, but as long as it's manageable, we've probably ruled out any red flags. It's probably gonna laying down and doing nothing's probably not the best. But can you work through that in a way that's comfortable and doesn't make you feel worse the next day? I for me, I feel that I could stand behind that. But the oh, just ignore it if it hurts because you're not doing harm, I think is is so I think there's there's an extreme that it can be taken to that might be unhelpful. And what are your thoughts on that?

unknown: 11:14

Well, so I definitely understand what you're saying in terms of where if someone comes in in an acute situation and it hurts to move, it's pretty expected, actually, that it's gonna hurt to move if you're in an acute situation. And that there's a process, perhaps, for you to like start to feel better. But part of that process will be you have to move. Like you have even if it's a your back's and spasm, you still got to get up and go to the toilet. So there's some level at which you have to negotiate movement with this. And that acute state is not necessarily providing any more harm than you're already in, because something's happened. There's something going on that's activating nose deception that's having these effects. And but I think when we start to blanket that in terms of it's like the way clinical practice guidelines often get used, where it's here's your guide. And then suddenly this guide becomes the sort of overarching umbrella that everyone must fit into in some way. And so when it's taken out of that kind of context and then perhaps placed into a larger context where any hurt doesn't equal harm, because that's because that's just a heuristic. That's just a little saying where it's hurt does not equal harm. There's no context with that. There's no instruction with that as to like where do you apply that situation? It just becomes this blanket, no pain, no gain, did all of that sort of thing. So it just becomes something like that, where it then gets applied to all aspects without caveat or without association. Now, I'm not saying that the people are stupid and can't actually figure out where that might be a reasonable thing, but I'm gonna put myself in this category. We don't always think through all of the depth and the breadth and the complexity that goes along with having these little heuristics that say, oh, here's a little tool that you can use and that use for your thought process, for your clinical reasoning. And now you're using it in a blanket way to reason when someone comes in. And you're gonna apply that to everything or to a lot of things. And then you stop thinking about it. This is where I have some issues with some of the ways in which we uh we can approach really complex issues. And in this case, complex issues that across the board we don't know enough about.

Eric: 14:43

And that's a big thing for us as a profession or anyone in the manual or massage therapy world is to say we don't know enough to make these definitive statements. And there's so often a oversimplification, the no pain, no gain is one, or that hurt doesn't equal harm, like these two kind of extremes often get taken.

unknown: 15:04

But they're sort of the same thing as well, which is that's that's how I put them together.

Eric: 15:07

They're kind of both sort of the same thing. But we often will hear these things, then we said we apply that to everything. Like you said, it's a blanket statement that gets used. And the key that I find to, and this is I think where we would both agree, is that the ability to reflect and think about our thinking and say, does that make sense for this person right here, right now, this situation?

unknown: 15:30

And maybe do I know enough? Yeah, do I know enough in this situation to be confident that if I cause this person harm, or not harm, but if I put enough pressure on this person that it hurts them, that I have enough confidence to say it will help them in this particular way. Without any of the other things that go on. But if we're talking about looking at then the definition of pain and the definition of no susception and what that all entails, I would have to say no to that question. I would have to say, I could not have enough confidence. I don't have the measuring tools, I don't have the ability to have enough confidence to say if I hurt you in a manual therapy aspect, that is a that is a therapeutic treatment. That that will ultimately help you.

Eric: 16:32

Yeah, we don't know.

unknown: 16:35

No, but I think it's safe for us to assume if we're going on our consensus understanding of these definitions, that we shouldn't be doing it.

Eric: 16:47

Yeah, that would be the less wrong kind of understanding or approach.

unknown: 16:52

Or I'd like to think of it as the more right understanding.

Eric: 16:55

The more yeah, the more right, yeah. The more right approach. Yeah, I like that better. Yeah, more right. I often use the term less wrong, but I I think I like more right. I think that's better.

unknown: 17:06

Yeah, because we have we have a certain level of knowledge. Yeah. And that knowledge tells us if we're really looking at what it is, that knowledge tells us if we cause someone pain on a manual or physical therapy level, we are possibly causing them harm.

Eric: 17:24

Yes.

unknown: 17:26

And we don't know the line.

Eric: 17:29

Yeah. And that makes perfect sense. I 100% appreciate that. I like how you've said that. So, question here then to keep going on this ethical discussion, because I think this is important for people to listen to. I find it helpful to talk this through with somebody too. If he's thinking out loud and having this conversation to try and put my thoughts together as well. So, looking at those principles of ethics, one of them is autonomy. So the person is respected and they consent. Very simplistic definition of autonomy. And say they consent to you hurting them. And they're okay with that. What are your thoughts? Like the reality, how much harm could we do? I know there could be a lot if we're really aggressive, but what would be the level of harm? So say someone did consent to it.

unknown: 18:11

I'm not sure that we're ever gonna, you know, that there's that silly cartoon where someone's doing a massage and then all the skin just comes off and you see the the skeleton. I there was a fascial one, I think. But it it's like we're not obviously we're not doing that level of harm. However, are we doing enough harm to impede healing or to create another level of healing that that person didn't need to go through? Yes. So I don't think we have the answer to those questions because we think, oh, that's going to be really helpful, but we might be doing a small amount of so a person's still gonna recover because time and natural course of the condition and regression to the mean and all of those different things that occur, but we may actually be impeding their process. Again, you or on a long-term basis, perhaps impeding their process, because we're doing this repeatedly.

Eric: 19:18

And that's something I actually wanted to touch on with what you said there, because it is unfortunately common that people have an acute injury or like a motor vehicle accident or sports or workplace accident, they go for therapy right away and they get treated like day one, day two, day three, while there's still those in that acute stage of tissue healing where there's inflammation and the fibroblast formations and things are neuroimmune processes, all those fun things that I'm sure someone can nerd out about. I think it's cool. But anyway, and I think that what you're saying, and this is what how I understand it too, is that if some if you go in and you do a treatment that is hurting them while those processes are happening, we could actually be having a we could be slowing down or impeding that natural healing process. Is that correct?

unknown: 20:09

Yeah. I mean, well we're adding to it. Right. Providing a level at which their healing is is impeded or slowed in some way, because we've just added another tissue insult. Yeah. So now we're all of those things that you're talking about are being activated every time there's a tissue insult. Yeah.

Eric: 20:29

And that would be increasing inflammatory molecules.

unknown: 20:32

Yeah, all of those things come toward for healing. There's neurophysiological processes that go on. We can look at what it means to have these same metabolic stresses or various other lifestyle stresses that are also the equivalent of tissue insults on a day-to-day basis. And there's this, there's this constancy within our systems where there's homeostasis, but that involves, like homeostasis involves a level of inflammation, just on a on a on a sort of a functional level, that's part of the process, a level, a low level of inflammation. And now we're adding a different kind of maybe a physical tissue insult along with that. So now there's a another level at which inflammation is required or other kind of molecules are drawn to that area. Yeah, I don't see how, when you look at it in that way, how we wouldn't, in some way, been impeding a process at that particular time.

Eric: 21:34

Yeah. And this is why it's so important, I feel, for us to really understand and appreciate neurophysiology and tissue healing timelines and those neuroimmune processes that occur. Because if we learned that in school, or if that was common knowledge throughout our professions, when we start to ask these questions that we're asking right now, the answer becomes a little more clear that of course we don't want to add more insult. We don't want to impede, because we're we have a better understanding of what's happening and how that's gonna impact the person and their system. And so hopefully that's information.

unknown: 22:08

And we also claim, we also we claim a healing profession, but are we claiming that we're providing the insult from which someone would be healing? Because should we not also claim that as well if we're if that's one of the things that we do, if we cause someone to hurt during that therapeutic process, then we need to make that claim as well. You're gonna heal, but I'm gonna give you something that needs to heal.

Eric: 22:36

It just doesn't make sense.

unknown: 22:37

Yeah. No, and like it's not overt tissue damage, but we also know that you don't have to witness it. You don't have to see the, as I currently have now, a massive ankle swelling and bruising. You don't have to see that to understand that tissue damage has or is occurring.

Eric: 22:56

Oh, if someone has, so just for people that are listening, just maybe there's a little thing to think about is that if someone comes in and they are in pain, we're not saying don't treat them. We're just saying don't add more harm or insult to the tissue. So we can still treat those people, but we should, I would say there should be a caveat that we're trying to not amplify their sensation of pain. We're trying to calm down their experience of pain or calm down the nociceptive system as best we can.

unknown: 23:33

Yeah. And I think for people who, even for people who deliberately cause someone pain, ultimately their goal is the same. Their goal is towards healing, towards less pain, towards better function, all of that still exists. What causing someone pain in a therapeutic context means is a fundamental misunderstanding of the neurophysiology of the sensation of pain. Right. And so that's where we start to see that huge knowledge gap that exists, where we've always done this, we have these outcomes, people feel better afterwards. Do we actually track them? Because how many times have we seen on social media where people have been like, this therapist bruised me and now I'm in pain or whatever it might be? So those things exist as well. All of those outcomes will exist. We're only gonna really remember the good ones for the most part. But yeah, where do we draw where do we draw our own line for that and our own understanding? And if we don't understand or if we don't consider that the definition of pain is what it is, because that's the current consensus understanding right now, even though it's it's debated, sure, it has it hasn't changed at this point in time. But if we're not willing to look at that, if we're not willing to follow the science, then that means we are treating on faith. And that's the other ethical question that we talked about as well. It was like, didn't did I talk to you about that one? Is it ever is it is it ever ethical to clinically reason for a healthcare context based on faith? Because faith is a belief you hold in the absence of evidence.

Eric: 25:38

We may have talked about that off-air. I don't think that made it to the recording last time, but I I think that is a really important thing to talk about belief-based or faith-based treatments.

unknown: 25:51

And we're not talking like religious faith here, we're talking about anything that is anything that is a belief in the absence of evidence is a faith. Um, so we want justified those. And if we cannot justify our belief that causing someone pain on a therapeutic, you know, therapeutic context leads to healing in some way. And I'm talking manual physical therapies, then we don't have a justified belief. Right? We have a faith. We're hoping that it helps. We're hoping that, and we're basing that on heuristics, we're basing that on our hurt doesn't equal harm, no pain, no gain, whatever our cultural therapeutic understanding is. I've seen people feel better afterwards, so therefore it must be helping.

Eric: 26:57

That's a problem, too, that is so common. You mentioned this briefly a minute ago, we forget or ignore the ones that did help, but we remember, we're biased, remember that the people that we did help. And so often, I know it works for me, it works for my clients, so therefore there's a it works, therefore it works. Yes, and it and people use that clinical experience to justify the potential mechanisms or to justify the approach. And I know that if we're talking about evidence, yes, part our personal experience is part of that evidence, but your personal experience doesn't justify the mechanisms of the outcome.

unknown: 27:32

No, and your clinical experience should be an illustration of something that you have used before to support your understanding of the mechanism. And then you may be able to use the clinical experience as an illustration of that, but not as a justification of it. Right? It does it, it is an evidence in itself.

Eric: 27:51

It can't be and I'm so glad that you brought that up because that's a conversation I've seen and heard and been a part of before, where people, well, evidence-based practice includes clinical experience and the patient.

unknown: 28:05

Research and evidence and the patient, yeah.

Eric: 28:07

And they're like, but two out of three ain't bad. I'm I'm kind of flipping on them. So we don't have the evidence, but we have we have the patient's needs, wants, goals, values, and we have clinical experience. So that's evidence-based practice. Well, no, it's not, it doesn't work that way, right? Right. People will say, well, it's 66.6%, so it's it's more evidence-based than not.

unknown: 28:27

But I like what you said that it's 60% of the time, it works every time.

Eric: 28:31

Every time I love the anchorman reference, thank you. So the point being that yes, clinical practice or your clinical experience is valid, patients' values are valid, but them in themselves are should be an illustration of the bigger picture. And it needs to be based on the understanding of the evidence. And if the evidence is not being considered, then those other two don't really fit.

unknown: 28:56

Yeah, then you have information, but you still don't have justified information to base a therapeutic treatment on, which I think is I I think is part of the main issue. It's very interesting when we get into this understanding of evidence because people see things that they want to be able to explain with the treatment that they did. And they say, Well, I did this and this happened, and therefore this is the mechanism, or it's the outcome, or whatever it might be. And any evidence to the contrary, like uh like studies that may show that all of these outcomes are just data blips, right? Once you start to get the bigger numbers, it's none of it's really super clinically significant. And you have perhaps as many harms as you do helps in terms of quality of life and how much of this is longevity, all of those kinds of things. So on a manual therapy basis, we don't necessarily have this awe-inspiring mic drop kind of evidence for anything that we do. But we do use basic science, which is evidence, and we do use research, which again is part of our evidence collection. We do use thought processes and clinical understandings. And what is often missing is or maybe what was too present is desire. It's this desire to be the healer, it's this desire to be the helper, it's this desire to say, well. Yes, what I did made this massive difference to this person's life. And therefore, it can't be wrong. And I can't be wrong, and they can't be wrong. And to and to say that that is wrong, but that's not the actual sort of average outcome that we get with people, or that these techniques don't actually have that mechanism. So there's some other perhaps thing that had gone on. To take that into account questions identity, and it becomes very challenging, it becomes uncomfortable for people to say, well, we have this knowledge. This knowledge does not explain the miraculous outcome that I saw. But when you look at all the variables, neither does that take me to that treatment. Because we spend in a person's life. Maybe you see them six times. Six hours in a person's whole life. And for us to claim that what we do is some sort of be-all and end all has these amazing curative properties or whatever it might be is just hubris. We want to be good people, we want to be we want to be the helpers, we want to be the healers, that's what we're trained to do. We have knowledge, we do have knowledge and expertise that the average lay person doesn't. But we are also educated in our therapist's expert paradigm. And if we're to question our expertise on this matter, then where does that leave us? Where do we actually fit into a healthcare context? Are we actually doing anything? Like I can understand that people then get to a place where where they're like throw their hands, I was about to swear that I'm not gonna where they throw their where they throw their hands up in frustration and say, Well, what am I even doing? I've done that. But I think maybe what's missing is is a different kind of an an a lot, like a different kind of uh understanding of what evidence is and what it shows. It's like, yes, this shows a limitation only in comparison to the claim I've made. And if that's how I see evidence, then that's always going to be inferior. So I have this claim over here that says I can do all these things. The evidence over here says I can, but this evidence provides knowledge, it provides reality, it's a grounding, and it means that we have to change something about how it we think, what we do. Once we start layer on layering on character building traits like ethics and honesty and integrity, we have to start looking at what it is that we're saying in relation to what it is that we can support. Go off on a tangent. Yeah, not even sure this is making sense.

Eric: 34:11

I one reason why I was so excited to and and wanted to do these episodes with you was because I wanted to hear Monica's tangents. I wanted to hear you go off, just share. So thank you. Thank you for feeling comfortable to do that.

unknown: 34:23

Well, I'll put a caveat here because everyone hold it lightly, because I've changed my mind many a time based on evidence. So even hurting people, like I have done that in my therapeutic life.

Eric: 34:38

The same here.

unknown: 34:39

I have hurt people, I have caused people pain when I have treated them. I have reported pain and I've basically told them to suck it up. Like I didn't necessarily use those words, but kind of close because there's this idea of no pain, no gain, and then that changed, and then so there's a different thing, and then that changed again, and there's a different way of approaching. And I have made some massive errors in my engagement with people on a therapeutic level. And I know that mostly we like to hold the successes, I tend to hold the failures, and the failures are where we learn the most because it's not their failure, it's mine. I was the one who failed them, and I think that is where we start to get that kind of honesty thing is I failed them. This is a process where I have to look at myself and I have to look at what I'm doing. And so I have changed significantly over the years in terms of how I approach people, in terms of the claims I make, in terms of the teaching that I do, the courses I've done for this and for Sheridan and for other things, have been fairly steadfast over the past few years. They've been updated, but they've not been fundamentally rock solidly changed. I've had courses before where I literally trashed them. I did all this research, I did all this putting together information, and there was evidence. Oh, I can't just buy any of this. And I just stopped. So this has been a little bit different. And I think it's probably the same for you, where you start to see these things that you can build on rather than have to break down to a considerate.

Eric: 36:38

100%. And that's very overlaps a lot with with my experience. And of if I think of back in the early 2000s when I went to massage school and what I thought and felt about massage and what it was and what it wasn't. And then through the first oh, probably close to 10, 7, 8, 9 years of my career, where I was heavily involved in structuralism and pathoanatomical thinking, and and which was kind of laid in those thoughts were laid into my brain in school, because that's what we thought. And I was heavily invested in the fascia narrative, and I was took all those types of courses, and I went to the fascia research congress. But the more I learned about that that way of thinking, the less sense it started to make to me because it didn't translate into what I was seeing in the clinic. I wanted it to, I tried to make it. I I just and it, but it just did it stopped. It didn't, and it particularly didn't make sense with those people that had I don't want to I don't want to say this in a way that sounds too flippant, but like people that had like strange pain stuff, like paint things that didn't make any sense. It didn't fit into a box, and they've had pain for a long time, and they reacted really strange to the touch that you put on them. You're killing me, and you're thinking, what am I doing? Or the other end where you could touch them and they wouldn't fit, they were numb. Like it was the stuff didn't make any sense. And so that started getting me asked these questions, and yeah, went into like explain pain stuff and looking more about the role of the nervous system and the brain and thoughts, blah blah blah, and then biopsychosocial and now where I am now, where I'm don't really know where I am, but feel more comfortable in my level of uncertainty now than I did at any point in time. And the stuff that seems, and like I said that seems to make the most sense to me is the stuff that we're talking about, about these kind of neurophysiology, and if we base things on pain, no seception, complex experiences, we don't know enough. Person, the person's individual experience matters more than anything else. I feel like thinking that way, I don't have all the answers, whereas I I wanted all the answers before, but I feel now, at least in practice and also in the teaching, is that we don't need to have all the answers. We just need to, I think, be curious and explore and see what it is that we can do for that person on that day to hopefully make them feel better than they came in. And we have lots of different options to try to do that without having to we have different, we have different boxes now too.

unknown: 39:26

Yeah. So there's a little bit better understanding, especially with relation to pain, where we could put someone into a category. And I say kind of because these categories are not definitive. They don't have any sort of absolutely necessary, well, some of them may have some necessary characteristics to be in that category. But there are variations between with and within the categories with relation to pain of being able to make some sort of assessment of the person based on it. Doesn't necessarily even have to be an in-depth neuroscience knowledge. Like don't have a reasonable amount of neuroscience knowledge, but it's this idea of confidence in reason and confidence in foundation. So we have this foundation science, and there may be changes within it to some degree. Pain is something you'll see, start to see some changes within in terms of some of the semantics around some of the term terminology. But it's not gonna be so extraordinary that it's gonna overturn all of the pain science that has gone before the basic pain science that has gone before it. What might be overturned is more of the bias psychosocial, where it relates to pain, where it relates as forces. That doesn't have justification. It's very, very challenging to justify that when you have other kind of foundational science that that doesn't really match those patterns. That's not saying biosexual is irrelevant. That's just saying that when it's applied, when it's been taken and applied to health and pain in various ways, it's gone into those heuristics that negate the meaning of the research.

Eric: 41:25

Today we're going to talk about deck two, module two for the course, and we haven't even really touched on.

unknown: 41:30

No, I know.

Eric: 41:31

But I think that this is maybe next, maybe we'll see that for now.

unknown: 41:34

This is a good, yeah, but this is actually a good, like just the understanding of the biosarocial is a good intro into that. One of the decks is very much about the the health, what do I call it? Health inequities and social determinants of health. Because biasecosocial is supposed to encompass that. And because of the and but but social determinants of health and health inequities are so complex. And I'm providing an introduction, but you can go into each of them in a really, really complex way that has to do with sectionality between all of these social determinants and all of other characters, other characters is cultural and social and various other financial, economic, race, gender, all of those kinds of things will come together in some ways. So it's not just that they exist, it's that they exist and they interact and they interact in particular ways. And what biosychosocial has done to some degree is simplified them so much down to one word that has a very sort of minimalistic meaning associated with it. These social determinants of health are supposed to be considerations within biosychosocial. And what I find is that that occurs minimally. And so we are missing massive amounts of information if we're not actually considering the depth and the breadth to which these social determinants, health inequities dictate to some degree, how we might be thinking of a therapeutic intervention or how we might clinically reason to treat somebody in any particular sense.

Eric: 43:35

Yeah, it's an important topic that doesn't get discussed enough. And love how you without giving away too much, because we don't want to tell everybody. But when we're looking at the social determinants, it it is it's very important from my understanding and from looking through the research that you've included. We're looking at racism and gender and sex differences and poverty or income wealth or income levels and how those things shape the experience of pain, but also the treatment that's available or not.

unknown: 44:09

And how they shape research as well, yeah. And they shape research questions and how things are set up to be disadvantageous to certain people, and that we don't that we live within that. We live within this system that is set up to disadvantage people, and we are part of it. And we we act as part of it, not necessarily as people who are understanding of that and can take any kind of action that might change something about that. So it's very easy to just be within the system that we're in and not question that because in some ways it's uh beneficial for us, but uh it's going to be disadvantageous to somebody else.

Eric: 44:57

Yeah, and maybe next week we'll discuss that a little. We can go into that a little bit more. I I think this conversation though today about uh ethics was probably something that wasn't scheduled, but I think I'm glad that we had it because I think it was very valuable, it was valuable to me. Hopefully the listeners were find it valuable too, because these are topics that so things like ethics, things like social determinants, which we'll talk about next time, are things that are so important to understand in the research as well as in the clinical environments or worlds that we work in, but we just don't have no these these conversations aren't happening enough.

unknown: 45:37

I I I agree. I don't think they're happening enough. I think they're and they're also happening too late. So you'll often find that ethics or research or these this uh understanding of social determinants comes at the end of a course. And it's usually an add-on as opposed to something that actually should be the foundational component from which the thought process begins. Because we should be understanding our context and understanding the context in which another person exists and how we exist in that context together before we could actually make some sort of reasonable determination. And then you add that of to that, of course, the knowledge that we do have of the basic sciences and of our skill set, and also then the knowledge that we're missing. It's a lot of work for us to do, and that's maybe a lot of work that people don't necessarily want to do at this stage of life, when people have been in the industry for a little while. Sometimes that's not where you want to go. But there can be other things that you understand that may help you out with that, with that, without having to do all the work. As long as in in to some degree there are certain fundamental things that you may accept, even if you haven't, because they can justify, because they can provide justification for what you might do on a clinical reasoning level without necessarily having to go into all of that. But but I think for younger people who are coming up, for people who are just getting into the profession or who are like wanting to move in different ways, these should be our foundational thought like bricks that we build our house with.

Eric: 47:21

Which is why we're discussing them in episode two.

unknown: 47:24

Yeah.

Eric: 47:25

Have these discussions for the forefront of knowledge and of having these conversations to be aware of them and these thought processes and to help shape your thinking. So as we move on through the rest of these podcast episodes, as well as as you move through when everyone decides to take this course that you're going to be presenting. Exciting, that they will this stuff is gonna be okay, I'm now thinking through this lens. Yeah, it's still gonna be foggy, it still might not be that clear, but and it's not supposed to be, but you're starting to think about it so you can shape how you how you take on that further knowledge.

unknown: 48:05

Yeah, and that's why I put these courses together was for my own understanding, for my own ability to think through these things. And that's what I'm sharing with people. So I'm also coming at it from a perspective where I also don't necessarily have enough knowledge, and we haven't even gotten into the idea of the autonomy and agency and what it means to be an agent in the world with free will, who, you know, wants other people to also have free will. And what does that mean when we're when we're not providing consent for it, like proper consent for a process that's causing them pain that could that that means actual or potential to she then? Yeah.

Eric: 48:48

So one thing I often will try to address in some of my courses, and I'm glad that you wanted to talk about it, was the idea of informed consent. Can somebody actually give you informed consent when your treatment is based on a belief?

unknown: 49:07

Exactly. Yeah, there's that foundational kind of ethical sort of question. Because belief does not require justification.

Eric: 49:16

Yeah.

unknown: 49:16

You can justify it to yourself, but you can't justify it with evidence that will make it a justified true belief and and an actual something we could actually say is knowledge, right? Is how we know something is a knowledge that we can have.

Eric: 49:34

Now, I don't know big T truth, but it it's the more right when it comes to anything that has this social component in relation to these are heavy conversations that I hope people listening will start to have because people that enter the profession, they just want to go and they learn, they want to learn how to perform massage and do assessment and help people. And that's why I think we all got in the profession. But the longer that I'm around, the more I start to realize that these foundational philosophies, these understandings are just completely absent in an entry-to-practice education. And uh I don't I'm not saying, and I don't think you're saying that you need to be a uh a philosopher, have a philosophy degree, but this stuff should be foundational in that entry to practice. So at least people are aware of this because it will shape how you think and look at your patients and how you pursue your professional development should come through these lenses.

unknown: 50:39

I will say and someone paying you for treatment isn't consent for you entering into their space and touching them in ways that you believe will help them. Right. That that's not consent because that's a transaction, but that that transaction involves because you believe you're doing something therapeutic or they believe they're doing something therapeutic, that involves justification. And if you can't justify that to yourself, if it's based on belief, then ethically you're in a no-go zone as far as I'm concerned.

Eric: 51:22

I hope some of the regulatory colleges and regulatory bodies out there, stakeholders, are listening to this. Because the conversations that I feel that you should be exploring at that regulatory level.

unknown: 51:36

Yeah. Yeah, consent's a consent's a checklist, basically. But it doesn't actually have a good understanding of what it means to have a an autonomous human being in front of you that you and that that you respect their autonomy as much as they as you respect your own.

Eric: 51:55

Yeah. Heavy stuff.

unknown: 52:00

I know. But fun. But fun.

Eric: 52:02

I know I love it. This is great.

unknown: 52:03

We can get we can get heavier. I don't have I don't have as much of the philosophical knowledge that I would like. I'm doing more of that kind of exploration, but I have enough to ask questions that I can't necessarily always clearly answer. But I know then some of those questions, it like it's yes or no. There's no middle here. Like it should you start with a question and your answer is either yes or no. No is just you would have to reject that it would, it would probably be morally reprehensible. And yes means that you have to now negotiate something about what it is that you believe. These are the these are your options, basically.

Eric: 52:44

I am not an expert at all either when it comes to the philosophy and the healthcare philosophy, but it's something that in the last year-ish or so, I've been trying to read more about and to understand and to to reflect and think of, and stuff I'm trying to incorporate a little bit into some of the courses things I do just to so people start asking those questions and start thinking that way. I don't know if people do, but I I I hope that uh there's the occasional person that maybe is starting to ask different questions. And I think that's when we're starting, that's all we can all we can ask.

unknown: 53:17

Yeah. Yeah.

Eric: 53:18

Well, that was great, Monica. Thank you for that today. We will be back next week and we'll talk maybe a bit more about module two, and probably we should talk a little bit more about module three because it's we're gonna do module produces.

unknown: 53:30

Are we gonna talk about any of the modules? Maybe not. We're probably just getting to all sorts of other questions.

Eric: 53:35

You know what? That's okay. They provide I find that the uh just kind of the general ideas of some of these modules actually provide a lot of information about just for us just to have conversations and then ask questions to each other uh about some of those things.

unknown: 53:49

And we will actually get into some of those knowledge aspects of pain that people perhaps don't know and that will help us gain more knowledge and fill that gap, right? We will actually go there.

Eric: 54:01

Yes, promise. So anyway, thanks Monica. We'll talk to you soon.

unknown: 54:05

Not a problem, we'll see you later. Bye, Eric.

Eric: 54:08

Thank you for listening. Pain Education, no script provided, is now available for purchase on my website, the CEBE.com. To listen to more of these episodes, please subscribe on your favorite podcast network. If you enjoyed this episode, please like and share to your favorite social media platforms. If you'd like to connect with me directly, I can be reached through my website or send me a DM through either Facebook or Instagram at EricPurvis RMT. If you want to support my podcast, please consider making a small donation. This can be done by clicking on the support button or heading over to buymeacoffee.comslash helloob.