Blog 19: Painless informed consent

Not only does it simply make sense that people need to be appropriately informed about the risks and benefits of treatments before they consent to having them, but it is also generally a medicolegal requirement.

There is recognised importance of practising medicine professionally, competently but, most of all, safely. The fundamental medical principle of ‘first do no harm’ is an underlying theme in this requirement.

When it comes to pain, people make decisions to take on risks of recommended management using information that is not up to date with pain science. The information received is, at best, incomplete and unbalanced, and aspects of it can even be misleading. The question to be asked is – how is this still acceptable informed consent in 2018?

The best science tells us that pain is robustly aligned with the perceived need for protection and not with body ‘damage’. This damage produces signalling  to the brain which generates pain for protection. ALL damage that is seen on scans is also seen in people with no problems as well. These are very common, well adapted changes. Certainly, these things can contribute to pain, but they are also highly adaptable. To make things more interesting, pain can be severe with no detectable damage at all. So, just seeing something on a scan in a region that hurts does not prove that what is being looked at is contributing to pain at all. Most of us are not told any of this; on the contrary we are scanned quickly and told the opposite, and sent to people who seek to ‘fix’ what is seen in areas of pain using various techniques including surgery.

Problematically, by simply being told that we are damaged and we ‘may need fixing if the pain doesn’t go away’, our protective processes are on alert and pain is MORE likely.

How do we know that this is correct? There are many examples but a good one is the evidence on which the international ‘Choosing Wisely’ program on back pain is based on. Put quite simply, if there isn’t a bloody good reason to have your back scanned, DON’T!! If you do, you are at a higher risk of a worse back pain experience. It isn’t the scan which is somehow causing the worse outcome, it is what is informed about the scan that is SCARY! Simply telling someone that a disc “bulge” or similar is ‘causing their pain’ is more damaging than having the bulge because these are seen commonly in people with no pain at all; a perspective that is still commonly not informed.

There are more ‘informed consent’ problems when it comes to managing pain by trying to ‘fix’ things seen on scans. For a long time getting rid of pain by operating on people was assumed to be directly related to being ‘fixed’ by the surgery. Over more recent times various surgeries directed to painful conditions have been looked at by comparing real surgery to fake surgery. These studies have been done with knee, shoulder and elbow surgery and one type of back surgery. So far, these surgeries have not scored a goal for direct effect. Patients do get better, but they get better in identical numbers just by thinking that they have had the surgery without actually having it. The surgery is effective in many, but certainly not all. When it is effective we now know that it isn’t directly effective but is working through our brains processing of what is going on. Our systems become reassured that all is well, stopping protective signals to our bodies and sending ‘let’s get better’ messages which translate to less inflammation, less protective behaviour and less pain.

This is the latest and best science. How many people are told all this before they accept the risks of surgery? The sad reality is that the likely answer is almost none. I was involved in a project recently on back surgery where people facing surgery were asked this question and almost all had not been informed.

Despite the unfortunate fact that this is the common approach, which the majority would still find acceptable, I cannot see how this ‘catch 22*’ process could possibly satisfy the requirements of informed consent and the ‘first, do no harm’ principle.

It is proposed that in 2018 it should be a basic requirement, and a fundamental consumer / patient right to understand their pain properly and then also understand the true risks and benefits of ‘fixing’ attempts. This comment doesn’t just apply to recognised complications from fixing interventions that are generally informed adequately, but to modern pain science itself and the up to date information on what the problems are with the ‘I can fix your pain by doing this …’ approach. It is further proposed that until all this gets sorted out properly, the warning – ‘consumer beware’ applies quite vigorously.

The following questions could be asked of people offering pain ‘fixing’ interventions:

  1. How common is it for people with no symptoms to also have the same physical changes that you have found on my scans?
  2. What is the reason why not all people with the same scan results feel the same level of pain, and why do many feel no pain at all?
  3. Is it true that simply being scared that I have damage that needs protecting can make me feel more pain?
  4. Please explain pain science to me or please send me to someone who can give me this information.
  5. Is it possible that my pain has become sensitised**? If so, what could happen to that sensitisation process after the scarring that will happen with surgery?
  6. I have heard that people in pain get better with ‘fake’ surgery; how does that work?
  7. How do you know for sure that what you want to do works directly and not indirectly the same way?
  8. Has chronic pain lessened statistically over the past decades with better technology and surgeries?
  9. If my surgery is structurally successful, what is the explanation if my pain is still there after surgery and what will I do about it then?
  10. If many people have pain management programs including pain education when their pain is still there after surgery, couldn’t it be helpful to do that before the risky surgery?

It is important to be aware of an elephant in the room. There is an unfortunate reality that many who offer pain ‘fixes’ still interpret evidence generously to support ‘fixes’ that have simply been accepted for a long time despite the overall outcomes, and are financially rewarding. Many may not understand the pain science broadly enough themselves. It would therefore help to do some self-driven exploration and be an ‘informed’ consumer. Many offered fixes, eg: spinal surgery for back pain, are a point-of-no-return and are best avoided, not consented. The informed consent process can only really be proper and ‘painless’ if it includes good pain knowledge.


*The meaning of the phrase ‘catch 22’ is essentially what happens when you do something to create a certain outcome but by doing that thing you unavoidably create the opposite outcome. I have another blog on how common this problem is in pain management.

**When pain continues there is an inevitable ‘winding up’ of the process. When that happens less signalling input from the body tissues is required for the same, or even worse, pain. The pain has become over-protective.



Blog 18: A Sports & Exercise Medicine and Pain Revolution Copulation

The Australasian College of Sports & Exercise Physicians have had the vision to sponsor the Pain Revolution this year. I was asked to provide a blog and the completed result has been posted on the ACSEP website - "ACSEP @ PRR 2018" and is copied here.

The altered title will make sense as you read on ...

In 2017 I rode the inaugural Pain Revolution Ride (PRR) from Melbourne to Adelaide as the oldest participant of about 25 riders. From the very first moment that I saw the ad for the event I knew it was something that I had to do. I ride my bike regularly for physical and psychological fitness as part of a Beach Road group of MAMWILs ie: Middle Aged Men (& Women) In Lycra. The PRR was the perfect combination of my chosen fitness activity and my obsessive interest in the clinical applications of pain neurobiology which has developed over the past decade or so. The PRR is not only a bike ride but an outreach program for rural communities. It targets both patients in persistent pain and those who manage them in presentations and discussions with these groups after riding over 100km each day. Further details on all aspects of this revolution as well as excellent resources relevant to contemporary pain treatment are available via –

I confess to being one of the slower riders in my usual riding group based in Hampton called the Brown Cow crew, especially on the steeper roads. As a result, I over-trained for the 2017 ride, often topping the Strava list for the enrolled riders in weekly kilometres. The inaugural event was, as predicted, a ‘bucket list’ life highlight and well worth the long, sweaty hours of training.

Those who attended this year’s annual ACSEP conference would have heard Lorimer Moseley presenting as a keynote speaker on pain neurobiology and were hopefully as impressed as I was when I first heard him speak. I met Lorimer previously but the PRR was a wonderful opportunity to build on this relationship as well as commence relationships with many others sharing similar ‘revolutionary’ views.

Following on from the first PRR, the money raised has been directed towards the funding of a program aiming to harvest local pain educators (LPEs) in non-metropolitan communities. These have been matched to mentors in a process that will hopefully encourage and facilitate a neurobiologically prioritised model of care in these communities. I am privileged to be considered worthy of being one of those mentors and am assisting in the formulation of the LPE program itself. We hope that it will be developed further over the next few years with the intent to measure outcomes and broaden the program. More detail on this program is available via –

In 2018, for various reasons, I found myself unable to commit to the required training for the second PRR, but it was a no-brainer that I still wanted to be involved in a support role for the event. Just prior to PRR 2018, I gave the third in my trilogy* of presentations at ACSEP conferences on pain neurobiology and models of care, supporting Lorimer in his keynote messages but with a SEP slant. Thankfully, once again the presentation was well received in obtained feedback. Given the wonderful alignment of the ‘exercise is medicine’ and ‘pain is protection; not damage’ messages, I proposed an ACSEP and PR ‘copulation’ and the metaphorical slide, which is copied here, received a wake-up chuckle from the audience as was intended. A similar response was obtained to this slide from the public audience in a presentation I gave in Canberra during the PRR 2018 event. It will hopefully imprint on those who were there that ‘PR fertilised’ SEPs are an excellent option to see for a safe and optimally effective re-adaptive program.

My metaphorical ACSEP & PR ‘copulation’ slide image

I am currently working on a paper which I hope to publish soon. It shares the title of my most recent ACSEP conference presentation. Discussions with Lorimer and others on the points I intend to make suggest that I am heading in the right direction so stay tuned!

* The trilogy:

  1. “Pain, paradigms and the problem with placebo” – Coffs Harbour Feb 2015
  2. “Models of care in musculoskeletal pain management. Context versus pathology & the role of pain literacy” – Gold Coast 2017
  3. “The Pain Revolution. A SEP’s view from the trenches” – Gold Coast 2018


As in PRR 2017, PRR 2018 was full of so many highlights that an attempt to record them would produce too large a blog. From a personal perspective, major highlights included being in discussion panels with those I admire and have taught me so much, such as Dave Butler (of, Explain Pain and serious custard tart eating fame) and Lorimer Moseley himself, as well as Tasha Stanton, a Senior Research Fellow working with the Body in Mind Research group. There were many others on these discussion panels equally deserving of mention.

The PR mantra / slogan visible on all publicised PR material including staff and bike clothing is:

  • Re-think!
  • Re-engage!
  • Recover!

The educational component of this year’s PRR in support of this mantra was directed by Dave Butler and was intended to provide a curriculum-consistent message based mainly on two categories:

  • The seven great science facts on pain:
  1. Pain is always real, no matter what is causing it.
  2. There are many potential contributions to anyone’s pain.
  3. Pain is all about protecting your tissues.
    • Pain and tissue state are poorly related.
  4. We are “bioplastic”
  5. Understanding pain is the golden key.
    • Re-think!
  6. Active is better than passive.
    • Re-engage!
  7. Understanding pain then retraining your pain system works.
    • Recover!


  • The eleven target concepts to change pain:
  1. Pain is normal, personal and always real.
  2. Learning about pain can help the individual and society.
  3. Pain and tissue damage rarely relate.
  4. There are danger sensors, not pain sensors.
  5. Pain is completely dependent on context.
  6. Pain depends on the perceived balance of safety and danger.
  7. Pain is one of many protective outputs that can become overprotective.
  8. We are bioplastic and adaptable.
  9. There are multiple ACTIVE treatment strategies.
  10. ALL current pain treatments are up for questioning.
  11. Persistent pain is best treated in your own community.


The target concepts were captured and summarised in a brochure provided to our audiences. This brochure attracted a notable tweet by a SEP who happened to be in the large Canberra audience, Larissa Trease:

Dave’s pre-prepared ‘super-charged’* presentations provided the core messages, but presenters were allowed some latitude to provide their personal experiences and perspectives. In my presentation to the Canberra audience** I included emphasis on the important role that PR-fertilised SEPs could play as ‘pain coaches’ to obtain the best and safest re-adaptive outcomes. The important ‘buy-in’ of ACSEP as an official sponsor of the PRR was publicised by Lorimer et al frequently in a slide***, along with other official organisations including the APA (Australian Physiotherapy Association) and the APS (Australian Pain Society) who similarly support the PR message. Presenting immediately after Lorimer and having him there for my talk and up on the dais with me on the panel discussion afterwards was both daunting and exhilarating simultaneously.

*Explain Pain Supercharged is a highly recommended text after the original ‘Explain Pain’ text. It is available with unfortunately no kickback to me via:





Fortunately, my role as the team medico of PRR 2018 was not tested by any serious events apart from a rather unusual necrotising hand lesion. This occurred in a delightful rider who had flown from South Africa especially for the PRR. She rode the first three days and partly on the last day despite needing a rather wide debridement for this awful lesion that may have taken out her extensor tendon/s if not surgically debrided in Canberra after some local knowledge assistance provided by David Hughes. This nasty condition and the rider’s unflinching response to the regular dressings afterwards amply supported the importance of contextual factors in pain.

Another integral component of the PRR is the ‘brain bus’. This bus precedes the riders into various town centres and offers the public a fascinating insight into the power of neurobiological processes using various interactive demonstrations, including virtual reality and the ‘rubber hand’ illusion. The bus (info available via – is mostly manned by Tasha Stanton and Dan Harvie. Like Tasha, Dan too is an impressive researcher and presenter. They have both taken time out from their important work to accompany the PRR in its first two years and are both great company over dinner at the end of the day. However, after a few drinks, Dan’s visual similarity to Jesus Christ becomes a bit disconcerting.

There was general concern in the PRR organising ranks as to whether it would be possible to re-create the extraordinary atmosphere of the first ride. At the conclusion dinner on the last night Lorimer addressed the revolutionaries with understandable emotion and was quite accurate in conveying that if anything, this year’s event surpassed the prior one in that aspect. Approximately 750km including 12,000 vertical metres was travelled in difficult weather and challengingly unhelpful winds. My day to day duties, in addition to medical support, included supporting the riders in a closely following vehicle matching their speed and radioing any potential dangers and traffic concerns. I have so much pride in the way the PRR 2018 riders overcame all difficulties in an uncomplaining and team-oriented manner. At times I could feel the struggle in each pedal stroke as if I was on a bike myself. Their jubilation on reaching Albury stirred emotional responses in many, including yours truly. Fortunately, on that final day the riders were rewarded with a perfect and relatively wind free autumn day. This stood out in contrast to early heat and humidity followed by rain and serious cold in the alpine region when passing by a mist covered Mount Kosciuszko. I doff my cap (‘chapeau’) in great respect to all involved in the PRR and to all who are working in our societies for meaningful change in the treatment of pain!

Chapeau PRR 2018 riders & crew AND vive la révolution!!


Postscript: The rider's hand now looks like this:

Blog 17: Harnessing placebo – “When I say whoa, I mean whoa!”

I recently attended an interesting two day symposium organised by the University of Sydney using the following banner:

The “harnessing placebo mechanisms” slogan was elaborated on in the stated aims of the symposium as “improving outcomes by augmenting the influence of the therapeutic context”.

It has long been my view that perceived responses and measurable biological responses that are induced by context, meanings, beliefs and expectations are a pivotal part of the chronic pain puzzle. I therefore found this symposium attractive. It contained a range of enlightening presentations providing  exacting, academic perspectives as well as  ‘left field’  views on these processes which are mostly still known as ‘placebo’ and ‘nocebo’ responses. Several presenters at this symposium have featured prominently in my self-education journey over the past decade or so. In addition to the large number of relevant journal articles encountered in this journey, there is a comprehensive text titled – “Placebo and Pain – From Bench to Bedside” which is heavy going in parts but worthwhile.

The symposium began with a presentation by one of my co-authors , Associate Professor Damien Finniss who has come a long way since his interest in placebos was first stimulated by forgetting to turn on the power switch to the ultrasound machine while working as a team physiotherapist.  His final slide was a reminder that our worlds are filled with things that influence our beliefs, preferences and expectations; something marketing professionals have long recognised to great advantage.

The academic approach to placebo research was headlined by Associate Professor Luana Colloca, with world renowned credentials in this field and the lead author of the text referred to above. She presented many impressive research based conclusions on the potency of placebo and nocebo processes. Importantly, she informed that negative nocebo responses were faster and more easily induced than positive placebo responses in those who are vulnerable. Both were modifiable by “expectation violations”.

A particularly entertaining presentation was provided by Professor Daniel Moerman, an American Anthropologist. This was done during dinner and was ingested alongside several excellent wines after a long day in the academic (harnessed) saddle. I was fortunate to have Daniel at my wife’s and my breakfast table for discussion a few days later after the conference had finished. Daniel provides the perspective that the terms placebo and nocebo are redundant, and largely unhelpful, because achieved responses are due to the complex meanings that are derived throughout our lives from multiple sources.  Indeed, they have little to do with the inert things that are eagerly provided, and are misleadingly perceived, to be the significant component of the process. He supported this viewpoint with his top 10 research studies. The study that stood out was that of a rise in Chinese cardiac mortality on the fourth day of the month coinciding with an entrenched cultural perception that the number ‘four’ is unlucky because it is only varied in meaning from the word for ‘death’ by a different intonation.

At our breakfast discussion Daniel advised me of the polarising rift in the placebo research community because of this fundamental disagreement. This reminded me of a similar opinion communicated by a comrade pain revolutionary, and pain academic, Steve Kamper. Steve was the first to introduce me to the idea that we shouldn’t be thinking of psychobiological effects in terms of inert placebos and nocebos, but in terms of context, meanings, beliefs and expectations. This resonated perfectly, but I am also intent on strategising to achieve meaningful change, and so I have maintained that it is useful, at this time, to use terms that are familiar to those hearing them.

The second day was highlighted by a presentation on the use of open label placebo, ie: the persistence of the response even when people know they are receiving a placebo. This was presented by Dr Claudia Carvalho, from Portugal, who authored a much publicised recent study on non-deceptive placebo in chronic lower back pain.  This study follows on from a similar study in irritable bowel syndrome but closer examination of both studies reveals that it was the information provided that primarily influenced the outcome even though the focus in publicity was on the placebo. The presenter advised something that was not published. She informed that the instinctive human quest for a ‘cure’ meant that those involved in the study sought to continue their placebo tablets even after the study had concluded! Back to you, Daniel Moerman and Steve Kamper; these studies support the view that it is the ‘meaning’ and knowledge that facilitates the responses but pragmatically, this view alone may not suffice.

Other presenters will not be detailed, but were equally deserving. The relevant research base was scrutinised with strengths, weaknesses and needed future directions highlighted. A linguist expert confirmed the problems and possibilities focussing on language communication. Non-verbal communication was also discussed and even product labelling and perceived trustworthiness can influence health responses. An ethical dilemma that is created by the statistically increased likelihood of complications and side effects induced by a nocebo response when people are pre-informed of these complications, was explored. Importantly, an enlightened public hospital anaesthetist informed that an altered communication approach in post-operative pain can avert long term opioid problems.

Overall, the symposium was excellent and provided information true to its aims. And yet, I remained strangely unsettled by aspects of the experience.

I have discussed in a prior blog my concerns about certain difficulties in educative processes. In my blog on the “Traffic Jam of Pain” I discussed my observation that many conference attendees interpret information selectively to suit preconceptions and refuse to surrender their  cognitive biases.

This concern was reinforced by several audience questions. The most prominent one was a question posed by a physician approaching the topic from a standard musculoskeletal, ’tissue change = pain’, perspective. He stated that what he gained from a presentation was that he had erred in the past by focussing on an evidence based approach (is there any robust evidence in musculoskeletal medicine?), but should have adopted a higher focus on simply ‘selling’  interventions in a more positive light. I don’t think that this is what ‘harnessing’ psychobiological responses is about at all, and found this interpretation disturbing. Better marketing of methods that have no direct benefits has a distinctly dark side. Few interventions are harmless and continuing to focus on ‘fixing’ things has an inherent pain perpetuating effect because it maintains a focus on ‘damage’ as the main cause of pain.

Following on from this, my concern lies with the group that are the placebo ‘non-responders’ after injuries and initial pain events.  This is the group that corresponds numerically with our troublesome chronic pain population. This is the group that is worryingly still growing in number. This is the group of people who have a pain event and are then swallowed by a health industry convinced that selectively observed effects and poor evidence justify the repeated use of pharmaceuticals and interventions. Placebo construct responses are intrinsically context dependent and the context of the ‘non-responders’ keeps violating any meaningfully positive responses. Most of those providing treatments are convinced of the effectiveness of their methods using an observational, flat earth science equivalent approach. Some are like the problematic question-asker described in a previous paragraph and are consciously manipulating placebo construct responses for ‘good’.

I emphasise again that the problem with these methods is that it never empowers patients to recover meaningfully. On the contrary, from a neurobiological perspective it likely has a major ‘catch 22’ role in pain perpetuation by convincing vulnerable people that they have non-adaptable damage that needs ‘fixing’. This type of harnessing of placebos never educates people to understand that it is the context, meanings, beliefs and expectations that need to be re-adapted for the best and safest results to be achieved. In this sense, I completely agree with Daniel and Steve.

In real world situations, people in pain go from one intervention to another, perceiving minimal / partial / temporary benefits from each. Both they and their treating clinicians perceive these responses as appropriately beneficial but the overall trajectory of the problem keeps going in the wrong direction.

There is an abundance of unhelpful contextual inputs generated by a health industry that is incentivised to intervene and disempower. From a neurobiological perspective, there are many reasons as to why re-adaptive processes are sabotaged by imposed context and expectations. This does not just occur via easily recognisable ‘nocebo’ messages; suboptimal interpretation of placebo responses has a similarly unhelpful effect.

I fear that harnessing placebo mechanisms alone is an insufficient message. I propose that comprehensively understanding and prioritising neurobiological mechanisms, which include placebo / nocebo mechanisms is a far better message. Education on such mechanisms with full perspective empowers us all.

Any who have read my prior blogs and various social media posts will recognise my tendency for associating my thoughts with quotes, films, books, song lyrics and similar. The troubling thoughts generated by aspects of this otherwise excellent symposium made me think of one of my favourite Looney Toon cartoon characters, Yosemite Sam –

I suspect that harnessing placebo processes meaningfully will require a different approach. Little did I know when enjoying Yosemite Sam when younger that he would provide such a useful metaphor in the future that would play in my mind repeatedly during a symposium. To those managing pain out there in a neurobiologically deficient context – “When I say whoa, I mean whoa!”

Blog 16: Le Bouchon de la Douleur ie: The Traffic Jam (literally ‘the plug’) of Pain.

I love riding my bike in France.

One of the reasons is that there is a notable difference in the temperament of the traffic, especially compared with Melbourne, my home town. Now that is not to say that all French drivers are perfect angels, but there seems to be only a small proportion who have adopted aggression as their driving mantra. I have visited a picturesque town called Annecy in the Haute Savoie (Northern Alps) region on a few occasions as a base for my rides and notably, despite the narrow streets and summer vacation hub traffic, the infinite number of cars flows patiently. There are frequent ‘pieton’ (I love the French word for pedestrian; it is so ‘un-pedestrian’) crossings and it is rare for cars not to stop promptly for any number and spacing of pietons. The traffic seems to flow in a well-ordered fashion, and on occasion when I hire a car I can confirm this from a motorist’s perspective as well. At times when I noticed a problem involving traffic participants, a typical French accented ‘pffffff’ and a gallic shrug of the shoulders was preferable to hysterics and outright aggression. As a bike rider, I rarely feel in peril from a car in this region, which is a stark contrast to the way motorists approach me regularly in my home town. On a narrow road in France, cars will stack up patiently behind me, and the many other cyclists, waiting to pass without any transference of irritation.

Observing this ordered flow of traffic as the norm, I started to formulate a thought about what can be achieved when a group of people think in unison, equalise the needs of others to their own needs and simply just calm down. Despite hating being stuck in traffic to the point where I no longer own a car, I started to see this regulated flow of cars as a somewhat beautiful thing. I often sense the same sort of beauty in a well organised peleton (ie: group) of bike riders helping each other to maximise the gain from efforts against a head wind in a steady rhythmic manner. It is the beauty associated with seeing a human collective achieve a common goal together with everyone understanding, accepting and playing out their role willingly.

In traffic and in group cycling, a set of easily understood and instructed rules is formulated based on knowledge of what must occur for the best ‘greater good’ result. However, this on its own is insufficient. For this to work optimally, widespread consensus, co-operation and goodwill is required. There are clearly sociocultural factors that influence the uptake and implementation of this process for the best possible result and so far in my travels, the French seem to me to have the finest temperament for traffic to somehow be considered ‘beautiful’.

In addition to the exceptional French food and wine, the superb countryside and the amazing ‘cols’ (mountain passes) to climb, this is another reason why I love to ride my bike in their country.

When cycling, there is a lot of time to contemplate (particularly at my uphill speed) and I often find my mind wandering to my work interests. I began to reflect what could be achieved if a similar approach could be attained in the contrasting, rather discordant world of pain management. Despite seeing beauty in the way pain science explains why pain can be so disproportionate and persistent, I rarely have a sense of beauty viewing the way this science is handled by the health professions.

At this point I will address the obvious criticism of what is to follow which is – ‘why should we all just do it your way?’ I certainly don’t have all the answers but I have learnt that the current confusion within the pain management fraternity itself is largely unhelpful and is paradoxically and irresponsibly only serving to feed the ‘danger’ side of many pain equations.

My recent attendance at a major pain conference left me musing similarly but without a view of beauty; quite the opposite.

I considered the audience which would have included many searching for methods and answers to take back to their clients. I considered that these people must have been either cognitively selective in their uptake of information or confused by the multiplicity and variance of pain management techniques and priorities. Presenters espousing the importance of a consistent curriculum in pain biology education co-existed uneasily with those targeting pain with standard therapies, interventions and pharmaceuticals. The evidence for the latter categories is wanting unless ‘belief’ and ‘self-interest’ have transitioned into scientific method. Furthermore, there seemed no consideration of the ‘catch 22’ effect of convincing people in pain that they need these therapies, interventions and pharmaceuticals while simultaneously trying to convey the pain biology message that the brain produces pain for protective reasons based on perceived need alone. There seemed inadequate appreciation that confusion and inconsistency of message feeds pain processes voraciously and that the conference educational methodology would only likely promote such a result with the variety of traffic jam promoting take home messages. I discussed my perspective with an ‘educationalist’ of renown at the conference to obtain a nod in resigned agreement.

The trade exhibit was another excellent example of the point being made in this piece. If attending a pain management conference, please score the booths. The tally for ‘ you are damaged goods’ targeting interventions and pharmaceuticals will be predictably overwhelming.

I attended this conference immediately after my spirit-lifting participation in the inaugural Pain Revolution Ride (PRR) this year; an event in which there was much beauty. I found my spirits deflated after the conference despite some excellent individual sessions. The beauty yearned for in a collective working together for the best possible result, and achieved in the PRR, was not forthcoming.

I recommend that a reform process be undertaken urgently by the pain management fraternity and that this reform process prioritise the following as pre-requisites:

  1. The best rules.
  2. The greatest good.
  3. The widest needs.
  4. Simplification of messaging.
  5. Safety.

Just like in traffic in which cars, bicycles, pietons and others need to co-exist, in science too, the best rules are the ones that cater to widest needs and serve the greatest good in the safest and most reliable way. To achieve this end-result, they best be widely consensual, easy to learn, understand and teach to others. For the most optimal French-traffic-like icing-on-the-cake result, sociocultural acceptance has a role to play. If people stick to rules such as these, then everyone benefits.

Only when this is achieved will it be possible for all to have the empowerment to process injuries, degeneration of tissues and pain events optimally, and trust in the power of biological and neurobiological re-adaptation for the best possible result. Only when this is achieved widely will beauty be sensed regularly in the real-world application of the scientific method relevant to pain. The difficulties in pain management will not then seem insurmountable as they seem now, but will be met with a shrug of the shoulders and a ‘pffffff’.

Blog 15: “Save a life, save a whole world”

I had an interesting medical experience in my role as a medico for the Melbourne Football Club aka the ”Demons’ in the AFL (Australian Rules Football) competition in 2007. One of the younger players developed difficulties breathing within a few minutes of the start of the game. Dr Andrew Daff and I were in attendance but I was the ‘first on’ medico for that day. I examined the player and was reasonably confident that he had a pneumothorax  which is air in the chest cavity between the wall and the lungs. This is a problem that does occasionally occur in contact sports as a result of trauma but Ricky (his name) told me he could not recall having had a knock at all. Ricky then steadily deteriorated to the point of losing consciousness which made me concerned that he had a life threatening spontaneous ‘tension pneumothorax’. I inserted a large cannula (needle tube) into his chest to release the air that was compressing his heart and stopping the flow of blood after which he rapidly regained consciousness and starting breathing easier again. After a short while the critical care ambulance officers that had been called arrived, praised the proceedings and took over his care. He subsequently was found to have congenital (born with) bullae (blisters) on his lungs that were dealt with surgically and he went on to have a reasonably long and successful football career with two football clubs. We have kept in contact with a special bond between us as a result of this experience.

HS Article

(NB: they spelled my name wrong in this article! If you are going to have 15 minutes of fame in a lifetime wouldn’t it be nice if the spelling was right …?)

This event attracted considerable media attention because it was in the public eye and involved an AFL player. Realistically, such life saving activities occur regularly in ED, ambulance and other environments involving ‘regular’ people with no media hoo-ha. Nevertheless, I have to say that I did enjoy my ’15 minute of fame’ at the time. My elderly father (86 at the time) heard of this event. He is a devoutly religious Jewish man who has shown great tolerance to his son for not following him down the faith road. He quoted something from the Talmud to me on hearing of my much publicised experience. The Talmud (Hebrew for “study”) is one of the central works of the Jewish people. It is the record of rabbinic teachings that spans a period of about six hundred years, beginning in the first century C.E. (Common Era) and continuing through the sixth and seventh centuries C.E. My proud father stated the following:

“Saving one life is the same as saving the whole world”

The actual quote from the Talmud is a little more interesting and is the following:

“Whoever destroys a soul, it is considered as if he destroyed an entire world. And whoever saves a life, it is considered as if he saved an entire world.”

What an interesting concept for the medical profession to consider how importantly each and every interaction and opportunity to ‘change people’s lives can actually be perceived.

The segue to my current work in pain management is as follows:

In a previous blog I apologised for my past approach in my clinical practice where I ‘judged’ people in pain when they didn’t respond to my narrow-minded attempts to fix their structural problems alone. I stated that I obtain much greater satisfaction now than I ever did before, in my newer pain science prioritised practice.

Sure, I used to have what I thought were ‘wins’ previously but I left even these patients vulnerable to future problems with their pain issues by reinforcing in their minds that pain and structural tissue damage are reliably linked. I didn’t know any better. When I ‘win’ now I provide people with the knowledge and skills to ‘save’ and protect them on a long term basis. In addition to that, I am also seeing patients in chronic (persistent) and amplified pain make remarkable turnarounds on a regular basis. These patients never really benefited meaningfully from my previous methods. And all this is done safely.

I feel like I ‘save the entire world’ quite frequently these days. Instead of returning home after a consulting session in which I struggled to objectively see consistency of outcomes, I return home frequently buoyed by the meaningful improvements made; many of which even still surprise me in their extent. I had a particularly good example of this the other day when a smiling, young lady of 26 years of age turned up in my waiting room just last week. But the story didn’t start there …

This lady was referred to me approximately 6 months earlier. Without going into laborious detail, and mindful of privacy issues, her pain was fairly wide but centred around one of her hip regions. There was no specific injury and her pain had been there for several years and was severe, constant and very easily aggravated. She had had to cease many normal activities including part of her studies, and her life was profoundly affected. She had been managed in the standard manner before seeing me and arrived with an abundance of previously advised ‘diagnoses’ eg: a “slipping sacroiliac joint”, “tension in the glute”, “psoas strain” and “nerve pain”. There was recent focus on the hip joint itself and an expectation that, as a sports medicine doctor, I would be providing her with magical injections to ‘fix’ her. She was quite desperate to rid herself of the pain which was completely understandable. The problem was that her pain did not fit at all well with a ‘fixable’ structural contributor and she did not know that there was any other explanation for pain apart from injured and damaged body structures.

I advised her that I was not comfortable performing a potentially harmful intervention for a pain presentation that did not make sense unless a pain science based perspective was considered. I asked her to consider this perspective, gave her an introduction to it and asked her to visit my ‘pain literacy’ website.

She had already had investigations of her lower back and sacroiliac joint (which were thankfully normal) but prior to seeing me a MRI scan of her hip had also been organised. I told her I would follow this up when available to make sure that there was no ‘red flag’ diagnosis and that all other changes would have to be considered and explained very carefully.

When scans are done in non-traumatic pain, and especially persistent pain the results that are obtained fit into three categories. They can be ‘normal’ which should be reassuring, but people in pain sometimes find this frustrating and not reassuring at all. They can very, very rarely show a ‘red flag’ diagnosis eg: infection or cancer, which is clearly important, but is RARE. The vast majority fit into the ‘there is something there’ category. The great majority of these changes are also seen abundantly in people with NO pain or minimal pain. This means to the logical observer who understands pain that just because there is pain and there is a ‘change’ the two things are NOT necessarily related. For others, these discovered changes present lucrative ‘targets’ for interventions that have no evidence of direct effectiveness but do have potential direct (and indirect pain perpetuating) harms.

In a typical unwittingly alarmist manner her obtained hip scan report stated the following –

“Right moderate cam lesion which disposes to cam-type femoroacetabular impingement. There is an associated superior and anterosuperior labral tear present …”

Even if you are not medical, this sounds bad doesn’t it?

In the interests of reducing the already considerable size of this blog I won’t explain these findings in detail. Google search this and you will mostly see the scary explanatory stuff based on the opinions of those intent on ‘fixing’. You will also find a small body of data that suggests this is not a big deal at all but merely a relatively recent ‘fad-equivalent’ diagnosis to justify interventions including hip surgeries in many people, while possibly producing real benefits in only a few (this group is described in the next paragraph).

Groan …! After getting this result I knew I would have be working uphill to try to explain to someone searching for a fixable ’cause’ for pain that this sounds horrific but is seen not uncommonly even in younger people with no symptoms. Furthermore, from a mechanical perspective it should only produce a protective pain response if kicking a football or hurdling or similar ie: loading the hip in a highly bent / flexed position. It was not an explanation for constant, unrelenting and very easily aggravated, persistent, non-adaptive pain. My notes indicated that her hip was not particularly restricted or irritable when examined slowly and carefully and with some distraction by chatting and asking questions at the same time.

This young lady lived quite far away and so when I obtained the hip scan result I communicated my concerns via a few emails and a direct conversation with her referring physiotherapist.

There was some engagement but then radio silence; I never heard or saw this young lady again … until she turned up in my office about 6 months later wearing a smile.

She (and her physio) ‘bought in’ to the pain science prioritised perspective provided, but I never knew it, and her pain improved. She had even gone surfing and surprised herself at how OK she felt! She has resumed her studies. We discussed her current improved state, she thanked me and I thanked her right back! What a beautiful smile and what a contrast to the desperate, upset person in pain who I met about 6 months previously. She tells me that she still has pain episodes and these can be amplified and severe. I have advised that this is most likely due to a longstanding sensitised pain processing system with many well-intentioned but unhelpful contributing inputs over a three year period. However, I am confident she is on the best and safest path to her best recovery and she seems keen to continue in this direction.

There was one more important component to her recovery and ability to get her life back. She told me that at some stage she met someone about her age who had hip pain, had a similar scan, injections and at least one hip arthroscopy procedure to try to ‘fix’ the damage. His pain had worsened and he was on daily morphine with more surgery planned; even possibly hip replacement surgery at his young age. The problematic ‘carrots’ discussed in the previous blog in this series incentivising her to seek interventional treatment were dealt a blow with this information and this helped her ‘buy in’ to the safe and empowering pain science based perspective and a fresh rehab program.

This case also reminded me of a contrasting and scarily typical case review I performed in my job doing such case reviews for motor accident and worker’s compensation patients. It was a case involving a 38 year old lady who had a relatively low intensity ‘rear ended’ motor car accident but felt hip pain afterwards. To cut a VERY, VERY long horror story short this person’s pain has persisted beyond about six surgeries, perceived short term benefits (weak placebo?) and at some point extended similarly to her other hip with similar management. Her scan results of both hips were almost identical to my young lady as was her pain presentation. On each surgical occasion she gained more scarring and minimal real beneficial change despite amplified claims made by her hopeful surgeon who is a highly credentialled hip joint specialist. At her relatively young age her clever surgeons (she was sent for a second opinion and had her last surgery from another surgeon) are doing more extensive ‘reconstructive’ surgery using tendon grafts etc, simply because her pain won’t go away (in a compensable – ‘there is someone to blame’ context). This patient was never given a pain science based explanation; instead her many structural diagnoses have been repeatedly speculated and offered as ‘expert opinion’.

Quite apart from the completely unbalanced surgical viewpoints based on discovered scan changes that wouldn’t have raised my concern, it is of interest to see what this person’s specialised physiotherapist was telling her. This is presented via this direct quote as I couldn’t paraphrase something this absurd if I tried –

“… After initial assessment it became obvious there was a deep damage to the musculature of both her hips … internal damage to both the attachments of a number of muscles which has led to a co-ordinated dysfunction between them … micro synchronisation problems … shock damage as per automobile accident leading to femoral head dislocation on a functional basis …”

I shudder to think what the future holds for this poor lady based on such dangerous, nocebo-effect inducing nonsense and other standard ‘fixing’ attempts. Her past is lamentable and her present is appalling.

It is important as a privileged health practitioner to do what it takes to ‘save the entire world’.

Many of us, without necessarily realising it, are doing the opposite and perhaps even ‘destroying the entire world’.

Is ignorance an excuse?

Blog 14: The problem with carrots.

Carrots are a well-known symbol for incentives influencing activity. Dangling a carrot in front of the donkey, there was incentive for forward movement in the indicated direction. Sticks were used painfully at the back end of the donkey simultaneously to accelerate the forward movement.


It is a simple concept to analogise the stick with pain in general, and then consider the predictable behaviour trying to escape its unpleasantness. A nice, big, juicy and healthy carrot would then be pain management based on a broad foundation of pain literacy and a health system that prioritises placing the ‘dangle’ in a SAFE and scientifically effective direction.

Unfortunately, this is not the case in current times.

There are also carrots in front of the person dangling the carrot in front of the person trying to escape pain. In fact there is a whole procession of carrots influencing behaviours all along the way and all these affect the first person trying to escape that stick causing pain in the first place. Going further with this analogy could really mess with the reader’s head so let’s just limit it there. I have written another blog on the ‘zoo in the room’  which is about such perverse incentives in the health system that reward quicker consultations, investigations, interventions, pharmaceuticals and surgeries. These are a general problem but are a distinct ‘catch 22’ problem in pain management. These incentivised methods, consciously or subconsciously, become part of the overall problem. They do not represent direct, reliable and scientifically robust solutions despite abundant ‘beliefs’ and poor science based claims to the contrary. Overall rates of success from the variety of treatments in persistent pain are equivalent to what would be anticipated from weak placebo effects. This is fine for the few who benefit (and would likely have done so in other safer ways) but disastrous for those who don’t. Profitable implementation of new ‘snake oil’ equivalent treatments rampage ahead of solid scientific justification and some obtain public funding just because they become popular. I discovered a recent graphic that makes this dark point again substantially more darkly and fits well with the ‘carrot’ theme –


From here on the topic of this particular blog is confined, more simply, to the everyday problems in relation to the first dangling carrot. As elaborated above, pain management prioritises interventions and pharmaceuticals to ‘quick fix’ pain. If trying to desperately move away from the pain stick and offered that carrot how many would choose a different direction? The hoped for ‘quick fix carrot’ wins hands down; there is indeed no contest. Just try to offer a better carrot that is further away and more difficult to reach and you will see that it is highly improbable that the person in pain will take that direction.

It is virtually impossible to manage pain effectively via an educative and re-adaptive neuroplasticity pathway while those suffering it retain the belief that their nirvana lies in a medication, an injection, another intervention or a surgery.

Differentiating between ‘helpful’ and ‘unhelpful’ aspects of care is difficult enough. Having the courage to climb a re-adaptive hill of pain due to perceived harm (not actual harm) to get to the other side is sufficiently daunting anyway. Trying to convince oneself of the need to do these vital things is made seriously more difficult when others offer those ‘quick fix carrots’ one after another after another.

Most who are offered these increasingly hazardous options retain very little understanding of their pain. I am once again drawn to the metaphor of a multilevel house built on a flawed foundation.

The group I am most concerned about in this blog is the group that I am fighting hard to turn around safely and facilitate their best best neurobiological (and structural) re-adaptive recovery. Despite ardent efforts and much time spent, patients regularly focus on any offered surgeries, medications and other offered interventions and therefore the crucial ‘buy-in’ factor in the brain is very difficult to achieve.

The relentless thinking that something needs to be fixed for pain to be relieved is one of the strongest factors perpetuating that pain (there is that ‘catch 22 effect again). This a powerful feed into the ‘danger’ side of the brain’s pain equation eg:-

“I need my disc to be removed / my spine fused or my pain won’t ever go away”.

“They are telling me to do exercises but my disc is torn and bulging and I could make it worse; surely it is best fixed first!”

“They tell me my (insert any) joint is degenerate / arthritic. There is no way it will just get better and stop hurting without an injection / clean up / replacement!”

When this thinking is fuelled by an abundance of expert practitioners endorsing flawed ‘fixing’ processes, the situation is rendered almost beyond help. I wish I had kept count of how many times I have encountered the neuroplastically disastrous comment – “one day I believe that you will need a joint replacement”, or many similar such statements.

The carrot I offer is based on science and not ‘belief’. It advises that the only relationship between pain and discovered ‘degenerate’ changes in regions of pain is via electrical signalling to a pain response. It confirms that this signalling is not actually even necessary for that pain response. Furthermore the signalling part becomes less likely to be involved as a significant factor with the passage of time. It educates that the context of a pain event is significantly more influential than the electrical signalling and becomes more so with time. It advises about powerful placebo and nocebo psychobiological responses and that as a result what is told to patients and what they subsequently believe determines their outcome much more significantly than their structural body changes. It honestly informs that pain has become a greater problem despite major scanning and ‘fixing’ technology advances and explains the ‘inconvenient truth’ that these financially lucrative carrots are actually part of the problem rather than the solution. Etc …

And that last bit is the main thrust of this blog. From a practical real world perspective, in order to convince patients in pain that the carrot I offer is the juiciest and most rewarding, what is needed is to get them to stop drooling over the other carrots. A vitally important component of ‘pain literacy’ is to provide an honest appraisal of the real outcomes and poor science base for pretty much all other treatments and the potential dangers, not true benefits, of following those directions.

You can probably guess how popular that makes me with some of my colleagues.

I look forward to the day when the procession of motivating carrots is whittled down to the best ones by a self reflecting health community more interested in truly meaningful outcomes than worshiping engrained beliefs, flawed processes and ‘stakeholder’ interests. However, the sad likelihood is that this will likely only occur when those who finance our health, create incentives for such meaningful outcomes rather than financially reward existing processes just because they are popular. It will be a shame if it takes reaching the inevitable financial crisis point to convince the need for such change rather than simply recognising the current, prominent human crisis alone. That too reflects the ‘problem with carrots’.



Blog 13: Politics, fear and pain.

The easy Donald Trump victory this last week in the US elections was predictable despite the polls that consistently suggested the opposite.

It was indeed my intention to write this piece last week before the USA election, but somehow the time wasn’t there and I suppose I figured that it may have been wasted in the event that the polls were correct and I was wrong. A diatribe on my personal political views is not, however, the intention of this piece. In fact I generally avoid using the internet to voice my political views and opinions on other such sensitive topics.

In addition to specific concerns on political processes that I share with many, I have also been troubled by the comparisons between political contests and aspects of my work in discussing models of care in relation to pain. There have been many theories offered as to how the Trump victory could have come to be, as there were similarly with the ‘Brexit’ vote and the rise of One Nation in the recent Australian elections. I’m sure that the reasons are many and complex but I suspect the following comments with respect to ‘fear’ and ‘messaging’ are also relevant.

Fear and messaging.

Quite simply, it appears that if the fear card is played and the messaging is kept as simple and repetitive as possible, those adopting this strategy stand a major chance of popular success. The problem is that not many things in life are indeed simple, and most worthwhile goals are achieved by the recognition, understanding and management of complexity. Similarly, just about any worthwhile achievement that I can think of involves a degree of courage and overcoming of instinctive fear responses.

simple answers

Fear and simple messaging may be effective tools to create populist behaviour change, but they are not things that are associated with greatness in human achievements. Quite the contrary is true in fact if we are to learn from history. The parallels between more recent political trends, ‘marketing’ methods based on fear / simple messaging and events leading up to the second world war are disturbing.

I have given many talks on pain literacy and why it is so important. I have a slide which asks the question – “What is the most influential emotion on animal / human behaviour ??”

There is certainly some variation in audience responses but the majority seem to agree with me that FEAR has the greatest role to play, especially in major behavioural effects. I discovered the following definition of FEAR on Wikipedia which seems to fit best with the point I am trying to convey both here and in my pain literacy message –

Fear is an emotion induced by a threat perceived by living entities, which causes a change in brain and organ function and ultimately a change in behaviour, such as running away, hiding or freezing from traumatic events. Fear may occur in response to a specific stimulus happening in the present, or to a future situation, which is perceived as risk to health or life, status, power, security, or in the case of humans wealth or anything held valuable … In humans and animals, fear is modulated by the process of cognition and learning.”

Hmmm … consider political strategies and in particular those that have proved so extraordinarily successful in recent times.

Consider also the brain’s pain equation discussed elsewhere on my pain literacy website.

When I compile lists of things that feed into the ‘danger’ versus ‘safety’ side of the brain’s pain equation with my audiences, it always seems to be easier to compile a longer list of danger messages than safety ones. In addition to the preponderance of fear sources generally (think of the definition above), there is also an ‘inconvenient truth’ in simple messages provided commonly by well-intentioned health experts that structural body changes are the cause of pain and will likely cause more problems etc. Such comments are made because of the fundamentally flawed belief that there is a good relationship between what is seen and what people feel. This is a perspective that essentially belongs in the realm of fiction and has little, if any scientific credentials if scrutinised beyond simplistic ‘flat earth’ like observations. Yet, it is a simple message that can, and does, ignite a fear fuelled fuse line that ends in predictable disaster in those who are psychologically and sociologically vulnerable. There are those who are permanently impervious to these sorts of messages, but there are many ‘swinging voters’ who may find themselves susceptible because of the timing of concurrent events and influences in their lives.

The somewhat more complex alternative to such simple, quick and easily repeated messages is to provide perspective, education, empowerment and facilitation of optimally re-adaptive ‘healing’ responses.

The aspect of my pain literacy crusade that I find most concerning is the resistance to the (not so simple) message. I don’t mean just from patients; most concerning to me is the resistance to meaningful change by health practitioners themselves. To make matters worse is the consistent observation that this occurs despite the message being well received! I have presented on this topic repeatedly and been given excellent feedback by my audiences. My website has been in existence for a long time now and by far responses have been praising and it has attracted generally constructive critical feedback only. The projects I have been involved in in the compensation arena have been based on a pain science model and have been objectively successful. Despite all this, very few have subsequently ‘gone into bat with me’ afterwards. Anecdotally, patient management using my new pain science prioritised approach has been so much more satisfying, in contrast to my previous musculoskeletal model ‘textbook’ management approach. Despite succeeding in turning many patients in seriously entrenched pain around and preventing others from taking this fork in the road, overall referral rates have actually declined since I transitioned from one model to the other.

In vulnerable people fear messages easily trump all others.

Complex messages, no matter how robust, struggle against slogans and ‘one-liners’ in politics and pain.

I must go back to the drawing board to think up strategies convincing people to fear the haphazard results really being achieved by the current flawed model of care more than they fear their scan results.

Back at that drawing board, I need to think up simple messages to try to create real change in a valid direction and then repeat it over and over and over again. “Know pain, know gain”, … “Let’s make pain not grate forever again” …

If you can’t beat them, join them … ???


PS: A few weeks after originally writing this blog I discovered the following in a speech by Martin Luther King:

” Ultimately a genuine leader is not a searcher of consensus but a molder of consensus. On some positions cowardice asks the question, is it safe? Expediency asks the question, is it politic? Vanity asks the question, is it popular? But conscience asks the question, is it right? And there comes a time when one must take a position that is neither safe, nor politic, nor popular but he must take it because conscience tells him it is right.

And another:

“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.”

Now, THAT is leadership!

Blog 12b: Be careful what you believe; it can become your reality (part two).

Following on from the first part of this two-part blog, here are some other examples of unhelpful comments. These comments are, at best, thinly evidenced in science and are therefore more accurately described as beliefs that can then become unwanted realities. Suggested alternatives are offered:

Common feedback to patients in pain

Alternative suggested comments

 “Your spine is degenerate / damaged / unstable etc.”

“You have a slipped / bulging / worn out / ruptured / prolapsed (etc, etc, etc) disc”

“You have bad arthritis in your spine”



“Your back / neck will likely get worse with time and ‘may need surgery’ one day if it doesn’t get better with physiotherapy or injections …”






“Any longer work period will put major strain on your lumbar disc and could result in permanent back and neurological injury”

“I do believe you will require spinal surgery … I am concerned that with each passing moment, you may be doing further damage to your S1 nerve root

PS: the last two comments are accurately quoted from a spine surgeon’s real correspondence in a worker’s compensation context.

“Your back does not look as good as it did when you were younger, but it is strong and adaptable. Most people have such changes and worse and feel no pain at all.”

“In fact, the recent research says that people who worry about their scans do much worse than those who don’t have scans at all. Let me explain how this works via the brain’s pain equation …”

“The long term results of pain is the same whether you have spinal surgery or not, but clearly with no potential harms if you don’t and just do your rehab exercises really well and confidently”

“The results of spinal surgery are quite different for the same problem depending on the context of the pain.”That can’t be logically explained by the ‘injury’ itself. I know a good blog that may help explain that to you based on really interesting science …”

“Going back to work is part of your physical and neurological re-adaptation process and is a vital component of recovery.”

“Discs tend to shrink with time, not get worse; nerve damage that doesn’t recover spontaneously is a rare event”

“Your worn joint needs a ”clean up'”.




“You have bad arthritis and will need a joint replacement one day”

“You have ‘bone on bone’ arthritis”

“You have degenerative disease”

“Your degenerative (fill in any body part here) is causing your pain”

“There is really good evidence that ‘cleaning up a worn joint’ is not directly effective but works through a placebo effect when it is effective. There are potential harms that can be worse than what you started with.

“Your joint is undergoing a natural wear process. The relationship between such changes and pain is really vague. Most wear in joints actually DOESN’T hurt. Every now and then pain and inflammation can occur due to a change in the adaptation process. It is all about how you go about your rehab exercises. There is no reason to think that it won’t re-adapt well. And let’s have a chat about how pain actually happens …”

“Degeneration is not a disease at all; it is just a change like skin wrinkles. That is because the vast majority of degenerative change does NOT cause any symptoms or disability at all. It is all highly adaptable and even people with a lot of degeneration can have very few problems.”

“Pain occurs commonly when the tissues are seen to be normal. Scans can be terrible but with no pain at all. And there is everything in between as well.”

“You better be careful and stop doing this and that …”

“You will be harming yourself by doing that”

“You will get worse if you keep doing …”


“Sometimes a short period of rest is required to settle inflammation. But even in this time some muscle contraction exercises can be done. And then when it settles the people who stay active and keep doing most things do much better than those who don’t. And let’s have a brief discussion about how pain actually works to explain how that happens …”

“You are doing no actual harm doing that exercise, even if it hurts. Let me explain …”

 “You have tendon damage which is causing your pain and may need surgery” “Tendons commonly wear with time and most times people are not even aware that it is happening. No matter how bad it looks, exercise, even highly provocative exercise, seems to help. Let me explain how this probably works …”
 “You have the (whatever) of an 80 year old”  “Changes are seen in body tissues at a very early stage in many studies. The model that equates tissue changes with pain is not a very reliable one and believing this can actually make you worse. Want to know how?”
“Because your pain won’t go away, you need strong painkillers; here are some morphine type medications”

“This medication isn’t working? Let’s try a different one.”

“Only getting some relief from this medication? Let’s increase the dose and/or add some other medications.”

“Strong painkillers have a role with great care in pain from fresh injuries or after surgery. The role of such painkillers on a long term basis quite often creates further huge problems. Often you just get a ‘high’ rather than really good pain relief – that is a problem. Feeling that pain has improved can also be explained by the very interesting placebo effect. When injury pain is persistent it is best explained by problems with the way it is processed by the brain, not by the injury itself. It is then remarkably resistant to all treatment.”

“Strong painkillers can cloud your ability to understand what is going on properly and make good decisions. Thinking clearly is vital so that you can understand your pain, make good decisions and start to wind your pain down.”

 “We have many options for your pain. We can do injections of this, this, this and that. We can ‘stun’ sensory nerves which is called radiofrequency. We can insert very expensive nerve stimulation devices into your body etc, etc …”

(PS: The following was tweeted happily by a physician, who offers various external interventions for persistent pain management, after what he believed to be a good day’s work:


I noticed a tweet from the same person a few weeks later:


“One reason there are a lot of options to throw at persistent pain is that there is not one of them that is really reliable. Many desperate people essentially turn into dartboards and just have one ‘dart’ after another thrown at them trying to hit a bullseye. Also higher level research actually questions whether these techniques are directly effective at all. Placebo controlled trials are deficient and when done, they are not flattering.”

“Quite often when such measures fail, you become more desperate and convinced that some structure needs to be fixed. This failure of treatment quite often results in seeking surgical ‘fixes’ of greater potential harms and highly questionable effectiveness. That pathway can end very badly.”

“Furthermore let me discuss with you how it works that simply thinking that you have something that needs to be ‘fixed’ can make your pain get stuck. And the more it sticks around the worse it gets. This is explained by the ‘brain’s pain equation’. Have you every heard of a ‘catch 22’ situation? Let me explain. Treating pain by convincing people that they are faulty, damaged and need ‘fixing’ can actually worsen that pain …”

“If there is a role for these sorts of less harmful interventions, it is as possible ‘circuit-breakers’. This is then best considered only after you learn to understand your pain really, really well.”

“Interventions mainly target the electrical signalling side of your pain. Now please be quite clear – you can have severe pain as an output from the brain even when there is no signalling input at all.”

“There is very little reason to consider that anything in the musculoskeletal part of your body is capable of producing ongoing signalling input tp pain that equates with the type of unrelenting pain you have.”

“You need to learn to live with your pain”.






“There is really nothing / not all that much wrong with you …” (Patient thinking – “I am in pain! Are you telling me I am imagining it!! I will go out and get someone else to check me and do more tests to find out what is wrong with me!”)

“I see no reason why you should have to live with your pain forever. There is no evident ‘injury’ that equates with that advice and people with serious injuries don’t all suffer that fate inevitably. Your nervous system has adapted badly to result in your current situation. Just as it has adapted badly, it can be re-adapted back to what it should be. Let’s discuss how this can be achieved …”

“There is nothing to worry about at all in terms of a visible contribution to your pain response. Let me explain pain to you according to the really interesting science so that you can understand what is happening to you and start to wind the pain down by doing the right things.”

Blog 12a: Be careful what you believe; it can become your reality (part one).

Furthermore, and more importantly if you are a health professional or in another position of influence, it can become someone else’s reality.

For those of you who believe they understand the science of pain, placebo / nocebo effects and (adaptive and maladaptive) neuroplasticity processes you probably don’t need to read on. The title says it all and almost certainly makes sense to you.

But for those who are interested in further understanding the neuroscience based significance of this comment, or find it hard to ‘buy-in’ completely, this blog is for you.

To begin with there is a relevant quote by Mark Twain – 

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”

My work in educating people in pain entails having a supply of suitable metaphors and analogies to help people to understand and re-conceptualise their situation. This is done to help re-balance their brain’s ‘pain equation’.

The other day I was seeing a patient who has been attending for some time and is doing quite well overall after the typical back pain / failed spinal surgery origins. An obstacle to further improvement is that this person (X) feels firmly that certain painkillers remain necessary despite the great likelihood that there is no residual nociception / neuropathic (electrical signalling) input to pain of significant and proportional severity. In an attempt to try to convince X to keep trying to reduce, and hopefully even cease the medications, I used the line in the title of this blog as an introduction to a discussion on the matter. It just popped into my head at the time and seemed to resonate with both of us. I’m sure I am not the first person to consider this comment, but it was the first time that I expressed it myself this way and in this context. As stated, it seemed to resonate and, after the discussion, my patient agreed that it was still worth considering their medication use from this perspective and keep trying to reduce the level of usage.

Another tool I use in my practice is to ask people – “what have you been told, by professionals you have seen in the past, is wrong with you and is causing your pain?”

I think an interesting paper could be written on the many and varied responses which indicate three main general points:

Firstly, there is a hell of a lot of nocebo-effect inducing information being given to people in pain.

Secondly, that the fundamentally flawed ’tissue change = pain’ model that most use doesn’t contain a lot of inter and intra observer consistency in the real world. That is to say that many different health practitioners come up with many opinions on the same patient’s pain (ie: poor inter-observer reliability), and the same health practitioner seems to come up with different views and diagnostic opinions based on the same patient when things don’t go as predicted (ie: poor intra- observer reliability).

Finally, that almost all these opinions that are conveyed to patients in non-adaptive, resistant pain are speculative at best, completely fictitious at worst.

Yet these are freely and abundantly offered by many, including the usual array of experts and ‘gurus’.

When patients improve, the person sitting in the musical chair at that time takes the credit.

When a patient doesn’t improve, this flow of information, based on ‘opinion and belief’, and low level research, feeds the danger side of their brain’s pain equation like a renewable energy source and fuels the patient’s beliefs. This in turn powers a maladaptive neuroplasticity process and results in the reality of continued pain, including a dependence on a system that can keep offering ‘I can fix / improve you’ options for a very long time. There is an ever increasing array of expensive and potentially harmful pharmaceuticals and interventions for people in persistent pain. This is despite there being no correlating improvement in the statistical changes of outcomes.

Some patients don’t listen to expert advice. In many areas of medicine this can be a serious problem eg: stop smoking in cardiovascular and respiratory disease. Curiously, in the field of musculoskeletal / orthopaedic medicine as it relates to pain, this commonly results in a much better outcome! For example, it is my consistent observation over many years that those with ‘degenerative arthritis’ who maintain function despite being told ‘don’t do this / don’t do that’ seem to fare much better. I have had many patients who chose to avoid surgery offered to them including eagerly offered joint replacements, and years later they are active and have minor levels of pain and pain related disability which was contrary to what was confidently predicted to them.

There are many publicised instances of people who have been given a verdict but chose different paths themselves with remarkable results. One caught my eye just the other day during the Rio Olympics:

Wrestler Talgat Ilyasov makes Olympic debut 12 years after being told he will never compete again …

The Uzbek-born athlete will represent Australia at the Rio Games, more than a decade after being told he would never wrestle again because of a back injury …”

(NB: Now, I freely admit that I don’t have the details of this case , but such situations are commonly observed as stated above – “Hey doc! I was told my knee was so bad I needed a knee replacement!! But I thought bugger that! And it’s been fine ever since!”)

These people choose to create their own beliefs, and in many, their inherent aversion to predictions of ‘doom’ based on scan results etc, resulted in a different reality. Many just have a natural (and sensible) aversion to surgical interventions and trade one fear for another.

Contrasting this group with those who harbour standard beliefs, there is no doubt that a proportion improve with standard interventions. Unfortunately, there is no evidence that unequivocally proves that these benefits are not being achieved by placebo effects, and a lot of growing evidence that this is in fact the mechanism by which real improvements in pain and function are achieved.

Unfortunately, there is also the large group who pass through the standard model and maintain beliefs and realities that are over-powered by their contexts, including life stresses and their subconscious responses to those stresses. This group has been growing for some time now in the same period of exponential increases in therapeutic options, technology and interventional expertise.

In this group, entrenched, scientifically unsound beliefs turn into seriously tragic ‘real’ realities. This occurs via those eager, maladaptive neuroplasticity processes. They do not survive the process like the others do.

As health professionals we have a great responsibility to deliver the most scientifically sound message. Our words have serious power at creating beliefs and realities in others in this way. If we give unsound advice some will ignore it, some will improve for reasons that include placebo construct effects, and some will find themselves on a pathway to persistent, resistant pain.

The worst thing we can do then, as health practitioners, is to consider that our beliefs, our experiences and our observations constitute a scientific method. Our ‘beliefs’ can then create beliefs and realities in certain vulnerable patients that we didn’t intend.

It is only now that a scientifically robust method of comparing real versus sham procedures is being applied to surgical and other interventions for pain, that some of us are realising how wrong decades of previously held ‘beliefs’ based on observations actually were. Procedures with highly perceived success rates have now proven that the most powerful form of placebo is a surgical intervention for pain.

To say that this applies only to those procedures studied so far, and that somehow all others are still valid, is a testimony to the power of hopeful ‘belief’ and cognitive dissonance over plain logic. This term refers to the state of discomfort which comes from holding two conflicting thoughts in the mind at the same time. A method of dealing with this tension that is used by many is that any information contrary to the preferred thoughts and beliefs, no matter how solidly based, is viewed skeptically and ultimately dismissed using convenient justifications. This reflects how much the belief is ‘wanted’ rather than how robust it is.

Belief and expert opinion is not ‘science’.

They only form the base for a robust scientific scrutiny process.

Such opinions are not necessarily wrong, but they are not scientifically valid either, particularly when there is reason to question the validity by other information. The scientific method intrinsically entails a continual questioning, not accepting, process. Test and retest is required. Minds need to stay open to new perspectives. Outcomes have to be measured carefully and honest appraisals are required taking into account all possible mechanisms of observed benefits or observed adversities.

Such opinions are not necessarily wrong, but in fragile situations such as those involved in maladaptive pain neuroplasticity, they can contribute to a dangerous reality if believed as factual.

To present such opinions as ‘factual’ and offer expectations and treatments with perceived success based on observations +/- inconsistent science to patients in pain is risky. This approach relies on many factors for benefit including powerful psychobiological placebo effects and are affected by the sociological subgroups of patients described above.

The health community shouldn’t rely on patients’ resilience to surviving unsound beliefs.

The reality of the world of a person with persisting, non-adapting pain is a reality that none of us would choose for ourselves. This reality affects the person’s family and the wider community. The children of people with such pain are more likely to have similar problems and adverse health issues.

Instead of encouraging a reality based on perceived fragility  and ‘danger’ by simple comments based on personal observations, experience and belief like “your spine is degenerate / damaged / unstable and will likely get worse” and “may need surgery”, a different belief should be informed from an early stage:- Eg: “your back does not look as good as it did when you were younger, but it is strong and adaptable. Many people have such changes and worse and feel no pain at all. It is the neuroplasticity response to perceptions and beliefs that is the fragile component of a persistent pain pathway in vulnerable situations, and this is why … (explain pain etc)”.

That information is at this time a more robust science based belief; furthermore it is safe and can foster a positive pathway of rehabilitation built on a solid foundation of knowledge and confidence. It encourages a pathway towards an optimal reality.

NB: In the second part of this blog I am offering other real world examples of many commonly made comments that are more accurately described as beliefs which transition readily into pain realities.

In discussions with my colleagues, I receive two common responses:

First – “The patients you are seeing are different!”

No, because pain is pain; the mechanisms are always the same. It is just the contributors and amplifiers that vary. Acute pain responses are also highly influenced by survival priorities and perceptions. Have a look at the blog with the “Tale of two nails” to illustrate what I mean. In persistent pain it is rarely, if ever, the structural contributors that we target over and over again that are responsible.

Second – “It is all about better patient selection for treatments and interventions.”

Yes, and no. Yes, because this should certainly be an optimal basic requirement but, in the real world too many select poorly. In addition, this perspective applies to ‘textbook’ patients as opposed to the ‘near enough is good enough’ approach of many. No, because of a really important perspective. This is that patients with absolutely perfect text book features, and excellently implemented interventions and surgeries, still have tragic persistent pain outcomes. In fact I know of no evidence that states that such outcomes are lesser in textbook cases when the context is poor. As stated repeatedly, and backed by abundant research, it is the context that predicts the outcome in the vast majority in persistent pain, not the pathology. What is said to such patients can contribute to their context in a powerful manner, influencing the many ‘fork in the road’ moments that they face.

So, to the health practitioners out there who are hopefully realising how powerful words are in contributing to beliefs, realities and outcomes, please consider this in therapeutic interactions and prioritise again the ‘first, do no harm’ principle.

And when someone sees you down the track with persistent, non-adaptive pain and unhelpful beliefs, help them re-conceptualise their pain first as a priority. Unfortunately, this needs to include addressing the limitations of the model that has contributed to getting them to their current reality, ie: ‘first do no further harm’.


There are many relevant references and resources that support the views expressed in this blog. Here are a few recent ones that have come to my attention and are of particular relevance (clicking should take you to a full copy of the article):




Blog 11: My first visit to Planet Academia.

A manuscript has just recently been submitted for publication with my contribution and collaboration. I have always been more of a coal face worker, basing my writings on my observations, supported by science and various references, but using a persuasive, metaphorical style. This was my first prolonged exposure to publishing in an academic style together with other co-authors. The manuscript is about helpful and unhelpful models of management of patients with injuries that have happened in the workplace ie: in a compensation  context. From other blogs, I think it may be obvious by now that this is a particular interest area of mine. The only explanation that currently makes sense for the different outcomes in injuries in different contexts is via the available pain science.

I was honoured and privileged to be involved with five other authors who are highly credentialled and respected people in their fields and who I hold in great esteem. All authors were from backgrounds highly relevant to the important messages conveyed in the manuscript.

And so my Star Wars-esque spaceship landed on Planet Academia for my first visit.


What an interesting experience from another perspective.

Basically, Planet Academia is a place where, the indigenous (let’s call them –>) ‘academians‘ impose high standards and will only write anything that is robustly researched unless clearly stated otherwise. That is a very good thing. Any sneaky effort by me to insert some persuasive, metaphorical styling to my contribution was dealt with mercilessly (I now have repeated nightmares where I see those dreaded tracking cross outs), reminding me that this was a serious piece and not just another blog.

The writing standard  was carefully worded and stringently referenced. The current editing process before publication is of a similarly meticulous standard.

My concern after this experience is based on my belief that there is desperate need for meaningful change in pain conceptualisation and the management model being used which is not the one strongly in play. Every day that passes condemns more vulnerables to steep downhill pathways that encourage undeserved persistent pain outcomes because of this model. Little meaningful progress is being made despite many similar highly robust academian publications over many years supporting such change. This is largely because this is there is another prevailing ‘first in, best dressed’ paradigm that is strongly in play and, for many reasons, highly resistant to change.

There are others on the planet pushing their own research barrows who care little for the uncompromising restrictions which the indigenous academians impose upon themselves and collaborators like me. Let’s call this rather large countering group on the planet – the ‘quasi-academians’. They are non-indigenous to the planet and the publications produced by this group, either subtly or overtly, provide thinly supported, yet influential, messages that support and perpetuate the prevailing, flawed paradigm.

So, to explain using one of my metaphors, if the sky on a regular day looks blue,  indigenous academians will only write that it looks blue if numerous high level studies have been conducted to provide strong evidence for that statement. The problem with that is that there are also studies out there from the quasi-academians supporting that the sky is yellow, green, purple etc. But the sky IS blue! Just look at it.

Essentially, it doesn’t matter how obvious the problem is, nor how terrible the actual outcomes are. If you are an academian you can’t push your argument for safe change too strongly or persuasively, but need to stick to strict academian dialect in any communication.

For various ‘real world’ reasons in reference to pain, which will be elaborated upon below, that may not always be possible, and so the existing faulty, but more strongly driven paradigm continues its messy, unchecked progress. It is therefore the quasi-academians, who are mostly in control, pushing poor quality evidence more aggressively to suit their end game and perpetuating the existing ‘norm’.

In response, all academian statements that are based on observing the problems that are caused by such poor ‘evidence’ from these sources have to be diluted and stated carefully so as to avoid criticism of being unfounded or too persuasive in style. This happens to the point where the final publication can actually sometimes say very little, or just go unnoticed altogether. Meanwhile, opposing quasi-academian voices are nowhere near as concerned about how their conclusions are critiqued and are happy to believe their own quasi-science, push it and act on it; no matter how directly or indirectly harmful.

And so it seems to me that academic entropy* is created.

*Entropy is a borrowed thermodynamic term which refers to an overall lack of order or predictability and a gradual decline into disorder.

This is a big problem which the indigenous inhabitants of Planet Academia may be insufficiently aware is weakening the core structure of their planet.

Please recognise that I vigorously support the sincere scientific methods of the academians of Planet Academia; it is just that I can’t help considering that the Planet is smoldering as the indigenous inhabitants are playing a violin concerto.

And so this may be yet another catch 22 in the field of pain management which is relevant to research supporting meaningful paradigm change. The question is how to maintain research and publication standards supporting such much needed change while simultaneously being persuasive in creating an actual real world outcome, including effectively addressing the poor standards of others. These poor standards produce publications that are very much easier to digest, and therefore more influential. There is importance and integrity in maintaining standards but from a strategic, game-changing point of view, there are also significant consequences in ‘losing’.

I note that this recognition of poor research standards is being addressed by some academians, but wonder if this will be enough to strategically turn the tide:


Lancet Editor: ‘The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue.’

It is just worth considering the limitations of current methods in battling poor quasi-academian ‘science’ and achieving true, badly needed change.


Is there relevance to pain literacy in all this? Absolutely!

As stated above, there has already been a huge volume of written material over many decades in Planet Academia of the importance of the biopsychosocial model in determining optimal outcomes with pain neuroscience at its core. Despite this, the practical uptake of this model has been very poor at all levels and the standard, faulty biomedical model management paradigm continues unabated. Pain science literacy levels, crucial to building solid foundations for pain management, remain perilously low in patients as well as health practitioners.

Despite this and in parallel, the therapeutic community has simultaneously made an uncomfortable transition to reliance on what is quoted as ‘best available evidence’. This term is used to justify potentially hazardous interventions and treatments with highly dubious effectiveness (1). This approach has advanced alarmingly due to many reasons including stakeholder profits and is amply supplied with material by the quasi-academians. It does not reflect the ‘null hypothesis’ requirement in science (demanded by true academians) that dictates that it is only when multiple attempts have failed to disprove a proposition that it becomes reasonable, yet still subject to scrutiny. Albert Einstein has been quoted as saying that “No amount of experimentation can ever prove me right; a single experiment can prove me wrong.” The true scientific process is relentless, not accepting.

In pain, the pendulum has swung very far to the end of the biomodel / structurally obsessed management spectrum on the momentum of various stakeholder interests, cognitive dissonance (2), poor quality evidence masquerading as science and convenient expediency. This pendulum swing has extended further being incentivised by insurer systems based on their trust in expert advice given, but with eyes closed to the type and trajectory of the outcomes being achieved.

An example of this is spinal fusion surgery for persistent back pain in general. Building on this example, and illustrating one of the messages of this blog well, is the manner in which spinal disc replacement funding was achieved via Medicare in Australia in recent times using the highly questionable model of fusion surgery as the comparator (3). The recommendation was for funding approval despite acknowledgement of the limitations associated with the fusion surgery comparator and despite noting the significant post-operative narcotic usage rates in overseas studies. This conclusion relied rather unscientifically on the expert opinion of three eminent surgeons that simply stated in opposing this inconvenient evidence that ‘this was not what was observed in Australia’. A subsequent Cochrane review opined contrarily (4) while not considering such geographic qualifications. This harmful procedure, and its older brother of spinal fusion surgery for pain, both continue to attract insurer funding despite copious research questioning the outcomes.

Given where the pendulum currently sits in prioritising a biomedical model approach to injury management and how wide and entrenched this simplistic conceptualisation of pain is, it is therefore predictably difficult to study the effects of a significant paradigm shift to where the pendulum should be swinging, ie: far enough to the other, biopsychosocial side, in current times. The pain literacy message is a ‘hard sell’ currently, to patients and, more significantly, to their treating health professionals themselves. A recent study illustrates this well (5). Conclusions were reached based on a study including pain education while still reporting the following crucial limitation of the study – “The internal validity and the compliance of the clinicians are difficult to assess. Only 50% of the patients were able to report specific content of the sessions which may indicate uncertainty in the providers’ compliance to the manual.”

So inevitably, optimal pain science literacy effects will be difficult to achieve, let alone study, and no doubt this will lead to continued support for the current management model in the absence of convincing, alternative, academic evidence of sufficient standard to satisfy academian requirements.

Hence, there will predictably continue to be no real change.

However, please consider the following from a logical +/- ‘persuasive’ perspective:

Should it not be considered a basic right for people in pain to obtain consistent, accurate information and education (this clearly includes optimal pain literacy) on which to base their many important and potentially life changing decisions?

Given the fragility of the neuroplastic pathways that are capable of cascading adversely after nocebo inducing thoughts are allowed to enter regarding perceived (but most often groundless) structural frailties, should it not be considered a priority to alter this common critical point in pathways to avert needless chronic pain outcomes?

Are health professionals not duty bound to avoid ‘harm’ and manage patients as the entire, complex people that they are rather than consider, simplistically, that technology has all the answers?

Is it not reasonable to consider that funding pathways should incentivise optimal outcome pathways and dis-incentivise others?

Given the described ‘pendulum-related’ difficulties in researching alternative management pathways, the alternative cannot be to continue to endorse and incentivise the prevailing biomodel management paradigm, pushed by the quasi-academians, that has been discredited not by just one ‘experiment’, but by many.

Let’s hope the indigenous academians figure out a strategic solution without lowering their own standards, so that academic entropy can be reversed. Then their planet can thrive in the way that it should, with flow on benefits to other regional planets.


  1. O’Connell NE, Moseley GL, McAuley JH, Wand BM, Herbert RD. Interpreting Effectiveness Evidence in Pain: Short Tour of Contemporary Issues. Phys Ther 2015;95(8):1087–94.
  2. McLeod SA. Cognitive Dissonance. 2014. Available from:
  3. Review of interim funded service: Artificial intervertebral disc replacement – lumbar. MSAC application 1090.1. Available from:$File/1090.1-Assessment-Report.pdf
  4. Jacobs W, Van der Gaag NA, Tuschel A, de Kleuver M, Peul W, Verbout AJ, et al. Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane database Syst Rev. 2012 Jan;9:CD008326.
  5. 1. Werner EL, Storheim K, Løchting I, Wisløff T, Grotle M. Cognitive Patient Education for Low Back Pain in Primary Care. Spine (Phila Pa 1976). 2016 Mar;41(6):455–62.