Welcome back to the Healing Pain Podcast with Asaf Weisman, PT, Phd(c)

How does language and logic impact the management and experience of chronic pain? Asaf Weisman, PT, Phd(c), joins Dr. Joe Tatta on the Healing Pain Podcast to discuss this topic. Asaf is a physical therapist, a PhD candidate, and a lab manager of the Spinal Research Laboratory at Tel Aviv University. He has 20 years of clinical experience as a full-time musculoskeletal physical therapist and studies musculoskeletal medicine, spinal health, as well as chronic pain. He discusses how language impacts pain, unpacks the positive and the negative aspects of cognitive approaches to chronic pain, and shares his thoughts around some of the more popular pain neuroscience analogies or metaphors and how they may not be so acceptable to people living with pain. Most crucially, he clearly defines pain as an experience and its relation to nociception. Tune in for more!

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The Language And Logic Of Chronic Pain With Asaf Weisman, PT, Phd(c)

In this episode, we discuss how language and logic impact the management of pain and the experience of pain with a physical therapist, Asaf Weisman. In each episode, we discuss the latest pain science as well as perspectives on pain so they can understand pain better. The field of pain science is the study of pain, nociception and the lived experience.

The International Association for the Study of Pain defines pain as an unpleasant sensory, as well as an emotional experience associated with actual or potential tissue damage. Nociception is different. It is the neural processing of encoding noxious stimuli throughout the nervous system. Pain and nociception are different phenomena and pain is always a personal lived experience that is influenced by many factors.

Asaf Weisman is at the forefront of studying many of the aforementioned topics. He is a physical therapist, a PhD candidate and a Lab Manager of the Spinal Research Laboratory at Tel Aviv University. He has several years of clinical experience as a full-time musculoskeletal physical therapist and studies musculoskeletal medicine, spinal health, as well as chronic pain.

In this episode, we discuss how language impacts pain, the idea of being able to process or reprocess nociception and/or pain and how modern pain therapies are, at times, helpful, may not be helpful and may even be harmful to people living with pain. We discussed the positive and the negative aspects of cognitive approaches to chronic pain and some of the more popular pain neuroscience analogies or metaphors and how they may not be acceptable to people living with pain.

This is one of the longer episodes. There is a lot packed into this information and we move fast. If you enter into this episode, I would like you to keep three things in mind. The first one is to keep an open mind and notice where your beliefs or biases may be challenged at some point during this interview. The second is the language we use in our communication is a vital part of pain care and caring for people with chronic pain. The third is realizing that cognitive and psychological processes have an important place in pain care. However, they are one component that contributes to pain, along with biological social epigenetic, as well as contextual factors.

With that in mind, cognitive interventions that use analogies and metaphors should be specific to the lived experience of the person you are working with who has pain. There is no one size fits all cognitive behavioral approach for people with pain. Without further ado, let’s begin and talk about the language and logic of chronic pain with a physical therapist, Asaf Weisman.

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Asaf, welcome to the show. It is great to have you here.

Thanks for having me.

I’m excited to talk with you about all things pain. I know that you are working on your PhD. That is exciting. Congratulations on that. A lot of it centers around pain.

My PhD is not pain related. It is related to computer vision in the radiology of the spine but it is somehow somewhat related. It is not off-topic but we do a lot of pain work in our laboratory.

You have published papers about pain more from a theoretical, philosophical perspective, which I appreciate because it makes us all think about how we approach pain, think about pain, treat pain and do research in that area and the nomenclature that we use, which you have discussed a lot. Where does this deep interest you have in thinking about pain in a different way come from?

It started with my skateboarding. I have been skating since I was 13 or 14. I hurt myself a lot. It is a dangerous sport. My interest in pain started from there. I started getting tattoos. I have a good friend who is a tattoo artist. Tattoos are mingled with pain. I started reading about pain even before I started my physio school. I have been reading pain literature for many years. I must confess that most of the stuff I read is only professional and pain-related. That is what I mostly read. I don’t read any novels, fiction or stuff like that. I learned how to incorporate it into my work. I guess I’m doing good.

Once you get involved in science, sometimes it pulls you away from fiction reading. I do the same. I don’t read much fiction at all. Most of what I read is science related. We are going to talk about a lot of concepts. The two most important concepts or definitions that we probably want to clarify first are, according to your view, what is pain and what is nociception? How do you define nociception or pain? What is the difference? That will inform a lot of what we are going to talk about here.

I came up with a good analogy and it is a good one. If I want to paint a picture, I’m going to need brushes, pens or colors. It doesn’t matter. I need a lot of substrates to paint the picture. The end product is going to be a pain but the substrate is also the canvas. We are going to need a canvas or paper. We are going to need all those colors. These are all nociceptors and the apparatus of nociception but they are different. It is clear from this example that the picture itself is not the material or the substrate. What do you think about this analogy? I also put it on Twitter and people liked it.

Pain is an experience and it is also defined by the International Association for the Study of Pain as an experience. What is an experience like? We all use this word and it is quite clear to most people when they use the word like, “I experienced that. What a great experience that was.” That is an experience. Nociception is the biological substrate that creates our experience of pain. All our experiences, everything that we know and whom we’re talking about are our conscious selves. This movie that runs before our eyes is more than a 3D movie. It is a multi-dimensional movie because we get smells sounds, interception and inner feelings.

It is like this multi-dimensional film that runs before our eyes. Psychologists call it The Mind. Our conscious selves are experiencing that. All of that is the result of biological substrates that are creating those experiences. It is a no-brainer. We live in the world through our senses, biological apparatus says and substrates that we have. They are there for us to use and experience the world. We have to differentiate between pain, which is the conscious experience like this thing, that we become aware that there is something wrong with our bodies.

Pain is an experience. At one point, you said, “It is like life. Life is an experience.”

From birth to death, it is all one big experience. Even death and birth are experiences. Nobody remembers his birth moment and nobody is there to talk about their death. When people go through death, they experience something.

If you go watch the World Cup Live, you are going to have one type of experience. If you go to a Broadway show, that is a different type of experience. Pain is a different type of experience. As human beings, we move in and out of these experiences or in some way, generated based on what is happening inside our body as well as what is happening in the environment around us.

Pain is a word that we use to communicate that we are experiencing something wrong within our bodies. Pain is a word that we use when our conscious selves become aware of sensations that we don’t like.

You mentioned the International Association for this Study of Pain’s definition, which has sensation or sensory built into it. Do you like their definition overall?

It is a good definition. There are problems. It doesn’t encapsulate everything that there is to encapsulate about pain, which is immense but it is a good operational definition. It is good for clinicians, patients and scientists to work with. It is not perfect. I don’t think that we can ever have the optimal definition for pain but it is a good one. It is quite ingenious and amazing that in 1979, they were able to conceive it. It is an important definition. It has been changed a bit several years ago but not that much because it is a good definition.

A lot of people waited on that.

The change was underwhelming. One of my colleagues, Professor Collin, is on the taxonomy committee. They found it hard to change it. It was good for what it is. It was not an easy task to change it but they did change the notes in the company.

There are about 6 or 7 notes that are done. If you read through those notes, you have to understand the full breadth of pain to understand what those notes mean and how you take action on that. What one term do you have the most problem with in the world of pain?

It is a sensitivity to pain or insensitivity to pain.

When someone has chronic low back pain, they have increased pain sensitivity.

This term is a misnomer. When you consider the existing ontology that we have for pain, it doesn’t make any sense. It is illogical. Insensitivity to pain doesn’t make any sense. You can’t be sensitive to an experience by definition. If we say pain is an experience by definition, you cannot be sensitive to it. It is like saying, “I’m sensitive to the color red. You might experience the color red.” It doesn’t make any sense.

Pain is a response. It is not a stimulus. People tend to ascribe stimuli, the qualities of pain but stimuli are just stimuli. Pain does not exist out there in the world where it can come and poke you. I can poke you with a pin and if I do it lightly, it is not going to be anything noxious. It is not going to do anything. If I poke you hard enough, it is going to turn noxious and you are likely to experience pain. That is a reaction. It is not something that you can be sensitive to.

It doesn’t make any sense but somehow people are still using it to describe protocols that they are doing to assess their pain sensitivity. It is not. What they are doing is checking sensitivity to different stimuli. That can change quite a lot between people and the different hours of the day and temperatures in rooms. You can get different results. It got nothing to do with pain, the reaction. The thresholds of those stimuli might change. Many things can affect those thresholds. That bothers me.

You read it all the time in research. They usually say something along the lines of, “25 patients were exposed to a painful stimulus.”

A stimulus in and by itself is not painful. Stimuli can be either obnoxious or innocuous. They cannot be painful. The quality of the stimuli is not pain. Its quality is either noxious or innocuous. The same pinprick can be innocuous or obnoxious. It is like a spectrum. Pain is the organism’s response to that stimuli. They are often conflated. It needs to be separated. For many years, I still think that people liked what is called congenital insensitivity to pain, which is a misnomer because you cannot be insensitive to an experience that you never had. Those people supposedly never had the experience of pain. How can they be sensitive to it? Try to think about being allergic to your allergy. Your allergy is a reaction. Can you be allergic to your reaction? You cannot. It doesn’t make any sense.

For many years, I still think that we can learn a lot from those people who are labeled as having analgesic or congenital insensitivity to pain. They hold the key to many insights that we can get from them about nociception is not about pain. We wrote a paper about those people. I used to be confused because the literature conflates a lot of the pain and the nociception. It is an old term. It is from the 1930s. It was first labeled congenital analgesia. In the 1940s and 1950s, they started naming this in the literature, congenital insensitivity to pain.

I read all the old literature. We did a thorough literature review of all the old case studies from the 1930s, ‘40s, ‘50s and ‘60s. We started reading and seeing a lot of strange things and discrepancies. For example, the first case by Dearborn is from 1934. He described this guy as from the circus. He used to be called the human pin cushion. He would get crucified in front of people. They would nail his hands with a hammer. When you read Dearborn, you already see the discrepancy. Dearborn writes, “This man had never had pain besides headaches.” That is strange.

Isn’t a headache a pain? It is written right there in Dearborn 1934. He never had any pain besides a few headaches. That is it. How can you say that this guy never experienced pain? He did but something in the language affects the way we perceive things. When you start reading all the case studies of congenital insensitivity to pain, you start seeing a lot of discrepancies. They say, “You never felt pain besides a few stomach aches here and there.” Eventually, you realize that it is a myth.” These people do feel pain but it’s the language we use, where we turn pain into a noun or a thing that exists or doesn’t exist. It is only the result of language when you use it as a noun.

If you read those case studies, it is quite apparent that those people do feel pain. I’m working on a continuation for that paper where we say, “What is noticeable from those case studies is that those people have like a blanket insensitivity to external noxious stimuli but they have intact deep nociceptors.” We still haven’t identified a complete absence of nociception because I don’t think these people would even be able to live one day. The deep nociceptors are crucial for everyday functioning. If we are going for number 1 or 2, we have nociception that is signaling that we need to go. We won’t be able to observe a complete absence of nociception because these people don’t stay alive. They died in infancy because they couldn’t urinate or do anything.

What you are saying is we probably have not found a human being that never experiences pain but we have identified people that have changes in the way they process nociception. I want to make that distinction for people. There is a difference when we say processing nociception versus a term that is commonly used, which I have a problem with, which is processing pain. There are a couple of things that lead to that. One is the idea that we have pain fibers, pain pathways and pain systems. Those things come together. Well-studied people say that we can “reprocess pain.”

I strongly disagree with this approach and this way of looking at things.

We should go in the opposite direction.

We cannot process pain because pain is the outcome of all the processing.

It is this idea of you take a grain and process a grain, which means you take the grain, take the shell off it, grind it down and process it so that it becomes bread but it is still some form of grain. I want to point people to the paper. The paper that Asaf wrote is called Pain is Not a Thing: How That Error Affects Language and Logic in Pain Medicine. You can read it. The idea of pain processing and the challenge of pain processing is in there. It is the idea that you can physically take someone’s pain as if it is a thing and reprocess it. My question is always, first of all, people don’t want pain. Why would they want to take their pain and reprocess it? The logic is poor.

Pain is a reaction. It is a result. It is there and done. That is what it is. You cannot process it any further. This is the result. All the nociceptive processing because nociception is processed. I must mark something which is important. I do not believe that we can have the experience that we call pain without nociception. I’m 100% sure of it that we need nociception to have this experience we call pain.

The idea that nociception is not needed for pain, you aren’t on board with that.

It also results from the definitions of nociception. It is mainly the definition of nociception, which includes tissue damage or potentially threatened tissues and that is because of that. Nociception is the processing of noxious stimuli. Once you remove the noxious stimuli, you can understand that nociception can happen without noxious stimuli. We have a lot of evidence for that. We have evidence from what is called neuroimmune crosstalking.

Aberrations in the immune system itself can cause the release of chemicals that sensitize nociceptors without actual tissue damage. That results in the firing of nociceptors. There is no tissue damage but we know it can happen. Once you remove the necessity of noxious stimuli from the definition of nociception, you can move on and realize that no deception is necessary for pain. If you use the current definition, you can say, “Noxious stimuli are neither necessary nor sufficient.”

If you say, “Let’s remove this,” you can see how nociception is right there in the logical equation that you must have it. A lot of people will love the brain and think the brain is the cause of pain and stuff. They don’t like it because it threatens their concepts and stuff like that. We have a lot of evidence that we can have nociception without noxious stimuli.

I want to pause a little bit here because there are a lot of interesting concepts. The first one we were talking about is pain reprocessing or pain processing, which is straightforward. Pain is not a thing. You can’t physically take the pain and reprocess it. What you are doing with patients is you are helping them to process nociception differently.

I don’t think so. My colleagues and I prefer to call it a nociceptive apparatus. The nociceptive apparatus is persistent in doing what it is doing. It is difficult to interfere with those biological mechanisms that are ongoing in the nociceptive apparatus. The research shows it. Most stuff that exists is not that good. That is the reality we live in. Most of the interventions are mediocre and not effective.

Single interventions are poor outcomes.

I don’t think we can have an effect in the short-term. Many things can interfere with or benefit patients in the short-term. Almost anything can benefit them in the short-term but eventually, most persistent pain states they persist. Otherwise, they wouldn’t be called persistent or chronic.

You and I both know even clinicians that have had chronic pain and have been able to “100% alleviate their pain.” Are you saying that their pain wasn’t going to be reprocessed? Are you saying that the nociception wasn’t reprocessed? Is it that something that occurred in their life changed their experience of pain so that it no longer exists?

Nociception is at the biological level. A lot of things can affect the biological level. We do have good research that points out that physical activity is beneficial. It is the best thing we have. It is not optimal but it is a decent intervention to alleviate a bit of chronic pain and people who have chronic pain. You help them alleviate it a bit. That is significant. If they are constantly on a pain level of seven and you get them to 4 or 5. For them, that is significant. You don’t heal them but you do help them a bit. We are far away from healing persistent pain states but we can help them a bit.

Another thing that is linked with chronic pain states is high BMI. There is some evidence for a change of diet for fibromyalgia. It is not high-quality evidence but there is some evidence for that. It can help them. When you combine those things, you get some small effect. It is not what we would like but it is the best we have. There is a clinical message here. We can probably help them improve their quality of life a bit, which for them might be significant.

I have written papers on those topics, especially nutrition and how multimodal intervention, specifically nutrition and increasing physical activity, do help people with pain. However, as you and I are talking, the zeitgeist is that pain is an output of the brain. Without the brain, you have no pain. We are immersed in a neurocentric and brain-centric world.

If I go on social, I spend most of my time on Instagram. There is a couple of people on Instagram. They put things up that say, “Pain is always about the brain.” People chime in with high-fives. I read it and I’m like, “This is duality at its best because everything from the neck down you are taking away.” It makes no sense because what happens in your body informs what is happening in your brain. Yet, we have clinicians from all walks of life. Most of them are physical therapists and some of them are mental health providers that are pointing people toward cognitive interventions only. Do you see a problem with that?

Yes, I don’t buy that.

I don’t buy it either. Is it a useful component?

I don’t buy into the brain stuff because it depends on how you look at it. Those people ignore the fact that you can look at it from a different way. I always give this example. If you look at it evolutionarily, it doesn’t make sense that all this brain stuff because the brain came in a lot later in the evolution. We first had a nervous system and nociceptive apparatus. It came way before the brain. The way I see the brain is superimposed on the nociceptive apparatus.

You can also look at it from a different way. People say, “The brain is the commander-in-chief.” I say, “No, the brain is a blue-collar worker. It is there to help the organism and it got so much stuff to do.” The brain is the organ in the body that does the most. It does many things. It is overworked and overstressed.

It can’t be the commander-in-chief. There is a great paper about it, which I like. It is called The Blue-Collar Brain Hypothesis, which looks at it that way. It says, “No, the brain is not the commander in chief. It is busy with many things all the time. It is overworked and overstressed.” If you understand that the nociceptive apparatus was there since the beginning of life, there was a danger. The nociceptive apparatus came early in evolution because it needed lifeforms and answers to all the threats that were around. Later, evolution reserved all those things that ended up being our brain because it works and is beneficial but it is not about that the organism is the brain. The organism was not a brain way before it had a brain.

I interviewed a psychiatrist. He wrote a book called The Embodied Mind and his name is Dr. Verny. He is bringing to light that our human experience is an embodied sensory experience. In some ways, we put too much emphasis on the brain. In his book, he has this great example of an adult, normal guy, married, has a family, kids, work and no problems. Something happened in his history where he had to have an X-ray of his brain. They found a huge hydrocephalus in his brain so large that his brain tissue was a thin layer. You couldn’t even tell there was a brain there other than some brainstem down near the foramen magnum.

The point is that there is so much wisdom in your body that we can access and use but we are in a place where everything is about the brain, the brain neuroscience and the brain and pain. We can sit people down for two hours. We can talk to them about pain, which is pain or neuroscience education and things are going to change dramatically. The truth is it doesn’t work like that.

It is a philosophical view. Being brain-centric or neuro-centric is one way of looking at things and people don’t realize it. There is a tendency to present that view as if it is the only valid scientific view. It is not. I presented a perfectly valid scientific view from an evolutionary perspective that doesn’t add up for the brain to be the commander-in-chief.

The head is the CEO. It controls and rules everything. I’m like, “If pain is an experience, that means your whole body is experiencing it.” Potentially, every system in your body is experiencing pain in some way or is reacting to pain in some way.

The nociceptive apparatus is widespread. It reaches everywhere in our buddy. It is not wrong to say that nociception is a whole organism response. There is a tendency to view nociception as being affluent only. Charles Sherrington, the famous neurologist, was way ahead of his time. He was amazing. He addressed it as an afferent and efferent response. For example, all our tendon reflexes are afferent and efferent. It is like a closed loop.

All those cognitive aspects are hardwired into that response. That is a good way to look at it. It is like an afferent and efferent hardwired response. People are like, “We are going to get a lot of backfire for saying a hardwired response.” It is like going back to the cart and stuff. For those opposers, I’m not talking about a hardwired nervous system. I’m talking about a hardwired nociceptive apparatus. That is not the same as a hardwired nervous system.

If the brain was in charge of all this, in some way, we would see greater outcomes on things like cognitive behavioral therapy or cognitive interventions that we have. There is the argument to say that we haven’t perfected them yet.

I don’t buy this argument. CBT, mindfulness and ACT have been studied for a few decades. There are thousands of studies. We should have been able to see some effect if it was there but the effect is underwhelming. That is constantly my argument. If pain was a purely psychological thing, we should have been able to see some effect.

This is going to be tricky for me to say. I’m a strong proponent of mental health but I wonder. If we frame pain as a psychological problem, how that looks to people with pain?

It is horrible. There is no other word for that. You cannot have the experience we call pain without activation of the apparatus. When I say that, a lot of people tell me, “What about emotional pain?” This is where it gets a bit tricky because we are using the word pain as a noun. We are using it as a metaphor like, “My boyfriend hurt me when he cheated on me with a girl.” We use the word here in this connotation as a metaphor that what we experienced is as bad as tissue damage.

We want other people to understand that it is not equivalent to pain and the experience associated with actual or potential tissue damage. People use it as a metaphor. People who keep coming back to a doctor and they complain about pain. It is not a mental issue. It is a biological problem of persistent activation of an evolutionarily reserved apparatus of nociception.

There is good research that people, who are diagnosed with depression, oftentimes their primary complaint is pain, whether it is back pain, neck pain or whatever the pain is. When people hear that, because it is embedded in the DSM-5, which is what mental health professionals use, that person’s pain is psychological.

If I can read forward a little bit, what you are saying is that if someone had something happen in their life that causes them to have a major depressive episode or they are experiencing grief from the loss of a loved one, those are negative emotions. Negative emotions produce inflammatory chemicals in the body, which could excite your nociceptive apparatus and cause pain. One of the reasons why I enjoy your work is because there is a place for working with someone on what I consider their mindset. There are a lot of different ways to do that but we have gone way too far over to the edge of we are going to fix this with education and psychology.

I teach courses on psychosocial aspects of pain but I’m always clear to say, “This is a component. This helps you work with someone in a different way.” It helps them understand their experience differently. It helps with their motivation, which maybe even be the most important factor but never that you are going to use this alone and it is going to alleviate their pain.

This is an important issue that I try to stress a lot. Psychological events are capable of initiating activation of the nociceptive apparatus. You have the HPA axis. Emotional stress can or distress can activate the apparatus. What happens is that pure thought initiates the process of nociception. What happens is that some people have a tendency for those biological mechanisms to fail. This is an epigenetic genetic tendency. That is where persistent pain starts.

Once the biological cascade got initiated and fails to shut down, the problem is no longer psychological. The problem is biological. The reaction persists because we know that epigenetic switching can maintain those reactions ongoing. This is no longer a psychological problem. It is bad luck, tendency or circumstance in their life that happens to be that something in their switches fails. This cascade keeps ongoing but it is not psychological. It is biological.

For example, a lot of work on fibromyalgia reveals that they got problems with their epigenetic switches. Those reactions keep on going and are self-initiated. It got nothing to do with the brain. It is some genetic failure to reboot itself. That is an important aspect that people ignore, don’t calculate or don’t take into consideration.

A lot of the research is around transgenerational trauma, which in many ways is transgenerational stress.

What they found are epigenetic switching failures that keep on going. It is a biological thing. It is not a mental thing. Those people are not imagining it. People with fibromyalgia live with muscle pain. If you ever had influenza and widespread muscle pain, they live like that all the time. That is what they experience. Influenza is a good model for those states because, in influenza, there is no tissue damage. It is an inflammatory reaction. All those neuroimmune molecules are released and they sensitize nociceptors without any tissue damage. These people live like that every day. That is horrible. It is in their head.

I want to make sure we point people to another paper that you wrote. It is called Attitudinal Responses to Current Concepts and Opinions from Pain Neuroscience Education on Social Media. In there, you go through a bunch of statements like, “Pain is an output of the brain. Pain is not an accurate indicator of tissue damage. The brain becomes addicted to pain.” These are phrases that people use all the time on social media but you tested these phrases and many of them were not okay with people who are in pain. They don’t like the phrases. They find them to be negative.

What we did is we distributed this questionnaire on social media. It is the largest study ever made on PNE. It is 1,315 respondents. We also designed it like an experiment. We directed people into four different groups. We asked them, “Are you a practitioner?” They were like, “Yes.” I’m like, “Are you a practitioner experiencing pain?” They were directed to practitioners plus chronic pain groups. We had healthy controls, people with chronic pain and health practitioners without pain. We needed those groups to show the differences for comparison because if you only give it to people with pain, you are not going to know how different they are compared to other people.

We gave them a list of ten statements. We made an expert committee and went through a lot of statements. Every expert brought in statements. We funneled many statements until we came up with those ten statements. We asked them, “What do you think about it?” We gave them words to choose from like condescending, helpful and useless. We gave balance to those statements. For example, useless is negative. It’s like, “What can I do? It is useless.” Helpful gets a plus. We dichotomized it like binary, good reactions versus bad reactions.

We looked at the percentages of differences between them. It is quite straightforward. It is not that complicated. Most of the stuff that came from PNE, people with chronic pain, didn’t like it. What was evident was that the practitioners without any chronic pain loved it, whereas the healthy controls were neutral. We did something in the statistics that if they gave one answer positive and one answer negative, they got a neutral. They were quite neutral about it.

We found out that healthcare practitioners with chronic pain tended to be the controls. They tended not to like the statements that much and did not hate them that much. They were ambivalent about them. They were unsure. It is clear that you got those healthcare practitioners who have never experienced persistent pain in their life. When you put them head to head, it is the exact opposite of those people with persistent pain. They loved it. Those with persistent pain hated most of the statements.

There were people within the persistent pain group that liked some of the statements and they were good about it. That is what you expect here. When you give a multiple choice, you expect to see some distribution between the choices. Some people were like, “I like it. I find it helpful.” It was interesting because you can see head to head that you got those two groups that are the opposite and you got those healthcare practitioners that what we think is that their experience of persistent pain moderated their enthusiasm from those PNE statements. They were like, “I’m not buying it because it doesn’t match up with what I’m experiencing.”

A lot of the criticism that we got from people on social media was like, “This study is not clinical. Those sentences and phrases need to be used in the clinic and the right context.” I don’t buy that argument. A lot of the developers of PNE programs that is what they do. They take them on social media and apps for your mobile and they show you those memes like, “Pain is an output of the brain.” That is what they do. That is why we did this study and said, “It was valid to do it on social media because all of those PNE staff became abundant on social media and people are getting exposed to it. It is a valid setting to check it.”

After reading a lot of this research, a lot of this comes down to the individual’s expectations. If you are someone who has had chronic pain, you have been to all the doctors, have all the X-rays and all the MRIs and you have arrived at the place where you have said, “This is not about my knee.” Someone says to you, “Pain is about the brain.” That meets your expectation. That makes sense.

If other people are like, “Let’s say pain is controlled by the brain. Maybe I will buy that but how does that help me? How is it helping me right here and now?” For those people, they are like, “It is not a solution for my pain.” It is interesting to think about what people’s expectations are when they come to different types of cognitive interventions. The CBT and the ACT would show the idea of being able to change someone’s thoughts versus the idea of allowing thoughts to be two different types of thinkers almost on some level.

There is a third way. I stopped pretending that I could change the way people think and reframe their thoughts. I don’t do that anymore. What I do is what I call negotiation. I negotiate the meaning with the patient like you said, “The doctor told me I got a herniated disk and it is not going to heal.” Instead of reframing it like saying, “The disk is healing,” I asked him, “Have you considered that maybe what he says is not an absolute truth and there are other opinions? We know some other stuff. Are you going to be open to listening to new information?” That is negotiation. I’m not like, ‘I’m going to reframe this guy.” I’m like, “You come to me and I’m going to offer you a new insight, a way to look at things differently. Would you like to hear about it?”

I find it a lot more grounded in patient relations and human relations. We see it in our everyday interactions with people. Some people have a preset mind. They have made up their mind about a certain topic and there is no point in trying to change their mind or reframe it. You were like, “Would you like to listen to me? I can offer you my insight if you are willing to listen.” I find it a lot better. I don’t try to do an ACT, CBT or anything. I’m like, “We can try to discuss it differently.”

Using your human skills a little more organically.

I find it a lot better. It causes a lot less tension. When I did the first PNE course several years ago and I came out and I started using it, I found that people were resistant to it. Another reason that we did that study is that I saw many patients that started coming to me from colleagues. In the beginning, some of my patients didn’t like what I said to them. That was PNE or stuff like that. I was like, “I had to rethink stuff.” I started seeing those people that come from my colleagues and tell me, “This guy told me this and that. It is in my head.”

I never saw any mention of that in the literature. The literature presents PNE as a benign intervention. I’m like, “I saw many people who didn’t like it and were appalled by that. The way we designed the study is to be able to falsify what I thought. I had to design it in a way that would not affirm my suspicions. That is why we did grouping and a lot of statistics that cancel each other to give them a neutral so it won’t end up like the way I framed it. We alternated the words like it was positive and negative. All those are negative and positive. We mixed them. We did a lot of de-biasing for the study so it won’t show up what I think.

It doesn’t shape someone’s opinion as they are reading the question.

We ask them, “What do you think about this sentence?” We gave them words and free text. We are working on the second part of that study. I hope we will be able to publish it. One of my co-authors is the guy who did the artificial intelligence part. We took all those 13,000 free text responses. We put them in an artificial intelligence program. That program synthesized synthetic narratives. For each statement, we have a synthetic narrative. The computer program takes all the words that all the people with a negative attitude towards that statement had. It compiles a narrative.

It is quite amazing that the narratives are readable. It is like a person says that to you. I’m looking forward to publishing that. The guy who does that got a lot on his mind. We are halting it but I already put some stuff on Twitter, like a synthetic narrative that the people who didn’t like the pain are in the brain or pain is an output of the brain. For all the people who didn’t like this statement, the synthetic narrative, if I remember, goes, “I don’t understand why you are saying that. Pain is not in my brain. It is a sensation in my body.” It is quite amazing.

When you read the statement and the generated narrative, it reads like a person in front of you. We got neutral narratives and positive narratives. You can compare them. You can read them. It was exciting because analyzing 13,000 text responses is crazy. We already did a study and it was published in 2021. Unfortunately, it wasn’t noticed because it is practically the largest qualitative study ever about people with back and neck pain.

It is called Individuals with Back and Neck Pain on Medical Forums: What Do They Mention? What Do They Fear? I appreciate it because it is a large qualitative study and you get good input based on what the person thinks and in some way, values. They are not valuing that pain is in their brain. There is limited value to that, depending on whom you are working with.

We were able to synthesize many useful narratives over there. The number one thing they fear is surgical procedures.

Everyone is focusing on fear of movement. I’m like, “Based on this study, you should sit down and talk to your patient about surgery during the first couple of days.” It is not fear of movement. That is not the fear that they are concerned about. If you can calm that fear and let them know that most people do well with physical therapy and they don’t have to have back surgery, that is better than fear of movement or, “Pain is in your brain. Let me show you how we can reprocess the pain.”

If you read our study, you can get good clinical insights. In this study, we utilized computer algorithms to analyze all those narratives from actual people’s questions in medical forms online. It got a huge amount of clinical insights that people can gain. Surgery is the stuff that they are most afraid of or even injections and medications. They are afraid to take them. It has gone unnoticed. It has been several years but it hasn’t been cited even once. It is the largest study ever. I haven’t seen any qualitative study with 13,000 narratives that were analyzed.

We have talked a lot here and I want to make sure you mentioned where people could find you and follow your work before we finish up here. The thing that is most impactful to me is when we look at all the cognitive interventions. These are all your pain education approaches, mindfulness, ACT and CBT. This has been studied for decades with a lot of money and “body power” going into it. None of those studies talk about adverse outcomes or very few talk about adverse outcomes and have a qualitative component where they ask someone’s perceptions and look at did they perceive this to be helpful and useful or not.

What we wrote in our paper about PNE is that there is a certain framing bias. It’s the way you frame your study, whether you allow people to express negativity or not. If you are only allowed them to express positivity, it is going to show that it is a positive study. That is highly biased. That is why we wrote that in the context of the existing literature about PNE. Our study is unique because we are the only ones who asked them whether they don’t like it.

I had a psychologist years ago. She asked me during the episode. She said, “Do you know what the mean number of visits for someone when they come in for pain psychology, in essence?” The answer was one. When they see psychology for pain, they come in for maybe 1 or 2 visits. There is a whole lot that has to be unpacked with that one statement because there is a social structure built around psychology. There is bias and stigma.

I don’t want to overlook that but in one sense, you are saying, “We can cure a pain that is working on cognition.” You are saying, “Here are the studies thereof with minimal quality and outcomes.” Most people come in for 1 or 2 visits and they don’t come back. It tells me that there is something that needs to be improved there or there is something that doesn’t work.

I tend to think that most people don’t buy that for a good reason. Someone with fibromyalgia who has been living with an influenza-like type of pain all their life and this guy comes to him and says, “You got to work on your positivity and stuff.” It doesn’t make any sense. I have chronic pain. I have lived with headaches since I’m thirteen years old. I had bad chronic headaches and irritable bowel syndrome, which goes with a lot of fatigue. I know what it is.

At first, I tried to play around with PNE. When I started seeing a bit of reaction, I immediately caught myself and felt like, “Why do they react? What have I done wrong?” I started thinking about myself and I stopped buying that. It didn’t take me that long but people with chronic pain know what they are experiencing. They know they know better than you.

The one theory that I have seen that holds some good weight is the theory of embodied cognition. I don’t know if you are familiar with it. It gives equal weight to the idea that you have a brain and body. All of that is embedded in a social context. You have these thoughts and emotions. If we help you change those thoughts and emotions, everything is going to be hunky-dory.

When I sit there alone at home with my headache, I’m not social. It is me and my headache. Pain is not a separate entity from me, which is also another ratifying pain. Turning it into a concrete thing that is outside of you. No pain is a part of you. It is not something that causes you to do stuff. Pain cannot cause me to do anything. Pain doesn’t move me around. It is an essential part of me. I can’t dismiss it. It is me and that is why when I’m alone and I’m not around social people, it doesn’t matter.

A lot of stuff that we have learned to say in the last few decades like pain is bio-psychosocial, all those things like mantras, we have to rethink them because pain eventually is a biological reality for all the people that experience pain. It is not a psychological and social thing. That is what I tend to think. You are a human embedded in this environment and you live with people. This is also biological, anyway. It all goes back to biology.

Everything is affecting a biological process in your body.

Everything is biological. Even psychological is biological.

Asaf, it has been great chatting. This is probably the longest episode I have ever recorded. I appreciate your research, time and effort and helping all of us think differently because that is what research should do, help us think differently. With that, hopefully, there is progress. Can you let everyone know how they can follow you and learn more about you?

You can find me on Facebook, write Asaf KIaf or Twitter, Asaf (Klaf) Weisman. I have a blog. It is called Painlosophy. It is on WordPress, Painlosophy.WordPress.com. On Instagram, I’m not that active but I have a research gate profile. You can find me there. Follow my publications when I release new papers.

Please make sure to share this episode with your friends and colleagues who are interested in pain science and nociception. Tag Asaf and me. Let us know what you think of this episode and if it helps you understand pain on a deeper level or gives you some insight as to how you can treat and potentially alleviate your pain or your patient’s pain. It has been a pleasure. We will see you in the next episode.

Important Links

• International Association for the Study of Pain
• Tel Aviv University
• Pain is Not a Thing: How That Error Affects Language and Logic in Pain Medicine
• The Blue-Collar Brain Hypothesis
• The Embodied Mind
• Attitudinal Responses to Current Concepts and Opinions from Pain Neuroscience Education on Social Media
• Individuals with Back and Neck Pain on Medical Forums: What Do They Mention? What Do They Fear?
• Asaf KIaf – Facebook
• Asaf (Klaf) Weisman – Twitter
• Painlosophy.WordPress.com
• Instagram – Asaf Weisman

About Asaf Weisman, PT, Phd(c)

Asaf Weisman (Klaf) is a Ph.D. candidate and lab manager of the Spinal Research Laboratory at Tel-Aviv University under the management of Professor Youssef Masharawi. Asaf has 19 years of clinical experience as a full-time musculoskeletal physical therapist at an outpatient clinic of Clalit Health Services, the second-largest healthcare organization in the world. Asaf studies musculoskeletal medicine, spinal morphometry, biomechanics, pain, and chronic pain. He incorporates philosophical angles into his lab’s clinical investigations and theoretical work.