Welcome back to the Healing Pain Podcast with Neil Pearson
Finding quality pain killer that focuses on teaching you how to move with more ease while integrating the latest pain science principles that keep your body, breath and mind calm, can be challenging to find. Many of these principles are not taught in primary medical education or integrated into clinical practice. What if I told you there are five simple steps you could integrate into your care of pain that would not only improve how you move but also improve the overall quality of your life?
Joining us today is Neil Pearson who is a physiotherapist and an adjunct professor at the University of British Columbia. He is a Founding Chair of the Canadian Physiotherapy Pain Science Division and the first physical therapist to receive the Canadian Pain Society’s Excellence in Interprofessional Pain Education Award. Neil is also a yoga therapist certified with the International Association of Yoga Therapists and a Yoga Alliance certified education provider. He has created a series of videos based on the integration of pain science, the lived experience of pain and yoga principles. Neil’s main focus is now expanding his ability to share what he has learned from people with pain as a physiotherapist and as a yoga teacher. He has a professional Distance Mentorship Program for practitioners, as well as developed an online Pain Education Platform and Movement Curriculum for people living with chronic pain.
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First 5 Steps to Moving with Ease with Neil Pearson
Neil, welcome to The Healing Pain Podcast. It’s great to have you here.
Thanks so much, Joe. It’s great to be back on.
I first met Neil in 2014. He was introduced to me by a colleague, Shelly Prosko, who we both know, and Neil spoke on the 2014 Healing Pain Summit. It’s been probably about three years. Time really flies. It’s great to have you back on. I know you’re super busy as a clinician, as a pain science expert, so I’d like to just start off with not only what keeps you motivated, but how do you organize all the amazing projects that you do for people with pain?
Basically, I have a piece of paper and I write them down every week and remind myself of all the things that I need to be working on. It’s a hard task and tense. I’m sure like most people, I’ve got too many things on the go. Two weeks ago, I had a company from the United States who are using virtual reality. They’ve created a virtual reality program and they’re calling me, asking me if I can do clinical research on this. For those who don’t know, virtual reality is when you put those goggles on. What you can actually experience is, say you have lots of pain when you move your right hand or right arm. In the virtual reality world you could actually be moving your left arm but seeing that you’re actually moving the right, and of course moving it without pain. This we found for some people can be really advantageous. What they want to do is tie that together with these ideas that we’re going to talk today of the things that we can do for ourselves that will help make movement easier.
What’s really exciting right now is there’s so much going on in the world of pain science, of pain care, that if you’re a clinician and you’re adventurous and you’re ambitious, there are so many different avenues to take. It also makes me think about so many of the principles that we teach people, as far as organizing, as far as pacing, as far as planning, starts to become lessons to ourselves in many ways, right?
Absolutely. One of the things that I pride myself on is listening to what people in pain say. We can be directed by what science says and what research says, but we can also be directed by the experiences of people in pain. I think Dr. Michael Sullivan who used to be at McGill, he put together this really great program of goal setting to really show people that if you ask people who have chronic pain or you teach them how to set their goals, because we are, as clinicians, asking people with chronic pain to do so many things. Pain management is this 24-hour day job with all these different aspects. One of the really interesting things that I’ve listened to and learned is that a lot of people who succeed say that they can take what they’re doing every day and put it into three categories they’re doing things, actually almost four, so there’s life. In terms of pain management, they have these three categories. One is trying to challenge themselves in some way to move forward. Another way is to calm their nervous systems down. The third thing is taking breaks or some people say, “It’s just I find a little distance from the pain or a little respite.” To realize that, of course, we need to do that very same thing in our vastly busy lives. Just to spend some time everyday taking breaks because sometimes we don’t. Just spend some time everyday trying to calm our nervous systems down, but then also just spend some time everyday trying to, especially around pain, to move with more ease. Live life with more ease is the big thing. It was really interesting when that epiphany hit me one day. People have been telling me these for years and I haven’t really heard it, and I don’t think anybody’s ever written it down before.
What’s really interesting to me about that is that it makes me think does a qualified practitioner, whether you’re a PT or a physician or a yoga professional or psychologist, do you need to walk your walk first and talk your talk? Is that almost a prerequisite to helping people?
I think for a lot of people, it is. I think we have to say the vast majority of people, if you haven’t experienced these techniques and the power of these techniques, it’s going to be really hard to pass them on. Simply, how could you possibly ever be convincing enough if you really haven’t had that personal experience? I say vast majority because I think there are some people who can really get the experience of others. Other people tell them their experience and they can really embody that. Most of us, we need it ourselves. As practitioners, we’re asking people to do very difficult things, things that require practice and persistence, and even compassion. That’s one of the really fascinating things to consider, is sometimes the piece that’s missing is compassion. If your clinician isn’t able to role model that to you because they’re so busy and they had to stay so disconnected to carry on with their work, it’s really hard to get that yourself, right?
Yeah, it’s true, especially in the American healthcare system, which I know is a little bit different than the rest of the world. There are so many different types of practices, especially for PTs within the United States. There are practices that see four to six patients an hour that have aides and assistants in their practices that are more one-on-one way. It’s the PT and the patient working one-on-one for 30 to 45 minutes. In a fast-paced environment, there’s not a lot of place for grace and compassion for certain types of clients. That’s a great point. I want to jump into the five steps that you’ve designed to help people move with more ease. How did you come up with these things? How did you create them?
Actually, I came up with them because initially I made a much more in-depth curriculum. I started off making this curriculum that had the key pieces that we understand from science and from working with people with pain. People need knowledge. They need to work on breath. They need to work on calming and resetting their nervous systems from desensitization of chronic pain. We need to challenge our body and we need to do some planning or some goal setting. I created this thing. It’s got over 60 lessons in it. I’m thinking practitioners are going to use it, they’re going to show it to their patients. Pretty much everyone said, “Neil, it’s too overwhelming. It’s too big. I’m already trying to deal with pain or my patient’s all right. To look at that is too much.”
To circle back, people who succeed, this is the stuff that they often are doing is trying to find which one works. People were telling me, “That’s not working.” I said how could we introduce someone to this in a more brief way, in a more succinct way so a person could say, “Let’s start with something small and see does this work for me? Is it something that seems to be my path towards getting better with chronic pain?” They really believe there are lots of paths, this just happens to be one. From that I went back and said, “There is probably not five steps for everyone that it’s going to be the same, but what do I think would be the most likely five steps that would probably catch the most people?”
What I decided to do is that the first step is about some more knowledge because we know that they only have pain that’s persisting. It’s good to understand what exactly is happening inside. With breath, I chose a breath regulation technique to something that would calm the nervous systems. Then there’s a body awareness technique. The fourth step actually shows you how to put that knowledge, the breath and the body in this together with the movement guidelines. The fifth step is actually practice. The fifth step is, “What are you going to do now?” If this works for you, which path are you going to take? If it’s not been a path that’s been engaging for you or this lead to improvements, where do you go from here? That’s really where it came from. I just want to make sure everyone hearing it knows that I don’t think it’s the answer. It’s a start.
If you were to go into any of these steps on my website, if people look at LifeIsNow.ca, there’s the bottom left-hand corner of the screen there’s a thing that says First Five Steps Are Free, an open access, and it is. People don’t even need to put in their email, nothing at all. I didn’t want there to be any barrier for this. I’m not retaining any information when people go in there.
There’s a little bit of description and the first step is knowledge. In each step, it gives people either an audio or a video that’s pretty brief, something that you could go through in say ten to fifteen minutes for each step. If a person finds that interesting and they want more, they can just scroll down a little bit more and there’s more. It’s like in the first one, there are these two brief educational videos. If you scroll down, you can actually see three 40-minute long educational videos that are full pain education session that we did as part of a research project for a General Hospital about ten years ago.
Then the second step, we move into a breathing technique. What we decided to choose was a technique that we just called Longer, Smoother, Softer. The idea is to make your breath last a bit longer, to breathe in a bit longer, to breathe out a bit longer, and then to try to smooth out the sound of your breath, the feeling of the air moving in and out, and even the feeling of your body moving. After you do that, adding in softer. It’s always an interesting one because people are like, “What do you mean soften my breath?” I say, “If a muscle’s holding on too tight and you want to soften that, we’ll do that with your breath. If your mind is holding on to an idea too tightly, you can soften that. Do that same thing with your breath.”
The reason we started with this was that for so many people starting with belly breath can actually be anxiety provoking. It can be really hard to get your belly to move in the right way. We want to get people away from this word of taking a deep breath, because so many people taking a deep breath pull everything up and engage all their neck muscles which turn on the fight-flight system and all that stuff happens. That was the essence of Longer, Smoother, Softer, is working with people for so long and thinking what words would work. Of interest around that is when I first started to play with those words. I would ask people to make their breath long, smooth and soft. What’s fascinating is that when I changed it to longer, smoother, softer, it was way more effective for so many people. There are lots of reasons behind that, but that’s essentially the second step.
The third step goes on to body awareness. People might say, “Why would I do something so passive as to pay attention to or listen to the subtle sensations of my body, the non-pain sensations?” Briefly we just say while we know that experience of persisting pain can distort how we can feel our body or a body image. There’s some connection that we don’t fully understand yet as to if pain makes it so that your body feels distorted, somehow that distortion in your body feeds the pain. No one’s been able to figure out the neural circuitry or the circuitry around that but it seems to be a case for a lot of people. As a physical therapist, I would say part of the other reason I want you to do it is if you can’t feel your body well, how are you going to come up with a good movement plan? Of course, the movement plan is important because we want you to use that for the next step.
The idea is that in the fourth step, which is about moving with more ease, can you use some of that knowledge to understand pain better and can you regulate your breath some and pay attention to your body in a new way so that you could move your body in a way that will actually with more ease? The idea is to do it by flaring up less. An example could be we’ve got someone who gets to this step and say they’ve got osteoarthritis of their knee. They get to that step and they’re thinking, “The reason it hurts when I move my knee is that I have osteoarthritis. How is this stuff going to possibly work? How could I possibly do it?” One of the things we need to recognize and hopefully the knowledge gets us there is that pain has to do both with what’s happening in your body and with how the systems are dealing with that. Often an example I give people is there’s a guy and his job is building bird houses and he’s at work one day and gets a call from his wife and she says, “You got to come home right now, the pipes have burst and the house is flooding and I need you.” He grabs his coat and hits the door, and between the work and the door his boss gets in between them and says, “Get back over there and finish that or else you’re fired.”
Now, he’s working on the bird house and he slams his thumb by mistake with a hammer. Is it going to hurt more this time or is it going to hurt less this time? The story is interesting because nearly everyone will say it would be more or it would be less. We say well if you know that, then you know that the amount of pain that he had didn’t just had to do with his thumb. It also had to do with how his nervous system’s dealt with that problem. We know it would be the same thing if you have an old big disc bulge or an osteoarthritis of your knee is that there’s that other part of the pain that we could have some help with. The next question people have is, “Hang on a sec, if I can change that part and make the pain less, wouldn’t I be damaging my knee more when I move?” We would say, “No, actually we know from science again that if you can move gently and persistently in a consistent way, even though the joint is worn out a lot, that gentle repetitive movement over a week will actually allow the tissue to be healthier again.” That’s contrary to what we think. We think any movement would be damage. These are the things that stop people from getting there.
My idea with the First Five Steps really is to hope people will be able to calm their breath and calm their body better while they’re moving because we know that tension in the body and tension in our breath or holding our breath, they can actually wind up the systems. Some of the scientists are saying when we hold our breath and we tense our body up, the brain gets evidence of danger. What we want to do when we’re trying to move with ease is to find a way to move while we’re increasing the credible evidence of safety. It’s one of the paths we can choose. By learning how to breathe calmly and keep our body tension low while we’re moving, we’re increasing the evidence of safety while we do it, and that can lower down that sensitivity of the nervous system, allow us to move without flaring the pain up, and then that will help the tissue again. That’s really where we’re trying to go with all systems.
There are so many great points in there. First from a clinician point, your story of how when you started out you had a very large 60-page manual, and I think that’s such a common mistake that all of us have made because pain science is quite technical, whether you’re studying the neuroanatomy of it, whether you’re studying the neurophysiology of it, whether you’re studying pathways and receptors and neurotransmitters. The truth is when you start working with a patient, you’re usually doing one simple thing first. You find that one simple thing that they like, that makes them feel safe, that helps to alleviate their pain or make them feel more comfortable. Then from that then you can develop a framework like you developed for your program. I know you’ve been given an award by the Canadian Pain Society. What’s fascinating is that in the United States of America, the American Physical Therapy Association has yet to create a pain subdivision specifically. Can you tell me about your journey along that because I think it’s an interesting piece in your history that people would be interested in?
I think it would have been somewhere around 2001 or 2002, a physiotherapist named Diane Jacobs was living in Vancouver at the time. She found out that I was interested in pain too and called me up and we got together. It turned out that she had already talked with a number of physiotherapists across Canada who were also very much interested in this pain science and physiotherapy. We thought we really needed to go to our professional association, our national professional association to say that we need this as part of what we do. We need to find a way to increase the education that physiotherapists are getting around this both in school and after, and change this. It’s not something we paid attention to and here we have this massive area of science that’s saying we should. It would have been around then that the study that came out of Canada showed how little education physiotherapists and doctors and even nurses got around pain. At that point, that study showed that physiotherapist got three times less education about pain than veterinarian students did. It actually showed that medical doctors in Canada got seven times less, so we were a little bit happy that we weren’t quite so bad. There was this whole lack of focus on it.
The journey was a difficult one because we got together and we went to our professional association and we were trying to find out what are the rules to create another division. In Canada, we call them divisions of the group and I think in the States it’s called sections. Really it’s trying to create a group of people who are interested in taking this field of our work forward. We went to the Canadian Physiotherapy Association and really were not accepted. It wasn’t that long ago but there was this, “We already are talking about pain in all the other different divisions, we don’t need this.” Some people even said to us that if a physiotherapist can’t figure out why a person has pain, it means they’re not good enough at assessing orthopedically. We’re getting a dated belief system of what pain provides to us. We actually then went off because it wasn’t being accepted. We decided to make a thing we call the Canadian Physiotherapy Pain Science Group outside of our professional association, and we started to network with other physios across Canada and start to put together some education and resources and courses outside it because we thought this still needs to be done.
I think it was about five years afterwards, we saw another new division spark up within the Canadian Physiotherapy Association. We were pretty upset that they would bring that division in when it was such a small interest group. We re-rallied and went back to them and provided them with what we would say a presentation that they couldn’t say no to. Actually, it was a presentation that we needed this so much, we wanted this so much as a profession, that we went in and we changed the rules a little bit of how new presentations for this would be accepted, because ours covered everything. It changed things a little bit there. Then it was created. Within the Canadian Physiotherapy Association, there is now a division that looks specifically on pain. We’ve been able to create courses within this. We mentor new physiotherapists. People who have been involved for a long time just volunteer and mentor people. We were trying to get together a research grant. I don’t think that has come all the way through yet.
The other big thing that we’re trying to do is to collaborate with other groups, because we know pain crosses into everything: orthopedics, wellness health, neuroscience, all those different areas. I’m happy to see that the American Physical Therapy Association is moving forward with this. It can be a bit of a rocky path to creating this because there are still some people who will have dated views of pain.
It will be really interesting to see what happens at the APTA, at the American Physical Therapy Association because there is definitely a belief that pain is a through line in all of what we do, whether you work in pediatrics, whether you work in orthopedics, whether you work in neurology, whether you work in geriatrics. I can see some of the sections of APTA saying, “We already talk about pain in the various places,” versus, “Why does this need to be its own section in the States?” It will be really interesting to see how it plays out. Thanks for sharing your story because I think it’s an interesting one. I’d be curious to see if it moves a little faster here in the States or if it gets marred down by opinion and red tape, as they say, or people’s outdated principles on what pain is and how it informs not only PT practice but a lot of other clinician’s practice as well.
You mentioned that you’ve worked with both practitioners and patients. Can you tell me how the message around chronic pain should be different or how your messaging is different when you talk to someone with chronic pain or when you talk to a practitioner who’s interested in developing a practice around treating people with chronic pain?
I think there are so many differences, but let me just focus on one. When we’re talking with practitioners, I think we really need to start with education around what we know about the science of pain, expanding understanding that pain influences every aspect of us. The flip side of that is that we can actually use every aspect of ourselves to change pain. The body is an amazing way to change pain. That actually is an interesting thing that some practitioners when they hear about this pain science, they think that we’re saying we should stop treating the body. No, there’s a massive door into, if we’re talking about the nervous system, to change the nervous system. I think when we talk with the academics or the practitioners, what we need to do is we need to do what you and I are doing right now, just talking.
When we’re working with people in pain, I think we need to recognize that although people need knowledge and they need education, they may not be well-trained in learning this way. Those of us who are practitioners went through years of school and we’re actually learning as a skill or learning different ways as a skill. We’ve often learned by having somebody talk at us or learn by reading a book. When we’re providing this education to people in pain, we need to recognize that this person may not learn very well that way. For a lot of the people we work with, we have to say kinesthetic learning is the most powerful thing. Kinesthetic means having to do with movement in the body. What we may need to do is use movement and exercise and the manual therapies that we do, which involves movement of the body of course, as an educational tool.
Say I’m trying to explain to you and tell you that pain is changeable. I could go through it and I could tell you all the science about the fact that pain is something we can change. I should step back and say one of the biggest misunderstandings about pain is we still have this idea that pain is immutable; there’s nothing I can do about it or there’s nothing that can be done about it. If I had this tissue injury, there’s nothing that can be done. I could sit here and tell you all about the fact that pain is changeable and you might get it, but with a person in pain, what I might need to do is actually get them to do something with their body where they can have an experience that the pain changed.
Say as a manual therapist, a person has a neck pain and have gone through assessment and decided to do some manual therapy things on their neck. Say I’m just moving the joints around a little bit. If at the end of that the person says, “That’s nice. I can move my neck better and actually it doesn’t hurt so much when I do it.” What I need to do at that point in terms of education is use this as an educational opportunity that the pain is changeable. That’s so easy to say, “That’s so awesome. Your pain changed, that’s so great.” People in pain need to get this message because often what happens at the end of that is the person thinks, “You can change my pain.” That’s right, but the point is that “Your pain is changeable” is a more powerful useful thing to learn by that. I think what we need to start to do especially in our physical therapy world is use movement and the effects of manual therapy as an educational tool. Let the person experience the change and then talk to them about why that would make sense and how we’re going to make that even better as time goes on, rather than sitting them down and having a talk with them.
If we look at the clinicians versus patients again, I think most clinicians can pick it up just by us talking to them. Whereas a lot of times people in pain need to experience it and hear it, and experience it some more and hear it some more, or maybe read it in a book or watch it on a video. It’s so personal, the pain is so personal in a body, it’s almost like we need to experience it in so many different ways.
Which can be interesting because we’re really asking people to keep confronting it in some ways, to keep at it in a lot of ways, but keep confronting how you can continue to bring this knowledge into your life. Eventually, it may be session three or maybe session 30, but you’re going to see a change happen eventually in some way. As soon as you see that change happen, that change could just be really small, but it tells you or it informs you that there is hope there. If I can change it just a little bit that means that a month from now I can change maybe a lot of it.
You said something that was brilliant. I had this conversation with a PT a couple of months ago who asked me, “Do you think it’s possible to alleviate pain without movement?” I said, “I think it’s possible but it’s not probable.” If you really want to alleviate pain 100% and return to an active life where your activity level increases, where you’re able to do more daily activity, where you’re able to return to the gym or basic yoga class or whatever your goal is, I think that you can’t just talk the pain away. I think there is a part of it, obviously there’s an educational piece that is cognitive that is crucial for all practitioners. However, I think what you said was brilliant, that movement is another window into the nervous system. People don’t quite look at it that way because they still look at movement as a nuts and bolts activity.
Even if we look at mindfulness meditation, there’s still movement in there. I wish they had more but there is still movement in there. If we look at Cognitive Behavioral Therapy for people who have chronic pain, when we look at the research, the people who get better best are the ones who do CBT along with movement. If we look at the research around pain education, the pain education can help but when you tie it in with the movement program, it does way better. We can look at this all over and if we borrow from David Butler, he doesn’t attribute it to himself, he says he heard it somewhere else, the idea that you have a medicine cabinet inside you. That’s one of his comments. I would say is if you want to think about how is the best way to open up that medicine cabinet, it’s through movement. Movement isn’t just about the body. When we can move better, it changes how we feel about ourselves and allows us to interact with people again. All of those things, for the science-y people listening, it’s going to change your macrophages and give you more beta input and it’s going to change your anterior cingulate cortex, all these aspects of you. We’ve got evidence that says that moving with ease gives you benefits from multiple or pretty much every aspect of your existence. Whereas we normally thought about the reason that movement works is because it’s making you stronger or more flexible. It’s really unfortunate when you still read most of this scientific literature and when they talk about movement, they nearly always talk about it from that very biomechanical, didn’t increase the strength and flexibility, science to that.
I tell patients all the time that as you start to move and now you can go to the store or go to the grocery store or the mall, and as your external environment changes, your internal environment changes as well. It changes both structurally and of course in your brain as well as chemically, so different chemicals, the medicine cabinet in your brain, which is so important for people to realize that it’s not just about strength and flexibility, although that is important.
I don’t know if you ever heard of Dr. Sluka on your program. Some of her recent research is phenomenal; looking at these cells called macrophages, which are part of the immune system. It’s really fascinating. So many people, when they start to move again when they haven’t been able to because of pain, there’s that initial increase in pain. Her research has actually been able to show that is actually a cellular process. When you first start to move, these particular macrophages thing create more inflammatory chemistry, which makes your nervous system wind up. When you consistently do it longer than that, then it actually can start to decrease it. That was so fascinating because a lot of people attributed that initial increase to other things like muscle by-products or even psychology. I love that word hope. It gives us hope that the first increase in movement often increases the pain, and to have hope to say, “If I can stick with this, I can find the right way and continue to do it with some ease, then that’s going to change too.” That will change the chemistry in a positive lasting way.
Beautifully said from a physiologic perspective as well as from a practical perspective, which I think is so important for the practitioners who listen to the podcast. I’ve been talking to Neil Pearson. He is a physiotherapist or in the United States we say physical therapist. He’s also a yoga therapist as well. Neil, can you tell everyone where they can find out more information about you and all the great things you have going on?
I have a website, www.LifeIsNow.ca. If you go to the website, you can find things on there about the pain care and yoga things that I do. If you’ve got pain, I would say the best thing to do is go to the free open access stuff, at bottom left-hand corner and it’s called First Five Steps Are Free. I think that’s probably the place where everyone accessing my website should start there. It tells you what this is about and introduces you to these ideas.
I want to thank Neil for being on the podcast. Check him out at LifeIsNow.ca. Scroll down to the bottom and you’ll see the First Five Steps Are Free. You can click on there for some great free information. I thank you for all being with me. Please share this information out with your friends and family. Hop on over to iTunes and give us a five-star review if you like Neil’s talk today and some of the information that we’re dealing out to the world that’s free and great information about pain science and pain care. Thanks very much. I’ll see you next week on the podcast.
About Neil Pearson
Neil Pearson is a physiotherapist, and Adjunct Professor at University of British Columbia. He is founding chair of the Canadian Physiotherapy Pain Science division, the first PT to receive the Canadian Pain Society’s Excellence in Interprofessional Pain Education award, a previous Director with Pain BC, and has worked for the Doctors of British Columbia to develop and deliver Continuing Medical Educatiton on pain management.
Neil is also a yoga therapist, certified with International Association of Yoga Therapists, and a Yoga Alliance Certified Education Provider. He developed the Pain Care Yoga certificate training program, and has created a series of videos based on the integration of pain science, the lived experience of pain, and yoga.
Neil’s main focus now is expanding his ability to share what he has learned from people in pain as a physiotherapist and yoga teacher and self-professed pain science geek. He offers a professional-distance mentorship program for practitioners working with people in pain, and has developed an online pain education and movement curriculum for people in pain – including his First 5 Steps open access program. Through these and the growing number of Pain Care Yoga teachers he hopes to increase the ability of people living in pain to move and live with more ease.
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