Helping A World Of Hurt with Annie O’Connor, MSPT

Welcome back to the Healing Pain Podcast with Annie O’Connor, MSPT

This episode will serve both the clinician who treats pain as well as patients who suffer from musculoskeletal pain through education about pain mechanisms and the active care necessary to recover. Orthopedic clinical specialist Annie O’Connor lectures nationally and internationally on the Pain Mechanism Classification System, neurodynamic evaluation and treatment, mechanical diagnosis and therapy of spine and extremities, kinetic chain evaluation, and exercise prescription as represented in the book, A World of Hurt, which she co-authored. Annie provides three amazing tools to explain pain mechanisms. She walks us through what these are, how to use them, and what they mean.

This episode will serve both the clinician who treats pain as well as patients who suffer from musculoskeletal pain through education about pain mechanisms and the active care necessary to recover. My expert guest is Annie O’Connor. She is a physical therapist. She has earned the title of Orthopedic Clinical Specialist, which is a board specialization through the American Physical Therapy Association. She is also the Chief Clinical Officer for the Musculoskeletal Partnership at the Shirley Ryan Ability Lab, formerly known as the Rehab Institute of Chicago. She co-authored an incredible book called A World of Hurt: A Guide To Classifying Pain, which offers a research supported paradigm shift in managing musculoskeletal pain by promoting effective and efficient outcomes. Annie lectures nationally and internationally on the Pain Mechanism Classification System, neurodynamic evaluation and treatment, mechanical diagnosis and therapy of spine and extremities, kinetic chain evaluation, and exercise prescription as represented in the book, A World of Hurt.

If you’ve been following this show, you’ll know that I have had on probably some of the world’s top practitioners and researchers in the field of pain. If you stick with this interview, I know that you’ll agree that this episode is perhaps the best because Annie’s able to hold the space as a pain researcher, a master clinician and a humanitarian. That’s why I believe this episode is so great. To accompany this episode, Annie has provided three amazing tools but I highly recommend you download so you can follow along with the training. The first is called the Yellow Flag Risk Form. These are thirteen questions that can help you identify which domain to target in the care of pain. The next is the Activity Traffic Light, which is a teaching tool and a guide to safe movement when you have pain. The last is what’s called the Lamp Analogy, which can be used to explain pain mechanisms in a way that is simple and easy.

On this episode, she will talk me through what these three forms are and how to use them and what they mean. Make sure you take the time to download it. To download it, all you have to do is go to or you can pick up your phone and you can text, 117Download, to the number 44222. Take the time to download the three free handouts before you begin. I know that you’ll love Annie, you’ll love her work and you’ll love her passion as much as I do. Let’s begin and meet the incredible Annie O’Connor.


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Helping A World Of Hurt with Annie O’Connor, MSPT

Annie, welcome to the show. It’s great to have you here.

Thank you so much for having me. I’m honored.

You wrote an amazing book called A World of Hurt and it’s a world of information for any practitioner who’s interested in learning about pain and chronic pain in all shapes, sizes and forms. You and I were talking about how many years you’ve been practicing. You’re practicing about 34 years and you’re working at the Shirley Ryan Ability Lab, which used to be the Rehab Institute of Chicago. Just tell everyone a little bit about your trajectory and how you stepped into the world of physical therapy and treating people with pain.

As you and I were talking about, that gets everybody into their career and then you realize at some point you’re either going to stay with that or you’re going to move out of that. Myself, I had to go to a physical therapist. A funny story on how I got into physical therapy was being the oldest of five kids and parents that were basically just making it. They were never going to allow their oldest child to go to school on sports scholarships. It just wasn’t going to happen. I distinctly remember the day my mom said to me, “I know you’re gifted in these sports and you’re going through this rehab with the sports people, but you need to have a direction. You’re not going to college because people want you to play sports.” At the time I was rehabbing a knee injury, etc. I had started to pay attention a little more to what was my surroundings and realizing, “What a great chance this is. These people, they’re wearing sweat suits. They’re working out with athletes.”

I’m inquiring a little bit more about the services that I was seeking. They said, “We’re physical therapists.” I didn’t even know what I was going to. I was just told to go. I remember that day I’d come home and I said, “I know what I want to be. I want to be a physical therapist.” My mom is elated. Being a nurse, she thinks this is great. I come to discover how difficult it is to get into physical therapy school. Fortunately, for my sports acumen that I had and the swim coach wanted me there. The next thing I know, I received a letter that I was in the physical therapy program. My journey into physical therapy probably was out of some necessity to go play sports at college but then deeply changed into a passion to want to serve people. That probably is the funny story about it. The next funny story of that is I would only have it that I was going to work at that time was the Rehabilitation Institute of Chicago. I remember showing up that day, it was like a cattle call to apply for jobs.

You didn’t have resumes and CVs and interviews. You showed up and there were 45 people waiting in line for a fifteen-minute segue to hopefully get the one or two jobs that were available because they were a very popular employer. I’ll never forget when I was being interviewed at that time, the guy was like, “We don’t take new graduates on our spinal cord floor and I only wanted to do spinal cord.” I said, “What’s it going to take for me to be employed with you? I’ll work in food service. I’ll do whatever it’s going to take because I want to work for the number one Rehab Institute.” He liked my spunk or God wanted me to be there. The next thing I know, I’m working for the Rehab Institute of Chicago and been there for 33 straight years, entering my 34th year and they have never given me a reason to leave. More importantly, they’ve shown me about every level of service for pain-related disability and functional disability that you could imagine. With that, they’ve nurtured young clinician into being sometimes a powerhouse teacher just because of the experiences that they’ve awarded me.

I would tell you that through that there’s been a lot of changes. You get very frustrated that you think your skills and your knowledge are going to cut it. I totally realize that it doesn’t. Then you seek because you think you’re not smart enough so get another degree, get another certification, go to another continuing ed course, stock another master clinician to realize, “That doesn’t work. Maybe I should just go into management because that’s what this degree was about.” I’ll never forget the 1995 Combined Sections, David Butler speaking about Pain Mechanism. That day I knew as he was explaining that there are six reasons why people hurt. I was like, “This is it. This is where that works. This is why that works. This is where this fits in. No wonder he can write a book about that because that works for this.” It was the largest a-ha moment I’ve had. Since 1997, we’ve been on track to put Pain Mechanism Classification into servicing pain specificity and functional disability. Three books later, three training manuals later, all of a sudden you have a published book. That’s been a whirlwind for me. That gives you a short synopsis over a very long career.

It’s a wonderful introduction. What I love about a podcast is not only do I get to interview great people, but I also discovered I have so much in common with my peers. You and I are physical therapists. We both started our career in adult rehab at major teaching hospitals. We both have moms that are nurses. We’re both collegiate athletes. I’ve been a PT since 1996. I do a lot of continuing education. When you’re in a longer career, you go through a lot of honeymoon phases with different things before you get married and then you say there’s no perfect way potentially. I have all these different things that I can pull from that that help you when you start to figure things out. You said something that a light bulb went off of my head. You said when you started practicing, that new graduates were not allowed on the spinal cord injury floor.

It’s funny because I started out at a small teaching hospital here in New York City, which is now closed. It’s called St. Vincent’s Medical Center. They had the best inpatient/outpatient rehab facility because it was a level one trauma center. There are a lot of great interesting things, you’ve got to hone your skills. When I graduated in 1996, 1997, there was this underlying current of before you go into private practice, you should first work in an adult rehab. See everything you can possibly see in adult rehab before you go venture out into outpatient physical therapy. I’m not so sure that we still have that current now because a lot of PT graduates go right into outpatient. I’m wondering if you can comment on that and what your thoughts and opinions are on taking our training from our DPT now? Should you first be exposed to acute care and inpatient rehab before you go into outpatient private practice?

That’s a great observation too. You’re right. We did not hire new grads on any of our inpatient floors especially spinal cord and we were most known for that. Our most experienced clinicians were there, which was a blessing for me. I’m a young clinician and I am working with high-end therapists that have been doing this for a long time. 2018, we’re all new grads on the inpatient floors. It’s a rarity to have someone with five years of experience on that floor or if they are, they’re probably in the management role, so that is a split. Going out into the outpatient world, you need to have a grounding of everything. You need to know acute care situations and vitals and how to manage possible red flag situations and what they are and how sneaky they look sometimes. You need to understand suffering and the Yellow Flags that are going on and how everybody is on their facade to look like everything’s great. As enticing as the outpatient is, because of the other time and things of that nature, it yields a need for greater levels of experience.

HPP 117 | Pain Mechanisms
A World of Hurt: A Guide to Classifying Pain

That’s partly what some of the problems that we deal with. We have very young clinicians in our outpatient facilities who don’t have that level of grounding or experience. They may have gone to three outpatient affiliations and they’re not even sure on how to take vitals and things like that. I believe that we’re not as well-equipped with clinical training as we are right now being with great administrators, great researchers and great educators. We don’t have that grounding of clinical training. It’s been interesting, I’ve been doing a little more teaching at the university level. I’m a postgraduate teacher and experienced clinician. That’s where my giftedness is in. I’m teaching now students and I have this a-ha moment like, “These clinicians aren’t ready to be clinicians. How do we do that?” We’ve advanced our degrees, but we haven’t advanced our clinical savviness. There’s a disconnect there. I’m not sure what the answer is but I can tell you that the solution is to get more clinicians involved in university teaching.

I know the group that has brought me in and I’m enjoying it. I bring live demos all the time. I’m bringing patients with me all the time because they need to see applied principles into everything. I bring patients with spasticity in there because we use Pain Mechanism Classification to manage spasticity. I bring chronic pain in there because they need to know how to have a tough discussion about Yellow Flags and how do explain protective roles of the brain. They need to see that because that’s what they’re going to be doing. They’re not just going to be going in there and running around doing little functional exercises. You certainly at this day and age of payer performance, with the new payer system going out where you’re going to get a per capita rate and you better be effectively efficient, you’re going to have six visits. You don’t have the chance anymore to do like we did when we came out of school, “You can go to PT as long as you want and everything.” It was endless, we have the ultrasound, the massage. We have few exercises three days a week.

You said something and I want to get to some of the important handouts you have, which are great that you’ve given to people. You threw a statement down there that I’m not even sure you said, but I want to pull it back into our topic here. You said, “You need to understand suffering first,” which gives me goosebumps because if you’re a physical therapist graduating now and maybe you did your affiliations where you did one into inpatient and one in rehab, but you knew you wanted to go into outpatient. My question is if you don’t spend a little bit of time beyond your affiliation, working with patients who are more chronic and potentially maybe sicker and potentially maybe even terminal, do you not fully grasp the full spectrum of human suffering?

I don’t think we will ever fully grasp that because it’s an individual situation. The word suffering alone is a debatable word. People feel like, “We shouldn’t be talking about suffering and the pain experience.” I’m not on that one. This person’s hurting. You can’t see what’s going on within them, but you can hear that things aren’t going well. Our ability to listen and we have to screen. That’s why I love that Yellow Flag Risk Form because it’s going to take a quick screening of the known suffering relative to pain. It allows you to have a tough discussion about it because they’ve answered the question, they’ve invited you in. As a clinician, you have to be delicate about asking that. I don’t think of people in pain, I think of people in suffering. We use pain as a catchword, but they wouldn’t be coming to you for the pain. They’re not coming to because of the functional issues. They’re coming to you because they’re suffering. As a new grad, the clinicians that I get to teach now, the younger ones, I’m like, “I understand why they’re coming.” They’re not coming for pain, they’re not coming for function and they’re not coming for massage. They’re struggling and they’re suffering and you’re now in a place to walk with that person.

Give us an overview of what is the latest science telling us that we should prioritize as far as pain education goes.

The biggest thing that is how we explain the brain’s role in pain. This isn’t new stuff. In the early ‘90s, we were very aware with explained pain and movement, “The brain.” How we went about that may have not been as advantageous as we thought. In these coming times, a second movement with pain science says, “No, you’ve got to get into the actual mechanisms that are involved in the brain.” As we collaborate, I work with a great pain researcher, Marwan Baliki. It’s been so interesting to work side by side the clinician and pain researcher. Here we wrote a book identifying these three mechanisms: central sensitivity, affective, motor/autonomic. Then he’s over here validating three different areas of the brain through fMRI brain physiology where that could be dominating in patients’ suffering.

When we finally got together and we are like, “We’re talking the same thing.” I’m like, “I don’t need an fMRI to pick up what that is though, but I can validate your thinking relative to these characteristics.” I’m like, “Let’s go, we need to do this.” When we get to the patient level of that, we need to have the patient understand that your brain was wired to protect you. It was wired to protect you and that pain is not a punishment mechanism, it is a protective mechanism. This is a normal situation. It’s working in you and I right here, talking right now. Be it that relative to what’s going on and the suffering that’s going on within your life. Certain sections of your brain have elected to be in a more protective mode than others. I can’t be blanketing my care in chronic pain and assuming that everything will work out just fine. Those that have been suffering for a while know this already because they’ve been through all that. They’re ripe and ready to go, “Interesting.”

I said this would be no different if you came in with a bad bacterial infection coughing and sputum up the green stuff. I send you home with the Amoxicillin because that’s going to get that virus. You come back to me in two weeks and you’re still as sick as a dog and I try to sell you Amoxicillin again. You’d look at me like I got a third eye. You’d say, “Doc, the Amoxicillin is not working. Let’s try Penicillin.” I would have to agree that I didn’t get the right intervention for the right mechanism. Getting the patients to understand that there are three different types of mechanisms within the brain is important in itself. They’re all there to protect and they protect for different reasons. For us to identify which one is dominating is going to be critical to changing the pattern of the suffering. Then we’re ready to put the Lamp document up there and try to give them a bigger picture or we’re ready to start talking about the three different mechanisms.

Let’s talk about the Yellow Flag Risk Form. Walk us through what this is and how it works. Why it’s beneficial and who should use it and all the good things that we have here.

What’s unique about the Yellow Flag, it’s been around for about 25 to 30 years. George Linton put it together because he was frustrated that we had too many forms. That’s such a funny story because if anybody’s working in a robust healthcare system now, you’re frustrated because we have too many forms. You have to understand, this was 25 to 30 years ago. At the time we knew that there were domains within the Yellow Flag for persistent pain that were relative to people’s suffering. Those domains were quite simply sheer avoidance behavior domain, emotional social domain, confidence in managing condition and pain control and hope to get back to activity, so self-efficacy domain. Those three primary domains 25 to 30 years ago dominated suffering. If we went into the chronic pain literature now, we would say the same exact thing. We haven’t changed.

What George did at that time which was brilliant is he said, “I’ll take a few questions from the FABQ. I’ll take two emotional social questions, I’ll take some self-efficacy questions. I’m going to draft it into thirteen. I’m not putting any body parts on here because it isn’t about the body part. It’s about the suffering and we’re going to rock this and we’ll use it as a screening form.” What we’ve come to learn is we’re having a paper come out where we’re showing the Yellow Flag Risk Form to be as robust as any functional measure out there. It can be used to classify two of the three pain mechanisms that we know exist within the brain. It can be used as a screening tool to whether or not you should be taking a so-called top-down approach with your patient in the sense of pain science education. That’s a little history of it. It’s made up to do that for you. It scores over 130. You basically go through the form and add up their score.

HPP 117 | Pain Mechanisms
We’ve advanced our degrees, but we haven’t advanced our clinical savviness.

Question number three is the only one. It’s an outlier question. If you look at that one, you’d see that all tens were terrible or the worst and then all of a sudden, ten here seems to be the best. What you have to do in order to score that question is take their circles. If they circle six, you go ten minus six equals four then, therefore, the score of that question would be four. It’s accumulative once you come out with your total score. What we know about the total score is patients that score less than 50 have low central nervous system characteristics and their perceived suffering is low. Therefore, you as a physical therapist, occupational therapist, chiro, and movement specialists should be confident about taking a movement-based approach. We should be looking for nociception to be dominating that mechanism of suffering. Thereby, we want to be very succinct with the type of exercises that we’re doing with people.

However, once we know the scores now are 51 to 64, we know they’re at moderate risk. Meaning there are essential characteristics, there are perceived suffering that are relative to these domains. Your effectiveness in your exercise could be less. Your effectiveness in your surgery could be less. The interventions of injections could be less because now you’re working with someone who is probably a little bit more centrally-dominated. Then we know that the patients that are scoring over 65 are at significant risk of dominated central nervous system mechanism. A top-down approach would be highly warranted and getting into the domains of their suffering would be would be needed. We color-coded it for you. Your questions nine, eleven, twelve and thirteen are all your fear avoidance questions. We know when patients score high on these questions, they are dominated by central sensitivity. We gave you a little bit of that in the document just to give you some idea of what you’re dealing with. We know that those patients would definitely need the Traffic Light Guide as the best piece of pain science education.

We’ve been studying this thing for too long and we know that when the patients are dominated by questions three and four and six and eight, they’re dealing with confidence. Whether it’s confidence in their ability, confidence in pain control, confidence in managing their condition, confidence in their general health, you as a therapist need to start moving your treatment toward building their stuff out so far because you have the confidence. Lastly the emotional domain, questions five and seven. Depression and anxiety, we know where patients are scoring high in the domain, especially in our system, if they’re scoring above seven. We may want to run a pass of the pain anxiety symptoms scale or a PHQ-9 and start appreciating whether psychology should be involved within this picture on top of good non-pharmacy coping. What the Yellow Flag does is it’s like a GPS for your pain science education.

What we’ve seen after studying are patterns. When we see the central sensitivity pattern, they score high on nine, eleven, twelve and thirteen. When we see the effective mechanism, they score high on three, four, five, six, seven, and eight. Those domains blow up we know what we’re dealing in the dominating mechanism. What has been so unique in some of the research that’s coming out this year that we’re sharing with people, albeit it’s a low sample but it’s definitely launched us into a grant. We can correlate the pattern of the Yellow Flag Risk Form, the central characteristics that we’ve been studying and presenting in those books in chapters six and seven, specifically and the brain physiology of the different centers of the brain through fMRI. This will be one of the first studies where you see characteristics and patterns on the outcome measure correlate with brain physiology and chronic pain. It’s very exciting times for us but I can’t speak enough of how thirteen little questions and it’s got an MDC of 11.95. If you’re making some green changes, you know that you’re statistically significant in changing that suffering. That gives you a little preview of that.

It’s an amazing work. Right now, me, as well as other physical therapists, are probably using anywhere between two to eight forms, maybe ten if you dig into it. Let me play devil’s advocate for a minute. One of the more common ones is the Pain Catastrophizing Scale, the PCS. In these thirteen questions, would you pick up the data similar to the PCS?

The pain catastrophizing scale is similar to fear avoidance and central sensitivity. When we talk about central sensitivity as the overprotective mechanism where our words and thoughts and the way we analyze, “Is this safer? Is this dangerous?” is now having an effect on the descending inhibitory system. We know that’s through sometimes the language that they use or sometimes the way they’re analyzing. In this, you would pick that up in questions nine, eleven, twelve, and thirteen and through avoidance. Those would be your questions that would be very similar to that scale. Another part of the paper that’s coming out, it was a five-part study. We put the Yellow Flag up against the PDI, the Pain Disability Index, the CSI, the Catastrophizing Symptom Index, put it up against the PASS, the CES-D 10, a depression scale, and what it was showing is it was as sensitive and as robust to pick up those sensitivities of those outcome measures just with one tool.

It is a scary time when you can almost statistically say one tool could do it all. It was just as robust as the ODI, the NDI, the lower extremity functional scale, the DASH. In fact, the Yellow Flag score have an equation to predict the DASH and the lower extremity functional scale score. We know it can represent not only the low-risk group who are very exercise-based but the high-risk group which are very suffering-based. We’re very excited about that potential, that’s why part of our future research is putting it up more and more against other forms. We’ve got an active study going right now in Canada where it’s comparing it to ODI and STarT Back, in a large sample back. That’s where we opened up on, “We’re treating suffering,” and suffering has been termed Yellow Flag and suffering of the Yellow Flags is defined as certain domains. This is unchanged over 30 years. What we’re not doing in the biopsychosocial approach and in our pain neuroscience, whatever our new buzzword is, is we’re not getting into, “What do I train?”

That’s what I love about what we’ve been doing is going, “If nine, eleven and twelve are high, this person doesn’t know how to analyze movement safe pain.” They’re dominated by central sensitivity. They’re thinking everything is dangerous. We need to give them a credible analytical way to measure “Is this safe or not?” People that are dominated by central sensitivity are very intelligent people. They are very analytical people. They have taught themselves how to ignore and distract which only pushes the brain into more protection. If you ignore a screaming child, what does the child do? It screams more. We don’t want to teach that, but these patients are dominated by that mechanism who will score high on that form. They are intelligent, analytical people who have taught themselves to distract and ignore which put the system into more sensitivity. Beyond that, they have willpower greater than anybody you’ve ever seen. They live in a yellow light, but they think it’s a red light.

Retraining them cognitively and behaviorally and functionally through the Traffic Light Guide, you’ll see huge changes out of their suffering just by getting them to understand what movement safe pain is. A person who needs confidence in managing their condition and pain control, they may have elements of fear avoidance, they may have a low domain there. They probably won’t respond to a Traffic Light Guide education session. I’m not saying it’s not worth your time but don’t expect big changes in that domain. As if you were to use important and confident scales to understand or their confidence and diaphragm breathing during painful times and managing their control over opioids. How they manage their condition, how they understand their condition, how they’re working on their general health. There are different things relative to different domains.

As I look at this, would you recommend a practitioner uses that at the initial evaluation? Should they potentially use it half way and then at the end?

HPP 117 | Pain Mechanisms
You as a physical therapist, occupational therapist, chiro, and movement specialist, should be confident about taking a movement-based approach.

We use this every two weeks. I’ve done this every week. I’ve retested their domain after a session of therapy to see if my education affected the way they’re perceiving their suffering. Right now, our standard of care in our practice is to use it every two weeks. We don’t have time in visits anymore to say, “Am I affecting them with the education in the movement plan that I have brought about?” We consider this form is how we’re tapping into suffering. We consider this form is how it’s guiding us for our pain science education or other cognitive interventions. Thereby, it is a form that we hold higher in its repeatedness within our care. Our lower extremity functional scale, we’ll do one at initial, we’ll do one every month. The only time we ever use the FABQ at this point is in workcamp or athletes because we know that this form, the fear avoidance section, is not sensitive enough for workcamp. The reason why is it doesn’t delineate the fear avoidance behaviors between work activity and physical activity.

If we have workcamps or athletes who are on disability, we will probably team that up. One, you’re going to see them score high in that domain but two, we’re probably going to also do a FABQ to understand, “Is it the fear of physical activity or is the fear of the sport or work activity?” This is important because we talked also about the pain science is trying to tell us, “You need to do better at explaining gradual exposure and what to gradually expose them to.” I love when people say, “The literature says gradual exposure.” To what? Not to Pilates and core therapy. It’s asking us relative to the dominating mechanism. If you’re in a fear avoidance situation you’re going at the avoiding activities. If the avoiding activities that are work related, how are you going to know that? Your FABQ in a workcamp situation would be far more sensitive to pull that out for you to design that gradual exposure program.

Speaking of movement, we’ll hop over to Activity Traffic Light because they intertwine.

The pain science literature if I said what’s the second thing outside of explaining Pain Mechanism and the protectiveness of the brain and the three different levels of the brain? The second thing it’s asking us to do is explain Movement Safe Pain. It’s asking us to return the control to the patient of, “Is what I’m doing safe and should I keep doing it? Is it something I’m doing too much too fast and I need to pace myself? Or no, is this presenting as a harmful situation and I should be stopping?” We do not want to get into the situation that we as a practitioner are telling people what safe or not safe. You’re not returning locus of control for them.

Often you know that you have a patient that’s doing this to you because they say, “Should I do this?” or “Do you think I should be doing this?” We get trapped as a provider and go, “Yes, you’re good.” You need to take that as a lead and say, “No. I’ve got to set them up to do their own analysis.” Because central sensitivity, intelligent analytical people, you need to turn that over to them. This is a beautiful way of cognitive exercise. I can’t tell you how many people I send home with a Traffic Light Guide in their lower extremity functional scale and say, “By the next visit, I want you to take all those moderately difficult activities and I want you to tell me what the light is.”

The great way to expose people, aren’t they?

Yes. You just need to think about it. In our book, we used to call it The Activity Pyramid and we had patients that tell us that they hated The Activity Pyramid and said, “You need to put this into a Traffic Light Guide because a Traffic Light Guide is the way people make decisions.” I was like, “This is brilliant.” We had this guy who was going through our program basically design this, relative to the education that we were giving them. Basically, all you got are the three lights, red, green, and yellow. You’ve got an area at the top where you’re asking people to baseline their pains. Whether their pain normally is at a ten or a seven or thirteen or whatever they like to put it at. Then we’ll also like to identify what we call is a harm check. A harm check is simply something outside of your pain that you can use every day that tells you, “If this doesn’t change, then I know that my condition is unchanged.”

It may be a range motion at a certain body segment. It may be a function: brushing your teeth, putting your underwear on or anything of that nature. What you need to understand about harm check is that it needs to come from the patients because they have to be confident in doing it. It has to be related to the body part that you’re working with. Once you come up with that, then it’s a simple form. You’re picking up the activities that they want to return to and then you’re starting to introduce those activities and you’re starting to look at how the pain behaves during the activity and after so that you can analytically say, “Are those symptoms that I’m incurring during that activity safe or are they presenting as a red light?” What I love about the thing, the number one check on each of those boxes is, “Did you lose any change in your range motion or function?” Immediately, we’re getting people off of how the pain behaves into the effect it had on the function or the motion.

We always say that that is more credible than the pain. Pain lies but motion doesn’t. If you can get patients to say, “I know it hurts but your motion is no different and your function is no different.” The only way you can be a red is if you lost 50% of that ability. If they’re no different then the only thing you can be is a yellow or green and both of them are safe. You’ve done no harm. Then we can start to look through, “Is it a pace situation or a push situation?” Yellow would be, “A little too much too fast. It’s safe but we’re going to pace this.” Green would be, “This is good to go, safe. We’re going to push this and add more. Keep going.” It gives you that idea of breaking it down. That’s what the second and the third steps are is how it persists or is it back to baseline quickly. The A, B and C on there are to recognize that people are different parts of their journey.

We can use this with acute situations that are four to eight weeks long or we can use these in a sub-acute eight to sixteen or we can use this in the chronic where it’s sixteen and greater. The only thing I always like to point out when I’m working with someone is the longer you’ve had it, look at how much longer it will allow you to be sore after the activity. You’re safe but you’re sore and then it gives a great action plan. We tag the patient with applying this and all you’ve got there is, everything I just said is detailed and written out. We want that per patient like a Broadway script so that they can feel and they can go in there and answer their own questions. This is about returning the control to the patient.

HPP 117 | Pain Mechanisms
People that are dominated by central sensitivity are very analytical. They have taught themselves how to ignore and distract which only pushes the brain into more protection.

It’s a great tool to use in the patients. You have an activity hierarchy here. It is great what you’ve created. In a way that’s simple and easy to use for, which is great for the practitioner as well as the client.

When your patients make your patient education materials for you, you probably realize you’ve got a gold standard.

It’s funny you say that because it also points to the fact that as practitioners, we should be collaborating with our patients more.

We’re in a partnership. The best partnership ever is the pilot and co-pilot. Anybody’s watching Sully these days, it was the epitome of what it takes. We are the co-pilot, not the pilots.

We’ve got one more awesome thing here that you’ve created.

This is the way we start to introduce how we get pain. The pain science literature is very much about like we have got to explain pain. We’ve got to explain the pain alarm system. As we enter in the brain’s role in pain, we have to be succinct with these three different mechanisms. This was a piece of material that came from my dad and a very funny story. Just to go through the document before we go into those funny stories is we always thought that there are five steps to a pain-free life. It’s very similar to how you would get your lamp to work. If you walked in your room, you flipped on your lamp and your lamp didn’t work. You’d go through a series of steps to figure out why that lamp didn’t work. The same analogy should be taken when your body’s hurting. We should go through a series of steps to identify what mechanism is at play too why I hurt.

It’s similar. When your lamp doesn’t work. Step one is to check the light bulb and check the switch on the wall. What is that in the body part, was there a sign of injury and is there the presence of inflammation? Is this inflammation chemical or is it mechanical? It’s got directional preference? If it’s not an inflammatory mechanism, is it an ischemic mechanism where the body itself just needs to be pushed harder with progressive exercise. Whether that be stretching or strength training or functional-based or motor control-based. If you’re working through that and those exercises are not seeming to have an effect, then we know we need to start to consider step two. Step two would be, “Maybe it’s not so much the body part. Maybe it’s the nerve going to the body part.” In that sense, it’s a referred situation, it’s a peripheral nervous situation. Either that nerve is getting trapped somewhere, whether it be at the spine or a muscle along its path or it’s gotten tight like any other tissue and it needs to be utilizing a neuro-dynamic approach in order to affect its health.

That wouldn’t be any different in the lamp that like it wasn’t the bulbs or the switch, it was the cord. Those are the things that we can see and we find tangible and we like the MRIs because they maybe correlate with us. If we’re doing these neuro-dynamic exercises and these progressive exercises and things are not working. They’re starting to score high in the Yellow Flag and they’re showing you a discrete pattern in the Yellow Flag. We’ve got to start working ourselves in the things that we can’t see, which lie within the brain. The three unique mechanisms that lie within the brain. I always like to use an analogy. I said, “This would be in your lamp. You know this.” How many people go to the basement on the circuit breaker? You got some good ones. They knew the sister was microwaving and blow drying the hair at the same time and blew the circuit but then you’ll be surprised at how many don’t even know about the circuit breaker. In your brain, the thalamus and the amygdala, the fear and threat centers of the brain, they’re interpreting every signal coming into the system. Every signal coming in is interpreted. Was it safe or is it dangerous?

That circuit breaker in your brain may need to flick the switch a little bit because we’re thinking that this is more dangerous when it’s safe. Now, I learned the Traffic Light Guide and I’m gradually exposing myself back to avoiding activities and I’m still hurting. We got to consider that maybe this wasn’t so much that mechanism within that part of the brain. Maybe this lies within the different part of the brain. Within the brain and the anterior cingulate, the ACC, the insula, the lateral orbitofrontal cortex or what we’d like to tell our patients is your coping center. When you’re struggling with conflict in emotions and you’re on step four and you’re struggling with conflict and social situations, know how wired your brain is to protect you when you’re not coping. When you’re not coping, it may pick certain body parts in your body and give you symptoms in a way to distract you or divert you to go get help. The issue is not in the tissue, the issue is in the brain in where you’re not coping. If I screen on a Yellow Flag and I see the pattern of self-efficacy in emotional-social struggling, I know that I’m dealing with a different mechanism. As much as the Traffic Light Guide might be helpful, my ability to help them through pain journaling, understanding, seeing the connection between emotions, stress and symptoms and guiding them into different coping mechanisms non-pharmaceutically and getting them back to some of the things that they want to do in life would be far more effective than working on a Traffic Light Guide situation.

We liken that in the lamp to, “This is your electrical provider. He’s decided to shut your electricity off. It’s going to take a call to the big guy to get your electricity back on.” The last step five, “We’ve gotten you back to great life activities. You’re coping. Your Yellow Flag Risk Form is improving and you’re still suffering?” We do have one other mechanism and it’s a very unique mechanism and it’s in the motor-sensory cortex of the brain. It’s been called all kinds of things from phantom pain to CRPS 1 and 2 to RSD. I’ve heard so many names but just the understanding that how cool it is that your brain in severe trauma sometimes or even if you think this should have been a trauma or that you elect to use words that suggest trauma or were such things that your brain will go into a protective mode where it starts to forget itself or neglect itself. It’s called cortical disinhibition or smudging if you’re reading the literature, where the brain is losing representation of the body part.

HPP 117 | Pain Mechanisms
The best partnership ever is the pilot and co-pilot.

In this unique situation, how important it is not to explain Traffic Light Guides and pain journaling, how now we need to work with the uniqueness of re-imaging the brain to the body with left-right discrimination, graded motor imagery, localization precision, graphesthesia, stereognosis, all these things to retrain that brain-body connection to the motor-sensory cortex. We liken that with at this point you called the provider. It wasn’t that. We had to go now and realize that little box on the pole lost recognition of your home and so your electricity was going to your neighbor. We had to literally send the little guy up there, run up there and re-image the home so that you could receive the electricity, so the lamp could work. In a way, we give this completeness that we’ve got to figure out the mechanism to why you hurt and not use an anatomical or a pathology-based explanation to that. We know that that will never represent three mechanisms in the brain.

The thing about pain science that people don’t understand is the science of it is extremely complicated. There are truly few people in this world who can take complex concepts like that and turn them into something that is simple, that the practitioner can relate to and the most important, the patient can relate to. People don’t realize that those three handouts you have that they can download for free are probably a PhD’s worth of information.

If I had to put the numerous amount of references that exist on that, it’s an undaunting task that I couldn’t do. One of the biggest influences in my life is the Lord. I am a very big Christian and I know He has ordained my life to do something like this. I have giftedness, it’s not coming from pride. I’ve been gifted to see the simple side to some complex situations. He’s awarded me an incredible amount of patience to do that and the institute that I worked for. Things of this come out of those situations and my mom and dad who have been so influential in what’s going on. This is the funny story behind the lamp. It took eight years to write A World of Hurt. Fortunately, if it wasn’t for Melissa Kolski, it probably wouldn’t happen because she’s the co-author and she just gets stuff done. If it existed on my table, I might have been the one that was charging it to the hospital, but she’d just get stuff done. We’re eight years getting this thing done and I’ll never forget my dad who did all the logos on every chapter. He kept going, “When are you going to get the book done? Get the book done.”

He starts reading and he’s like, “You need to have something funny to go along with this. Nobody’s going to read anything.” Then he’s reading it more and he’s an electrician by trade. He’s like, “As I see it, this is no different than a lamp.” I’m here at a dinner table one night and he’s explaining to me the lamp. He’s explaining the lamp connection to the different mechanisms. I’m sitting there listening to this man and I’m going, “That’s brilliant, dad.” He goes, “You need logos.” He draws. He’s like a jack of all trades. He starts, “I draw up some logos for you.” We’re two weeks from the publisher. The publisher has said, “Please, no more. You can’t put in more information.” I called Melissa up, “You’ve got to look at these drawings.” She loves them and the publisher’s like, “This is amazing. We’re going to have somebody illustrate these drawings.” This is the stuff. When simple people come together and try to make a complex work comes to life. The lamp came to life through dad. The Traffic Light Guide came to life through a person who suffered and understood what we were trying to do. As clinicians, we have got to open ourselves up more to having those relationships with our patients. They have the answers. They got them.

They’re taking whatever information you’re giving them and in their mind, they’re trying to make sense of it basically. It’s so important. Just me listening to all this. It’s wonderful like continuing education session and the cognitive intervention all at one. Thank you for that. If I were to ask you as we start to wrap up and talk about your book and the other things you have going on, where should the focus of our future of research and teaching go?

I can’t tell you where everyone else’s focus should be. I’ve learned to keep my opinions to myself in some respects. I do know where mine is. Mine is definitely right now into the strengths of the Yellow Flag Risk Form. We know it’s got merit. I know we’ll continue to research it and put it up against other forms and validating the central nervous system. I know Dr. Baliki and myself are motivated right now by being able to show that these characteristics are unique. These mechanisms are unique and the brain physiology goes right with it and thereby the interventions are unique and so through the match and unmatched trials will be validating the central nervous system. That’s going to be the future where we need to go for this thing called chronic pain and our persistent pain or whatever name you want to give it. I know that’s where our focus is going. I would love to see pain mechanisms become a bigger entity in the educational curriculums.

The opportunities I’ve had in physical therapy and chiropractic universities to train clinicians. The numerous emails and Thank Yous just because it’s simple. You’ve got six mechanisms. If you can now organize everything into six, your grocery cart, it could be very freeing. Instead of organizing everything by every anatomy part or every possible pathology that exists even though we have no reliability or validity with these classification systems. I’m not saying that they aren’t important. What I am saying is that we as providers need to be proficient in classifying based on anatomical when anatomical is needed, classifying by pathology when pathology is warranted. We should be just as good at classifying by mechanism and recognizing and putting that as much importance. That would be my push is that you as a provider, get good at that.

It’s been great having you on. I’ve interviewed a lot of people in all walks of life as far as pain science goes and professionals. I’ve got to say some of your information pulled together so many different areas of medicine, physical therapy, psychology, even started to get into the spiritual realm which I didn’t touch on. Maybe I can have you back on and we can talk about that. It’s great work. Please tell everyone how they can access your book, get in touch with you, tweet you to say, “This is a great podcast. Thank you so much.”

I want to thank you. I’ve been following you a little bit more now on Twitter and I love what you’re doing with foods. You and I are on these words, moves and foods, bandwagon to cure chronic pain. I just love it. First up, thank you for retweeting things from A World of Hurt. Thank you for having me on. It’s been my pleasure and I’m glad that you take some from it. If people want to get into any dynamic dialogue with me. I ask them to use A World of Hurt Gmail. It’s just [email protected] or follow us on Twitter, @WorldOfHurt2. We’re trying to get the word out. Get the information more out and we’ll have A World of Hurt website coming up soon where we put the testimonies and videos and try to give more action steps and provide all the information. It’s a movement to serve. It’s not a movement to do anything other than that.

Can they find the book on Amazon?

HPP 117 | Pain Mechanisms
When simple people come together and try to make a solution, a complex work comes to life.

The book is on Amazon or you can also go to the book’s website, Know first off that as an author, I get nothing for the book. I love writing a book where you get no money from it. All the money that I get and that you buy from the website goes back to feed the Research and Education Fund that we use to train the Pain Mechanism Classification System. First, that’s a very important thing. Whether you purchase on Amazon, those funds don’t go to feed that fund but if you do purchase directly from the book’s website and the publisher, a certain percentage of those proceeds goes to feed that fund.

It’s mostly a practitioner book but there are some things in here that are beneficial for those who have pain. Annie, thanks so much for being on the podcast. It’s a pleasure.

Thank you. It’s been a pleasure myself.

At the end of every episode, I ask each of you to make sure to share this podcast out with your friends and family and colleagues on Facebook, Twitter, LinkedIn or wherever you are social. If you’re new to the podcast hop on over to On the right-hand side, you’ll see a little box. You can put your name and email and I’ll send you the latest podcast in your inbox each and every week. You can join our community of people learning about pain science and the care of pain. I want to thank you, Annie, and all of you for being here with me. We’ll see you in the next episode.

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About Annie O’Connor, MSPT

HPP 117 | Pain Mechanisms

Annie O’Connor, MSPT, OCS, Cert. MDT, is the Chief Clinical Officer for Musculoskeletal Partnerships at the Shirley Ryan Ability Lab formerly known as the Rehabilitation Institute of Chicago. Annie has co-authored 2018, Pain Mechanism Classification Chapter, Rehabilitation of The Spine: A Patient Center Approach, Liebenson C (3 ed). Wolters Kluwer Philadelphia publisher. She has co-authored 2017, Therapeutic Exercise Chapter, Orthopedic Knowledge Update Spine 5, American Academy for Orthopedic Surgeons publisher. This chapter specifically is dedicated to helping Medical Doctors understand pain mechanism classification and the importance in therapeutic exercise selection. She has co-authored 2015 book “A World of Hurt: A Guide to Classifying Pain” and September 2016 Journal Article in JMMT “Validation of a pain mechanism classification system (PMCS) in physical therapy practice.” Both publications offer a research supported “paradigm shift” in managing Musculoskeletal Pain promoting effective and efficient outcomes with significant cost savings. She is an Orthopedic Clinical Specialist (OCS) of the American Physical Therapy Association and has a Certification in Mechanical Diagnosis and Therapy in the McKenzie Method (Cert. MDT). She lectures nationally and internationally on the Pain Mechanism Classification System (PMCS), neurodynamic evaluation and treatment, mechanical diagnosis and therapy of spine and extremities, kinetic chain evaluation, functional manual therapy and exercise prescription as represented in the World of Hurt book and training courses. She was instrumental in establishing the PMCS at the Shirley Ryan Ability Lab formerly known as the Rehabilitation Institute of Chicago. She is a member of American Physical Therapy Association in the orthopedic section and canine special interest group, the North American Spine Society (NASS), and McKenzie Institute. She serves on the specialty panel for physical therapy for the AIM healthcare and the research and advisory board for MyAbilities an Ontario based software company. She continues to treat orthopedic, neurological patients, and canines with pain and spasticity to achieve the best life possible.

The Healing Pain Podcast features expert interviews and serves as:

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If you would like to appear in an episode of The Healing Pain Podcast or know someone with an incredible story of overcoming pain contact Dr. Joe Tatta at [email protected]. Experts from the fields of medicine, physical therapy, chiropractic, nutrition, psychology, spirituality, personal development and more are welcome.

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