Pain Education And Psychosocial Interventions In Physical Therapy Practice With Carolyn Vandyken, PT


Welcome back to the Healing Pain Podcast with Carolyn Vandyken, PT

We’re joined by physiotherapist Carolyn Vandyken and we’re discussing how to implement effective pain education and other psychosocial interventions into the practice of physical therapy and others who are helping people with chronic pain. Carolyn has been a practicing physical therapist specializing in orthopedics and pelvic health for decades. In addition to being a licensed physiotherapist, Carolyn is also certified in the McKenzie method and acupuncture as well as a certificate in cognitive behavioral therapy.

In addition to clinical practice, Carolyn is heavily involved in postgraduate pelvic health education, research in lumbopelvic pain, speaking at numerous international conferences as well as writing books and chapters on pelvic health, orthopedics, and pain science. In this episode, you’ll learn why pain education is essential for the treatment of chronic pain as well as how to implement other bio-psychosocial interventions such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and mindfulness for the treatment of chronic pain. Without further ado, let’s begin, and let’s meet Carolyn Vandyken.

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Pain Education And Psychosocial Interventions In Physical Therapy Practice With Carolyn Vandyken, PT

Carolyn, welcome to show. It’s great to have you on.

Joe, thanks for having me. I’m excited to be here.

I can’t wait to talk to you about all the things regarding pain education, both for people living with pain as well as practitioners that are starting to learn about pain neuroscience education and methods in clinical practice and use it as a form of education for people with pain. As you know, on this show, we speak to both people who are living with pain as well as practitioners. I want us to speak to someone living with pain because pain education sounds funny almost like, “If I’m in pain, why should I read a blog on pain education?” In your own words, can you first describe what pain education is and then why that’s important for someone living with pain?

It’s at the heart of what we do as clinicians in 2020. We’ve had evidence for many years that we need to start to educate our patients more about the pain system and how it works. One of the ways that I start with almost all of my patients is to go back and look at the definition of pain at the International Association for the Study of Pain. I don’t say, “Joe, it’s nice to meet you. Come on and sit down in my office. Let me tell you about the definition of pain.” I start with them filling out a fair bit of paperwork for me because I want to understand both their physical complaints but also their distress, lived experience of pain, and what’s going on.

I’ll put that down on my table and I’ll say, “Joe, tell me a little bit about your story. I want to hear in your own words what’s going on.” When they start to talk about pain, and almost always, I would say to my patients within the first 20 or 30 minutes, start to say things like, “When I’m stressed, my pain is worse.” That’s a great opportunity for me to say, “Can we explore that a little bit more?” I’ll then say, “Let’s talk a little bit about what pain is exactly.” When we look at the definition of pain, it is a sensory and emotional experience.

I’ll stop there and I’ll say, “Why do you think it says and in the definition and not or?” Pain is always sensory. We feel it in our body and it’s always emotional. There’s always an emotional distress component to that. We need to think about pain not only from its physicality and what’s going on in the tissues, which is how we’ve been trained to think about pain and more of the biomedical model, but also the sensory couple with the emotional component to that. When they start talking about, “When I’m stressed, my pain is worse,” it gives us a great opportunity to link those two phenomena.

If we go on to look at the definition of pain, it is not only sensory and emotional, but it protects us from harm. When we run across the street, fall into a hole, and sprain our ankles, we tear ligaments, pain is produced then to protect us, but it is also produced to protect us from potential harm. That’s the other piece of the definition. When we’ve had pain for a long period of time, people are often stuck in this loop of pain.

What they need to understand is that pain is also produced when the tissues are approaching harm or the brain thinks that the tissues are going to be challenged too much. We can get pain even though the tissues are healthy and that’s an important concept. Pain is produced by the brain. Pain is not produced by the tissues and that’s 100% of the time, whether it’s acute pain or persistent pain. The other piece of that definition helps patients to understand why we need to delve into pain a little bit more in understanding it. It’s because it’s always described in terms of damage to the body. That’s the last part of the definition.

Even if there is no harm, damage, or injury to the tissues at this moment and you have pain, it always feels like the tissues are being injured or damaged. That’s why we as clinicians and why patients get stuck with treating tissues and trying to look for a tissue-based explanation for pain. That often comes up short and that becomes frustrating for clinicians and patients who seek MRIs and other tests to try and understand what’s going on.

A wonderful way to start this episode. Let’s rewind for people and let’s revisit some of those bullet points. Pain is both a physical as well as an emotional experience. That’s first. Pain is about protection and that protection could be with regard to a recent injury where there’s actual tissue damage or potential damage when that damage or injury has not occurred yet. Finally, pain feels like damage but with regard to chronic pain, that’s not necessarily the case.

It’s nice to bullet point things for people because as you and I both know, we’ve been practicing this for a long time. Pain is a wonderfully fascinating thing to us as clinicians, those of us who are into pain neuroscience and of course, into helping people clinically. Learning to break this down for patients to make it simple. Now, we have these five bullet points. That’s one thing we can discuss during the initial evaluation. It may take someone a week or months to figure out what that means for their particular life context. You mentioned the lived experience of pain. We should add that in there, too. We then start to build out that lived experience people, so they understand, “Here’s what my pain is about, and here’s how I can move forward with your help as a skilled, licensed clinician and overcome what’s happening.”

It is about understanding the context of the person who’s living with pain in their life, what was happening at the time that the pain started, and what’s been going on since that time because if you are suffering right now with persistent pain, you’re not alone. 1 in 4 people continues to have pain after the injury has healed. One of the things that we need to remember is that tissues heal in 8 to 12 weeks, full stop. If we have an injury, our body is incredibly capable of healing itself, but then when pain goes on after that healing timeframe, it often becomes a pain system problem.

That’s why pain education is important. If we can understand that system and how it works, we have another way into their experience of pain to help them desensitize or change that experience in a way that either helps them to live more functionally with the pain. Even better, helps them to desensitize the pain system so that they can go on to live a happy and productive life without pain always rearing its head when there’s only potential tissue injury involved.

Carolyn, there are, of course, physical therapists who read this blog and they’re familiar with the concept of pain neuroscience education. For those few potential PTs who aren’t quite sure what this is or why I should be implementing pain neuroscience education as an intervention into my practice, a nurse reading, or another practitioner who is a little bit outside that realm of information, why is pain education is important as a first-line intervention for people living with pain? Why should we be using pain education in clinical practice?

If we look at evidence-based or evidence-informed practice, we do have level one evidence that educating patients about the pain system and how it works. It’s one of the strongest strategies that we have for people in pain. There’s good evidence behind it. Adrian’s meta-analysis in 2012 is one that we can point to but there are many other studies that have been shown to demonstrate that teaching patients about pain is a helpful intervention, but it is not. It may be the starting point but it cannot be the stopping point.

One of the things that we need to do is recognize that there’s good evidence that we can teach patients about pain and it will change their pain experience. If that’s where we stop, and then we go on to treating the tissues, then we’re doing ourselves and our patients a disservice in that process. That’s often where we get stuck because most of our ongoing education in PT is still tissue-focused at this point. We have good evidence that understanding the pain system and how it works can change pain, but it’s a jump-off point.

It’s where we start, but it’s not necessarily where we finish. In that sense, if I’m reading into this, what you’re saying is there are potentially some practitioners who are on board with pain neuroscience education explaining pain and they start using that in their evaluation or maybe they use it in the first couple of sessions, but then there’s this flip of the switch where the rest of the treatment continues along with a more traditional biomechanical approach.

HPP 219 | Pain Education
Pain must not only be seen from its physicality but also the sensory coupled with the emotional component.


That is the transition period that we’re in. As you know, we have 15 or 20 years of some research behind us around the pain system. Certain patients are understanding the pain system. I’m not a firm believer that everyone gets the same pain education talk and give the same information to every patient. You have to tailor it to what that person needs in front of you, which means that you need to understand if your clinician pain education as well as you understand anatomy and physiology of a joint.

I’m Canadian and in Canada, that is not the case. I would say that most Canadian physiotherapists do not understand pain education to the level that they understand the anatomy and physiology of a joint. We tend to default back again to what we’re comfortable with and that’s human nature. It’s what we have been trained in, the body as a machine and biomechanical approaches. Even though the person in front of us may be presenting with persistent pain and we know there’s more going on, we’ve been trained to look for yellow flags, for example. Those distress markers that we talked about that may be affecting pain. However, we haven’t been trained to intervene with those yellow flags, so we default back to what we know, which is treating the tissues.

It can be confusing for a patient, I would imagine. This is not a judgment. Of course, all of us have made mistakes in our careers. The reason why they call it clinical practice is because you learn new things and you put them into practice. This works well with a middle-aged man with chronic low back pain, but this didn’t work so well with an elderly woman who has a hip fracture, let’s say. You learn how to tailor, which is what personalized pain medicine is all about.

However, it’s so interesting for me to think that all of us are on this continuum with figuring out how to implement PNE, and then adding that plus on to it. Now that we’re using pain neuroscience education, where do I start to taper down that Pain Neuroscience Education and then start to add the 1 plus, 2 plus, 3 plus other type interventions that are going to help with that chronic pain? It’s what we know as a sensitive nervous system on this show.

To start with, I’m a big proponent of using questionnaires to assess distress. We’re going to call it that emotional component of pain. I always find it interesting. I love that you said we’re all on this continuum because we are. I started in 2008 where I jumped into my first paying course. Curiosity kept me going and kept me interested but I’m still on this continuum. I’m a McKinsey credential therapist and I still use those skills in my practice every day, but I have layered on to that all these other skills.

If we’re going to look at pain neuroscience, who needs it and who doesn’t? When we use questionnaires like the Pain Catastrophizing questionnaire, we do have some good evidence on Traeger’s research study in 2015 or ‘16. It showed that in acute low back pain, giving everyone pain education did not change the trajectory to persistent pain, except for those who are catastrophizing. Those who were catastrophizing did much better when they when you give them pain education.

We do have some evidence that people are catastrophizing, which is a normal phenomenon. Let’s not make that pejorative or judgmental in any way, shape, or form. I always say to my patients, “We all catastrophize. That’s normal.” If I sprained my ankle, I’m going to start to freak out a little bit and go, “I’ve got to teach tomorrow. I’ve got to see patients the next day. How am I going to get through this?” Catastrophization serves a function, but when we get stuck in that mode, it is highly connected with persistent pain.

We do have research that catastrophizers, people who are freaking out about their pain, do much better with pain education, or people who are fear avoidance. Using the tempest scale of kinesiophobia, for example, which isn’t a perfect scale, but the best one we have for fear is the Fear-Avoidance Beliefs Questionnaire. I don’t use it because of the work component. I don’t see so many WSIB anymore in worker’s comp.

When we use a screening questionnaire, it helps us to tailor what the person in front of us needs. I always use the example of my daughter-in-law, who had chronic low back pain for about four years. In COVID, she was suffering from this back pain. She had gone to see a chiropractor. She lives about three hours away. I had sent her to a couple of different clinicians, but she wasn’t getting any better. Finally, I said to her, “Would you like me to take a look? I’m going to treat you like a patient.”

I gave her all the questionnaires and I started from scratch because we do what we do with a lot of friends and family. We jump in and give them a suggestion and leave again. I treated her like a patient this time. She knows we’ve recorded her sessions, so she’s okay with me talking about this. She’s a beautiful 26-year-old vivacious, gregarious, outgoing phys ed teacher who was starting to become fearful about participating in her phys ed classes because of her back pain. Her catastrophization was at a severe level.

She was convinced at this point after four years that she needed surgery. What we had to do was a lot of pain education with her. I would never have guessed, Joe, that her catastrophization was not severe unless I had measured it. We use questionnaires to help us profile the person in front of us and figure out, are they avoidant? Are they fear-avoidant? Are they experiential-avoidant of activity? Are they catastrophizing? Are they stressed? Are they depressed? We look at Timothy Wideman’s work from McGill, who looked at the strong comorbidity between depression and musculoskeletal pain.

25% to 50% of people with MSK pain have comorbid depression. There’s mounting evidence that if someone has comorbid depression with their pain versus comorbid catastrophization, we need to address that in a different way to desensitize the nervous system. We have sixteen special tests for the shoulder. Maybe there’s more at this point. Why do we have so many special tests for the tissues, which most of them aren’t reliable and valid tests either? Yet, we won’t use reliable and valid questionnaires to assess the sensitivity of someone’s nervous system and help guide our treatment process.

What my take home from all of that is for the practitioners who are starting to use evidence-based cognitive and behavioral interventions is to test, don’t guess. We don’t know everything that’s going on in that person, both mind and body with regard to their perception and experience of pain as they come into our clinic. Often as we think we know, it’ll be a good idea but this is a family member of yours who you know, who’s healthy, who’s a physical education teacher, who’s used to moving her body and understands the importance of the promotion of physical activity and exercise. Yet, once you tested, this big red flag or a yellow flag showed up, “Here’s the problem,” so to speak. If you didn’t test, you might have eventually come across it, but it may take longer or may not have worked well. You also do the CSI for a lot of things. Can you talk about that a little bit?

I’m going to finish up Emily’s story if that’s okay because it’s quite interesting. For years, she had a lot of treatment. Her two biggest issues from a sensitive nervous system were sensory-motor smudging as shown on the Fremantle questionnaire and catastrophization. I looked at her mechanically first and she was a flexion responder. I repeatedly flexed her for a week and she was 50% better just doing that. We would have got stuck there if we got stuck in the mechanical model. We then started addressing the catastrophization piece and then the sensory-motor smudging piece.

In four visits over a period of about 2.5 months, she was pain-free and remains pain-free at this point. It is a matter of targeting the phenotype or the profile of every individual sensitive nervous system. How do we measure a sensitive nervous system? We got good evidence from Randy Neblett and his group. In 2013, they validated a questionnaire for a clinical practice called the Central Sensitization Inventory. It’s a two-part questionnaire. Part A is 25 questions that get patients to report experiential symptoms or physiological responses to a sensitive nervous system like dry mouth and not sleeping.

There are 25 questions, so if they score greater than 40 on that part of the questionnaire, we can say with confidence that their nervous system is more sensitive. That’s not a judgment thing. We all come in and out of sensitization depending on life circumstances at any given time. Part B in that questionnaire is a list of conditions like fibromyalgia, tension headaches, idiopathic low back pain, and depression and anxiety. The conditions that happen alongside pain comorbid conditions that are highly linked and have been shown by many researchers to be connected with central sensitization or a sensitive nervous system.

The CSI, if they have greater than 40 on Part A or one or more conditions on Part B, and physiotherapist should make note that TMJ is one of those conditions. How many of our patients have TMJ? The other condition that we see a lot of is a whiplash-associated disorder. If they’ve had a WAD that lasts longer than the healing timeframe of soft tissue injuries, then that is highly connected with a sensitive nervous system. Now you have a jump-off point to start discussing with your patients the nervous system and its role in their pain experience.

HPP 219 | Pain Education
If the pain goes on after the healing timeframe, it often becomes a pain system problem.


From there, we all have these branches of the tree now. How do you then decide, “I need to do pain education, but I need to tag on a caboose to this trolley, so we have something that’s more impactful for decreasing the sensitivity of the nervous system.”

We’ve got some good evidence-informed basis for our practice, that alphabet soup. We have good evidence behind CBT. CBT is helpful for depression and anxiety. If someone has comorbid pain, depression, and anxiety, I might think about adding some CBT to their program. I have about 60 hours of CBT training myself, so I do a little bit of that. When it comes to doing thought records and that more detailed, getting into that real emotional component of life, I often will refer to a social worker or psychologist.

I want to piggyback off what you’re saying here. You have 60 hours of CBT training, which is a lot of CBT training for non-mental health professionals. I’m talking about this more and more, so I want to thank you for bringing this up, Carolyn. Cognitive Behavioral Therapy for the treatment of pain can be delivered by any licensed health professional. As effectively as a mental health professional if you’ve gone through proper training and mentorship with regard to using those types of skills and practice. I say that because more people ask me, “Can I do this? How can I do this? Why shouldn’t a mental health professional do this?” A mental health professional should and they do use this in clinical practice. However, when you look at nurses, OTs, and PTs delivering CBT for pain, they’re equally effective.

We do have some good evidence behind CBT and pain. That’s something that we can incorporate. This is my bias as a physiotherapist. I’m Canadian, so physio versus physical. Same thing. I’m biased that we, as physical therapists, are primed and ready if we can get some good skills development in some of those cognitive-behavioral types of approaches that we also can deal with the physical. That biopsychosocial approach, whereas a social worker or psychologist, their hands are a bit more tied.

You were at the Boston IASP Conference in 2018. I didn’t know you then. I didn’t meet you there. I’ll never forget Dr. Christopher Eccleston’s keynote address when he won the Ron Melzack Award. He said, “The time has come where all physical medicine specialists, physiotherapists, or physicians need to incorporate the emotional, psychosocial components in every interaction with their patients. Psychologists and social workers need to incorporate the physical embodied component as well. We can no longer separate the individual in front of us and say, ‘This is my piece. I’m going to deal with this piece. That’s not in my scope of practice, so I’m not going to do that piece.’”

The way I’ve started talking to professionals about this is I’ve had the same conversation with psychologists about more physical activity during their sessions instead of sitting down in the chair across and talk to someone. I’ve learned that’s a larger scope of practice shift than what we’re experiencing as physical therapists, which is interesting to me. We have to overcome our own fear-avoidance as practitioners to change and start to use these interventions in clinical practice.

That’s a huge barrier.

You know I have an ACT course. As I teach this to professionals, they love it. Of course, as you go through any type of cognitive intervention, in a certain way, you apply it to your own life context first, and that’s completely fine. Get over that barrier, but they don’t see the second wave over the first one. “Now I have to overcome the fear of using this in practice,” which I make an attempt to normalize that for people. I graduated in 1997 in biomechanical-based schooling like we all had back then if you’re a little bit older like me.

Even then, there was a fear to see your first ACL patient. Fear to see your first patient with a coronary artery bypass. Fear to work with the first pelvic floor patient you’ve ever worked with. We overcome those things as professionals, so we are at a place now where we’re learning how to overcome the psychosocial aspects. Let’s loop back around to where we were. I want to back up a little bit there. You start to use some Cognitive Behavioral Therapy if depression scores are high.

This will link back to our psychology colleagues as well. What do we have great evidence in depression for? We need to get our patients walking. It doesn’t have to be walking. What do they enjoy? Swimming or cycling. They need to get their heart rate up to that 65% target for 30 minutes, 5 or 6 days a week. We have great evidence that depression is reduced by 50% when people do that. Our psychology colleagues can recommend walking to their patients. We’ve got to include that component.

In depression, World Health Organization says as well that 2 to 3 times a week of resistance training for depression have strong evidence behind it. You interviewed someone on your show with regards to that. It was a brilliant interview. We also have good evidence around yoga and depression. Can you see how our job is to get our patients moving in a non-threatening way? That’s an important component. They have to love what they’re going to do. Engaging them in what’s important to them, that value-based approach that I know you talk about in ACT.

Start to be a little bit more targeted around someone who’s depressed probably needs to be activated in some way. Someone who’s anxious probably needs to be calmed down in some way. Maybe they are going to start a worry journal or start an alternate nose breathing practice for five minutes, 4 or 5 times a day. When you start to profile their presentation as part of their sensitized nervous system, you can be more targeted in your approach. That also means we need to develop more skills in a broader area, including CBT, ACT, motivational interviewing, and different breathing techniques. Having a more broad psychosocial toolkit to draw on, so we don’t default back to our biomechanical, biomedical approaches.

Eventually, cognitive-behavioral therapy. The other thing that we often talk about is mindfulness, which in the scientific literature has started to get taken up by psychology. Although one of the nice things about mindfulness is that it’s not psychology, but it has principles of psychology that can help people. Of course, you’re a pelvic health expert, so there are probably some certain applications for that. Where did we start to tag that on to PNE plus?

Is anyone ever an expert? I would say I’ve got expertise in public health and I am still learning as we go. I’ll tell you another little story. I picked up a patient from the East Coast in Canada who had had twenty years of pelvic pain and she was being seen by a lovely physiotherapist with a biomechanical approach. She came and took my course on using distress questionnaires to help to profile the nervous system. She said to me after that, “I’ve got this complicated patient I would love you to see.” I said, “You can do this. You’ve got the tools. Go and try.” She’s like, “I’ll try.”

Her concern was that this gal had had many previous failed attempts that if she changed directions and she failed again, it would become more of a nocebo for her and that was a reality. I said, “Play with it for a couple of weeks. Call me. We can do a Zoom co-treatment if you want to,” so she did. She called me a couple of weeks. We did a few co-treatment sessions with this gal. What’s interesting is that six months before I saw her with her therapist, she had spent about a year in a chronic pain management program in a hospital that she’d waited two years to get into.

It was much focused on graded exposure, graded functional activities with the physio, and mindfulness with a psychologist. She spent six months doing one-on-one training with mindfulness with a psychologist and she left that program absolutely no better than she started. I also saw her after she did six months of mindfulness, so I didn’t get any pre-scores prior to her doing that. My observation when I saw her and I gave her 6 or 8 questionnaires that I standardly use with patients is that she was not catastrophizing at all.

What I look for in the Pain Catastrophizing questionnaire is the rumination component. I like to use mindfulness for people who tend to do a lot of rumination or hyper-vigilant because we know as well that mindfulness calms down the front insular cortex. It makes it thicker, stronger, and more resilient. That’s the area that tends to become more active in hyper-vigilance and rumination. She’d spent all this time doing mindfulness. Her catastrophization scores were absolutely normal, but what was not normal for her was her sensory-motor smudging scores. Her Fremantle questionnaire was high, so that’s what we addressed.

HPP 219 | Pain Education
Everyone comes in and out of sensitization, depending on life circumstances at any given time.


We did a little bit of pain education so she could link the pain system, and she knew some of that already. It was about addressing more specifically what she needed, which was sensory-motor reorganization. We have to find novel movement practices that were non-threatening for her to start to work on that piece, and then she started to see functional gains, which was beautiful. That’s who I tend to use mindfulness for are people who are quite stuck in that rumination or hyper-vigilance mode, or just even someone who’s stressed like ADD, ADHD, busy type A and they need to calm down and become a little bit more centered in their day-to-day experience.

How much have you started to use acceptance-based approaches in clinical practice? At times, it weaved into traditional Cognitive Behavioral Therapy in some way. It definitely weaved into mindfulness. An effective PNE practitioner or someone who’s trained to use PNE isn’t aware of how much acceptance work they’re working in there, but it’s present there.

I’ve done some work with Kevin Vowles in Acceptance and Commitment Therapy. I haven’t done nearly the extensive training in Acceptance and Commitment Therapy as I have in CBT, but I tend to use more activate-based principles in patients who are more functionally disabled. If my patient is with persistent pain and is still participating in their day-to-day activities but with pain, I wouldn’t use ACT for someone like that. I’m going to use ACT for people who are starting to not function in their day-to-day. The experiential avoidance patient that we’ve chatted about is the type of patient I might use ACT more with.

High experiential avoidance, high pain avoidance, low physical activity, and low ADL respond well to ACT, which is great because we have a decent amount of evidence in that range to a phenotype person. That’s the person you’re seeing based on the Chronic Pain Acceptance Questionnaire. There’s an 8 and a 20 you can use as part of this battery of tests that we’re talking about. It starts to tell you, “I need to work towards more mindfulness and acceptance-based approaches with this person,” at least in the beginning. We can then move on to other things that we’re talking about.

I always talk about ACT a bit like if a patient is going on to this highway of change and they’re on the on-ramp, and they haven’t been active and engaged in life a lot because of their pain, ACT takes them into the slow lane. ACT gets them on the highway, and then once they’re on the highway that used to driving again and get used to doing things in day-to-day life, now we can spend a bit of time in the fast lane and see if we can change their nervous system a little bit more. Look at desensitizing their system, which is how I might talk about that piece. They need to go back into the slow lane for a while again and they go back and forth, so it’s never a straight line as you know, Joe.

We’re not saying high experiential avoidance, you have to use ACT. You can’t use PNE or you can’t use cognitive behavioral therapy. Some of the cognitive processes that are at work here are at work no matter what type of intervention you’re using, even if you’ve never trained in the cognitive intervention. It’s wrapped up somewhat in effective counseling and communication that we’re using with patients.

When physiotherapists talk to me about using CBT in their practice, I will say, “You’re already doing it. You’re already changing thoughts, beliefs, and behaviors. You just haven’t put the structure around it, per se.” When you put structure around it, you become a more skilled deliver of that system. That’s all.

The million-dollar question as a physiotherapist, is there a place for physiotherapists to have one session or multiple sessions where there’s no exercise, physical therapy, or manual work and you’re dedicating just that time to whatever it is whether it’s playing to your ACT, CBT, mindfulness, or whatever alphabet you want to add to this?

I would say that as a physiotherapist, I touch most of my patients still, but not necessarily every session. I’m a pelvic health physio, so if I think about what I do from a pelvic health perspective, there used to be a day. I’ve been practicing pelvic health and I’ve been a physio for many years. There used to be a day where I used to talk about releasing trigger points and doing manual therapy, tissue fixing processes. I no longer talk like that.

We’ve done some research and there’s some building research that says in pelvic health for sure that when there’s tenderness on palpation, it’s a top-down process. It’s a sensitive nervous system guarding an important part of the body. If I do some internal work, what I say to my patients is, “I’m having a conversation with your nervous system right now.” That means that I have to be non-threatening and we first have to have a strong therapeutic alliance.

That also means that gone are the days where I’m assuming that in that first session, I need to do an internal exam. By the time we’ve had a good conversation about their story, there usually isn’t time in the first session at this point. My subjective values take 20 or 30 minutes. Sometimes, it takes that full hour. That leaves that next half hour when they follow up with me again to do a careful, thorough conceptual exam where they’re not being threatened by my touch. If they are, then we need to unpack that piece as well.

Whereas I touch, I would say, all my patients at one point, there are many sessions where we are problem-solving, digging a little bit deeper, looking at behavior change, and what that might look like. I’m taking a much broader and lifestyle approach, which I know you also talk about looking at nutrition and many factors that are involved in sensitizing the nervous system. That takes a big step to be comfortable with that because that’s not how we’re trained.

That was my next question. Did that develop naturally on your part or someone helped facilitate that in your practice change? Was it like, “I’m looking so much at all the psychosocial variables that I need to learn about my patients’ experience with their pain first, and then we can move on to these other aspects of it?” What you’re saying is developing that bond with someone, which is part of that psychosocial, will help later on with some of the interventions that cause more fear and anxiety for people such as touch, exercise, physical activity, pain exposure, graded exposure, etc.

There’s a psychological study by Lambert in 1992. It’s in the psychology world. There have been some other studies that have gone on to show that the same thing happens in physiotherapy that 30% of the outcome is dependent on therapeutic alliance. Fifteen percent of the outcome depends on the intervention you use and yet, we spend so much time learning the interventions, we don’t spend a lot of time learning how to connect with the person in front of us, and taking that time to connect. I send every one of my patients a fourteen-page questionnaire that they fill out before they come to see me and some therapists roll their eyes and think, “I can’t do that to my patients.”

It takes them about 20 or 30 minutes. Many of those four sessions, especially with complex pain, are talking, working through all of the information, story, and questionnaires, and putting the story together. The majority of my patients will sit back at the end of that and say, “I knew I was in for a different approach as soon as I filled out your questionnaires. I appreciate the fact that you took the time to learn about me as a person. I feel like you understand my pain problem better than anyone has yet to date because you took that time.” Where we think as clinicians, patients aren’t going to value that. In fact, the opposite is true.

People say, “How do you give people all that paperwork?” I say, “Here’s how I do it. If it’s someone who’s coming into the office and their appointment is at 1:00, I asked them to come in at 12:30. They have 30 minutes to sit in the treatment room to relax. I give them a cup of tea, they sit down with the paperwork, and they fill it out while I’m finishing up my other patient. If it’s virtual, my assistant is sending them that packet of paperwork.”

HPP 219 | Pain Education
So much time is spent on learning the interventions, but connecting with the person in front of you is rarely given attention.


In the email, it says, “Please take your time over the next week to sit down with his paperwork either in one sitting or a couple of times because there’s a lot here, and send it back to us because it’s important for your continued care.” There are lots of different ways to do it, but those are two ways to help people 100% negotiate a lot of paperwork. People get a different sense of, “This person is interested in what’s happening with me.”

We take a whole-person approach. It’s how you set it up and how you introduce it. There are ways to do it. It’s our confirmation bias that suggests our patients will resist that piece. I send it ahead of time, but with the same proviso’s that you talked about. I would say I get a 90% completion rate of the questioner beforehand. It is over and over again appreciated. Nothing is worse than you’d give this questionnaire, you don’t talk about it, don’t integrate it, and then they’re like, “Why did I fill out all of that information?”

To some extent, why we as physical therapists are challenged by questionnaires is because we’ve used them historically as outcome measures. No one gives a crap. It was that type of thing. It didn’t change our treatment intervention. Whereas when we use questionnaires to assess a sensitive nervous system, it is like doing a range of motion special tests, palpatory tests that I would do for the physical piece. I don’t know how to address their sensitive nervous system if I don’t use questionnaires. End of story.

That’s why if you come to my website at the Integrative Pain Science Institute, on the homepage, there are five evidence-based questionnaires that are public and you can download them. Those are a taste of what I use and a taste of what Carolyn is talking about. I found when I started training professionals, they’re not measuring anything, so we have to measure before I can start to work with our patients and dive into their lived experience. Carolyn, it’s been wonderful talking to you about Pain Neuroscience Education Plus and everything that you’re doing in clinical practice. For many years of practice, you’ve seen how our profession has changed and how we’re now able to serve people on a completely different level. If people want to know how they can follow and learn more about you, tell us where you can find you.

At the beginning of 2020, as COVID hit, we started a new teaching company. It’s myself and my daughter who’s a physiotherapist, and my daughter-in-law’s helped run the business. It’s a bit of a family company, which is a lot of fun at this point. It’s called Reframe Rehab. The idea behind Reframe Rehab is to break down the barriers between pain science education, pelvic health, and chronic musculoskeletal pain.

As clinicians, we live in silos. We identify, “I’m a musculoskeletal therapist. I’m a pain science therapist,” I’m a pelvic health therapist. Our research over the last couple of years has shown that you cannot work in silos and effectively treat the person in pain in front of you. That’s our goal. You can find us at You can follow us on Instagram. We have a closed Facebook where we talk about all things bio-psychosocial. We’d love to have that conversation with you.

I want to thank Carolyn for joining us on The Healing Pain Podcast. Make sure you check her out at You can learn more about her. Make sure you share this episode with your friends and family on Facebook, Twitter, LinkedIn, or Facebook group. There are thousands of practitioners interested in learning about pain neuroscience education. I’m Dr. Joe Tatta. It’s been a pleasure as always.

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About Carolyn Vandyken

HPP 219 | Pain EducationCarolyn is the co-owner of Reframe Rehab, a teaching company engaged in breaking down the barriers internationally between pelvic health, orthopaedics and pain science. Carolyn has practiced in orthopaedics and pelvic health for the past 33 years. She is a McKenzie Credentialled physiotherapist (1999), certified in acupuncture (2002), and obtained a certificate in Cognitive Behavioural Therapy (CBT) in 2017. Carolyn received the YWCA Woman of Distinction award (2004) and the distinguished Education Award from the OPA in 2015. She has been heavily involved in post-graduate pelvic health education, research in lumbopelvic pain, speaking at numerous international conferences and writing books and chapters for the past twelve years in pelvic health, orthopaedics and pain science.


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