There is a widely held belief that faulty movement patterns are a significant source of musculoskeletal pain and injury. The idea here is that improper joint motions put excessive stress on tissues that have trouble handling such a load. Over time the tissue breaks down leading to injury. Clinicians subscribing to this view hold that improving and correcting these faulty or compensatory movement patterns is a critical and necessary part of care.

On the surface this model may seem appealing. Even logical. But there are several problems with this line of thinking.

Perhaps the biggest and most glaring issue is agreeing on what these so-called “faulty” movements are. Is there a best or right way to move? Or do the variety of movement patterns and strategies seen across patients simply reflect the complex, adaptive, biological system that is our body?

But there’s another elephant in the room. One that’s pretty tough to ignore. That’s the fact that research has failed to find consistent support for the relationship between these “faulty” movement patterns and pain. 

Do Faulty Movement Patterns Really Cause Pain or Injury?

We reviewed this topic in much greater detail in our Rethinking Pain article series, so the interested reader can dive into this a little more there. But to briefly summarize, when looking at prospective studies (remember these are the studies that follow a bunch of healthy people across time to see who develops a certain condition and who don’t) we really don’t see a consistent or predictable relationship between these so-called faulty movement patterns and who gets injured.

Failure of pathoanatomical or movement-based models has lead clinicians to search for other frameworks to guide treatment. Most recently clinicians and researchers have advocated the biopsychosocial or cognitive-behavioral models to help understand and to guide the treatment of pain.

These models are attractive as they take into account the multi-dimensional nature of pain. They recognize pain is not always about tissue damage or injury, but is often more about the brain’s processing and interpretation of the state of the body and the world around it. (Again, we covered this in detail in our Rethinking Pain series).  

These models still view movement and exercise as critical factors in the treatment of pain. But here it is thought to be less about how we move and more about building tolerance. Both on a tissue level as well as a neurological one. The idea here is to build more resilient tissue, but also to teach the brain that movements can be safe and non-threatening.  

But Movement Still Matters 

On one hand I think this is good thinking. There is powerful messaging here. The human body is resilient and adaptable. But on the other hand I am not quite ready to completely abandon the notion that how we move matters.

But perhaps we need to look at the relationship between pain and movement from a different angle.  Maybe it’s not that we need to move in an idealized way. Instead, maybe it’s more that we need to strive towards developing a more adaptable system that is able to move and respond in a wider variety of ways. 

This is the concept of movement variability.

Movement Variability

Most routine movements are complex and involve the coordinated positioning of multiple joints and body segments. Think of bending forward to pickup a box. This involves the ankles, knees, hips, intervertebral joints, scapulothoracic joints, and elbows. 

But notice how there are various joint configurations that can be utilized to accomplish the task (see figure 1). The traditional view has been that certain patterns of movement are more desirable than others. As if they represent more skilled or safe movements that have been learned and refined over time.

But here’s the thing.

Movements will naturally vary from repetition to repetition. Even with repetitive activities like bending, running, and walking the positioning of body segments will vary from cycle to cycle.  If you were to take a snapshot of the leg across ten consecutive running strides you would see a slightly different joint configuration in each picture. Likewise EMG readings would demonstrate different patters of muscle contraction. These differences are termed “movement variability”.

There was a time that this variability was considered undesirable. From a motor control perspective it was viewed as system noise. A characteristic that was expected to reduce as the system learns to control unwanted motion in the kinetic chain.  

But this view is changing. 

More is Better

Like other physiological responses such as heart rate, greater variability with repeated movements is now understood as a positive attribute. A characteristic of a healthy and adaptable system that is able to respond to a multitude of stresses and to changes in movement and environmental demands (Latash 2012). 

Movement Variability and Injury

Take knee pain for example. Here studies have failed to find a consistent relationship between lower extremity kinematics and knee conditions such as PFPS. But these studies typically look at peak or mean measurements of joint angles or segmental positions. 

Instead of following this traditional approach, Hamill et al. (1999) looked at the variability of joint coupling between the thigh, tibia, and foot during running. Using this convention the authors reported consistently greater movement variability in healthy runners versus those with PFPS.

In a similar study comparing subjects with unilateral PFPS, Heiderscheit et al. (2002) reported reduced variability in stride length and thigh-leg rotation between the injured and healthy limbs within subjects, as well as reduced variability between the injured limb and that seen in healthy runners. 

Similar findings of reduced movement variability have been shown in ACL injuries (Georgoulis et al. 2006), neck and shoulder pain (Lomond and Cote, 2010 & 2011), and lower back pain (van den Hoorn et al. 2012, Falla et al. 2014).

So with respect to pain and injury, it’s not that we need to move the right way. Instead, it appears to be more important that we are able to move in a wide variety of ways. It’s more about having movement options and being able to utilize different solutions to solve the same movement problem.

With Movement we NEED Options

Remember movement variability is dependent upon the degrees of freedom associated with the movement task. Recall our forward bending example from above. Because the task involves multiple body segments, it provides various combinations of joint positioning that can be utilized to accomplish the task. 

In other words, the motor system can utilize different solutions to accomplish the same movement task. 

But to express this variability each joint segment in the kinetic chain must be functioning properly. If any of the individual segments are limited by muscle weakness, poor motor control, or limited flexibility it will affect how the motor system is able to respond. It limits the movement options available to the system and results in more narrow, repeatable movement patterns.

Cognitive-Behavioral / Brain Factors

And it’s not just mechanical factors that come into play here. In cases of longstanding pain cognitive-behavioral factors such as fear of movement or beliefs that pain represents tissue damage may also restrict available movement options.   

This relates back to the purpose of pain. From an evolutionary perspective, pain is a powerful driver of behavior. (Again, see our Rethinking Pain series.) If the brain understands a situation as threatening or potentially threatening it can call upon the pain system as a means to modify behavior. Full avoidance of the feared activity is one possible response, but modifying the movement pattern is another. This would reduce load on the threatened tissue while maintaining function.

Support for this idea is found in studies comparing movement variability in acute versus chronic pain. Here we see increased movement variability with acute experimental pain, but reduced variability and a more narrow movement patterns with chronic pain (Madelaine 2008a). 

Greater variability in the initial stages of pain and injury is presumably an attempt by the motor system to explore potential movement options which would allow the CNS to maintain function while minimizing stress on the affected tissue. Over time the CNS then adopts the movement pattern that most successfully achieves this goal, thus leading to reduced variability. 

These more narrow motor responses may be helpful in the short term to allow injured tissue to heal. But they are likely to be detrimental to musculoskeletal health in the long term as they limit the adaptability of the system.

Compensations Are Not Bad

Restriction or dysfunction at one joint affecting movement at another area is often referred to as a “movement compensation”. Personally, I don’t like this term because it gives the impression that the compensated movement is a negative thing. That we need to correct this compensation because it is a harmful or dangerous way to move.

But I think this is the wrong way to look at things. I think the body’s ability to utilize an alternative movement strategy that allows it to maintain function despite other problems is representative of an amazing, adaptable system. From an evolutionary perspective this ability to “compensate” has allowed us to adapt, survive, and get to where we are as a species. 

But I do think problems can occur when these “compensations” become the only way the body is able to move. When joint dysfunction starts to accumulate and the movement options available to the system become too limited. This is when the body gets stuck in the same repeated movement patterns and loses the ability to move in varied and adaptable ways.

How Does Variability Affect Treatment

So when it comes to pain I think how we move does matter. But hopefully what is clear from the discussion so far is that we’re not trying to fix faulty movement patterns or get everyone to move in a specific, idealized way. We are trying to build a more adaptable system and give the body movement options. To do this we need to get each joint segment moving and working as good as possible.  

With a lower back pain patient that demonstrates tight hamstrings or limited hip flexion, I want to target these deficits. Not necessarily because they are causing compensatory lumbar flexion, but simply because a hip is supposed to flex. And if it can’t it limits the movement options available to the system.

So keep it simple. If the hip is weak get it stronger. With a restricted ankle explore options to improve flexibility. If there is poor control of the lumbar spine address this. View the system through the lens of adaptability.

The whole is greater than the sum of it’s parts. But good parts are still needed to form a better whole. 

Will this fix all the issues. Of course not. Pain is complicated and is influenced but a lot of variables. Sometimes you also need to address maladaptive beliefs with targeted pain education. Factors like stress, depression, anxiety, and medical co-morbidities will often play a role as well. But how you move still matters. After all, “bio” is an integral part of the the biopsychosocial model.

References

Falla et al. (2014). Reduced task-induced variations in the distribution of activiy across back muscle regions in individulas with low back pain. Pain. http://dx.doi.org/10.1016/j.pain.2014.01.027

Georgoulis et al. (2006). A novel approach to measuring variability in the anterior cruciate ligament deficient knee during walking: The use of the approximate entropy in orthopaedics. J. Clin. Monit. Comput. 20,11–18.

Hamill et al. (2014). A dynamical systems approach to lower extremity running injuries. Clinical Biomchanics, 14, 297-308.

Heiderscheit et al. (2002). Variability of stride characteristics and joint coordination among individuals with unilateral patellofemoral pain. J. Appl. Biomech. 18, 110–121.

Latash, M. (2012). The Bliss of Motor Abundance. Exp Brain Res. 217 (1): 1-5.

Lomond & Cote. (2010). Movement timing and reach to reach variability during a repetitive reaching task in persons with chronic neck/shoulder pain and healthy subjects. Exp. Brain Res. 206, 271–282.

Lomond & Cote. (2011). Differences in posture-movement changes induced by repetitive arm motion in healthy and shoulder-injured individuals. Clin. Biomech. 26, 123–129.

Madeleine et al. (2008) Changes in the degree of motor variability associated with experimental and chronic neck–shoulder pain during a standardised repetitive arm movement. Exp. Brain Res. 185, 689–698.

van den Hoorn et al. (2012). Mechanical coupling between transverse plane pelvis and thorax rotations during gait is higher in people with low back pain. J. Biomech. 45, 342–347.

PART 5: Re-Thinking A Movement Based Approach to Pain

We’ve been talking a lot about pain in this article series. And from our discussions so far hopefully one thing is clear…Pain is far more than a simple reflexive response to tissue damage or injury.

In fact, we now know pain is not a sensory input at all. Instead, modern science tells us pain should be viewed more as a perceptual output.  As an experience that your brain generates when it decides pain would be helpful given your current situation. 

This is all based on the fact that pain is meant to be protective. It is a tool your brain can call upon to modify your behavior to help protect you from a potential threat. (See Part 2)

Think of it this way…

Your brain is continually taking in information from the internal state of your body as well as the world around you. It uses this information to run simulations of available actions, responses, and potential outcomes. But when your brain encounters a situation that it perceives as potentially harmful it can call upon the pain system as a means to change how you do something or avoid doing something all together. Here we see the protective value of pain, as a modifier of behavior.

This interpretation by your brain is based on several factors, including real-time information coming in from your body and surrounding environment, as well as memories and past experiences with similar situations. Mindset and beliefs about pain are also a big player here. This is where pain education comes in.

Explain Pain

We know pain is not necessarily about tissue damage and injury. It is often about a hyper-sensitive and over-active pain system. And worry, catastrophizing, and avoidance of movement for fear of further damage can add fuel to an already sensitized pain system. This has been the entire focus of this article series.

But this is not always obvious to our patients

And beliefs that pain is always consistent with damage can be a significant barrier to movement and activity. This can detrimental to recovery.

This is where we see the value of pain education. Helping patients to understand the meaning and value of pain, specifically that hurt does not necessarily mean harm, and that pain is often more about a sensitive pain system can be a powerful part of the treatment process. This messaging and awareness can help turn down the alarm system and open the door for movement based interventions.

But education is not enough

But as important as pain education can be, it’s not enough. However, it can be a powerful tool to utilize in conjunction with other therapies.

In Part 3 of this article series we made a connection between pain and phobias. Remember Little Albert? This connection provides a nice framework to illustrate the connection between education and action here.

A phobia is an irrational fear that is out of proportion to the danger posed by the presented stimulus. The realization that the stimulus does not pose a serious risk does not eliminate the exaggerated response. But it can be leveraged and combined with other interventions to help eliminate, or at least reduce and control, the maladaptive response.

Think of someone who suffers from a fear of snakes. Here encountering a benign snake in their garden may create a release of chemicals to elevate respiration and heart rate and shunt quickly shunt blood to their muscles. While this sympathetic flight-or-flight response may be perfectly appropriate if they came across a cobra in the jungle, it is clearly out of proportion to the garden snake.

But simply telling this person that the garden snake is not dangerous is unlikely to eliminate this exaggerated response. But this knowledge can be paired with gradual exposure to the stimulus to help reduce and/or control the response.

Exposure Therapy

Traditionally, exposure therapy is a technique used by therapists to help people overcome unwarranted fears by gradually exposing them to threatening stimuli, but in an environment that is known to be safe. The idea here is that exposing people little by little to stimuli that cause distress in a safe environment helps to break the association between the stimulus and the conditioned response. It helps the individual to learn to feel safer in a given situation. 

The key here is the exposure is gradual. In other words, it starts off small and progresses over time.

We wouldn’t just tell someone with a snake phobia that their fears are irrational and throw them a python. The process would start more subtlely. Like maybe with a rubber toy snake or even a picture of a snake. Then as they start to be less anxious and fearful the brain starts to turn down the alarm system and recalibrate the smoke detector. The exposure can then be progressed.

The toy snake could be followed by a video of a snake. Then maybe some virtual reality goggles to make the experience a little more life-like, then perhaps a real snake in a cage.

Exposure therapy has been used to help with things like phobias, anxiety disorders, or PTSD. But these techniques also have a role in the treatment of pain.

Take back pain for example. Here it is common for movement of the spine to cause pain. Patients often associate these symptoms with the potential for further damage or injury to the discs and joints of their back. This can lead to fear or avoidance of activities such as bending, walking, lifting, or a regular exercise routine.

Graded expose can be helpful here.

Graded-Exposure For Patients in Pain

For lower-back pain patients this may start with some basic movements to create motion through the lumbar spine. Pelvic tilts from a supine or quadruped posture are a great starting point here. These are pretty safe exercises from a load/tissue perspective, but this may not be obvious to the patient as these movements often re-create symptoms.

Here we see an opportunity to re-frame the meaning of pain. As these are non-weight bearing exercises the physical stress on the spine is relatively low. So symptoms here are more related to sensitivity as opposed to tissue damage.

Using an ankle sprain as a frame of reference here can be helpful. Performing open-chain AROM exercises for an injured ankle may create some symptoms, but because the stress is low we know the tissue is safe. Symptoms here are a result of tissue sensitivity and the accumulation of chemical/inflammatory mediators as opposed to further ripping or tearing of the ankle ligaments.

As the patient continues the exercises the pain response typically diminishes. This de-sensitization response may be partially due to tissue changes, but cognitive-emotional factors are at play as well. Just like the brain is able to turn down the alarm system with exposure to the rubber snake, the brain starts to “trust” that they can move the spine without penalty. And just as with the snake phobia, as tolerance improves exercises can be progressed to increase tissue stress and more closely resemble the feared or offending activity. This may include transitioning the pelvic tilts to an upright position, then to a hip hinge type exercises, then to deadlifts or other bending type exercises.

But what about how the patient is moving. Where does that fit in?

But Do We Need to Move the Right Way?

Faulty movement patters are often thought to create pain and injury. But as discussed in Part 1, research has failed to find consistent support in this belief. Yet patients consistently get better with exercise interventions designed to correct these “faulty” movement patterns.

But these improvements occur without coinciding changes in movement. So the exercises help. But it seems not for the reason we thought they would.

Given our modern understanding of pain it is possible that the real benefit of these interventions (at lease with respect to pain) again lies in the brain as opposed to the tissue.

So with respect to pain, maybe the primary benefit of these exercise based interventions is not so much in getting the person in pain to move the correct way, but just to move more. Here it is not so much we need to move the right way to get rid pain pain, but to move despite the pain. Maybe these corrective exercises are another from of graded exposure.

Again this goes back to the CNS response. It helps teach the brain it is safe to move so it can turn down the alarm. It gets back to the idea idea of trust and safely. Does your brain believe it can safely accomplish a given movement task?

Part 2: Pain and the Brain

So we’ve been talking about Pain. More specifically, we’ve been trying to understand what causes pain? The hope here being a better understanding of pain will lead to more effective treatments. In Part 1 of this article series we discussed the shortcomings of traditional approaches to musculoskeletal care. There we left off with a problem that went something like this…

Clinicians and therapists often direct their treatment towards improving “faulty” movement patterns believed to be the source of pain. This will typically involve manual therapy or exercise prescription aimed at improving ROM or strengthening weak/inhibited muscles that are driving the compensatory movements.

Despite there being little to support the connection between faulty movement patterns and pain (again.. see Part 1), clinical studies consistently report improvements in pain and function following these interventions. But, (and here’s where things get really interesting), improvements in pain are not accompanied by changes in the movement patterns.

So what mechanisms are driving the improvements? If movement doesn’t change how are these interventions influencing pain? This of course is a critical question. The more we understand how our treatments work the better we can refine and utilized these interventions in patient care.

This really comes back to understanding the nature of pain itself. It is here we have made big strides in recent decades. We now know what we feel, including pain, is ultimately a function of your central nervous system CNS). So to understand the modern view of pain we need to understand a little bit about how how the CNS works.

Pain and the Brain – CNS Processing

In the most basic sense, information regarding the state of the body is passed via the peripheral nerves up to higher brain centers. This flow of information allows the brain to continually monitor and regulate key biological and physiological processes necessary to sustain life and to successfully interact with the physical world around us.

The concept here sounds simple enough. But the actual mechanisms through which this occurs involves exceedingly complicated processes that we are just beginning to understand. We will save the mechanistic details for another time. For now just realize that incoming sensory information is really just raw bits of data passed on to the CNS. For these signals to have any meaningful effect or significance your brain must interpret and process this raw data to formulate an accurate picture of your current body state.

Your brain is like a computer… sort of…

In one sense this is similar to a computer. As your fingers move across the keyboard, raw data in the form of numerical strings of 1’s and 0’s are relayed to the CPU. Your brain then performs complex information processing functions in an effort to create meaning from these incoming neuro-chemical signals. 

But unlike computers with a primary CPU, your brain processes information simultaneously through a vast array of parallel networks, each made up of millions of cells wired together and widely distributed throughout the brain. 

This modern view of information processing through parallel brain networks has significantly changed our understanding of pain. We now know that pain is not just a straightforward 1:1 encoding of sensory information. There is no single specific molecule, receptor type, or brain center responsible for pain.

The feeling of pain does not simply occur as a reflexive response to tissue injury or damage (this is why the patho-anatomical model and KPM have trouble accounting for pain).

Brain Decides When Pain is Appropriate

In fact, we now know pain is not a sensory input at all. Instead, modern science tells us pain should be viewed more as a perceptual output.  As an experience that your brain generates when it decides pain would be helpful given your current environment or situation. 

On the surface this may seem hard to grasp. After all, in what way is the acute low back pain your experience after bending forward to tie your shoes beneficial? How does waking up with a painful neck help in accomplishing the pending tasks of the day?

Modern science views pain as an output… it occurs when you brain decides pain would be helpful given your current environment or situation

Pain – An Evolutionary Perspective

If we want to understand the experience of pain in our modern world it is necessary to know how the body and its various systems were formed in more ancient environments. The fact is everything about our basic anatomy and physiology (including our “pain system”) is the way it is now because somewhere along the line natural selection found favor in certain genes over others. It was these helpful genes that allowed our species to survive long enough to pass this genetic information on to subsequent generations. 

So in our modern world we may see pain as an unpleasant feeling that we just want to go away. But when viewed through an evolutionary lens we can more readily recognize the importance of pain in the survival of our species.

Pain Is Meant To Protect Us

In our modern world of antibiotics, specialized medicine, and well staffed emergency departments we don’t worry too much about injuries and infections being the end of us. Cuts, burns, and breaks may happen, but life goes on. But this was not necessarily the case for your ancient ancestors. Physical ailments and afflictions that serve as an inconvenience to modern man could have disastrous consequences in a hunter-gatherer world. So natural selection was tasked with developing a mechanism to protect our developing species from physical harm. To protect our tissues from injury. 

Pain is a critical part of that system.

That sudden searing pain your ancient ancestor felt when reaching his hand into the fire protected his flesh from a serious burn. Likewise, the pain felt after twisting an ankle while out foraging for food also plays an important protective role. In this case to protect the ankle from further injury and help promote healing and recovery.

Pain Changes Behavior 

But there is a critical distinction that needs to be realized. Something that is absolutely critical to our story here. For pain to be protective it is not the unpleasant feeling itself that is helpful, but rather the action that it causes. The value of pain is that it causes us to do something different. It stimulates us to take action or change our normal way of doing things in an effort to alleviate or avoid the unpleasant feeling. 

As your ancient ancestor feels the burn of his flesh he quickly removes his hand from the flame. His injured ankle changes his gait, causing him to limp around on the damaged ankle and temporarily reduce his hunting and gathering activities allowing the damaged tissue to heal.

It is here we see the true evolutionary purpose of pain: As a powerful driver of behavior.

Up to this point all of this seems pretty obvious and straightforward. Of course if I burn my hand or sprain an ankle it’s going to hurt. And sure, that is going to make me jump, flinch, pull away, or all together move a little differently. But what does that have to do with my neck hurting for no obvious reason?

Great question. That brings us to the next critical discovery regarding pain. That your brain has the ability to greatly modify the pain experience based on your current environment and situation. Perhaps an example would be best here.

Lions, Tigers, and Bears, Oh My!

Let’s go back to the hunter-gatherer world. Here your ancient ancestor is still feeling the effects of his injured ankle. But what if his injury occurred in a different context? Instead of while out foraging for food he twisted his ankle while running from a lion? Would we expect his level of pain to be the same. Of course not. 

But let’s talk about why?

Pain Only Occurs When Your Brain Thinks It’s Useful

Remember the brain generates pain when it believes it to be helpful. This helpfulness is dictated by the sensory information coming from the body itself, but is also heavily influenced by the external environment. By situational context.  

So your ancient ancestor’s brain has a decision to make. What is the bigger threat to survival? The injured ankle, or the the lion? Of course it’s the lion. So while starring down the king of the jungle your ancestor’s leg probably doesn’t hurt. Pain in this context is not helpful at promoting the most appropriate behavior, which in this case would be running away as fast as possible. 

But what goes up must also come down

So the brain can dampen or inhibit the pain response when needed. No real surprises here. But here’s the key point. As with most regulatory systems in the body, mechanisms that are able to dampen or inhibit pain must coexist with systems that are able to swing the pendulum in the opposite direction. So the system must also have a means to amplify the pain response.

Again, in our modern world this idea of amplifying pain may seem like an undesirable trait. Why would we want to increase such an unpleasant experience of pain? Why would we want pain to be excessive? From an evolutionary perspective, why would natural selection shape a regulatory mechanism that expresses pain when it is not actually needed? 

The answer again comes back to promoting survival of the organism, and the notion that pain is meant to provide a protective function. 

Pain Is Related to Uncertainty

Remember pain is a tool the brain uses pain to influence behavior. To get us to take action or do something differently. But what happens when the brain encounters uncertainty? When the safety or potential for damage or injury is unknown?

Here the brain has another decision to make. It must weigh the costs of expressing a certain response (in this case pain) against the potential cost of not expressing it if the threat or danger is actually present. And from the standpoint of evolutionary survival, the cost of pain is relatively low. Especially when compared to the potential dangers that could result from bodily harm and tissue injury.

This is often referred to as the smoke detector principle. The cost of a false alarm from your smoke detector is a small, mild annoyance. But the cost of not sounding the alarm if a fire was actually present could be catastrophic. As a result, the smoke detector is calibrated to be highly sensitive, but prone to going off unnecessarily. Our pain system is similar. 

Impaired Regulatory Control

It should be emphasized that the pain system as discussed up to this point – including the ability of the brain to sensitize and upregulate the pain response – should be viewed as a normal, adaptive, and healthy system. At least when viewed as a short term response. 

But as helpful and adaptive as these pain regulatory systems are, and as much as they have been instrumental in allowing our species to survive and ultimately get to now, they are not failsafe. 

Like other biological regulatory systems, the pain system is also prone to errors and maladaptive responses. The mechanisms responsible for keeping the system balanced can become disjointed. One side of the feedback loop begins to spin out of control and dominate the clinical picture. 

These “errors” in the pain system can result in the pain system becoming hyper-sensitive. The system becomes primed for pain. It becomes easier for incoming signals to activate the pain system. The result is a system on edge, put on high alert, ready to engage (or stay engaged) at even the slightest hint of trouble.  

Most conditions of chronic, long standing pain, and even many cases of recurrent pain are now known to be driven not so much by ongoing or recurrent tissue injury as conventional thought would have us believe, but by these errors in pain processing. By a hypersensitive pain system that is no longer protective or helpful. 

The real problem of pain

This is the real problem of pain. And this concept has been one of the most profound discoveries in our modern understanding of why we hurt. These discoveries have not only changed the landscape of treatment paradigms for chronic pain sufferers, but perhaps just as importantly has identified the critical importance of trying to prevent these “errors” in the pain system from developing in the first place. To try to identify and provide critical treatment and education to those at risk from transitioning from a “normal” adaptive pain response to a chronically sensitive pain system.

But before we get to that we need to blow the dust off our first year psych textbook and talk about some well known experiments with some famous dogs. We’re all familiar with these experiments, but at the time nobody really knew how important they were in understanding the experience of pain.