There is no doubt that back pain is a complex problem. A massive amount of research has revealed that almost everything we study seems to relate to back pain in some way, but nothing we study seems to get close to explaining it in its entirety. What is more, each time our field discovers what seems to be a potent predictive or causative factor, sparking a firestorm of media, professional development courses, and conference presentations, subsequent research sucks the oxygen right out again. This cycle can become wearing and often leaves us with yet another assessment that we might have to consider in a minority of presentations. We suspect that most clinicians, when pressed, would share our view that back pain is complex, yet many appear reluctant to really embrace this complexity in the way they think about back pain, the way they explain it to patients, and the way they plan and interpret their interventions.^1,2 This perplexing dissonance might be due in part to the insidious processes at play—the commodification of care, the moral hazard,³ the cultural context of the problem.⁴ Or perhaps it simply reflects human nature—as George Engel, the pioneer of the biopsychosocial model, wrote,

One constant among the apparent chaos is that we should do our very best to help patients make informed choices about their own care.⁶ Clinical guidelines internationally clearly state that education or “advice,” is first-line treatment.^7,8 A recent iteration from a “who’s who” of the back pain research world made it central to their call to action, yet even still, the vast majority of attention was given to “exercise and psychological therapies.”⁹ We were among those who were critical of the focus of attention and that education was glossed over, as it tends to be when such contributions are published.¹⁰ Arguments we made then and iterate here are that, even though education is central to all we do for people in pain, clinicians don’t often understand why education is so important, they don’t know what is involved in education, they don’t know how to do it, they don’t know what the content should be, nor how to work that out on a case-by-case basis, and they don’t know how to evaluate whether or not it has hit the mark.

This chapter will briefly address each of these questions. Full coverage of pain education is well beyond the scope of this chapter, so the reader will be referred to other resources to pursue a greater understanding of this critical field.

There are two ways to approach this question. The first is from the classical perspective of education as a pathway to knowledge and knowledge as a prerequisite for informed decisions. From this perspective, the more the patient understands about such things as the normal course of back pain,¹¹ the poor relationship between pain and evidence of pathology,¹² the evidence-based indications for surgery,¹³ the importance of exercise and remaining active,¹⁴ and the effectiveness, risks, and side effects of medications,¹⁵ then the more likely they are to make decisions that will optimize recovery. Broadly speaking, these types of issues are central to conventional back school-type approaches to education, although those programs tended to also involve education on the structures of the spine, supposedly safe lifting postures, and load characteristics of different postures.¹⁶

The content of “conventional” back education was well covered in the 1980s and it was for a time quite popular, but its effectiveness has been in doubt for some time, with participants gaining new knowledge about the back itself, but, as a rule, not demonstrating improvements in pain or disability.¹⁷ Increased understanding of pain biology and a shift in the conceptualization of pain from that of a marker of structural pathology to that of a feeling that compels us to take protective action¹⁸ offered some explanation for the lack of effect of back schools.¹⁹ It also led to the emergence of a new approach to education, an approach that has variably become known as “pain biology education,” “pain science education,” “therapeutic neuroscience education,” or simply “explaining pain.”^20,21 Early approaches such as intensive neurophysiology education²² have now been superseded as the science of pain has expanded. For this chapter, we will stick with the label of “explaining pain” but use it interchangeably with “contemporary pain education” to remind the reader that contemporary models have
moved beyond just neuroscience or neurophysiology. Explaining pain is often discussed as a stand-alone intervention and clinical trials have tested it as such, but it might be best considered an essential and keystone aspect of good practice.

The emergence of explaining pain reflects the second approach to the lead question “Why is education so important?” Contemporary understanding of pain emphasizes its protective function and the critical importance of context in whether or not someone will experience pain. Nociception—activity in high-threshold free nerve endings and their spinal projections—is highly influential over pain,²³ but it is neither sufficient nor necessary for pain.^24,25 This distinction between nociception and pain is a key concept of explaining pain, but it remains a difficult concept for many to grasp.²⁶

Pain is a truly biopsychosocial event. It is an unpleasant feeling that emerges into consciousness, is allocated a location within your body, and possesses qualities that at once prioritize your efforts to remove it and thwart your efforts to not attend to it. The anatomic location of pain is of course illusory—pain is merely constructed by your brain and allocated a bodily anchor—but it is terrifically effective at targeting our protective response and it is always real no matter what is causing it. Poignant and oft-recounted examples that demonstrate this include referred pain with angina—there is clearly no tissue pathology down the arm—and refractory angina—there is clearly no compromise in blood flow to heart tissue. That pain is real no matter what is causing it is a critical key “target concept,”²⁷ particularly for our understanding of why education is important because it points to pain being the brain’s “best guess” that protective behavior is likely to result in the optimum outcome.²⁸ It also means that pain is therefore modifiable, or indeed can be generated from anything, from any domain, that provides credible evidence that protective behavior will be beneficial.

This contemporary view—that pain really is affected by any cue that is relevant to the benefit or not of protection—means that anyone’s pain has many potential contributors. This view accommodates the fully biopsychosocial nature of pain, including the possible shaping of pain by culture, context, and conditioning. Accordingly, changing how one understands the biology of pain so as to extend the cause of pain beyond a structural pathology in the tissues should change one’s pain. It should also change someone’s beliefs about the risk of injury associated with movement, with painful events, and with physical upgrading. It should increase one’s conviction that, after a long history of pain, mechanical loading of the tissues is likely to be safe. The evidence in favor of these propositions is now overwhelming, with several systematic reviews making similar conclusions.^18,29,30,31 We have previously argued the case for pain education, within the context of back pain, like this:

Explaining pain refers to a widening range of educational and conceptual change strategies that aim to change beliefs about how to optimize recovery from a pain state, through imparting knowledge about what pain actually is, what purpose it serves, and what biologic processes underpin it.¹⁸ That is, explaining pain targets belief, attitude, and behavior change through a process initiated by the provision of new knowledge. The design and implementation of explaining pain is guided by conceptual change, instructional design, and cognitive science, and the content is contemporary pain science. As scientific discoveries continue, explaining pain changes too. For example, the proposal³³ and subsequent discoveries^34,35,36 that suggest classical conditioning mechanisms may well contribute to the persistence and generalization of pain (an idea that intriguingly carried weight among clinicians despite there being no supportive evidence²⁶) led to the introduction of “modules” on classical conditioning within the explaining pain curricula (e.g., see www.tamethebeast.org).

Explaining pain has become known as more than simply education, but a conceptual and operational framework that underpins the implementation of the biopsychosocial approach to understanding and treating pain. This is important because it points to the integration of education into each component of
care, rather than simply as a “stand-and-deliver” intervention. As such, the format of explaining pain ranges from the delivery of a didactic multimedia presentation to a group of sufferers, family, clinicians or politicians, to clinical reasoning and nuanced aspects of the therapeutic encounter (Table 13.1).