Pain Education Is Stuck — And We Know It

Pain Education Is Stuck — And We Know It

There’s a new paper out from Moseley and team.
They’ve renamed Pain Neuroscience Education (PNE) to Pain Science Education (PSE).
Same message, but now with comics, VR, and some storytelling added in.

They’re trying to freshen it up.
But anyone paying attention knows… it’s still the same old stuff.

Pain is a brain output.
Pain doesn’t mean damage.
If you change how you think about pain, your pain might go away.

That’s the pitch. It always has been.

But Let’s Be Real

The model hasn’t changed. Just the wrapping paper.
Still focused on explaining.
Still preaching from the top down.
Still acting like pain is a belief problem — and they’ve got the belief correction manual.

But does it actually work for most people?

The research says... not really.
And in clinic? It misses the mark more often than it hits.

The Neuromatrix: Useful Once. Now Just in the Way.

The whole thing is built on the neuromatrix model.
That pain comes from the brain, and we just need to update the software.

It sounded smart 20 years ago. But now?
It feels more like a belief system than actual science.

And yet, it’s treated as fact.
Taught in courses. Sold to patients. Backed by authority.
And if it doesn’t help someone? That’s their fault.
“They didn’t get it.” “They weren’t ready.” “You didn’t teach it well enough.”

But no one stops to ask:
What if the model itself is the problem?

A Different View

Bud Craig’s work shows us something deeper.
Pain isn’t just a brain trick.

It’s a homeostatic emotion — like hunger or thirst.
It comes from the body when things are out of balance.

• Inflammation

• Acidic tissue

• Nervous system overload

• Fatigue

• Low energy

• Disconnection

You don’t fix those things with metaphors.
You fix them with movement, rhythm, breath, food, recovery, trust.

You don’t talk the body out of pain.
You help it feel safe again.

It’s Time to Say It Plainly

The problem with PNE isn’t just the method.
It’s the mindset.

It’s the attitude that “we know better.”
That the brain is the answer to everything.
That patients need to be re-educated.

And that if the education fails — it’s on them.

That’s not science.
That’s sales.

And the worst part? It’s delivered with a smile, a TED Talk, and a research grant.

The Brain Took Over the Room

Let’s call it what it is.

Neuroscience didn’t just join the conversation — it took over.
The conductor became the soloist.
And now everything revolves around the brain.

Pain is no longer in the tissue. Not in the immune system. Not in the gut.
Nope — just a misfiring prediction machine that we need to talk into calmness.

We’ve lost the whole person by obsessing over one organ.

Taleb Saw This Coming

As Nassim Taleb wrote in Antifragile:

“When it comes to narratives, the brain seems to be the last province of the theoretician-charlatan... Add neurosomething to a field, and it suddenly sounds scientific — even when it’s just psycho-neuro-babble.”

The brain-based model gives the illusion of control.
But it hasn’t delivered the outcomes it promised.

So Here’s the Truth

We don’t need more education.
We don’t need another metaphor.
We don’t need another cartoon or animation explaining how pain is a brain output.

We need a new path. One that starts in the body.

One that:

• Builds real capacity

• Resets balance

• Teaches through experience, not slideshows

• Trusts the body's signals, not overrides them

Thanks for the Input. We’ll Take It From Here.

Neuroscience had its moment. It gave us some tools.
But it’s not the whole answer.

It’s time physios, coaches, patients, and people doing the real work reclaimed the space.

We’re not here to be educated.
We’re here to heal.
And that starts by turning down the noise — and tuning back into the body.

Let’s move forward.
With honesty. With humility. With both feet on the ground.

Is It Time for a New Pain Model?

Is It Time for a New Pain Model?

In the early 2000s, pain neuroscience education (PNE) emerged as a revolutionary approach to understanding pain, spearheaded by prominent figures like Lorimer Mosley and David Butler.

Their work shifted the conversation away from a purely structural perspective and introduced the world to the concept that pain is not solely a result of tissue damage, but also a brain-driven phenomenon.

For some in the rehab profession, this helped us move beyond simplistic reductionist narratives (some other practitioners continued the narrative - see below).

How many overly simplistic nocebic inducing narratives could you fit in one physiotherapy session?

This was an exciting revelation at the time, and it gave clinicians and patients alike a new way to explain chronic pain.

However, as the years have passed, it’s become increasingly clear that PNE, while groundbreaking, may not have fully lived up to its promise.

Many have “drunk the Kool-Aid,” so to speak, fully subscribing to the PNE narrative without recognizing its limitations.

As a result, it may be time for a new explanatory model—one that embraces both the brain and the body in a more profound and grounded way.

Enter Bud Craig’s homeostatic model.

The Cognitive Focus of PNE: A Double-Edged Sword

Butler and Mosley’s PNE revolution gave us the gift of understanding the brain's role in pain perception.

It showed that pain is a complex experience that involves more than just signals from the body—our thoughts, beliefs, and prior experiences shape how we experience pain.

This has led to cognitive-based interventions aimed at reshaping our understanding of pain, helping patients reframe their pain experience and reduce fear.

But this approach has its downsides.

The heavy focus on cognition—the idea that it’s all in the brain—can stigmatize patients, making them feel like their brain is "broken" or diseased.

Just today I heard on the Curable podcast (link here - 38 min mark) Sophie Hawley-Weld discuss her negative experience with PNE as a stand alone approach - “It made me feel crazy, because I did ALL the things!”

Lisa Feldman Barrett points out in her book How Emotions Are Made:

“Scientists now consider chronic pain to be a brain disease with its roots in inflammation.”

Therapists, too, can get stuck in this model, sometimes doubling down when their approach doesn’t yield results, leading to frustration and cognitive dissonance on both sides.

While PNE has helped many, its reductionist trap—the idea that pain is purely a cognitive or brain-based experience—can leave patients feeling confused, alienated, and in some cases, harmed.

The Quiet Work of Bud Craig: A Model Ready for Its Time

While PNE experts have been front and center, promoting their work as being of the highest evidence-based standard, Bud Craig has worked quietly and diligently in his lab for over two decades.

Without any fanfare or jumping to premature conclusions, Craig has steadily built his homeostatic model of pain, focusing on understanding how the brain and body interact to maintain balance. His approach has been one of careful observation and deep research, avoiding the sensationalism that often accompanies new theories.

Unlike the self-promotion that has often characterized the PNE movement, Craig’s work has been humble yet profound.

While PNE experts have confidently marketed their approach and, at times, looked down on therapists who use what they consider to be outdated modalities, Craig has taken a more measured, thoughtful path.

This divide between the PNE camp and other healthcare professionals has created divisions within the profession that threaten to tear it apart. As the PNE model gained traction, those who embraced different methods, even those rooted in manual therapy or movement-based approaches, have often been labeled as being behind the times or lacking evidence.

This division is unhealthy.

When experts adopt a fixed stance, particularly when that stance dominates the conversation, it can prevent the evolution of new ideas.

The rigid adherence to the neuromatrix theory has made it difficult for PNE proponents to integrate other valuable insights, particularly those that focus on the body’s physiological processes.

Bud Craig’s Homeostatic Model: A More Balanced Approach

This is where Bud Craig’s homeostatic model offers a refreshing alternative.

Craig’s model doesn’t disregard the brain’s role, but it brings the body back into the equation in a more meaningful way. His model focuses on interoception—the way the brain perceives signals from inside the body—and homeostasis, or the body's ability to maintain internal balance.

Craig suggests that pain emerges from the brain's interpretation of signals related to disruptions in homeostasis.

In other words, pain is a result of the body trying to maintain balance, involving not just cognitive processes but also metabolic health, the immune system, and the autonomic nervous system.

This multi-dimensional approach goes beyond the brain to include a broader understanding of the body's physiological state.

Why PNE Has Reached Its Limits

The current PNE model, with its strong focus on the brain, misses out on these broader dimensions. While it’s been helpful for some, it has also led to iatrogenic harm—the unintended negative consequences of treatment.

Patients who don’t respond to PNE can feel as though their brain is at fault, or that they’re failing to think positively enough to overcome their pain. This can lead to a sense of disempowerment, where patients feel like they’re not in control of their own healing.

On the flip side, therapists who are deeply invested in the neuromatrix theory of pain, popularized by PNE, can become stuck in their thinking.

They may struggle to embrace newer models like Craig’s, falling into expert bias and resisting change due to their commitment to a theory that no longer fully explains the complexity of pain.

Big organizations or thought leaders who have built their careers on the neuromatrix theory may find it difficult to pivot, even when emerging evidence suggests a new direction is needed.

The Risk of Reductionism

When we boil down pain to a purely cognitive process, we risk oversimplifying a very complex experience.

Pain is not just in the mind, and it’s not just in the body—it’s an emergent experience that arises from the brain’s interpretation of the body’s internal state.

PNE’s reductionist approach may have been a necessary stepping stone, but it’s clear now that it’s not enough.

We need a model that honors the complexity of pain—one that integrates the brain, body, and emotions.

A New Paradigm for Pain: Bud Craig’s Homeostatic Model

Bud Craig’s homeostatic model offers the kind of paradigm shift that the pain world desperately needs.

His model moves beyond the brain-centric view of pain and looks at how pain is a signal of the body’s struggle to maintain balance.

It integrates brain and body, cognition and physiology, offering a more multi-dimensional and empowering view of pain.

This model suggests that pain is not just about faulty neural circuits or maladaptive thoughts but is a multi-dimensional signal that can arise from metabolic imbalance, poor immune function, or disruptions in the autonomic nervous system.

In this way, it respects the body's role in pain, and it offers patients a more empowering framework for understanding their pain and healing.

Instead of being told that their brain is “the problem,” patients can see how their body and brain work together to maintain balance.

Time for a New Direction

As with any scientific revolution, there comes a time when we must move forward. Karl Popper’s philosophy reminds us that science should be open to change, that we must always be ready to discard old theories when new evidence challenges them.

The PNE revolution, while groundbreaking, may now need to give way to a more nuanced, integrative approach. The homeostatic model offers a new direction—one that respects the brain’s role but also fully embraces the body’s physiological contributions to pain.

It’s time for a new pain model—one that’s more grounded in science, one that empowers patients rather than stigmatizing them, and one that helps therapists and patients alike see the bigger picture.

The time for Bud Craig’s homeostatic model has come.

Final Thoughts:

We owe a debt of gratitude to Butler, Mosley, and the pioneers of PNE for opening the door to a new understanding of pain.

But now, we have the opportunity to take the next step. By embracing the homeostatic model, we can help patients reclaim their power, and in doing so, move away from the reductionist trap that has limited our approach to pain for too long.

Let's bridge the divisions in the profession and build a new, unified path forward—one that honors both the brain and the body.

"Back to the Body": Charting a New Course in Physiotherapy

In the dynamic field of physiotherapy, a transformative wave is reshaping our traditional approaches to pain and injury.

This evolution, termed "Back to the Body," represents a significant departure from past practices, integrating modern science's revelations with a renewed focus on the body's intricate signals.

As we delve into this shift, it's essential to appreciate the context from which we're moving and the promising direction in which we're headed.

The Traditional Paradigm: A Focus on the Physical

Historically, physiotherapy has been deeply anchored in a biomedical model, concentrating on the body's physical aspects—its joints, muscles, and tissues.

This approach, while foundational, often adopted a reductive lens, aiming to "fix" what was perceived as broken or misaligned.

Diagnoses frequently highlighted deficiencies: a "weak" core, "tight" muscles, or "improper" posture.

While these assessments were made with the best intentions, they inadvertently introduced a nocebo effect, where the negative framing of conditions could exacerbate patients' perceptions of pain and disability, sometimes with minimal relevance to their actual experience of pain.

The Shift Toward Mind and Emotion

The field's expansion to encompass beliefs, emotions, and the broader neurocentric model—largely influenced by the pioneering work of researchers like Lorimer Moseley and David Butler—marked a significant leap.

This phase brought to light the brain's integral role in pain perception, advocating for a more comprehensive understanding that transcends mere physicality.

However, this shift, for all its merits, occasionally led to an overemphasis on the psychological at the expense of the physical.

Patients sometimes felt their pain was being dismissed as purely a construct of the brain, leaving them feeling invalidated and overlooked.

"Back to the Body": A Holistic Reintegration

Today, we stand at the precipice of a new era, inspired by Bud Craig's insights into homeostatic emotions and the complex interplay between mind and body.

"Back to the Body" advocates for a return to a more integrated approach, where pain is recognized as an interoceptive signal—a cue from our body indicating a need for attention and care.

This perspective sees pain not as a mere symptom to be eradicated but as a critical piece of feedback within our body's attempt to maintain balance.

With advancements in technology—such as heart rate variability monitors, blood glucose tracking, and sensors for lactate and inflammatory markers—we're now equipped to decode the body's signals with unprecedented clarity.

This technological leap, combined with principles of load management as outlined by Tim Gabbett, empowers us to identify and respond to the body's cues more effectively, fostering an environment where positive adaptations are more likely.

Empowering Through Understanding

This shift towards an integrated mind-body model is about empowerment and education.

It's about guiding patients to tune into their bodies' messages, recognizing the signals of overload and stress.

It encourages a response to discomfort informed by understanding and mindfulness, rather than fear or the pursuit of immediate fixes.

This approach demystifies the sensations we've labeled as pain, reframing them as part of our body's broader context of response.

Moving Forward

"Back to the Body" heralds a return to physiotherapy's roots, enriched by our journey through the realms of psychology and neuroscience.

It's a call to embrace the body's complexity, leveraging science and technology to deepen our connection with ourselves.

As we chart this new course, we embrace a model of care that is both empowering and educative, one that places the patient's experience at the forefront of the healing process.

In doing so, we not only address pain more effectively but also foster a holistic sense of well-being.

Daniel O’Grady