Phantom Limb Pain: Refuting the PNE Neuromatrix Trap

One of the most seductive arguments Pain Neuroscience Education (PNE) proponents make is the use of phantom limb pain to support their brain-centric neuromatrix model of pain.

According to this view, pain is constructed entirely by the brain, drawing from memories, emotions, and beliefs, and therefore, they argue that even when a limb is missing, the brain can "create" pain.

It’s an alluring idea: if you can feel pain in a limb that no longer exists, then clearly, the pain must be "all in the brain," right?

Wrong.

This oversimplified interpretation leaves out critical aspects of how pain really works.

While it’s true that the brain plays a role in pain perception, phantom limb pain doesn’t necessarily mean that pain is purely a brain-made phenomenon.

In fact, we can better understand phantom limb pain by looking at how referred pain works, which reveals how the brain misinterprets signals coming from other parts of the body.

Let's explore why falling into the trap of the neuromatrix model leads to a skewed understanding of pain—and how the concept of referred pain offers a more grounded explanation.

Referred Pain: A More Balanced Explanation

Phantom limb pain can be better understood through the well-known phenomenon of referred pain.

Referred pain occurs when pain is felt in a different area of the body than the one actually causing the disruption.

A classic example is heart attack pain that is felt in the arm or jaw, despite the issue being in the heart. Here’s how it works:

1. Disrupted Homeostasis: Referred pain occurs when something disrupts homeostasis in one part of the body (like an organ or muscle) but the brain mistakenly interprets the signals as coming from a different location. For example, muscles can directly refer pain to other areas—trigger points in the shoulder can cause pain in the arm or hand.

2. Sensory Confusion: The nervous system is complex, and the brain sometimes misinterprets signals, getting the location wrong. Just because you feel pain in your arm during a heart attack doesn’t mean the pain is purely emotional or brain-generated. The pain is still real, even if the brain misreads the location.

In phantom limb pain, this same mechanism could explain why the brain continues to feel pain in a missing limb.

The neural pathways that used to represent that limb are still active, and the brain gets confused by lingering signals from the body or even from nearby muscles and tissues that are still sending sensory input.

Why Phantom Limb Pain Doesn’t Prove Pain is "All in the Brain"

PNE pundits use phantom limb pain as a case to convince you that pain exists entirely in your mind, an argument that can lead to cognitive dissonance.

They try to show you that if the brain can "create" pain where no limb exists, then all pain must be brain-generated.

This is a slippery slope, and while it may sound plausible, it’s not the full picture.

Here’s why:

1. Misinterpretation of Signals: Just because the brain is involved in the interpretation of pain doesn’t mean pain is purely in the brain. The brain relies on signals from the body—whether they’re coming from an intact limb or the surrounding tissue that used to connect to a now-missing limb. The brain is simply misinterpreting the source of the pain, as it often does with referred pain.

2. Referred Pain Patterns: Many pain patterns are well-documented and follow predictable referral routes. If we can accept that the brain sometimes gets these signals wrong (as in heart attack pain referred to the arm), we can also accept that the brain might feel pain in a missing limb because it's mistakenly interpreting signals from surrounding tissues or nerves.

3. Not "All in the Brain": Referred pain proves that even when pain is felt in one area, the root cause lies elsewhere. PNE proponents like to point to brain imaging studies showing activity in the brain during phantom limb pain, but this only shows that the brain is part of the process—it doesn’t mean the brain is the sole cause of pain. The pain is a result of misinterpreted sensory signals, not purely emotional or cognitive constructs.

Don’t Fall for the Trap: The Role of Cognitive Dissonance in PNE

PNE pundits often push the idea that if you accept phantom limb pain as brain-generated, you must accept that all pain is brain-generated.

This tactic creates cognitive dissonance—a psychological state where you hold two contradictory beliefs at once. PNE advocates hope this dissonance will force you to see pain through their lens.

But here’s the problem: just because the brain can misinterpret pain signals doesn’t mean the pain is imaginary or only in the brain.

The PNE model oversimplifies pain by focusing too much on emotions, thoughts, and beliefs, while ignoring the critical role of body-based sensory pathways.

Just like referred pain, phantom limb pain shows that pain is complex and multi-dimensional—it involves both the brain and the body.

Conclusion: A More Comprehensive View of Pain

Phantom limb pain may seem like the perfect example to prove the PNE model, but when we dig deeper, it’s clear that it doesn’t tell the full story.

Like referred pain, phantom limb pain highlights how the brain sometimes misinterprets signals from the body—it doesn’t prove that pain is "all in the brain."

By understanding referred pain patterns and recognizing the importance of sensory input, we can see that the brain is not the sole creator of pain.

Pain is a complex experience that involves miscommunication between body and brain, not just emotional or cognitive constructs.

So next time someone tells you phantom limb pain proves pain is "an output of the brain," remember: the brain might misinterpret the signals, but that doesn’t mean the body isn’t involved.

Let’s not fall for the trap.

Instead, let’s embrace a more comprehensive and nuanced understanding of pain, one that recognizes the critical role of sensory pathways in shaping our experience.

References:

Erlenwein J, Diers M, Ernst J, Schulz F, Petzke F. Clinical updates on phantom limb pain. Pain Rep. 2021 Jan 15;6(1):e888. doi: 10.1097/PR9.0000000000000888. PMID: 33490849; PMCID: PMC7813551.

Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Esa WAS, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Ma C, Padwal JA, Turan A; PAINfRE Investigators. Ambulatory continuous peripheral nerve blocks to treat postamputation phantom limb pain: a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain. 2021 Mar 1;162(3):938-955. doi: 10.1097/j.pain.0000000000002087. PMID: 33021563; PMCID: PMC7920494.

Amoruso E, Terhune DB, Kromm M, Kirker S, Muret D, Makin TR. Reassessing referral of touch following peripheral deafferentation: The role of contextual bias. Cortex. 2023 Oct;167:167-177. doi: 10.1016/j.cortex.2023.04.019. Epub 2023 Jul 13. PMID: 37567052; PMCID: PMC11139647

Arendt-Nielsen L, Svensson P. Referred muscle pain: basic and clinical findings. Clin J Pain. 2001 Mar;17(1):11-9. doi: 10.1097/00002508-200103000-00003. PMID: 11289083.

Managing Neck, Back Pain, and Headaches with the Guitar Framework

What Would It Look Like If It Were Easy? Managing Neck, Back Pain, and Headaches with the Guitar Framework

Let’s face it.

Persistent neck, back pain, and headaches can make you feel like you’re starring in your own personal reality TV show: Pain Island.

Every day is a quest for survival, navigating the perils of flare-ups, discomfort, and endless expert opinions on what you should do to fix it.

"Stretch more!" they say. "Strengthen those muscles!" another expert shouts.

Before you know it, you’ve tried everything short of strapping yourself into a medieval torture device to stretch yourself out.

But what if, instead of doing more, the solution was about making things easier?

Cue Tim Ferriss’ golden question: “What would it look like if it were easy?”

You’re not broken; you’re just a little out of tune.

And just like a guitar that’s been knocked around one too many times, you don’t need to be rebuilt from scratch.

You just need to re-tune your strings.

Welcome to the Guitar Framework: a beautifully simple, dare I say, luxurious approach to persistent pain.

(And before you start thinking “luxury = expensive,” let’s clear that up right now: The luxury I’m advocating has nothing to do with money. It’s a state of mind, and it’s free.)

What Is the Guitar Framework?

Picture your body as a guitar.

You’ve got six strings, each one representing a modifiable aspect of your health.

When these strings are in tune, life is easy—even luxurious.

When they’re out of tune, life becomes complicated, painful, and, well, kind of like listening to a middle school garage band for hours on end.

But what if getting those strings back in tune wasn’t as hard as you think?

❌ What if more effort wasn’t the answer?

❌ What if more expert opinions wasn’t the answer?

❌ What if more money wasn’t the answer?

❌ What if more stretching wasn’t the answer?

What if it were, dare I say, easy?

The Science Behind It: Pain as a Homeostatic Emotion

The Guitar Framework is based on modern science, particularly Bud Craig's work on pain as a homeostatic emotion.

Just as emotions help us navigate social situations, pain helps us navigate our physical state, signaling when something is out of balance.

Instead of seeing pain as a sign of damage, the Guitar Framework views it as a homeostatic signal—a prompt to adjust your strings and restore balance.

You can read more about Bud Craig’s revolutionary work here

The Easy Path vs. The Hard Way

It’s tempting to think the solution to your pain is complex and hard.

That you have to try harder, do more, and follow every expert’s advice to the letter.

But what if the path to healing wasn’t about fighting or struggling?

Jean Cocteau said it best:

“You have comfort. You don’t have luxury. And don’t tell me that money plays a part. The luxury I advocate has nothing to do with money. It cannot be bought. It is the reward of those who have no fear of discomfort.”

The luxury here isn’t in paying for more treatments or pushing through more pain.

The luxury is developing the skill of knowing how to tune your strings and managing your body with ease.

That’s the kind of luxury that makes life a little bit easier, pain a little bit quieter, and stress a little less overwhelming.

So next time you feel that neck pain or headache creeping in, ask yourself: What would it look like if this were easy?

The answer might just surprise you.

Ready to Tune Your Strings?

If you're tired of pain controlling your life and you want to explore a simple, actionable approach to relief, take our free Tune-In Archetype™ quiz.

Find out which of YOUR strings is out of tune and which stress pattern is guiding your response to life’s pressures.

Hi, I’m Daniel O’Grady, a physiotherapist and coach, and I’m here to guide you—not fix you. The Guitar Framework isn’t about quick fixes or endless treatments. It’s about helping you tune your strings, regain control, and move toward your North Star functional goal.

We currently have limited spots available for those ready to take the next step. If you're an early adopter, you have nothing to lose—just an easier, more tuned life to gain.

Email me directly at dan@kinfolkwellness.com.au with a subject line of STARTNOW to join the waitlist today!

Top 3 Long-Term Benefits of Understanding Your Tune-In Archetype™ for Persistent Neck, Back Pain, and Headaches

1. Break the Pain-Fear Cycle: Each of the 9 stress reactivity patterns in the context of persistent neck, back pain, and headaches has blind spots that unintentionally make pain worse. By identifying yours, you can stop fueling the pain-fear amplifier and regain control.

2. Personalized Pain Relief: These stress patterns make you good at certain things in life but can be your Achilles' heel when managing persistent pain. You’ll know exactly what works for your body and mind, helping you make smarter, quicker decisions to reduce pain and prevent flare-ups.

3. Proactive Healing: Learn to tune into early signals from your body and take small, easy steps to prevent pain from escalating—leading to long-term relief without constant external treatments.

I will personally guide you through a simple, effortless approach.

First, we need to take a courageous step through the complexity—it might seem daunting, but with the Guitar Framework, we’ll guide your decision-making and help you tap into your internal power.

If you’re tired of winning the battle but losing the war, take the free Tune-In Archetype™ quiz and discover how your stress pattern can unlock lasting relief from persistent neck, back pain, and headaches.

We currently have limited spots available for those ready to take the next step.

If you're an early adopter and are curious, you have nothing to lose—just an easier, more tuned life to gain.

Email me directly at dan@kinfolkwellness.com.au with a subject line of STARTNOW to take the FREE Tune-In Archetype™ quiz.

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.

A new view of pain

“A new view of pain as a homeostatic emotion Bud Craig”.

Neuroscientist Bud Craig wrote this research paper 20 years ago.

I just discovered in last year and was blown away by the explanation of pain through the lens of homeostasis and interoception.

It links the body and brain in a plausible and scientific explanation that is based on Mr Craig’s decades of pain staking anatomical dissection and innovative tracing methods.

Currently as a society we are going through a epidemic of pain.

Our traditional models are not helping.

It could be argued they are making the problem worse due to iatrogenic harm.

Once you are caught in the biomedical matrix, it is very challenging to escape.

I found this paper to be a game changer as it helps us to use a m0re accurate explanation of pain that links body and brain in a way that is much more empowering.

Subsequently I have been reading more of Mr Craig’s work as well as his amazing book.

Making sense of pain is arguably the greatest therapy there is.

I have included the full PDF in the link below.

Some of the highlights from the research paper I have also outlined below.

As it is written for a scientific lens, if you reading this and would likely to comment or connect to find out more - just leave a message below or send me an email dan@kinfolkwellness.com.au

“Pain is both an aspect of interoception (the sense of the physiological condition of the body) and a specific behavioral motivation. This striking conceptual shift incorporates the multiple facets of pain into one concrete framework, and it provides sound explanations for pain as both a specific sensation and a variable emotional state”.

“Changes in the mechanical, thermal and chemical status of the tissues of the body – stimuli that can cause pain – are important first of all for the homeostatic maintenance of the body.”

“Pain normally originates from a physiological condition in the body that automatic (subconscious) homeostatic systems alone cannot rectify, and it comprises a sensation and a behavioral drive with reflexive autonomic adjustments.”

“The behavioral drive that we call pain usually matches the intensity of the sensory input but it can vary under different conditions, and can become intolerable or, alternatively, disappear, just as hunger or thirst.”

“The new view of pain as a homeostatic emotion arises directly from functional anatomical findings in cat and monkey, rather than from philosophical considerations.”

“These results have identified specialized central substrates that represent pain, temperature, itch, muscle ache, sensual touch and other bodily feelings as discrete sensations within a common pathway.”

“These data indicate that in humans pain is an emotion that reflects specific primary homeostatic afferent activity.”

“Activity that produces pain in humans ascends in this pathway because its primary role has been homeostasis for millions of years.”

“Humans experience increasing discomfort at temperatures below 24C, but cold does not normally produce pain until 15C, where HPC activity accelerates and, significantly, cooling-specific lamina I cell activity plateaus.”

“This physiological evidence confirms the anatomical finding that homeostasis, rather than the heuristic simplification ‘nociception’, is the fundamental role of the small-diameter afferent fiber and lamina I system and is the essential nature of pain.”

“These findings indicate that pain in humans is a homeostatic emotion reflecting an adverse condition in the body that requires a behavioral response.”

“The new findings provide specific substrates for each of these aspects within a common framework of homeostasis.”

“This new view differs fundamentally from the prior conventional view in several ways. It incorporates specific sensory channels for different kinds of pain and for pain of different tissue origins. It provides a fast (sharp) pain channel that can elicit fight-or-flight behavior and a slow (burning) pain channel that can engage long-term responses, sickness behavior and immune function”.

“This perspective suggests new directions for research that could have strong impact on clinical therapy. For example, other homeostatic variables, such as salt and water balance, could have direct impact on the integrated activity that underlies the motivation called ‘pain’, as in the mysterious fibromyalgia syndrome.”

“Understanding the mechanisms underlying the augmentation of activity in the polymodal nociceptive channel could be particularly fruitful for identifying new therapies for chronic pain.”

When Biomechanics DOESN'T Matter

Greg Lehman has been a pioneer in helping us to understand pain and biomechanics and finding out when they matter.

He is a advocate for “Movement Optimism” - an approach that helps you build confidence in your body and avoid the common trap (fueled by well meaning health care professionals) of getting stuck in sometimes irrelevant biomechanical narratives that create fear and entanglement in the body.

I would encourage you to watch at least the first five minutes as he pulls apart the most common things you might hear coming from your health care professionals mouth.

“What I often say is, it’s not the pain science or neuroscience that challenges these biomechanical ideas, it’s the biomechanics itself. And if you know the biomechanics well, you can really see the holes in the common arguments.”

I hope you enjoy this eye opening lecture at the San Diego Pain Summit (click on image below to watch on youtube).