To me, chronic pain is pain that persists to the point that it gets in the way of recovery. And this is to do with the I guess with the utility of pain. So chronic pain, when pain has low utility, this it's this is different to saying that chronic pain is pain that last more than three months, which is fine. These are just definitions.

But for me, I love this as an approach because it's looking at the kind of mismatch between actions and what we perceive. Is that perception leading to useful action or is it hindering useful action? And to me, pain should be a useful thing for our survival. And I have this core belief that it is in the right context. And it can be, so it can be constructive in the right context. It can be really useful, but it can be destructive in the wrong context.

And by context, I mean understanding, social context, cognitive context, the time that we're in, where and where we are, where and when we are, living, and all of this kind of broader contextual stuff. So for me, pain, utility fits with this definition, and we just always have to be asking, is this pain that we should listen to or is this become more chronic in that it's encouraging us to actually stay in this ongoing cycle of pain in an ongoing way.

During the course, you'll hear us contrasting active versus passive treatment. We we just when we use passive treatment, we really mean things that things that are done to you as a patient or things that you will do to your patients. This is massage and manipulation and acupuncture and taping and all these things that are done to you. Whereas active treatment are things that a person's going to do for themselves.

So this is behaviour change or exercise and all of this. We have a an extremely strong bias towards active self-management because the patient is going to spend a lot more time with themselves than you are. And we say that the net effect of increasing, even relatively small, helpful factors is going to be much larger than doing a few specific treatments in those little snapshots of time that we get with our patients. So we think of this as, we call it, high value health care, not high cost, but high value. Because for every dollar spent, we we look at the lifetime value of that health care dollar as much more long lasting, much more general in its effect, and ultimately much more effective than just treating a specific problem in a passive way.

And this fits with our model, our explanatory models for pain that say that pain is an unreliable measure of tissue state. And it's this sort of emergent phenomenon which is affected by all sorts of different factors. And so where passive treatment just addresses, well it's got a more limited scope of effect, an active self-managed approach can affect every domain in that biopsychosocial model.

My clinical practice has, like hopefully all of us shifted over the years as I've learned more and reflected on what was successful and what wasn't. One of the interesting things that's sort of emerged fairly consistently is a trend toward more structure in the early stages. So if it's true for a person that they could put their pain on a shelf for a week and their body would be healthy, i.e. they're fully safe to move physically. In the past I would have gone, I would have used that knowledge to say, well, they're safe to move, so. And I would have approached it in a really an a more accelerated way than how I approach these days.

And that's because of the, I think, known but unpredictable cohort that won't respond well to that. So I know that there's a percentage of people that won't that will have a negative response. And I also know that I can't identify them with tests that I know and to protect against that risk, not necessarily of increasing injury, but just this flare up in pain that might hit their confidence.

To protect against that, I usually these days go in with a build or base phase where I do activities that are still practical for our long term goal, but more controlled in with the hope of building a sort of base of fitness and also a base of confidence. So that after this sort of six, ten, twelve week block, we can then move into less structured discovery learning, trying things, pushing into pain a bit more. But both the patient and myself have confidence that we've we've earned that, that we've sort of we've proved proven that foundation.

And this really fits with the principle of hypothetico-deductive reasoning. So I know that our reasoning process is fallible, that the specificity and sensitivity of tests is not perfect, and that over a career I'm going to make mistakes like everybody simply because our assessment isn't good enough. We are not perfect.

So to protect against that and to protect against these variables in the pain system and someone's pain response, I've moved to this place of a base build phase, followed by more exploration once we've earned that.

A person that's lived with pain for a long time probably almost certainly doesn't exist in a silo. They live alongside loved ones and friends and coworkers that have learned about how pain affects that person's life. They've watched and seen the choices that person makes and if probably from a place of care, started to adapt the way they relate to that person sort of, account for the things that set off their pain and try and make their lives easier.

But when it comes to changing a person's concept of pain and approach to recovery, those good intentions from loved ones can be, also need to be updated so that they don't hold someone back to their own, to their old understanding. So we look at pain recovery, not as this sort of siloed activity, but as something that happens in a community of other people. We look at this person is deeply embedded in this social context that can, that can play a role in either maintaining or changing their recovery. So this means, in a practical sense, inviting a person's partner into the appointment. Getting a person to think about and spend time thinking about how they're going to change their interactions with friends, how they're going to explain their new approach to friends, because otherwise those factors can become real barriers.

Imagine if every time that we go out to dinner for the past ten years, I've I've told you that the chair I couldn't sit down for more than half an hour and I'd need to take a break. And then suddenly I'm actually trying to expose back to that and develop that skill. If I was a caring friend, I might be worried for you. So yeah, we need to sort of like think how these interactions from others maintaining someone's state and how can we really use that care to leverage recovery. So just thinking about the person's social context, context is, yeah, sometimes gives a very helpful and important input to recovery.