Facts About Pain
The Problem with Passive Care
Capacity & the Starfish Model
Symptom Modification
The Rehab Framework
Resistance Training for Pain
The Ideal Care Pathway
Many treatments exist — but they all come down to one purpose:
not just reduce the pain
- Symptom Modification — reducing pain to create a window for rehabilitation
- Capacity Building — systematically expanding what the person can do and tolerate
Not passive treatment forever
A structured pathway to independence
- Everyone in pain wants less pain
- Everyone in pain is "pain focused" — consumed by what they can't do
- Everyone is acutely aware of the potential cost of doing things
- The longer someone is in pain, the greater its effect on every area of life
- The longer someone is in pain, the worse their experience with healthcare tends to be
before we meet them
Do not add to their list of things to fear. Begin by reorienting attention toward what is possible. Patients arrive pain-focused, loss-aware, and healthcare-fatigued — your job is to shift that frame.
The first job is not to treat the pain — it is to understand the person
The common — and failing — care pathway
- Increases dependency on clinicians and passive interventions
- Reduces the patient's belief in their own capacity
- Delays the only thing that actually works — graded exposure and capacity building
- Worsens the healthcare experience with each failed encounter
3x/week · 12 weeks · All passive — the wrong model
Passive treatment has a role — but only as a tool within an active, progressive plan. It is not the plan itself. The answer lies between refusing all contact and doing nothing but passive treatment.
Information alone won't help — at some point, they have to do something
Full capacity
Damaged by pain & disuse
- Each "arm" of the starfish represents a domain of physical capacity
- A healthy, full starfish = well-rounded capacity across all areas
- A damaged starfish = capacity reduced — arms shorter, weaker, or missing
- Pain, disuse, fear, and poor healthcare all shrink the starfish
- The goal of rehab is to restore — then exceed — the original starfish
The goal is better capacity than ever
Damaged
- Reduced range
- Reduced strength
- Avoidance of load
- Pain as the limit
Rehab Goal
- Restore all arms
- Systematic loading
- Progressive challenge
- Rebuild trust in body
End State
- Full starfish
- New life goals
- Non-pain goals
- Clinician redundant
even when it feels like help
Collaborative Uncertainty
- Honest about what we don't know
- Works with the patient
- Builds real understanding
- Empowers decision-making
- Maintains therapeutic trust
False Certainty
- "You'll never run again"
- "Your spine is worn out"
- "Don't bend — ever"
- Creates fear & avoidance
- Damages confidence
- Patients stop moving based on an unfounded clinical prediction
- Fear of harm replaces belief in capacity
- Nocebo effect — being told you won't recover is itself a barrier
- Trust in healthcare is further eroded at every encounter
- "I don't have a perfect answer — but here's what we do know"
- "Let's try this together and see how your body responds"
- "We'll reassess as we go and adjust the plan"
- "Your job is to move — my job is to make it safe to do so"
Honest uncertainty with a clear plan beats confident misinformation every time
ask: Better, Same, or Worse?
What did this tell them about pain?
How can they recreate this effect independently? What does this open up that they couldn't do before?
What is the upside of that?
Explore options between now and next session. What can they do in the meantime?
Right area, wrong dose.
Assess irritability. Provide options to calm down. Offer support and reassurance.
- It demonstrates that pain is modifiable — not fixed
- It builds trust in the clinical relationship through direct evidence
- It creates a positive expectancy violation — doing more than feared
- It gives the patient agency: they learn what helps and can replicate it
to their stuff
It reduces symptoms, builds initial confidence, and proves the concept that movement is safe. But it is a stepping stone — not the destination. If the patient only ever does "your stuff", they remain dependent on the clinician.
It is specific to what the person values. It connects rehab to their life. It builds the kind of meaningful capacity that allows them to eventually forget they ever had a problem.
Avoiding meaningful activity is the enemy — the target is re-engagement with life
not where the textbook says to start
- Low cost — low pain provocation (not financial cost)
- Meaningful — connected to what the patient actually cares about
- Easy logistically and physically — accessible, repeatable, low barrier
- Symptom targeted — particularly if early success is expected
- Positive expectancy violation with low risk of failure
When a patient does something they believed would cause harm — and it doesn't — that is one of the most powerful clinical events that can occur. It directly challenges the fear-avoidance cycle and builds real belief in capacity.
- Tasks that are too hard and risk a significant pain response
- Imposing your preferred exercise before understanding what the patient values
- Loading too fast before the patient trusts the process
but they still have to jump
There is always a gap between where the patient is and where they want to be. The clinician's job is to make the leap smaller and safer. But the patient still has to jump. You will never know you can until you do.
- Start Here — easy, safe, symptom-targeted, high chance of success
- Then Here — slightly harder, more load, more uncertainty tolerated
- Then Here — capacity-targeted, approaching life goals
Small wins stack. Momentum builds. Confidence compounds.
- All "arms" of the capacity starfish are bigger than before the injury
- New life goals — beyond pain and beyond the original complaint
- Better capacity than ever before the pain began
- Non-pain-related goals dominate the clinical conversation
- The patient has largely forgotten what the pain was like
- The clinician is no longer needed
Does the pain change — or does the person?
The most important evolution is not a reduction in the pain score. It is a change in the person's relationship with their pain, their body, and their capacity.
everything the patient was told to fear
Proof of concept — the patient sees they can load without harm
Proof of safety — direct evidence the painful area can be used
Maximum nervous system adaptation
Positive expectancy violation — doing more than feared
Positive chemical effects — endorphins, anti-inflammatory response
Instant evidence that overly cautious advice was wrong
- Creates genuine tissue adaptation — stronger, more resilient structures
- Produces real-world evidence of capacity — not just symptom reduction
- Builds the kind of confidence that comes from doing, not from being told
- Generates the largest positive expectancy violations of any modality
Low-load, high-rep exercise that never challenges the system does not produce the same nervous system adaptation as appropriately dosed resistance training. The dose matters — and it should increase progressively.
Resistance training is proof that the body works — not evidence it is broken
Successful pain rehabilitation is not just about the right exercises. It requires the right conditions for change to occur.
Trust
- Especially where lost
- Built through honesty
- Built via early wins
Contact
- Information alone won't help
- Hands-on engagement matters
- Not passive — purposeful
Exposure
- They must DO something
- Graded, supported
- The jump must be jumped
Time
- Reversing a systemic process
- Recovery is not linear
- Manage expectations honestly
Control
- They have to do it
- Clinician facilitates
- Autonomy drives adherence
Success
- Hard to continue when losing
- Engineer early wins
- Stack positive experiences
or does the person?
The most meaningful outcome is not a reduction in the pain score. It is a change in the person. A person who has evolved their relationship with their pain will live well — regardless of whether the pain is completely resolved.
do not make them worse
Best Case
- More equipped for next episode
- Increased capacity & understanding
- Stronger than before
- Doesn't need you again
Minimum Standard
- Not made worse by the interaction
- No added fear
- Not more dependent than before
- Still believes in their body
Every clinical encounter is either an asset or a liability in the patient's pain story