#47: Active Inference, Pain, and Movement with Dr Mervyn Travers

[Music] Welcome to the Shoulder Physio Podcast, a podcast dedicated to exploring meaningful topics in Musculoskeletal healthcare. I'm your host, Dr. Jared Powell. Before we begin, the primary purpose of this podcast is to educate and inform. The views expressed in this podcast by myself and any guests are information only. Do not constitute professional advice and our general in nature. If you act on the basis of any podcast episode, you should obtain specific advice from a qualified health professional before proceeding. Today's guest is Dr. Mervyn Travers, a physiotherapist, strengthening conditioning coach, researcher, and someone who brings both scientific depth and clinical clarity to the world of Musculoskeletal pain. In this episode, we're diving into active inference, a framework that doesn't just explain pain differently. It re-imagines how humans perceive, move, and experience pain. It's about brains predicting the world. Body is confirming those predictions and how the entire loop can either trap people in pain or free them from it. This episode is deep and involves the name-checking of key figures in the field of active inference, and you may need to listen to this a few times to fully grasp the topic. But please don't let that deter you. At the end of the episode, Dr. Travers suggests some resources that may help extend your learning and knowledge of active inference. Without any further delay, I bring to you my conversation with Dr. Mervyn Travers. Dr. Mervyn Travers, welcome to the show. Thank you very much. Thanks for having me, don't you? You're very welcome. Mervyn, can I call you Merv? Yeah, we're close enough. I should ask you this before we went live, but anyway, we've been having a really productive conversation. So apologies for that. So, Merv, I know who you are, but do you mind introducing yourself briefly both professionally and personally to the audience? Yeah, so I'm a physiotherapy training. I trained in Ireland where I'm from, and I qualified 20 years ago now, I think, or even more, and did my, you know, bit in general hospital and my basic rotations worked on the side and some clinic and advanced through transitions to the private practice and working in sports. I came to Australia to do my post-grad at Curtin University and only planned on staying for 10 months, but here I am. I don't know, 15, 16, 17 years later, and a citizen on my life here now. So yeah, did my post-grad went on to work in professional sports and then did my PhD here too. So, I kind of sit on both sides of the fence, both on the physio and an SSC coach and I've kind of worked in roles on both sides of that fence in the past. So, my kind of professional interest, my research interest, my teaching interest is kind of trying to merge kind of high-level exercise rehab and kind of an understanding of pain. And so the types of patients that I see are often, you know, patients who've been struggling with pain and like compromised performance for a long time to go off on athletes or more athletic populations, but their goals are very lofty. So, my leg hurts and I cannot run even three steps, but I would like to run a marathon. So, it's kind of bridge that enormous gap. So that's kind of what I spent my or spent a lot of my time doing clinically over the years and still doing a little bit of medical work, seeing patients like that. On a personal level, I'm a proud father and hopefully decent husband enjoy getting out. If you find me, you'll find me out in the dark early morning running along the coast of Perth. Beautiful. Running your major sport or physical activity of choice? Oh, look, I'm no good at it. I can tell you that. I didn't grow up as a runner and I don't know the body size or type 4, but I'm happiest in the gym, to be honest, but I do I do pan the pavement a little bit. Cool. And as an Irishman, how's your Aussie accent coming along? I think I'm as Irish sounding as they come. When I go home at times, my mates will pull me up and the plow and say, "You sound Australian. I'm not sure any Australian has ever accused me of that." So, I heard you say a word that was Australian-ish before we started recording. You said Ripper. And that was all I could do. There you go. But it is funny, my daughter, she was born in Australia and she, you know, we were trying to say, "Well, you've got Irish family and a lot of myself." And it's like, "Where was I born?" Australia. I was like, "I'm Australian." Having said that, Rubey is having worked in professional Rubey and been around it and played and kind of being a big part of my life. Rubey's kind of one of my major sports that I'm interested in. She's seen some Arlene games and she's crossed the fence when it comes to cheering for Rubey. I was going to ask you the rugby question. Ireland's very good at being number one between World Cups and don't turn up at World Cups. You guys can contact the number one for those few years. Oh, mate. It's a big tournament. I was in the World Cup in '07 and France. I was there with my head and my hands when we were drastically underperforming. Our performances were very strong in the last World Cup. Amazingly strong. And in our defence, the game we lost against New Zealand, I reckon, is about the highest quality game I've ever watched. I thought it was. Maybe I just caught up in the drama, but with the vested interest, of course. But small margins at there. They're small margins. I mean, it was a tremendous World Cup anyway. The New Zealand Ireland game was amazing. The South Africa France game was amazing. Any of those four teams could have won the whole thing. It was that coast. But it is what it is. We roll forward. The most important thing, the last point on rugby is we have a British and Irish Lions tour coming over to Australia in a few months. That's going to be massive. The Wallabies were written off a couple of years ago. And I think we're going to do a little bit of damage. So that'll be interesting to see. Oh, mate. I'm much more nervous about the prospects of the Wallabies. I'm playing the Wallabies now than I would have said 18 months ago on question. The 18 months ago, I think people would have said this is going to be a whitewash. I don't think that will be the case now. You know, and not like the Irish team is a little bit in transition. The Welsh teams very much in transition. There's a lot of kind of rebuilding happening across the kind of teams that make up the Lions. Whereas the Wallabies have been rebuilding at a kind of a bit more on that ascendancy. I think you've got, we're in for a much more entertaining series than I thought it was going to be. Yeah, I agree. And we need it. So and that's because we have an ex-Island coach, Joe Schmidt at the helm. Yeah, yeah, yeah. Well, it's like all things. He's not Irish, but when it comes to rugby, we're going to claim him. He did wonderful things with the Irish setup. He did wonderful things for my hometown team, Lancetort, which would be kind of provincial and professional team in the part of our line from. He was coached there as well and needed amazing things and it's probably no coincidence to a rugby zone. The rise. We're going to leave rugby. I could talk about it for hours, but I'm sure we're marginalising and alienating. I'm so proud of that. Yeah. Join us for the show to Physio Rugby Podcast. All right, let's get into the meat and the academic aspects of the conversation. So, Merv, I've read a lot of your work in Tendent Opathy. I've heard you talk at length about strengthening conditioning, something that I know you're interested in, which maybe you have some works underway. I know you've talked about it as well on podcast before is something that is broadly called active inference. First of all, explain what active inference is. Maybe define it and just help all of us, simpletons understand what it is at a very superficial level. So, I suppose I'm going to go back and kind of it's always nice to tell as a story here. You know, 2017 started writing this paper with one of my colleagues at University of Notre Dame, especially with friend colleague and mentor Ben Wond. Look, it's 2017. We're not winning the war on on back pain. Like, where are we at? Like, what are the promising treatments? What's the evidence base of where we're at right now? But also, does it align with how we think pain works? Because if it doesn't, then we're kind of barking at the wrong tree. And so, in that reading, I started not space, I kept coming across these concepts of kind of predictive processing at the time, predictive coding, predictive processing, to try and explain conscious experiences. And so, you kind of have to understand pretty good processing to really get active inference. That's kind of why I start there. And so, this idea of predictive processing, which has been around like the idea that we have a predictive brain has been around since like the 1800s. So, it dates back to Helmholtz. And so, you know, this is an idea that we don't just sit and wait passively for stimuli from the external world. Okay. That actually we are constantly making predictions about sensory information coming from the outside, but also from within our bodies. And so, we're constantly making predictions about it, and to try and explain what's causing the sensations that we have. And then you use that information to kind of successfully navigate our world. And so, one of the way I think about this is, if you remember the days of CDs and cassettes, even a record that would play songs sequentially, and maybe we were too used to having playlists and stuff now that don't. But back in the day, if you were listening to your favorite record and it was skipping between tracks, you'd almost start to hear the next record It's not like I know it's coming, but you can actually have the sensation that you're hearing this before it comes as an example of how predictive our system kind of is. And so, from there, from predictive processing, there's this idea that, you know, I'm making predictions about sensory information, but of course, the sensory information that impacts my system is never going to be exactly the same. So, there's this difference or prediction error. Okay. It can be also referred to as a surprise. And what active inference is, it's based on this idea of surprise. It's a grand kind of unifying theory of planning, cognition, memory, learning, perception and action. So kind of how do sentient beings, how do humans work really, and how do they survive and navigate their world. And so, it's got links to computational neurobiology, it's got links to philosophy and links to cognitive neuroscience, it's kind of this overarching umbrella framework. The idea when the key tenets of it is that we and all living systems are engaged in trying to suppress error all the times. We're trying to minimize the surprise all the time. And so, we use our bodies to minimize surprise. And so, what do I mean by surprise? Well, you have preferred states that you'd like to stay in, and there are dispreferred states. So, for example, the common example is often given as a fish. Its preferred state is to be in water. A fish out of water, that's a lot of surprise all. And it will stop being a fish very quickly. It will become a dead fish. Right. And so, that's a very extreme example. But we have, like the whole concept of alistacis is based on this idea that we have preferred states. It's a temperature range, which we want to stay. So, we have systems to, if we get too hot, we'll start sweating. But we might also take a drink or we'll go and turn the aircon on. So, this is range from physiological to broadly societal policies that we can use to try and suppress the error associated with being in a dispreferred state. And so, active inferences is really all about that we have this biological imperative to minimize surprise. And I know that will sound really abstract because I've not painified that example, but I suspect a conversation will go there and discuss like what that means for pain and for clinical practice and for movement. But I think the fundamental people think that people need to understand is it's about surprise on minimization. So, about having boundaries in which your system wants to stay in and using error and suppressing that error to stay within those boundaries as best as possible. And so, the active component is your acting upon the world as it were to minimize that error or prediction error? Yeah, okay. So, we got this idea that we are agents in this world and we engage in kind of reciprocal feedback loops across multiple timescales with the world around us. So, basically, we're acting on the world and the world is acting on us. And so, action can be as simple as the rapid eye movements that you have to pick up stimuli when you're investigating. You know, you pick up a golf ball and you kind of look around, look at the little dimplings. That's a form of action. You're trying to learn, okay, or suppress error. Cool. So, let's just define terms again. So, we've got active inference, we've got predictive processing, we've got, I've even heard something called Bayesian inference. All of these terms interchangeable, do you feel or do you think that different and should be demarcated? Look, I think active inference kind of sits like, they're all steps along the way to active inference. I'm not sure if you've read the actor inference textbook, Carl Frystsen, Pizzolo, and Harzbook. It's a wonderful book. It's actually available as a PDF online and it's a wonderful, as a free PDF online. And it's a wonderful, it's a wonderful read. And they speak about like the journey to active inference as a concept and kind of Bayesian inference and predictive processing that kind of steps along it. So, I don't think you can probably use predictive processing and active inference interchangeably, but I have less of a problem with kind of people talking about the other ones interchangeably because they're more about this idea that what you see and what you feel and what you hear, et cetera, is not a direct reconstruction of what's actually happening. It's inferred from the interaction of incoming sensory information and your predictions, okay, so the idea that you never truly, I've got a coffee cup here. I never truly experienced that coffee cup if I'm looking at it because my cranium houses my brain, so it's separated from the world and photons hit my retina, it's transduced into kind of chemical electrical signals, they propagate along my after nerve, but really all my brain receives is beeps and clicks and whistles, right? So, in order to make sense of it, it's also using predictions from past experiences. And so, the idea of Bayesian inference and predictive processing are really about interactions between your incoming sensory information and the top down predictions held within your system. So, you have these genoid of models, you have these internal models of yourself and the world and how you interact with it. And so, you use that to make predictions. And I like the key thing is most of this is subconscious. It's not that you walk around all the time, saying I'm going to predict this. This is just how we think from a cognitive level, things work, but easily on a neuronal level, like people trying map hierarchically how the brain works in this way. But, you know, the key thing within that is active inference, then speaks as an overarching framework to the idea of trying to suppress error within that that's a biological imperative to suppress the error and kind of in our chat earlier, you mentioned Jacob Howey's work. And so, I think it was Jacob Howey who coined the term self-evident thing. You can flip the script and say, "Surpressing error, minimizing supplies, all is really, really important." Or you can actually sort of describe it in terms of constantly confirming your model that you are you and that you are still alive. Hey guys, Jared here. I'm stealing you away from the pod for exactly 30 seconds. I want to inform you about my online course on shoulder pain. It is a comprehensive 16-hour course that is broken up into digestible chunks that you can complete at your own pace. You also have access to the course forever, all for as long as the internet exists. Thousands of clinicians have graduated from the course from 50 unique countries around the world. If you want more info, check out the show notes, all my website, shouldervisio.com, and I'll see you in the lectures. So, is it fair to say that all of this is basically predicated on the fact that our brain is a prediction machine? Oh, 100%. Yeah, yeah, it gets away from that kind of stimulus response kind of perspective on our brains and it makes us more kind of goal-oriented based on our predictions. Yeah, cool. And that seems to be fairly uncontroversial as far as I'm aware. In my reading, you know, and my listening to cognitive scientists, to philosophers all around the world, it seems to be like there is a consensus that the brain is predictive rather than receptive. Do you have any insight into that? No, I think there's been an evolution, probably in the last 50, 60 years to kind of for that to become more mainstream and certainly in the last 20 years, from me trying to put dates on the things I've read and I've certainly not read everything that exists on it. But I think it's it's probably fair to say the pendulum has kind of swung that way for it and acceptance for people that we are predictive machines. Cool. Okay, so let's take all of this and apply it to musculoskeletal pain. No small task, I'm sure. So how can an active inference lens, how can a predictive processing lens be used to explain musculoskeletal pain? Yeah, look at this is really interesting because it's funny because I'm really interested in cooking. I love cooking. And again, going back as a clinician and reading pain stuff for years and years and years, one thing that always struck me was, you know, we can change your perception of smell and taste and your experience. So I remember reading these old experiments. I think one of them was called great expectations. I mean, what a fantastic name where they got a bunch of people. Oh no, I think great expectations was it was a review of these papers I progressed. But they didn't include an experiment that was done a number of years ago where they got some, you know, fancy wine people, people who can smell wines and get I don't I don't have such a refined sense of smell. I think we know people they get a glass of white wine, they put their nose in it and they can say, Oh, that's that's oaky or that's the code they're called some oh yeah, so something like that. Yeah, yeah, that's right. So they got a bunch of those and they they brought them out of white wine and they asked them to smell and kind of describe what they smell and the kind of consensus from most of these people was the kind of descriptors you often see from white wine like citrusy and lemon and melons and grass and whatever else, right? And so they took that tray away and they brought them out a red wine and they asked the people to now give their description of that and they all cherry and chocolate and rich and so the mahogany like the the smells is it's all changing it's different right? Except what the people didn't know is that the red wine was actually the same white wine they just applied a odorless flavorless red dye to all right and what that suggests is that their perception their experience was influenced by the color which they see before the even holders their nose. I think for me that's a real example of how what we experience can be led by our expectations or predictions in our system and so you've asked okay why what does that matter in terms of pain? Well it matters because for me I don't see pain as any different than taste or smell or hearing it's it's another conscious experience and I was always wondering how come the other conscious experience are so malleable right? We can we can change them so why is pain so difficult to kind of change and so I started reading that space and also doing experiments in that space to see how do how malleable are these experiences and how predictive are these experiences and so first thing for me is that means the information you hold it already it does not be explicit information it could be just built up to your past experiences prior knowledge social cultural context they influence what you experience and so maybe when when your doctor shows you that scan or your physiotherapist says that's the worst scan I've ever seen or you tell that 25-year-old you've got the back of a 90-year-old or you tell jar jar you know if you don't back off from exercise you're gonna end up in a wheelchair well maybe that information influences what the person experiences much like the color of the wine influenced the experience of smell so that's the first thing for me is saying why is it relevant so the first thing about being predictive for me is that prior held information may well influence what people experience yeah so so we're saying that pain is an experience like any other conscious experience as you mentioned tastes smell touch etc and if it is that then it logically follows that it can be influenced by lots of implicit things that are going on within our system that we may not be aware of in terms of socio-cultural factors what our clinician is telling us what the general beliefs are out there that we're hearing that we're inundated with maybe on TikTok maybe on Instagram etc etc etc pain might be malleable by all of these factors yeah and what it suggests to me is that pain is about more than just what's happening with tissues and what's really important here is it doesn't mean that I'm saying pain is about it's in your head it's in your brain it's not an active inference would suggest that your body as large you evolve in these things and we'll get there but I don't I don't for a moment think that pain is just a concept that's in your mind or in your head I think we should really careful that not laying that on on patients in any way because I think it's not only on a helpful narrative for patients I don't think it's academically honest and then if so that's the first thing that it's a bit more than just what's happening in the tissues and that opens up all sorts of possibilities around you know there are some kind of ways of treatment that have a kind of central concept around demonstrating modifiability you know and if you can demonstrate modifiability of pain through non tissue-based things you know my pain was worse than I was doing my exams it was better when I was on holidays maybe maybe they're the moments that allow a patient to explore the idea that it's been more than just their tissues rather than a saint than it's been more than just their tissues but my perspective in doing that is informed by knowing that we're predictive and therefore all their factors may well influence their conscious experience of pain but for me the kind of obvious example we look at in that in a clinical world is the kind of common narrative around damage to generation you know it means that we need to deeply probe our patients understanding of what's going on what they've been told what they think is happening what they think the consequences of their pain is going to be yeah so I just want to reiterate you're saying that predictive processing in this series do encapsulate and include no seeception and neuroimmune contributors to pain oh I think what encapsulates is sensory information from the body and from multiple sensory streams and so what we're saying is that your pain can't be just about your tissues they equally can't be just what's going on your brain and if you look at that's kind of where the two caps have kind of been for a long time and pain research this is kind of very very neurocentric cap and then this is very kind of pathology oriented cap and I actually think active inference in these perspectives we're talking about replace those and kind of unify them and say look you're right and you're right it's just that when Jared comes in the door I don't know if Jared his pain is 90% caused by his tissues and 10% top down or 50/50 or vice versa but I think the key thing is getting away from this idea that it's just about the tissues or it's just about talking to people because in their brain and understanding that what we experience is a complex interaction of incoming sensory information and top down predictions and then we've not got into suppression action and suppressing of the error associated with that yet right but I suppose the key clinical concepts at this point are one pain is unquestionable more than just tissue damage and that it doesn't mean tissue damage is irrelevant I think that's really important I think tissue damage is relevant and so when we talk about predictions people you don't just predict your incoming sensory information you predict what we call the precision or you can call a crossworthiness we prioritize information in our system based on its precision right and so we select we attend to our system shines a spotlight on high precision sensory information and so my contention would be that no sees option would likely be a high precision signal and so it's going to have a spotlight shone on it by its very nature and so that that means that this is not just about what's top down right it's also about what's bottom up and so no sees option is real no sees option is relevant so with that activation of your immune system you know all of those things are real this this idea of active inference or a creative processing these kind of views they don't they don't say none of the biology is relevant in fact they're I think an explanatory framework for encompassing both sides of that equation it's funny Moe as you're talking it sounds uh you know this whole dualism thing that Descartes sort of invented three four hundred years ago we're still stuck we're still separating the mind in the body aren't we and it's a bit sad well yeah well we still talk about biopsychosocial as though we've been composing it but that term and its perspective by its very nature kind of says there's a biological component there's a social component and there's a psychological component and what active inference says is they're entirely entwined because the experience is governed by all of those things interactive um bit of a curveball he emove how does active inference and predictive processing relate to inactivism oh yes so you're probably talking here about like the five these perspective of pain and uh got to gone blank on the authors of that wonderful paper still a still a department of cancer harmin yeah Peter still in cancer harmin i thought that paper was fantastic like i remember reading on this is wonderful i wonder if it's too early like is the world ready for this and so i think it's entirely compatible with this idea of it you know that you are an active agent who is you know embodied and within the world and interacts with the world so i think they are you know very similar flavors of the same ice cream i i think that the that five e are an active perspective because you got you got mip tackers paper with healing caivristine and michael kyrikoff as well that that kind of goes into that space as well um and so i think that we are having a shift in our thinking rampane there's certainly some stuff starting to be out last couple years that are kind of talking in this way but i think active inference is basically explanatory fame work for that oh great yep in my reading of both theories it seems like they're equivalent in terms of what they're saying so that's good to hear okay so let's get into how can we use these principles of active inference to help somebody with musculoskeletal pain and how do we apply it how do we be clinical about this instead of just being talking heads in academia yeah sure i think i think there's a couple of things that and their concepts that we've not touched on yet that we'll get to you know the idea of suppressing error will come in here a little bit and i think the first thing is that you know i think people's beliefs they're understanding their social cultural context their history their expectations ram will they get better etc are life you're going to influence their pain in their recovery trajectory you know as a clinician that's really hard i'm going to say some that could be reasonably controversial but the patients that i see and have seen over many years generally by the time they end up with me they've been on a long journey and they've read a lot of things they've been told a lot of things some witches are unhelpful some witches maybe unhelpful their their pain is still a function of all of those things bound up because their internal model encompasses all of those things they've been told all that they've been seen every experience they've had in their life implicit knowledge explicit knowledge etc what really matters there is i will never understand the fullness of that as a clinician because the person will never understand the fullness of that the only access i have to their model is by probing and asking questions about their explicit understanding that will you know only get us a small piece of a large proposal but i think we need to be deeply curious and get to truly know our patients we need to really understand and know our patients and that's really hard in clinical practice because you know we have a model of care that is you know 30-minute appointments and charges this much etc etc and you know people need a livelihood so i'm not criticizing that but time constraints are a barrier to truly knowing and being able to explore those concepts but i i think we need to really get a deep insight into the person's understanding of their pain and their problem because that is part of the equation and so that's one kind of thing i think really matters within clinical practice but the second thing probably more controversial about it is that we're not responsible for the person's model i will do my best for every patient i see and i am deeply invested and i want them to get better and i want the best for them but i recognize that for some people maybe their model is incredibly fixed and isn't forechanging and they may not resonate with what i have to say or what i'm my approach or what i'm doing and i can't take on the responsibility of things that i can't control because clinician burnout at fatigue is a real thing and one of the things that understanding the system understanding how much of this i can't control and i'm not responsible for has allowed me to lift that burden and probably as part of what has allowed me to stay in the profession you know to have gray hairs is to be not that i'm okay with the fact that i can't help everyone but to accept that that is the case yeah i mean acceptance in in coping therapy is a thing for patients i think it should be something for clinicians as well but it's it's implausible to think that you can take on all of these burdens all of these problems and be responsible for them that's not a sustainable attitude or mindset no it's not but i think i think i think recognizing that you know some people's positions are fixed that their internal models may become what we call in our group sticky and hard to change the next thing is i think i've said it's about both sides of the equations that top down and bottom up so that our treatments need to consider the cognitive behavioral aspects of pain of course but also consider this idea of sensory information from the body so i'd like to touch on that if we may sure and so i said before that we deal with error and we effectively deal with error and this might differ from some of the things that you've read Jared on it because because a lot of the books and papers will talk about dealing with error in two ways which one is by updating your model and learning well can you just define prediction error again yeah sure prediction error of surprise all is basically the difference between incoming sensory information and your predictions another way of looking at it is also not being in your preferred state that is an error and so a boil out of imperative to suppress that and we do it in a couple of ways you know you learn all right that's when you update your model so you can change your internal model to fit the narrative or fit the sensory information that's coming in so i tell you you get my back my back is hurting i got this pain ago yeah that's because you've got a bulging disk and end up in a wheelchair well you know you update your model and you learn right and then you think about head that's going to influence the predictions within your system another way to to suppress error is to use your body okay i'll give a pain example of this like if you were floating around the physio landscape i'm going to say like from like 2005 to like 2010 like Pete Sullivan had that wonderful work on back pain at the time where he was kind of trying to subclassify and it was the passive extensor subgroups and the you know actions, co-activation groups and all of that kind of stuff so think about this and i think this is really really important so you've asked for exercise and move and i think this has been part where this comes in so it does take one of those examples and probably lots of people have seen this back then we'd say we would have said look these people are sore because they're co-activating and bracing this this co-activation pattern people but actually an activation or an active inference perspective suggests that you're constantly making sensory predictions and you move in ways you use your body in ways to confirm your predictions so you're trying to suppress error by confirming your model or less of an error if you move in a way to change the sensory information so perhaps those people they've got a system i got a cognitive level they're expecting things to hurt on a neuronal level that's a system that's trying to shine a spotlight and expect nosy receptive information you could argue that the changes in the dorsal born from central sensitization for example are just that second order in your own modeling what is expected from the first order in your own for example when i say you could argue i do argue that right and so so you've got a system that was in that way shines a spotlight or a tends to or expects or signs a high priority to nosy receptive information so what do you do you move in a way that confirms those predictions within your system so by co-activating and increasing the load to the tissues are you actually fulfilling those predictions not on a conscious level saying i'm going to make myself worse and this is where you have to be careful i never use these terminology with patience this drives what i do and my thinking these are words that never speak to you but with patience but active inference suggests not that they're sore because they move in a maladaptive way using the terminology of that time but actually the opposite that you're moving in this way to confirm the predictions of your system and so when peak does his light demonstrations he gets the person to breathe through their belly and let go and move forward what you've actually created is a positive surprise on right and that pretty long way that feels better i can go and watch further etc you're actually creating you're actually a shy jacking that system of surprise you're trying to create positive surprise on and so for me the whole concept of movement experimentation is extremely important trying find ways a person can move or do a task they wanted to do in a way that is in some ways better my thought will be a positive surprise that could be less fear laden less anxiety laden less painful but the idea is understanding they move the way they do in order to fulfill the predictions of their system okay so if we can violate those predictions in a positive way then you lay down a new model and then you're trying to strengthen that over time that's where i see exercise is a way of strengthening models because you're costing self-evidently your system when you move yeah i love it can i just jump in for a sec so you said violate is prediction error and surprise the same as expectancy violation in the psychological literature i suppose in some ways yes in terms of like cognitive expectation but i'm also speaking here about if you change this experience the person has then you change the model in some way so you may well have changed how information is weighted at a neuronal level so i suppose it's not just about cognitive expectation violation i suppose a distinction there cool so prediction error would go all the way down perhaps whereas expectancy violation is more of a higher order cognitive phenomena i would see it that way but i can also see how and i probably do people just use the terms interchangeably yeah cool yeah i suspect there are a million different ways people could phrase that yeah cool i really want to sort of hammer in on the exercise component here so i think you were just getting into it so we can use exercise as a vehicle as a vessel as a method as a way of positively changing expectations or beliefs to how however deep seated they might be yeah and updating their sort of model or world view of of how this should feel or and how it actually feels yeah 100% 100% and you're laying down new models right and that that's really what it's all about and to me that's what pain education is i think someone learning they don't learn that well like by being told it's not just about your tissues but if you're able to find a way for someone to do movement or act in some way and use that body part that's better than expected then they lay down a new model right and that's that really really matters i think people learn experientially and the way that we learn about our body is to use it that's how we learn about our body i mean there's some visual information you can look down and see if your arm is crooked yet probably broken but largely it's by moving like you what happens when you you're buying your elbow or something you kind of you do this what are you doing you're you're updating your model about that arm right and so we're a high jacking that system is the flip of that it's it's a really challenging thing because you know if you look at the exercise like i'm going to use back pain as an example but use this for any real body part you look at the data on exercise as a treatment it's not very strong right it's like from back pain you got Jill Hayden's amazing coquetry review on low back pain exercise there it's maybe a couple years old now but it's just just it's just a stellar and enormous piece of work but you look at that and and basically the summary the highlight reel is exercise is just meets the MCID when compared to basically doing nothing and is no better than any other treatment for improving pain and doesn't seem to do a whole lot for function for back pain people all right and that's that's not a great premise of which we should be basing a great evidence based on which we should be basing our profession like haven't said that there's a real challenge and a real problem there because i don't think the way we execute exercise often in clinic and certainly in in exercise trials is consistent with how we understand how pain works and this is where this whole evolution of thinking of mine came from way back going well is what we're doing notching how we think pain works because if our solution doesn't target the problem what are we doing so if you look at most back pain studies and lian will insist on a lot of work in the space there's a number of the people who've kind of analyzed them you look at most back pain interventional trials they'll start off all the same the introduction says back pain is a big problem worldwide and it's the global burden of disease index means it costs us a lot of money and lots of absenteeism from work pain is a biopsychosocial experience meaning that it's going to buy a lot of component psychological problems social they're all the same we wanted to see if strength training would help back pain well why and you read the method section and the method section I just said because it's about increasing tissue capacity or doesn't most of them don't really list a mechanism what's actually targeting so why do you think this would help what what are you what are you trying to do here right because we've just said pains read top down predictions and incoming sense of information in what way is your intervention going to pull either of those levers there's a third lever by the way which is differential weighting of sensory information will get to that moment but now it's no surprise to me that trials that are geared that way and have a philosophy that way give you know a best modest effects because they don't target the problem they're not geared towards the problem so I don't see exercise in pain for people in pain as being a bad tissue capacity as being a bad you know flexibility or some change in the tissues I see it as a form of learning about the body a form of self-evidence a form of laying down and reinforcing new models that my body is capable so I don't know if you've read that fitness for purpose model paper Ben Wong Gem Orange a couple of my colleagues the glomer was on it as well and a few years ago it aligns some of these kind of concepts but I think exercise is a bad you're demonstrating to fitness the capacity of the body not actually about getting stronger it just so happens that you know I was lifting 30 kilos last month now lifting 45 gives you objective measures and that really helps with that learning process right so I think it actually I think exercise can be enormously useful I think the evidence base is not strong for but I think the way it's applied is non-compatible what I'm arguing for is as applying it in a way that's more compatible with how we understand pain works and it's it has been done in part if you look at the resolve trial which I think is I'm going to say this I declare my offered ventures I wasn't on the trial but a number of my friends colleagues and mentors were part of this trial but I think it's the most important trial and back pain certainly this comment last kind of five or ten years this is where they looked at graded sensory retraining for low back pain and it was compared to a truly credible sham and so for the first time ever and they outperformed the sham for the first time ever we've signaled above the noise as far as I'm concerned we have true evidence of a intervention a non-surgical non-formalized intervention that shows important and long lasting improvement in pain and disability in a cohort of patients that are very unlikely to get better on their own these are patients I think the average pain duration of them was about five and a half years yeah these are patients with back pain that's probably not going anywhere in a hurry unfortunately and so they outperformed a truly credible sham which is very different than most trials where it had to head trials and you don't know if people have actually truly recovered we've got signal above the noise above natural history regression to the mean contextual factors all of those things and so they actually went on a journey along the lines of consistent what I've just described this idea of learning using the body okay rather than three sets of 10 40 percent of your one rat max and adding five percent a week or whatever else and so we have high level evidence randomized control evidence demonstrating in meaningful outcome using a treatment that is basically aligns with an active inference perspective one critical aspect though that's missing that they had and they started their training which was this idea of rated sensory training so to probably fill back up and for people I think yep cool okay so I love it a lot to get through there I got a lot of questions with it with that resolve trial that you just mentioned it sounds like it's consistent with the theory of active inference but but how do we know so how do we know that underpinning the effectiveness of the resolve trial you know was this sort of updating of beliefs like the causal mechanisms underpinning improvement I know that they did a mediation analysis on that study I'm pretty sure and it showed that a change in back beliefs almost explained the entirety of the fact it was change of back beliefs reduction pain catastrophizing and if I remember off the top my head improvement in self-help pain self-platification I think they were the three main things that came out of the mediation analysis yeah yeah the usual suspects when it comes to mediation analyses of anything for musculoskeletal pain really it's never strength it's never by mechanical variables it's typically psychological variables self-reflexive yeah I'll say that though very often psychological variables that are measured right so that's comes up in the mix in the wash right what happened said that the data that exists on correlation between changes in physical capacity and improvement in pain is doesn't support that idea yeah so this is I guess I'm getting to a wider question here and and tell me if it's too early but there are criticisms for active inference and predictive processing most notably how do you know how do you how do you test it I how do we you know it's like the theories of quantum mechanics the many worlds theory of quantum mechanics how do you know there's all these other worlds out there we can't go and see yeah it's just to follow the logic that's just yeah what you have to accept so how do we how do we deal with these criticisms yeah I think the criticisms are fair because we're going to that true kind of philosophy of science world like you're dealing with the system or at trains and assumptions that can't be falsified right so how do you really test it I don't think that's a problem that we can't overcome I think the key thing is that we don't hitch our wagon active inference to say that's everything I think what we do is we go this seems to make a lot of sense and across our whole series of domains and worlds that aligns and makes sense of some of the existing problems we have okay that's a tick doesn't prove it's a thing but it go okay that's something it has there's some plausibility there to it okay well what are the assumptions that you can that this makes in terms of pain for example because that's the world we're talking about well what are the assumptions that are brought about by this framework and can we test some of those assumptions so for example we're I'm saying that I think your internal model would like to influence the pain that someone experiences so that would suggest if we could alter influence someone's internal model via information for example that we could alter the person's pain so we've done a series of studies on patients we chatted about them before before we came on to our but obviously they're they're not published yet though accepted where we tested those assumptions even things like like condition pain modulation these ideas that hit you with a hammer on your hand you'll that'll be really sore but if I shoot you at the foot at the same time then you won't be too worried about your hand and you won't feel it so bad type of thing we've done some experiments where we've looked at the predictive nature of that where we've used deception to make people think and really believe something really bad is going to happen and we've examined how my set of a shining spotlight on prioritizing sensory information in that moment we tested the acuity of some of sensory information and demonstrated a predictive component to it where people make themselves more sensitive where they expect there to be a some kind of a damage or harm and completely suppress sensitivity in areas where you know it's not a priority right then again suggesting that predictive nature right so so we can we can test and we are doing that some assumptions around it we can also develop treatments that seem to make sense and align with that perspective and test their effectiveness could we ever test that on a neural level we change the kind of waiting and hierarchy within your nervous system to reflect probably not I'm very comfortable with that I think all of these ideas are evolution you know we're talking about active inference now but if we've done this podcast five years ago it will be a predictive processing and if we've done it 10 years without a predictive codel and so and if we do it in five years time but we something else will add to this and understand and so it's an evolution and so if that evolution allows us some testable hypotheses that that we can see and do the stand up that's really important if it allows us to develop treatments and directives in ways that have demonstrated efficacy and trials that we can move forward in a clinical world from I'm willing to accept that it's you know there's no way we can truly truly test every aspect of it and you can't touch it you can't see it in the same way of many worlds you can't reach out and touch them yeah yeah I'm at pace with that as well you know as long as there's a sort of rigorous pursuit to explain as much as you can and test as much as you can and not just evaluate and explain away you know and that's what I think it sounds like you're suggesting as well yeah 100% it's the same as you know my respectable shift and so it should cause scientific endeavors is based on going where the river of evidence flows and so one thing that people will use to dismiss active inference for example or any other philosophy that does not lie with their beliefs they'll say well that's not testable I'm like okay we'll demonstrate to me the evidence of your framework as well for me that's what frameworks are for like when you put forth the framework it doesn't necessarily need to be based on all of these like every assumption having been test we're saying tests we're saying at this point we think this is the best explanation of framework let's go test these things and that's kind of where we're at with certainly with some degree of promise the reason why I like or this I find this model so appealing is because we did a study a qualitative study where we interviewed a bunch of people with shoulder pain and just asked them about their experience with exercise and also we see this in our clinical practice as well a lot of times they report something that they say I just know it's going to hurt when I lift my arm up you know that painful arc movement and then a therapist tells them they they reassure them they may be experiment with movement they may be change the movement or the context of the movement the lever arm something they change the movement and that person then has a different experience the pain is less or it's positively improved and for me that just it's such a neat fit with the active inference model and it just it just works really well when patients are just reporting these things so explicitly you know it's really hard to get away from like how can that pain be so reduced via distracting them or via going from a two kilo to a one kilo or just simply changing the context doing it in a slightly different way you know like you can't you can't minimize or completely abolish the pain just by doing those little tweaks of movement I don't think do you have anything to add to that move yeah like 100% but that's what movement experimentation is you know like people would sort of scapular dyskinesia remember when that was really popular I mean facilitate you know upward rotation when someone lifts their arm up like for me that's like just doing it with a sensory information that doesn't necessarily match the predictions of the system but creates a positive experience it's not retraining where their scapular tracks it's not moving the position you don't mean it's just some modification I think if you think about what exercise I don't think about what are the what are the ways that you can modify like I mean you mentioned something like you can change the load you could change this this velocity you could change the type of contraction you can change change all sorts of things one of the things that I also play around and experiment with patients is reverse the origin and insertion right so a patient can't bend forward hurts too much but I can get them to do a reverse hyper extension which is just reverse the origin insertion like oh that's much better and I'll video them I'll put real-time videos so they can see it right and like we have all that data on visually and Jews sound easier where actually it hurts less when people can see their back moving right you've got a Ben Wands proofing concept study where they they made a used VR to make someone's back seem artificially extra muscular so suddenly they've got like the rocks back or something and saying they're holding a box that's hurting them about that hurts less because you know my back is when they like you ask about embody when they embody that illusion then it hurts less right so like that predictive nature that interaction between top down and bottom up I think is kind of unquestionable but going back to what I say I'm going to reverse origin insertion it's the same movement it's using the same body part through the same range and it hurts less and that allows us to reflect then although why do you think it hurt because that disc will to be the same or that degenerate would be the same whether you lean this way or lift your legs up so as you reflect and help develop those models and then reinforce it with kind of practice or repetition that's where your structured exercise kind of comes in yeah I agree so we've touched on it already briefly so where do you see the future of all this going we we seem to have a camp mostly on social media that think there's going to be some miracle pharmaceuticals that are going to come out that's going to cure persistent muscular skeletal pain and that's great I hope that happens I'll I'll buy all the medications when they do come out then we have a different camp that suggests that it's going to be more of these cognitive behavioral higher order strategies that are going to change the game and we have proof of concept there with the restore trial and the result trial and a couple of others as well we have discussed though that you think that active inference and predictive processing might be a way of sort of integrating and combining the two give me your five minute TED talk on this I think it's the idea that you're trying to kind of pharmacological interventions particularly ones that have kind of effect on kind of a neuroimmune system I think they've enormous merit and I think that is so worthy of research interest and research money as well I think you know because what it's saying is it's both sides of the equation I think we should be exploring both and I think there will be a role for both for treatments that target both sides of the equation because as I said before like we don't know if yours is driven 90% by really high signaling no-seception from your system and we can't measure that in real time in humans right and we don't or we don't know if yours is driven largely by a top-down influences that cause you to highly highly highly wait no-seceptive information right so we don't know if it's both side or which side the equation it is and so I think there's merit in pursuing both and I hope both are successful because your suggestion is around treatments that are very tissue based and I've mentioned this idea of sensory information and I said that we suppress error to learning or by using our body I put this in this category when it comes to pain though it might differ from some things you've read in this space I think that we have to think about and discuss the idea of differential weighting of sensory information okay it's a very very fancy way of putting everything you know all these studies where I got to remember them like I remember reading Penny Moss's work years ago saying hey your people would neo-way of cold hyperalgesia and people with you know low back pain they're not as good at detecting postural sway and all of those things that suggest there's some kind of sensory disturbance or difference or change the person represents their body and I remember 10 or so years ago you said well hold on they're cold hyperalgesia is that causing the cold hyperalgesia causing their pain or is that just another symptom of this if like if I could make them non-coal hyperalgesia without resolve their symptoms like what do I do with this and I've vividly remembered the conversation with one of my colleagues again it was actually with Ben Wanda in his beautifully pure and simple way of just putting things like more of can't you see when you put all of those studies together kind of look at there's this consistency that people in pain seem to be very very good at detecting noxious information and not very good at detecting non-noxious information penny drop moment for me like yeah that's it it's differential waiting okay so prioritizing information from different sensory streams so if you've got a system that's incredibly good at prioritizing noxious information what do you think it's going to use to confirm its model so that's where great sensory motor retraining is of enormous value as far as I'm concerned because it's a better training I think the person's attention to non-noxious sensory information from the area also why I think when we go to the movement experimentation we spoke about before and I get the exact example of the correctivation then I said hey if someone's correctivating they're likely increasing load on the tissues and tissue ischemia and causing more no-susception likely you don't think they're doing is if you stiffen and you're not moving you're depriving your system of competing non-noxious information the sensory information that would come from your body parts saying I'm okay I'm actually moving this is normal so you're shining that spotlight further on no-susception information again I hope this makes it clear how much I think no-susception is relevant and important and the concept of context of pain so is the top down and I think they're inseparable so I think you're saying by treatments in the future I think the most promising treatment is great sensory motor retraining right now and I know the groups behind it have large brown funding to explore in different different centers and different body parts etc and different pain types I think they're doing a CRPS as well I think and so I think it's got an enormous promise because it deals with treating if you will treat it's probably the wrong way understanding and trying to modify someone's internal model about the brokenness of their body and their tissue capacities and that what their body can do they're looking to train and retrain the differential weighting of sensory information and then learn that the body's capable of movement true training or a capable of recovery and movement true exercise that I say like that is entirely compatible with active influence it's shown promise when control compared to a really credible shaman I mean it's a single center trial so you can criticize that there's always criticism that you can make but it's incredibly rigorous like you mentioned the the resolve or the restore trial the CFT trial there's unquestionably amazing things in that an amazing promise in it equally it's not being compared to a credible shaman right so it was as a really important effect size we don't know how much that effect size is residual bias and how much of it is a true treatment effect so if you're asking me on a pure evidence where the future is like they both need to be pursued further the third treatment I think that has enormous promise and again would need to be done in a more rigorous way and compared to a with a better control group and larger numbers but its effect size was enormous was the pain reprocessing therapy treatments and there's I know people have been critical of them and I'm critical of the rigor of the study but the effect size is so large the ash-r and l paper that was in jama maybe a year or two ago and their effect size is so large it warrants real future investigation this treatment called pain reprocessing therapy is a very talk-down kind of reframing and understanding of pain and trying to modify your pain type of treatment and it was compared to an open label placebo so they you know there's problems there's only about 50 people in each group there there are problems with the design do not get wrong and I think trial by compared to usual care that's a problem as well because usual care can also be labeled as denial of care you know so they're set up to show naturally a large effect in favor of the intervention that's why with the PRT trial pain reprocess therapy I'd love to see it done again against a truly incredible sham as a standard we have one treatment that has done that and so if you're asking where the future is the future is there for me or at least the present is there and developing treatments around that and I'd love to see more CFT work particularly against credible sham and I'd love to see PRT tested more rigorously alongside the pharmacological interventions and all the other things that are happening to because development is not space really matter yeah we've got a lot of work to do I think it's quite exciting really I think a lot of people are cynical and no realistic and have a bit of a doom and gloom mentality but I think the next 10 to 20 years are going to be incredibly exciting in terms of I totally agree the landscape has changed I mean I think if you'd asked me five years so when I started writing the paper I'm referring to that hopefully will submit this week my this active inference and low back pain paper I've been working on since 2017 if you'd ask me then what are the hot treatments one of the ones that are showing real merit and long lasting effects on pain and disability for bad I'm using back pain as an example I just said we don't have any that's really hard to say do we have any large rigorous good quality trials that show a meaningful effect of let's say a physiotherapy kind of based or psychological based intervention I'd say I would say then we dealt in the last two three years we now have three that I think show in the almost promise I'm putting resolve at the front that list simply at the greatest sensory motor retraining simply because of the rigor of that study and the design of that study answers that question this does have a true treatment effect the design of uterus doesn't quite do that but they have enormous promise and so I'm not in any way poo pooing kind of CFT for example I think it's amazing work and done by amazing people the research designer asked us a slightly different question and likewise pain and process therapy got some flaws in the design so I really like that done again but I can call from the Sanders there's three treatments that I feel show promise and so that's exciting time to be a clinician and even more so an exciting time to be a patient unfortunately in the shoulder where I live it's not as optimistic it seems to be just high load strength training and or motor control exercise and changing the way the scapular move so we've got a little bit of work to do but I think we'll get there yeah but I think like pain isn't region specific so like as a clinician like I've got case studies that I present like conferences and courses and stuff of applying these approaches to knee pain and to Achilles tendon pain like if you want funding for research say that you're studying back pain right so then you roll it back pain in first but like why would a CFT approach or you know greatest sensory motor retraining approach be successful in the back but not for knee pain not for shoulder pain I don't think that this is going to be in any way region specific 100% agree there's just my knowledge of the in the research areas is that nobody's pursuing these things yet and we're sort of I mean we're still struggling we've only ever done one placebo control trial of exercise in shoulder pain so we're we're currently involved in designing one at the moment so that's going to be fun to do and then hopefully other people not myself will start to pick up the slack and start to do these these trials as well yeah I know it's so important that we do that and I think in some ways back pain and knee pain kind of get to lead the way a little bit simply because it's probably an easier condition to get funding for just the burden as well yeah yeah yeah well that that's why yeah yeah yeah yeah yeah watch the governments more likely to give you the five million dollars so back pain than it is for you know a thumb pain or whatever yeah sorry to all the thumb people out there with chronic yeah we're not no but it's it's it's it's it's this societal burden I know what you saying yeah key resources move there's a lot out there where where should people start is there a good entry point and we've discussed Andy Clark and he's got a new book out where should people stop yeah look I think for delving into active inference I would probably it's probably an easier way to dip your toe in with predictive processing I would dare say and so there are some really well written books Jacob Howie's book the predictive mind and I'll set this book being you Andy Clark's book surfing uncertainty are probably really good ones to start in that space if you're then gonna go from there their Michael Kierkopf and Julian Kyrgyzstein have a wonderful book it's a little bit expensive and it is quite technical but it's a wonderful book if you've read the other ones then it's predictive processing the third wave that's a wonderful resource really really wonderful I could have read that about 10 times I reckon just to try and get my head around or you'd probably figure that which fast and me jargon then from there Andy Clark's book the experience machine is a wonderful one Mar Psalms book the hidden spring that's really excellent and then there's the active inference textbook which is written by Pizzolo Par on first and I do feel this to get our head around it there's an evolution it helps to start reading a predictive processing first I do think so before going to active inference but maybe other people might have more familiarity with it than I had at the time and launch straight in there and that book's only a bit a year old so it didn't exist at the time or maybe it's two years old but it's rather new in terms of other resources and things that are out there look if I may be some books so bold like I buy around the world teaching clinicians how to merge paint science and exercise and the stuff that I do is in my courses my paint on stock course is heavily influenced by this because it's really important that it's not about telling and explaining to patients about predictive notions and precision waiting it's not none of that narrative comes across to my patients it's a it's a framework of influence and determine what we do rather than us pain explaining to people about this stuff I think because what we're saying really is you are an active agent in the generation of your pain and it's caused by your predictions as much as by what's happening in your tissues now could you imagine saying that to a patient you're causing your pain because you're predicting it because technically on a neuronal level that's what happening not on a conscious level right and so you had like so could not be more strongly in my statement of like don't express sentiments like that to patients because it's not really true and it's likely very unhelpful pain education for me is experiential through both our physical examination process and through our interventions it's not talking point for most people I think quite this sort of comes to mind there is information is to behavior is to a brick it doesn't change a thing yeah a hundred percent a hundred percent and I do reflect on the patient I remember I just finished my post-grad and I learned all of this wonderful pain neuroscience from Max Usman at Curtin who Max is no longer with us unfortunately but a wonderful educator in that space and I remember I had this patient who came into me and she was like chief of anesthetics at a local hospital chief and he's anesthesiologist or whatever I was at a local hospital where I was working at the time and I thought to myself here we go I'm going to talk her about her pain and that's kind of just fix her pain like this is a long time ago right but if we've all I don't know I certainly found out that trap at a time and like I had this long discussion where she and I were talking about nitric oxide feedback groups and glutamate was and blah blah blah we're talking all of this right I'll all the kind of heavy euro for the all day like after about 20 minutes like this is really interesting but what does this got to do with my pain and I remember thinking myself not if like if she doesn't draw the link between the kind of neurodollity and her pain giving what she does and her knowledge on this I need to change what I'm doing here a little bit it really was and so for me one of the things that I really like is is shifting and again it's about you know changing people's models but you know in university we're so often thought to try and use our physical exam to detect the biology with a bunch of tests with very low sensitivity and specificity on my dad and so of course you to make sure the person is not having sinister and if we do suspect a serious pathology we should kind of act on it but we should recognize that our physical exam a really well handled really well communicated and really well conducted and thorough physical exam can be an opportunity to demonstrate that the system is better than I thought it would be right you do a neuro exam and it's clear that that's awesome I was just checking that all the nerves were working that's the really sinister stuff we don't want to happen you're completely clear on that like that's that's how you do it not like okay okay okay and moving on so off you getting through team for me that's pain education right you're clear of that you know you don't have any that you don't have that sinister sign that's completely normal I really like that that's stronger than I thought it would be all of those things influenced the person's model there and then and I think are probably more powerful like you never have a control and heavy you know but for me with my biases I think that's more powerful as you know telling someone about G-protein couple receptors yeah I'll let you in on a little secret my physical exam is my treatment almost all the time because I just see patients on telehealth now so this I'm like show me what you can do move your arm around let's experiment with it and then okay let's put this into some sort of program that's it well that's it it's like it's funny you know I know like if you watch the movies Lord of the Rings and they're having that big siege outside the castle all those big work guys comes along and he blows a hole in the castle and they file all the troops in them right it's just like that we're experimenting you found something that was positively surprising I'm gonna funnel all my troops down there and that's gonna become your program right and so I agree and it's really interesting like if I if I can give you an example right I had a patient that I often presented at conferences and courses and that kind of stuff with really really severe and debilitating long history of post surgical knee pain before he came to see me he about eight weeks before he came to Perth to see me he had had a scope on this knee that he'd had repaired previously and the scope showed that like it was his tissues were all disease femoral condos were all in generative and he'd loose flaps of cartilage here and there and he woke up in the surgery and the surgeon basically flashes these awful images of his knee and tells me he's gonna need a knee replacement by the time he's 30 that's pretty much it and he comes to see me and goes I just don't have that knee replacement I'm 25 I don't want to have any replacement when I'm 30 I've got young kids like you know walk and we do during my physical exam he's really nervous when I'm gonna go and do some bit worth a pt test to me now I've got the inside line that I know that his physical I know that is ACL is intact because he's had a scope on a few weeks ago right but I'm like I'm gonna do this physical exam anyway and I said well would you feel as nervous if I sat you up because yeah and if you could see your knee yeah that would be really helpful what if I do everything on the opposite knee first so you know what's coming yeah that would be great but if I start off really gently and like only build up the pressure as we feel more calm as again deathly that would make me feel better about this like isn't that how we talk like in first year uni had to do an exam but I'm communicating that and making that clear and explicit to him that that's how we're gonna do it so then anyway I'm doing the orthopedic test to me and it's no surprise I'm coming up with very little right I'm pulling gently and I go to his effect and I'm pulling gently and I go to the whole really hard I like you can't see me but at the time I was about it was about a hundred and nine kilos worth of nerve pulling on this guy's leg so he's you know it probably feels like he's been mulled by a bear but the key thing is I'm saying to him hey look can you can you feel that stopping point to sit up there can you see that stopping point and you see how it's stopping over here that's normal that's the same did that for every ligament every menistial test that I could even think of to show they were the same and he sits on the edge of the bed and I finished my physical exam and I remember the time I was like I was talking away to him like this as I almost always am and I realized all my it's not paying attention to me at all he's looking down at his knee straightening and bending it turning it looking around at his knee and I just I'm gonna sit here for a moment and let him update his model on his knee I thought my knee was gonna fall apart your hands I said made that knee is stable and strong it's much better I thought of being he's like yeah it is right now you tell me this was that pain education was that treatment or was that assessment I don't know yeah you know and so so this is the thing they know it's not assess somebody talking about their pain then delivers some treatment that's not how you deal with like the top down and bottom up components of pain and so an active influence view understands that like your approach that deeply understanding the person and understanding and trying to create positive surprise beautiful I love it I think that's a really solid beautiful place to wrap up I think we could keep talking for hours and hours but I think people are into their third cup of coffee now and I want to let them go and look up all these books that you've recommended because I highly encourage people to pursue this line of inquiry and thinking and more specifically though where can people find more about you what are your socials and what's your website yeah so I'm I'm I'm optimized rehab that's me I'm in that very forced position where I do get to fire in the world and work with different conditions and on how to implement these things I have some courses on strength and conditioning and put it in particular my pain and still course is a bed you know implementing treatments based on this on this framework based on the evidence and really optimizing exercise rehab outcomes for people so I'm optimized rehab on Facebook I'm on Instagram I've got my website you can check out core states and that kind of stuff got a ton of kind of paper published last week there in European Journal of Pain where we looked at the influence of words and information on people's experience of pain and we've got a whole series of papers coming out in the future with that so keep an eye out for for those and once that active inference back pain paper gets over the line job I'll be sure to to send it your way yes and I will force you to come back on the show and talk about it as well especially the paper that we channeled about before as well I really want to get my teeth stuck into that too but in the meantime good luck to the the Irish rugby team good luck to you and I'll chat to you soon yeah man thanks someone for having me and it's a real privilege and well done everything you do thanks mate cheers thank you for listening to this episode of the shoulder physio podcast with Dr. Mervyn Travers if you want more information about today's episode check out our show notes at www.shoulderphizio.com if you liked what you heard today don't forget to follow and subscribe on your podcast player of choice and leave a rating or review it really does help the show reach more people thanks for listening I'll chat to you soon the shoulder physio podcast would like to acknowledge that this episode was recorded from the lands of the terrible ang people I also acknowledge the traditional custodians of the lands on which each of you are living learning and working from every day I pay my respects to elders past present and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia