Aphora - Pain Coaching and Education

02/04/2026

I have been thinking about a post on social media that I saw last week. The topic was a query about the prevalence of adverse childhood experiences in the history of those who are living with persisting pain. The gist of the post was ‘can childhood trauma “cause” persisting pain’. Like most questions, the answer is “it depends”.
Persisting or chronic pain is complicated. Understanding that it complex can be helpful because most who live with persisting pain have more avenues for relief than they have explored to date. This is because they are assuming a much too simplistic concept of cause. In that way searching for a single cause is hazardous. That impulse is much too simplistic and the ongoing search for the simple cause limits the searcher from acting on some potentially helpful targets.
The way I conceptualize this concept is the old story of the straw that broke the camels back. The simplistic concept of a single cause might be blaming the last straw. However, the last straw is better understood as the trigger rather than the cause. The total load on the poor camel’s back is of much more interest as a cause. In medical terms this is called the total allostatic load. It is the sum of the many stressors that the person is struggling to deal with. Please note that some of those stressors are things which are in the past and cannot change such as age, gender, and a history of trauma. But there are others that can change. Those are the helpful targets for intervention.
Kevin Cucaro MD, a board-certified anesthesiologist, uses a modified fire triangle as a way of conceptualizing pain and targets for finding relief. Firefighters use the fire triangle concept to control fires. If you reduce the fuel, or the oxygen, or the heat, you can bring the fire under control. In the same way, people living with persisting pain can often improve their pain experience by means of becoming less fearful of the pain, by thinking about it differently, and improving the sensation. All three broad concepts are potential targets for intervention. The key is that these things are more in the control of the person living with pain than some outside “expert”.
I suggest using these concepts to identify potential targets for exploration. Accepting that there are modifiable targets for decreasing your total load and taking action to change them has helped many. Changing your thoughts about your pain and how you feel about it has helped many. Focusing on what you can control rather than wasting energy on things that you cannot control has helped many. There is often a path forward.

06/03/2025

Truth. It's essential to be open to difficult conversations.

Are we really practicing what we preach with psychologically-informed care? It's time we moved beyond theoretical knowledge to meaningful patient connections. The most transformative moments happen when we're brave enough to have difficult conversations and create experiential learning opportunities, not just prescribe exercises. True healing begins when we step into discomfort alongside our patients rather than avoiding it.

03/17/2025

Sandy Hilton and Mark Kargela , great information https://m.youtube.com/watch?si=sQt_nK2kEa-fnh2s&fbclid=IwZXh0bgNhZW0CMTEAAR0HWevVIa7qf7wQeIl5kO1XW35P08VoKFDrvq98SXoIGCevGjC4uOP2qk0_aem_NMDFN1Fz6gW_miSNKWsQEg&v=_WFkwRfk4rA&feature=youtu.be

🚨 In this episode of The Modern Pain Podcast, Mark Kargela interviews Sandy Hilton, a pioneering physical therapist and expert in pelvic health and pain car...

03/03/2025

I shared this with a client this morning. They found it helpful. They were transitioning from fear to learning stages. Where are you?

Working on a new slide for a presentation on the value and challenges of acceptance. Attempting to connect progress with the development of a growth mindset and including some components of Sharna Prasad's Titanic model of recovery. What do you think?

03/03/2025

This image is in my mind after listening to a great video post by Mark Kargela on his Modern Pain Podcast.

Image credit Sigurd Mikkellsen

02/19/2025

so true and valuable

Rest is vitally important. Often with chronic persistent spine pain it is difficult to rest for any beneficial amount of time. Implementing pain self-management techniques can assist us in this.

Practice pain self-management. Need support? Message me.

02/15/2025

This is a complicated topic but I think that this is a very good start.

02/13/2025

💡ME/CFS 101: What is PEM?

The Price of Exertion

PEM is a worsening of symptoms after physical, cognitive, or social/emotional exertion and can also be triggered by orthostatic, sensory, or environmental stressors. This "energy payback" can hit 12-72 hours later, leaving patients feeling like they ran a marathon with the flu.

Understanding PEM is key to living with ME/CFS. Stay tuned for more in our ME/CFS 101 series!

Learn more: https://loom.ly/kINwHTQ

02/07/2025

This concept is common with patients and clinicians.

Ever wonder why a ‘new’ treatment suddenly works when nothing else did? 🤔 It might not be the treatment itself—but something much deeper at play.

Clinicians often claim, "My patient didn't respond to anything until I tried this new treatment." It’s a compelling statement—but one that deserves deeper scrutiny.

Attributing success solely to a new intervention ignores the powerful context that drives outcomes. Here’s what’s often at play:

✅ The Uniqueness Effect – When a treatment feels new or different, it captures attention. Patients may perceive it as more valuable simply because it stands apart from previous interventions.

🔄 The Ritual & Novelty – The structured, intentional process of introducing something "new" adds weight to the experience. The novelty alone can enhance engagement and expectation-driven effects.

🔥 Clinician Excitement & Certainty – A fresh intervention often reignites a clinician’s enthusiasm. When we truly believe in something, we deliver it with greater conviction—and patients pick up on that energy. Confidence, attention, and belief all contribute to the outcome.

🛑 The Contextual Shift – A patient who “suddenly” improves with a new treatment has already gone through multiple attempts at care. Their pain experience has evolved, their mindset may have shifted, and their condition might have fluctuated naturally.

The danger? 🚨 When we mistake contextual influence for treatment specificity, we reinforce the illusion that a single technique holds the key. This leads to unnecessary interventions, wasted resources, and clinicians chasing the next "miracle fix."

🔑 The Real Takeaway: The response isn’t just about what we do—it’s about how we do it, the meaning it carries, and the context in which it’s delivered. Even with this “amazing” new change, we need to shift to a now what? mindset. Changes in clinic are meaningless if they don’t translate into durable improvements in daily life.

👉 Have you seen this pattern in clinical practice? Let’s discuss below! 👇

01/18/2025

I see 5 key steps for anyone who hopes to be successful in helping manage chronic pain. The first 2 are for the clinician. The second 3 are more for the person who is living with pain.
1. Validate the patient's experience. This is by far the most important part of the process. Without that validation, nothing useful is likely to come out of any clinical encounter. Please note: validating the experience is very different than validating the story of why someone is living with pain. Often that story is a pain story as opposed to a healing story. Finding a healing story that helps the person living with pain to understand their pain in a useful way is very valuable.
2. Look for and attempt to create expectancy violations. Expectancy violations are movements, activities, positions, etc. that the patient expects to hurt but in fact do not hurt as expected. These expectancy violations elicit the question "why didn't that hurt?" No explanation about pain will have any value unless the patient has the experience of doing an activity that usually hurts but they now have some control over that pain.
Now for the 3 keys on the patient side of the equation.
3. Make sense of their pain. Most often that means the understanding that the pain does not equal more tissue damage. The clinician has a role in bringing the patient to that understanding but it must be the patient who really comes to that conclusion. With chronic pain this is true the vast majority of the time, but it is hard to come to terms with.
4. Acceptance / willingness to move forward despite the presence of pain. Here it is important to clarify the meaning of acceptance. I mean it in the sense that this is the current reality and not to waste time or energy fighting that reality. This is where exploration of current possibilities can start. This is very different than resignation where hope is lost. Acceptance for me is the starting point in moving forward.
5. Flexibly persist. The larger goal should not be pain relief, it should be the ability to have a life of meaning. Very often, more progress on pain intensity relief occurs when the focus is more on how to do the things that you enjoy and find value in rather than making reduction of pain as the main target.
I must acknowledge the influence of Bronnie Lennox Thompson for the last 3 points. These points come from her research "Living well with chronic pain: A Classical grounded theory.

12/30/2024

Here is the link for an interview of me by Mark Kargela of Modern Pain Care. Link in the comments.