Dr Nick Penney
Talking the patient better 1989 Emigration to New Zealand 1999 A switch to Australia EBM Guidelines for management of Acute Low Back Pain
6:20. Psychososcial factors – as things that may prevent patients recovering from low back pain
Stress Distress Anxiety Depression PhD using BPS approach to pain – at University of Queensland (completed in 2009).
One iteration of the biopsychosocial model…
8:04. Dr Nick’s Outline of Working with a Persistent Pain Patient
In the pain medicine world, patients are referred. The telling question… “what’s going on?” Pain & Depression are two sides of the same coin
11:46. What do Sir William Osler, A.T. Still and Hippocrates have in common?
12:55. Hypothetical Persistent Low Back Pain with Depression
Figure out how much pain is interfering with their life Impact on enjoyment, on sleep, on ability to sleep, on emotions, on physical activities… How much does it bother you? Depression / Anxiety / Diabetes etc are all part of the patient’s life experience
15:30. Neck Pain in Women in the Workplace
Biggest predictive factor – unsupportive management style at work
16:58. Dr Nick Penney’s 6 A’s Approach:
Apprenticeship Application Attention Awareness Acceptance Action
Apprenticeship – learning about pain education pain as a sign of threat, not damage. Learning the ropes One of the big factors in inhibiting recovery is fear of pain, movement or re-injury Shifting beliefs – a challenge when there are mixed opinions among medical professionals Nocebo / nocebic effect George Institute, Sydney: recommendation to be very careful who you offer a scan to. Scans… NOT so reassuring
21:17. Migrating from Biomechanics to Pain Science
Boos et al 1995 – 76% of asymptomatic people have disc bulges Pain Neuroscience suggests “this is normal – and therefore not a problem” Mind viruses & Memes Pain catastrophising scale Doesn’t respond to simple education and reassurance Mindfulness based cognitive therapy Mindfulness based stress reduction Actual experience as opposed to story (or negative emotion which comes from it)
25:11. Simple take-home mindfulness technique:
Take a single thought like “My back is damaged”… let it percolate for 10 cycles of breath Prefix the thought “My back is damaged” with “I’m having the thought my back is damaged. Prefix the thought “I’m having the thought my back is damaged” with “I notice I’m having the thought my back is damaged”.
27:40. CHEK Training: Beliefs
Getting up from the front row and walking to the back – Diffusion technique Identify a painful thought or emotion and sing it to yourself to the tune of “Happy Birthday”
Working within the limits The body saying “this is enough”, rather than “this is damaged”
The Salience Network (The pain neuromatrix) Is paying attention to the pain helpful? Threat to survival can àthe pain being dropped to zero
36:09. “Pain is designed to grab our attention”
Pain can be seen as the unconscious nudging the conscious mind to pay attention… what Paul Chek terms “The Pain Teacher”.
Facilitating pain pathways… Toe tapping Beware of avoidance! Acceptance can mean we stop struggling with it, which can then mean it starts to dissipate
40:44. EPOCC Collaboration.
Acceptance vs clinical improvement Living well with pain, versus living well without pain Rewiring occurs in both directions Socioeconomic disadvantage – pain positively discriminates toward lower socioeconomic advantage. Results of Dr Nick Penney’s Integrative Pain Care
Integrative = Nick’s Clinic All services = all the other clinics involved in the research X (horizontal) axis = percentage of improvement y (vertical) axis = percentage of patients In short, the data suggests Nick’s approach is vastly superior to others, with a high percentage of patients recovering so well that they can no longer be classified as persistent pain patients.
47:24. What do you put your success down to?
Effective Application of the BioPsychoSocial Model Engel: getting too caught up in the data BPS is intertwined with other clinical tools
49:57. Socioeconomic Disadvantage
Trend toward increased pain in lower socioeconomic status … Or may just be that chronic pain is under-reported Chronic back pain among aboriginal people… saw it as being part of life – accepted the situation… but didn’t have the belief that it would last Over medicalising back pain
UK Mindfulness in Schools Program Living in our heads – in our stories… Non-judgemental awareness
54:18. Reconciling the clinical with the New Age or the Spiritual
“ Your biography becomes your biology” – Caroline Myss Lisa Feldman Barret – How Emotions Are Made – “ If we change our experience today, we can change who we are tomorrow”. Brain as a predictive organ
56:26. Pain as an emotion
A sensory and emotional experience Emotional experience of pain may be “suffering”… but suffering is optional Pain generates emotion, but it’s not a primary emotion Life experience tells us to feel certain things in certain situations It takes work, time, patience, persistence to change that Avoiding avoidance!
Doesn’t mean being hopeless and helpless Accepting current reality Open to change Working towards acceptance, but have to remember “there’s no negotiation with terrorists” Concerns with acceptance: nutrition, lifestyle, sleep, mindset, breathing pattern Anxiety leads to breathing pattern disorder, which switches autonomic system sympathetic Slow deep breathing in the face of acute pain (in experimental conditions) is more effective than a single dose of morphine We have an in-built capacity to deal with pain than we’ve been led to believe
Mindfulness, sleeping, breathing, moving… are free! Resistance from patients? Happy when they’re healthily sceptical Ultimately people have to experience Relatively small amount of training can be enough to capture patient’s interest Virtual bodies – phantom limb pain and cognitive reorganization Guided narrations for daily practice (20 mins / day of focused practice) Overtraining? … Striving for change ASAP… focus is key Tiger Woods Repetition is the mother of skill, so long as there’s skill in the repetition (P Chek)
1:08:21. Mindfulness-based Cognitive Therapy
Derivation of mindfulness based stress reduction (for relapsing depression) Nearly 50% of those trained do not relapse – because it’s a life-skill Avoiding the cues that make you abuse a substance
1:10:47. Unconscious Cognitive Function – versus Conscious Cognitive Function
Choosing to pay attention gives glimpse into unconscious / subconscious Rummaging through the garbage! “Alright XXXX, what are you thinking?” … “Is it helpful?” … Drop attention to feet for ~30 seconds Default Mode Network (the “me” network) goes quiet when we practice formally Default Mode Network does not come back online as much as it did before formal practice Safety / Security, Sustenance, Sex
1:16:09. Action – committed action
Putting what we learned into play Values more than Goals (things that bring meaning) Sense of purpose
1:18:22. Dan Siegel
Ascending information is beginner’s mind as experienced in meditation
Ascending Information = Beginner’s Mind Integration is more about choosing & observing to understand “what is” Stephen Porges’ Neuroception The brain is the one organ that can grow itself by thinking about itself. Dawson Church – Mind to Matter… 14 minutes meditation over 8 weeks for demonstrable improvement in sense of wellbeing and happiness and brain growth. Black Cab Drivers in London – doing “the knowledge” Plasticity – be careful of what you pay attention to If you blindfold someone, within 24 hours the visual cortex begins to become recruited by other parts of the brain.
1:24:45. Where Dr Penney’s work overlaps with Spirituality
May enhance it, but not at odds with it Problems with beliefs as external locus as power Pain science was seen for many years through the lens of Christianity Meet patients where they are Beware of invalidating experience / ostracising people from their tribe People seeing pain as a judgement on them
1:30:57. Preventive Work / Prehabilitation
Modifying beliefs when headed toward an orthopaedic procedure Easier to teach these skills BEFORE pain or stress is experienced Myriad Study in UK 3500 kids, 11-14year olds. Funded by Wellcome Foundation… following for 7 years… can this set kids up for different experiences Pilot Study: British Journal of Psychiatry Decreased anxiety & stress
1:34:54. To find Nick or learn more about his work, head to
In March 2020, I’m heading out to Nick’s home-turf – Auckland – to put on a 2-day Seminar to help health & fitness professionals better understand how to facilitate a return to optimal function for people experiencing persistent pain.
I will be showing how Nick’s amazing work can be applied clinically using evolutionary modelling to help prioritise; while expanding on the information presented in the “
Ghost in the Machine” papers* I wrote with Paul Chek. If you’re local, I hope our paths will cross there!
To find out more or to book your place, head to this
*NOTE: this paper is usually behind a $31.50 pay-wall, but has been made available for free by Elsevier at this moment in time.