Myth of Pain, A Good Health strategy, and more! An Interview with Paul Ingraham from PainScience.com

Philippe: Thank you Paul for joining. So today, I’m with Paul Ingram is a science writer, in Vancouver, Canada, and a chronic pain patient since 2015. Paul was a massage therapist for a decade and left the field because of its embarrassing mess his word, the omnipresence of pseudo science several years after Paul was the assistant editor of science-based medicine.org. Working closely with a world-class team of physician while building Penn science.com, up to be the sister site. His goal is to make painscience.com a credible source in an era of rampant medical misinformation, despite his medical credential.

Philippe: So he doesn’t have medical credential, but he does extensive citation with annotation and links to the original source. He’s transparent when he is presenting his opinion pieces and his biases. He’s consistently seeking input from substation network of expert, clinician, and researchers. Paul has always presented himself not as a medical expert, but a rigorous science investigator.

Philippe: Keep in mind he’s also human and one of his favorite non pence science subject is paleontology, astronomy, and classical history. 

Philippe: So, hi Paul. Thank you for joining in. Today, we got to talk a little bit beforehand. So you’re, you’re in a good mood, so that makes me happy. 

Paul: That’s right. I’m in a good mood after our introductory chat.

Paul: We have, I’m all, I’m all tuned up. 

Philippe: So I have, a few question for you. I send them to you and I got a secret question at the. And, and then we’ll go for a conclusion. So the first question I have is, what myth would you like to put to rest once and for all? To the benefit of all client and patients practitioner when it comes to Pain science would start light. Mm-hmm. 

Paul: Yeah, very late. Nice, nice. Easy one. So many myths to choose from but there is one myth to rule them all in, in the darkness. Bind them and that it’s gotta be the, the one, the one cause myth. And this is, you, you could argue about whether this is a myth, but, you know, go with me.

Paul: It’s a very prevalent misconception that most pain has one relatively easy to understand source and that that bias shapes so much diagnostic thinking it is a plague on the field. The reality is that most pain is complex and , it is a concert of many factors. Even if there is one relatively easy to understand source.

Paul: If there is a dominant source, you can still and almost always do, still have many other factors affecting how it works, how it goes down and so it’s, you know, it’s very common for people to suffer in puzzling ways, that are very difficult to account for with anyone explanation. And this is, technically this isn’t quite the same myth, but the other aspect of the complexity is that not only is it is very often, you know, the pain is in fact being driven by multiple things, but there are so many possible causes of pain that people aren’t even aware of.

Paul: So even if it is caused by just one thing, the full set of possibilities. All the things that one thing might be. It’s a really big list and most people, even, even experts, in fact in some cases, especially experts, because they’re specialized, tend to be aware of only one part of that list or one subcategory in the, you know, the mighty total list of all things that can cause pain.

Paul: Most people will only be aware of some one of the reasons that I know this to be true is because, first by accident and then more and more deliberately as my career advances, I just keep discovering causes of pain that I didn’t know . And when you’ve been doing something for 20 years and you’re still on a nearly daily basis learning about new things that make people hurt.

Paul: it’s impressive. There’s truly a lot of possible causes of pain. So just to give one simple example, that I like. The thunderclap headaches are a subspecies of headache. Not even that common. It’s not a lot, you know, they’re, they’re out there, but it’s not a super common thing. Many people have never even heard.

Philippe: I’ve never heard about it. 

Paul: Right? So even that in itself, just one kind of thunderclap headache, is a bit exotic to some people. Like, wow, there’s thunderclap headaches and yes, they are as horrible as they sound. It’s exactly what it sounds like a very sudden onset of intense pain.

Paul: Well, and here’s, and here’s the fun. There’s a, a good paper about thunderclap headaches that lists, I think the number is about 120 known distinct causes of thunderclap headache. 

Philippe: Wow.

Paul: 120 different pathological ways. That you can get a thunderclap headache. 

Philippe: That’s a lot. 

Paul: That’s a lot. I mean, it would be a, it’d be a lot even if it was a dozen.

Paul: Mm-hmm. But we’re talking over a hundred. So I have thunderclap headaches. Oh, lucky me. And an example of how the one cause myth affects healthcare. I had a neurologist once who assessed me for thunderclap headaches. He eliminated one cause and then confidently looking at me across his desk said, well, that’s it.

Paul: We know that that’s not what’s causing your thunderclap headaches, so we know you’re okay. Cuz that’s the only thing that we have to worry about. Oh God, that could cause thunderclap headaches and so yeah, it’s, that’s the myth I’d like to bust above all myths is that, is that there’s mostly, usually just one cause and that there aren’t that many causes.

Paul: There not only. Probably literally thousands of possible ways to hurt but many of them are often active in the same case at the same time. 

Philippe: This is a great point. I really like that. And it’s interesting because out of all the research, you have on your website for you to go to that one text it home for me.

Philippe: I’ve came across and the bio psychosocial framework, and it was the first time. Someone told me, yeah, it’s not just biomechanical. And I was like, no.

Paul: What?

Philippe: It has to be what I know. If it’s not what I know. I am so not doing well. Good. So I, I really like that you said that the multifactorial the, the list, what can it be?

Philippe: And it’s not just one thing and it’s true that professionals sometimes just lock people in what they know. Like they go at, you know what, it’s my. You have that and I will save you. And the person will say, okay, I’m gonna trust you, you’re the expert and go through the the protocol and don’t get better.

Philippe: And they feel, that’s me. It’s on me because he’s a professional, he’s an expert, and he knows it’s that one reason, and people feel terrible about that. So I really like that you insist on that point. 

Paul: Yeah. Another manifestation of it is if, if someone actually gets helped or they recover from their pain and they believe it was caused by X, then they become an evangelist for that and they go around telling everyone, oh, most pain is caused by that.

Paul: And I know because I had it and I was fixed and that really perpetuates the impression that yeah, there’s very specific and not that many things that cause. 

Philippe: Yeah. 

Philippe: Confirmation bias, right? 

Paul: Mm-hmm.

Paul: Yeah. 

Paul: Yeah. 

Paul: Once you think you know how something works, you start ignoring other explanations.

Paul: Just, , not that interested in other ways of looking at it. Cuz you’ve got what you need. Mm. But every patient is different and man, there are some bizarre and exotic reasons why people hurt and they’re not that. So, yeah, that’s that’s the myth I want to get rid of. 

Philippe: Would you agree then to say something like that?

Philippe: Like, if you are in pain and you’ve tried one thing and it doesn’t work, try something else.

Paul: Oh God, yes. 

Philippe: Right. That’s not a bad, that’s not a bad, simple, tidbit here. 

Paul: Well, and, and, and more, more than that. If you, if you try a hundred things, keep going. It’s amazing how many people finally, Find the explanation for their pain after years of trying.

Paul: Very late. Diagnosis is extremely common with chronic pain. So yeah, doesn’t really matter how much you’ve tried, there’s always more to do. If you can find the right help and the right ideas. 

Philippe: That’s a optimistic message. I really like it. So I like that. 

Paul: Yeah. It is a source of hope. 

Paul: Yeah.

Philippe: And it leads me to seamlessly to the next point.

Philippe: So what are the best health strategies that you find in your research, and I know some of them are actually so basic but I know you came across a lot of things. Did you find some and you were like, oh, yeah, that’s not a bad idea. 

Paul: Some, yes. You know, the bad news. Here is, is that so many pain treatments are kind of nonsense.

Paul: And that’s a product of literally decades of very busy quacks who have worked very hard to advertise their ideas and and so we have, you know, the public has been given the impression, you know, by all of these very aggressively marketed treatments that there’s lots of treatments for pain and, and, and even the cynics who might think, oh, most of it’s bs. Just the sheer volume of them leads people to believe, well, there must be something that works.

Paul: The right. There must be, you know, if not, if not that crap, then maybe this one over here, somebody’s gotta have the answers, right? Mm-hmm. 

Paul: So the sad truth is that we have very few good treatments for chronic pain and many, many of those causes that I discussed, both, both the sheer number of them and the fact that they tend to often coexist makes it, you know, it’s a hard problem.

Paul: So that makes this a hard question to answer. 

Philippe: I was a speaker on that one,

Philippe: but that just so. It’s a honest answer at least. That I think we need to agree. 

Paul: Well, , I’m also, I’m teeing up for some good news, right? I’m, I’m, I’m, I’m setting the stage with the overall badness of the situation, you know, and, and, and everybody gets it, right? Mm-hmm. We know chronic pain is a hard problem but that doesn’t mean that there’s no hope. 

Paul: So if I had to pick sort of the overall champion of, you know, the, the best overall strategy, I would probably go with lifestyle medicine and the reason is, is it’s not that impressive and it’s very unlikely to cure any one problem.

Paul: However, For the very large numbers of cases of puzzling chronic pain. Anything you can do to improve your odds overall is welcome. Right? Cure isn’t always a realistic goal. So, you know, looking for treatments that are expected to cure is really, really a tall order but something that could give lots of people some help is more realistic.

Paul: And the, the power of lifestyle medicine and what, and what I mean by lifestyle medicine is basically do everything you can to be as, as healthy as possible, as healthy and fit as possible. and That’s a treatment. It’s not a very specific treatment, which is why it’s not gonna cure much. But it does cast a very wide net. And the principle that, that makes it a little, you know, better than it sounds like. A lot of people’s first reaction to that might be. Really? That’s the best you got. Lifestyle medicine, come on, I’m pain here. And, and I get it cuz I’ve got that pain.

Paul: So I, I know that, you know, the, the being, being told, well you need to get, you know, maybe better shape and, you know, lose some weight and improve your diet and it’s like, that’s pretty weak sauce but here’s the magic, here’s where the magic is vulnerability to pain is something that we can probably reduce.

Paul: A really common theme in the science of pain is that people with precisely the same biological situation, like for instance, a herniated disc in their spine, one of them hurts and one of them doesn’t. Why? That’s also, by the way, a good example of the complexity of pain. 

Paul: That it’s not just the herniated disc, there’s something else going on because some people’s herniated discs hurt and some peoples don’t. And so what’s the difference? Well, one of the differences. Is probably the messy, systemic, biological, biochemical situation. The biological milu, for instance, systemic inflammation, which broadly correlates with fitness people who are very unfit are typically more inflamed and that in turn correlates with heart disease and all kinds of other things that that crop up when you’re just chronically inflamed but the other thing that chronically pops up when you’re chronically inflamed is more pain. So reducing your vulnerability to pain by increasing your overall health and fitness is kind of like, It’s a slow motion and uncertain painkiller, but a very reliable one.

Paul: It is a really great way of improving your odds of doing okay over long periods. So that gets my vote as the overall best and then the final thing I’ll say about it is that it’s also one of, it’s one of these great treatments where even if it doesn’t work, what’s the worst thing that happens?

Paul: You get fitter. 

Paul: Right? 

Paul: Hell of a side effect, right? Yeah. You try all kinds of other treatments and they have side effects like costing you an arm and a leg, like causing other symptoms like eroding the lining of your stomach. You know, there’s all kinds of terrible adverse effects to other treatments, but you know, if you try real hard to get healthier and fitter, the worst possible outcome of that is you get healthier and fitter and maybe your pain gets easier to control as well. 

Philippe: And you know, it’s a very interesting point that you’re making, and I really like that you chose something that is not, a cookie cutter.

Philippe: Cuz it’s not, it’s, it’s really, you made it clear, pointing a sense of direction. This is what health and science shows us. Like this is where the evidence lays that but you, it’s gonna be different for you, for you, for you because we all have different life, different lifestyle, different challenge, different vulnerabilities and yeah.

Philippe: And then after you need to spend the time to discuss with the person and really listen to them to see what the challenge are and, and try to overcome them one at a time. So it’s not satisfying to some because some people want a fix and I think not because that’s what they want, but because they’ve been told some technique work as a fix, which they don’t.

Philippe: Or if they do, they might have like tremendous side effect, like you say. So I appreciate you, you candor here. You are not trying to, to have a quick fix, to have a quick solution in trying to simply say, well, you need to work on your health and that lifestyle change will be mostly beneficial and you’re not trying to guarantee it, which is also, we cannot really say, yeah, it’s gonna work for everybody for sure, and, a hundred percent success.

Philippe: We can’t do that. That’s not how it works. So it’s a, it’s a, it’s satisfying to me but I hope people see the sense of direction here. The way I put it in my word is you have to put an effort to talk to someone. The other person has to put an effort in listening to you, and then you have to, yeah, put up some effort into discovering the strategy you’re gonna implement and then the effort into actually doing it.

Philippe: And it’s gonna take a lot out the view, but it’s not meaningless and it’s not a bad idea. 

Paul: Everybody takes a different path to fitness. It’s, some very, very different ways of getting to that goal. So that I realize my conversational style is making it impossible for us to do this in 15 minutes.

Paul: Well, I’ll try to answer the next question a little more briefly. 

Philippe: I say that, I’ll say that I had two more question, but the next one is how do you process the integration of new knowledge, basically? And new conversation style goes in depth and I have the time to do that, but we can shorten it.

Philippe: It’s up to, it’s up to you. I put the weight on you here.

Paul: I think I can answer this one more briefly. I think. 

Philippe: Because you’ve experienced that as a massage therapist. You were in Pseudo Science and you had you faced like confusion and you had to find your way through and I faced that and it was challenging.

Philippe: But still today you, you come up with new research, new information, well, you don’t come up with it. You find them and you 

Paul: Correct.

Philippe: I came up with this today, but you’re like, wow, this challenge is something I knew. So how do you process that? And actually my next question kind of goes into this as an advice you could give massage therapist when they market themself.

Philippe: Because you, it’s Hard to say, like, well, I’m gonna market myself because I know this, but that might change, and I know you’ve been quite savvy in that too, so maybe you can link those two question. 

Paul: All right. I’ll try. Yeah, I’ve changed my mind about a lot of things over the years, and I take it for granted that, you know, what I know now is a work in progress, that all knowledge is provisional.

Paul: Critical thinking is a skill that has to be learned painstakingly over many years and this was one of the best things that I got from my experiences working with the folks at science-based medicine.org. Is they weren’t just smart about their medical knowledge, they were also really, really good quality thinkers.

Paul: And I learned a lot of thinking skills from them it’s also an emotional skill. When I’m challenged and I get challenged a lot. I imagine, yeah, everything from very high quality constructive criticism from people who genuinely know way more than I do about, you know, x everything from that to unhinged, incoherent hatred.

Paul: I see it all, and the, the tough ones, and this is this, I’m gonna use this as the example to, to answer the question any number of ways I could answer it. But I, I’m gonna, I’m gonna go with this, so what? What happens when I get something that from someone, I get some criticism from someone, and it’s kind of in the middle of that range.

Paul: It’s not clearly from someone I should shut up and listen to, but it’s not clearly from an unhinged troll either. Those are the hardest. Because it would be so easy to dismiss it. I get a lot of email. I get too much email. It would be so easy to just say, let’s just file that one under ignore.

Paul: Cause you know, you have to, you have to have to ignore lots of the feedback that I get cuz a lot of it is kind of terrible. So when I get, you know, good feedback, that is maybe not as well presented as it could be. My initial emotional reaction is, Practically any human, it’s defensive. 

Paul: Right. I feel attacked. Yeah. You know, my ideas are, are under assault. The only way that I’m gonna get, you know, let, let’s say that for the sake of argument, there’s something for me to learn there. I need to learn from this feedback that I’m gonna ultimately change my mind to get there. I have to master that emotional reaction..

Paul: And so the number one skill is don’t react defensively. Don’t start that way or you’re never gonna get through it, right. You’ll just end up in an argument. So for me, the number one emotional skill is to, you know, to, to be, to pause long enough for me to start thinking, yeah, maybe I am wrong about that.

Paul: I have to, I have to get past the defensive reaction, which is just pure emotion. And that’s a skill and it’s something, yeah. That I’ve had to, to just practice over the years. Something, you know, there’s a lot of ways to answer this, but that’s a particular that good thinking is a skill.

Paul: And it also takes emotional maturity. That’s, that’s the, the key. And of course, you also have to accept, you know, just as a general principle in your life that you’re probably wrong about some stuff. Yeah. And that, you know, that that in itself is a big hurdle for a lot of people but I crossed that Rubicon 25 years ago. 

Paul: And, it’s the, you’re good now. It’s the fact, the superpower is that I learned the hard way a long time ago that I could be really, really wrong and once I had dealt with that, once I had, you know, cuz I used to believe a bunch of weird crap. 

Philippe: No, me too.

Paul: And, and, and many, many of us do when we’re younger and many of us overcome it, but not everyone.

Paul: And I had, you know, I just, once I learned that it’s like, oh, oh, okay. I guess that’s it. For the rest of my life, I have to deal with the possibility that I’m gonna be wrong about stuff. This is probably not the last time that I’m gonna be wrong. 

Philippe: The way I looked at it was like, I like the term of cognitive dissonance.

Philippe: Like you have two beliefs and they come and your brain explode and it’s very stressful. And when you go and you can’t just dismiss it and ignore it, but then you cannot get stuck in a rut. And if you pass through, it’s gonna be difficult but then when you’re on the other side, well use 10 corrected and you’re a more lenient. It seems gets easier. 

Philippe: Yeah. So if you have that

Paul: And the connection to, sorry, go ahead. 

Philippe: Oh, and the connection to. 

Paul: To marketing. 

Philippe: Yeah.

Paul: You asked, you asked to market, how do you market? 

Philippe: Yeah, because it’s it’s hard, right? It’s like, oh, you gonna say, oh, my whole, practice used to be about myofascial release and that could be like Right.

Philippe: Six episode right there. Yeah. But, then I had to, to say, well, maybe I can use it as marketing because people know about it. But when they come, I will tell them. Yes, but no. So, but people are like, I don’t want to hear you telling me that I came here because I thought it would work. So what would you say to massage therapist, to who starts now after, like studying all those crazy stuff?

Philippe: Or I mean, the program is getting better in, in places. What would you tell them they should sell themselves for? Like, what is it that they’re doing? That still 

Paul: Skill as a wise coach. 

Paul: Yeah. Sell process, not product. Sell your ability to, to be a wise guide and the number one property of a wise guide is humility.

Paul: Right. It’s not what you know, it’s how easily you admit what you don’t know. Yeah. What we see a, a lot of an alternative medicine is, you know, there’s a lot of lip service to humility. People who, you know, praise the concept of humility, but then immediately Act as though they know it all.

Paul: Yeah. About whatever. Right and in the number one form of this is, you know, they’re supposedly humble, but they have absolute faith in their technique or modality. And they have, you know, very little insight into how well people actually. Do with that that they, they think that they’re helping lots of people, but in fact, many of their clients are walking away and sending a note to someone like me saying, I can’t believe the weird, you know, treatment that I got that did nothing for me.

Paul: And so the, it’s very important to actually be humble. It’s super liberating. And it’s, yeah, the good news is it’s not nearly as bad as it sounds. 

Philippe: It’s not the pressure on the shoulder actually. It’s like, Hey, you know what? I don’t know it all, man. 

Paul: You really don’t. I mean, when I look back at what I, you know, what I knew in my early in my clinical career, it’s, it, it’s a joke and I was a well-trained massage therapist as massage therapist for, 

Philippe: Yeah, 3000 hours.

Paul: The amount that I didn’t know was, I mean, the sheer tonnage of what I didn’t know. It’s staggering that I was. You know, out there in the world, selling my services for, you know, more than a buck a minute, amazes me, you know, how much therapy I sold with that much, you know, youthful ignorance.

Paul: Anyway, it’s a great selling point. Ernest Lee telling people I don’t know, is very powerful. They really like it. I used to tell people when, when they would say, How does this go? Oh, right. When they would try to book me and I’d say, I don’t have anything available.

Paul: I got a waiting list that’ll take six months. And they say, you must be very good. And I say, actually, I’m not sure that I’m good. I am charismatic, but I’m not sure that I’m actually any good. I would always get a laugh and people would just eat that up. And I would, I would fail with people and, and I would say, I have failed with you. I am not succeeding in helping you. I think you should stop paying me. And they would say, no, I want to keep paying someone who admits that they are failing to treat me.

Philippe: And i, you know what? It’s something, 

Paul: it’s a very attractive property. 

Philippe: Yeah, it’s something I’ve heard too, like you said in the first place, a guide. A guide is what they’re looking for. They’re not looking for someone who’s omniscience, omni buttonin. They’re looking for a guide. We’re all in this kind of together in a sense.

Philippe: I know it’s a corny way of thinking, so I think it’s a very solid piece of advice for marketing for people now. Course, just like, Hey dude, you try to try to do your best and stay humble. 

Paul: Yeah. Yeah. So was that the secret question or is there one more? 

Philippe: That was the secret question. The marketing was a secret question.

Paul: Yeah. So, yeah, I think the secret, the secret to marketing is anti-marketing. It’s undersell yourself to yourself and to your practice true humility, and you will be rewarded with people’s trust and loyalty. It’s almost a bit of a magic trick that, that thing of, you know, I don’t know that I’m really doing you much good.

Paul: Oh, really? Great. Well, I want to pay you more. I, I saw it again and, you know, it has, As the great virtue of being honest. You know, it’s, you’re not, you’re not bullshitting, you’re, you’re just honestly saying, I don’t know how to fix this and I have many experiences with clients where we would, you know, we learned about their case together.

Paul: They would discover something with another healthcare professional, and we would, we would go over that together and go, oh, wow. Well that’s really interesting, huh? What are we gonna do with that? Is there anything we can do with that? So if you’re, if you truly see yourself as A collaborator as a humble collaborator with clients, that is excellent marketing.

Philippe: Mm-hmm. 

Philippe: Part of the team. I like that. And I know, like I came up with like five other questions, but I wanna save them for later if we do that again, because they 

Paul: for next.

Philippe: Thank you so much. Yeah. Yeah. So much. 

Paul: Thanks very much. 

Paul: It’s been fun. You’re very welcome. 

Philippe: Thank you so much for humoring me and coming to, that interview with me and, I want to close it.

Philippe: That’s the sentence I’ve put on the website, but I want to close it as this is, as of today as far as we know, guys. Yeah, so don’t let this be necessarily the only knowledge you got and keep on looking for something else and please do go on Painscience.com. This website is my Wikipedia of Pain Science, and every time someone ask me a question, Yeah, gimme five minutes and then a quick go on painscience.com, answer the subject.

Philippe: And it gave me like, over the years, I cannot tell you how grateful I am. And I was talking with someone else on LinkedIn and they told me the same thing. Say, I think I told him thank you, but I’m not sure this website has ton of people and you pray, do receive this message, but I wanted to say it from the bottom of my heart, thank you.

Philippe: And from other people, thank you too for putting all that effort and dealing with so much BS online and, the sheer volume of what it means to to, to do all that work. So I’m looking forward to put that online, to share with other people, and looking forward to talk to you soon.

Paul: Thanks Philippe, and we’ll we’ll talk again soon. I look forward to it.