[headline style=”1″ align=”center” headline_tag=”h2″]The Best Pain Science Book You Haven’t Read….


I got a book recommendation a few months back from a colleague of mine. I am always interested in reading great books with solid content. The book that I was recommended was called:  A World of Hurt.

I was a bit skeptical at first because as many who know me personally, I am not a big pain science fan.

I do apply it with chronic patients but I think it is overdone and many believe this form of treatment is the end-all be-all.

I could be wrong about this statement but it has been my experience clinically.

However, I did fall in love with this book. It has a lot clinical application.

The authors work at a the renowned Rehabilitation Institute of Chicago.

Both authors use an eclectic approach but use pain science with Mechanical Diagnostic Therapy (MDT) which is Robin McKenzie’s method and approach.

The reasons I like it better is because they classify pain peripherally and centrally and break this down further into three groupings. This way you can discern their pain mechanism bottom up and top down.

I could be wrong but I don’t recall Butler and Mosley classifying central nervous system pain into different categories. This book did just that.

Below you can see some of notes.

[headline style=”1″ align=”center” headline_tag=”h2″]Bottom Up Pain Mechanisms


This book talks about three different pain mechanisms that are caused from nociception.

Nociception is a afferent signal to the brain that tissue damage has taken place and the brain produces pain.

There are three categories of nociceptive pain that happen in the tissues:

  1. Inflammation
  2. Ischemia
  3. Peripheral Neurogenic


[headline style=”1″ align=”center” headline_tag=”h2″]Inflammatory


If you haven’t taken the time, I would highly recommend reading Robin McKenzie’s books of MDT.

These books provide great clarity and insight on clinical reasoning and justifying what treatment you provide.

He talks a lot about inflammatory or “chemical” pain.

For instance, is your patient’s pain constant all the time?

If so, they may be experiencing chemical pain due to inflammation. This is usually the case after surgery or acute injury. There is nothing you can do that day except for telling that patient to rest, PRICE principles, gentle movement, and possibly take NSAIDS.

However, chronic pain can also be constant. You need to discern this with your history.

Similarly, inflammation can also be mechanical in nature and produce pain with certain movements only.

For example, your patient may have pain backward bending which irritates the facet joints. The inflammation can cause pain in only one plane.

Mechanical inflammation pain typically has a diurnal pattern. This means pain is usually worst in the morning and evening and better with movement and as the day progresses.

In contrast. ischemic pain, which I will talk about below, is generally worst as the day progresses.

What kind of pain does your patient have?

This is something you need to discern to give the appropriate treatment.


[headline style=”1″ align=”center” headline_tag=”h2″]Ishemic


Ischemic pain is due to reduce blood flow to tissue.

This is usually due to abnormal posture or tissue dysfunctiion based on the McKenzie classification.

Basically, your patients need to move more often and load their tissues.

Think of this as your patient who gets buttock pain from sitting at their desk all day.


Perhaps a deconditioned patient that comes in with periscapular pain.

The treatment for these patients is quite simple …. get them moving!


[headline style=”1″ align=”center” headline_tag=”h2″]Peripheral Neurogenic


This form of pain is basically nerve related pain and symptoms. It can be caused from nerve entrapment, neuropraxia, axontemesis, neural tension, and other mechanical interface impairements around the nerve .

This form of pain, again, is bottom up to the brain. Again, this patient has nociception happening. The tissue is damaged.

If you haven’t already, you can learn how to treat these conditions with Michael Shacklock’s books.

You can find it in my resources page by going HERE.

This book has been a game changer in the way I practice and assess the nervous system.

If you don’t have this on your book shelf you are leaving a lot on the table with your patients.

In essence, you want to discern is the nerve itself irritated? Is it sliding optimally? Or is the mechanical interface around the nerve not opening, closing, or too restricted which is compressing the nerve?

If the mechanical interface isn’t moving optimally, you will want to either mobilize the spine or if it is moving too much with hypermobility, you will need to stabilize.

Similarly, if the fascia and muscles around the nerve are bound down you will need to do stretching and myofascial work around these tissues.

If neural tension is present, you will want to induce induce movements that will put tension on the nerve bottom up and top down to help change the visceoelastic properties of the epineurium and perineurium (the connect tissue around the nerve).

[headline style=”1″ align=”center” headline_tag=”h2″]Top Down Pain Mechanisms


In contrast to the bottom up nocioceptive pain mechanisms there is also top down mechanisms.

This is your “pain science” patient for lack of better terms.

They have pain three months or later after their injury.

These are the patients that need education that although their pain is REAL, it isn’ stemming from the tissues in many cases.

Rather, their nervous system is presenting with FALSE information to the tissues.

This part of the book was one of the better application that i have seen on pain science. It doesn’t “label” a patient under one broad category for pain science.

Rather, it categorizes patients into three different groups.

The three groupings of top down pain are the following:

  1. Central Sensitivity 
  2. Affective 
  3. Autonomic 


[headline style=”1″ align=”center” headline_tag=”h2″]Central Sensitivity


Central sensitivity is a “heightened” nervous system or what they called “facilitated” nervous system. Typically these patients will present with allodynia and hyperalgesia.

Allodynia is where pain is produced with a non-painful stimulus. For instance, I had a patient the other day where I just touched her skin and she jumped off the table. She wasn’t acute either. She had been suffering from lower back pain for years.

Can you think of patients that you have had in the past with this?

The treatment for this condition is quite simple by educating the patient that their nerves are overly sensitive and it is safe to move.

Similarly, you will want to provide optimal loading of the tissues with a gradual progression.


[headline style=”1″ align=”center” headline_tag=”h2″]Affective


Although you central sensitivity patient and affective patient typically share heightened nervous system input, they are slightly different.

You affective patient may also have allodynia and hyperalgesia but they have more of an emotional component to their symptoms.

For example, usually they have abnormal views as to why they are in pain, have anxiety, depressed, or even sometimes can have a type A personality.

Treating these patients need education and movement similar to above.

When educating you need to come their friend and trusted advisor. You also need to uncover something that is going on in their life. It can be something in their past, work, relationships, and etc that is further causing their pain.

The book talks about giving your patient a journal to help discern what is causing your patients pain.

The patient needs to journal when they have the most pain. For instance, is it when you are at work? What social activities? Or some other area of your life.

I think this could be a game changer because the patient will slowly start to see they are having pain only with certain thoughts or times of the day related to their emotional imbalance.

[headline style=”1″ align=”center” headline_tag=”h2″]Autonomic


The last top down pain mechanism is autonomic. These are patients that have signs and symptoms of chronic pain but also have an autonomic response. Typically all systems will be involved.

They will usually lack sleep, have s/s of irritable bowel syndrome and related sickness, more extremity involvement, sweating, chain in color of the skin, hair growth, swelling and etc. The patient will also have allodynia and hyperalgesia similar to above.

With this form of central pain, the brain has changed it’s cortical representation. For instance,  their field of pain has expanded. When you touch their thumb it may shoot pain all the way up into their head or neck.

Can you think of a patient that had this type of symptoms?

Another key point with the autonomic pain mechanism is they will have a hard time with proprioception and stereognosis.

To treat these type of patient’s you need to do what Mosley calls as Graded Motor Imagery. GMI is a three part series of

  1. Left to Right Discrimination
  2. Imagined Movements
  3. Mirror Therapy 

Left to right discrimination would be to watch a series of pictures that are distorted sideways and up and down. The patient would sub-consciously evaluating which is the left and right extremity.

Imagined movements would be to literally imaging your body moving pain free and doing simple to more complex tasks. This is training the body that you basically can move.

Last but not least, mirror therapy is used to help desenstitive the nervous system. Mirror therapy would be to put your non-involved limb in the mirror and exercise/move the limb. This makes the brain think they are moving the affected limb through their vision. Basically they are tricking the brain that it is OK to move the limb.


Here is a link to the NOI group’s GMI course where you can learn more info about GMI:


[headline style=”1″ align=”center” headline_tag=”h2″]Concluding Remarks…


As I have said from time-to-time, I really have been one of the biggest critics of pain science.

It isn’t that I don’t agree with it. It is the fact that the majority of clinicians I feel use it as the “end- all be-all” in treating their patients.

Perhaps my caseload is more acute patients rather than chronic pain patients as well, too.

Regardless, this was a great resources for clinicians that are wanting to understand the difference between peripheral and central pain.

I would highly recommend you rent it from your local library or add it to your bookshelf.

You can purchase it on Amazon by CLICKING HERE.