Self-Efficacy A Well Used Term But Well Understood?

Self-efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact, my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well-defined definition for a well-used term.

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Let’s Start With What Does It Mean?

It was a term first coined by Bandura in the 70’s, he described it is the ‘belief of an individual on whether they have the ability to perform behaviours relative to a specific activity’. Self-efficacy has also been described as a ‘resilient self-belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self-efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment-related activities such as a specific activity or exercise.

So let’s say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self-efficacy may result in challenges, such as changes in behaviour, being seen as threats to be avoided rather than things that can be overcome. Bandura identified a number of psychological processes involved with self-efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be associated with these factors as well and self-efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self-efficacy.


Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of successes.

If our successes have been easy then we may be quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view, we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.


The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely to see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE


Now, this can be both positive and negative, and of course, it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative Emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self-efficacy someone has. Self-doubt is often an emotion that influences behavior negatively.

So We Have To Also Ask, Why Is It Important?

It appears that self-efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence-based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self-efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact, better than fear avoidance, catastrophizing or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self-efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self-efficacy.

Self-efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self-efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)Slide2

What Can We Do To Alter It?


The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self-efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self-efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads to some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer-term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer-term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self-efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”


Motivation also appears to be a key aspect of self-efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal-setting process that identifies valued activities.  We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor associated with successful exercise, HERE, so also giving choices and options rather than a ‘this is the exercise you have to do’ approach.


Sitting down and planning with people when they might do things and how much might also have an impact on self-efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smartphone?

How to progress?

Alternative options if you do not succeed?


  • Previous experiences with behaviours are involved with future self-efficacy
  • Social environment and support is important
  • Self-efficacy can make or break an active approach to treatment
  • Self-efficacy is involved in outcomes for pain and disability
  • Self-efficacy is important for exercise adherence
  • Create behavioural wins and good experiences
  • Your input in terms of planning and motivation is vital if self-efficacy is low

Testing, Graded Exposure, And Reassurance For Low Back Pain


Over the past couple of weeks, we have been looking at and discussing the clinical guidelines for treating low back pain.

We have covered how important reassuring our patients their tissues are safe is a crucial component in their recovery from pain as well as building our therapeutic relationship with them.

We also discussed how important using graded exposure as part of that reassurance is, along with its importance in getting them moving again. So, this week we’ll cover how you can do some simple and effective graded exposure right in your massage therapy treatment room.

But first, we’ll have a look at the orthopedic test that was commonly recommended throughout those clinical guidelines and how to do it. There is a bit of controversy between papers as to how effective this test is, but it is the one that was most commonly recommended, so we felt it important to review.

Here is how to do an SLR (straight leg raise).

Even though the more common use of an SLR for low back pain is to look for a disc issue if you get a positive it is still important to reassure your patient they are okay. Use terms like “it just shows us the area is sensitized right now, so we just need to calm it down”. Try not to alarm them or instill any fear around there being a damaged disc or tissue.

Quite often when patients with low back pain come in, there will be some movements they are fearful of doing. Commonly forward flexion is the one I’ve seen in practice that most people have an issue with, so we’ll look at how we can do some graded exposure to help with that.

If you have a hydraulic table here are some simple things you can do to not only reassure the patient movement is okay, but also to help build up their trust in you:

If you don’t have a hydraulic table, here’s how you can do the same thing with some of the furniture most of us have in our treatment rooms.

The biggest takeaways:

  • Provide reassurance to the patient that they are not “damaged”.
  • Make them feel safe with the movements.
  • Gradually expose them to an increased range of movement.
  • Encourage, encourage, encourage your patients!

Learn How Movement Will Change Low Back Pain

Last week we posted an article discussing some of the research around the clinical guidelines of low back pain.

There are several modalities commonly used that aren’t recommended like Tens, laser therapy, imaging, and corticosteroids,  but when we look at what is recommended we have an opportunity to make a real difference for those suffering from back pain.

One of the big things recommended is a biopsychosocial approach along with education. In order to start this kind of approach, patient reassurance is critical in order to help the patient feel safe (as we talked about last week).

In addition to reassurance, supervised exercise is also a crucial part of helping patients deal with their back pain. However, these two go hand in hand as it will quite often take a considerable amount of reassurance to convince a patient that it is okay to move.

One way to help is by looking at what the research says for exercise and low back pain, which you can use as a tool to convince (and reassure) patients this is the best course of action.

Exercise For Low Back Pain

Remember the old days when bed rest was the main prescription for low back pain?

Well, now bed rest is actually discouraged unless the pain is too severe, then only two days of bed rest are chosen. In contrast to this, we now understand that staying active has far better outcomes than the way we used to manage this.

And I know many of you might be saying “exercise is out of my scope of practice” and while this may be true, active and passive range of motion probably is within your scope, so there is no reason you can’t incorporate some of this into your treatments. 

I know there is probably some concern over being able to recommend “specific” exercises (or movements) but don’t worry it doesn’t have to be all that complicated…in fact, it shouldn’t be! Supervised movement without the use of expensive equipment is one of the specific recommendations, so you can do this right in your treatment room.

This is especially true in the acute stage, where strengthening, extension, and specific exercises are not recommended. Rather, in this case, we want to use graded exposure to physical activity. Graded exposure is essentially getting a patient to move (gradually) into a feared or painful movement (we’ve had articles about this before which you can read HERE for a more detailed description).

For example, when it comes to acute low back pain, if your patient is scared, or experiencing pain with a certain movement like standing forward flexion, have them change the plane of movement and try flexion again. Try having them sit comfortably in a chair, then lean forward. This is still spinal flexion, it’s just in a more supportive position. When they can move in this position comfortably, point out how capable they are of the movement and reassure them that flexion is safe. You can then gradually work up to standing flexion until this feels safe again.

There are many ways to do this, it just takes a little experimentation on your part.

When it comes to chronic low back pain there is no evidence that one exercise is superior to another.

However, recommendations show that remaining as physically active as possible along with an early return to work is well supported by evidence (probably why some workplaces have a gradual return to work program). While there are no specific exercises highlighted as more effective than others, the exercises that work are simply the ones your patient will do. Find out what’s important to them and encourage them to do it. Whether it is strength training, going for a walk, playing with their kids, or playing hockey, the intent is to build confidence in their bodies as opposed to fixing a problem.

Inevitably the question of dosage comes up and the research shows that too much, or too little exercise with some patients can run the risk of developing persistent pain. This is where it’s important to experiment a little to see what works best for the patient, we don’t want them to overdo it, but also want to avoid not doing enough (one of the reasons bed rest has been eliminated).

Overall since we know a biopsychosocial approach is most effective, encourage things like movement in general, getting back to work, staying connected with the things and the people they enjoy. Just make sure these things are done gradually. If we can address peoples fear of movement by using graded exposure early on, we have a better chance of avoiding prolonged pain and disability. So, don’t stress about ‘specific’ exercises, the overall goal is to get our patients moving and keep them moving. Movement along with some education and reassurance can go a long way in not only improving low back pain but also the patients quality of life.


Next Time You Treat Low Back Pain, Be Sure To Provide Reassurance


When the patient came into the treatment room, I sat down and welcomed them to do the same.

They refused, preferring to stand, as sitting hurt their lower back too much. When asked how long this pain had been going on, it was an astonishing two years.

Unfortunately, they had been run through the medical system for the previous two years, had seen every kind of practitioner and been given competing advice from all of these medical professionals. When asked what has worked well in the past, getting massage seemed to be the most beneficial. While this sounded great, there was still a lot of work to be done, which had nothing to do with what technique I could use to help ease the pain.

There was now an education and confidence building process that had to take place.

This person was so scared of their pain, they were afraid to sit (even though they had just comfortably driven their vehicle to the clinic).

How could I help this person? What kind of education would help? Would I be able to help?

Clinical Guidelines For Low Back Pain

Looking at the studies on the clinical guidelines for low back pain,  they revolve around primary care settings, which can be described as the “first point of contact regarding patient care”, so generally thought of as doctors in medical clinics or hospitals.

Fortunately, there is a lot of good advice about managing both acute and chronic low back pain.

Unfortunately, when we look at the European guidelines it says “they cannot recommend massage therapy” for the management of low back pain. But when we dig a little deeper when it refers to treatments they cannot recommend “it is owing to lack of/conflicting evidence of effectiveness” and while many of these treatments may be effective, they require the use of more studies to prove their effect (which is a big reason we need more research on massage therapy to be done, we know it’s effective).

But, massage isn’t alone in these studies as the modalities that “aren’t recommended”, there is quite a long list of things they would not recommend which we see used quite regularly:

  • Radiographic imaging for chronic non-specific low back pain.
  • MRI, CT, or facet blocks for diagnosis of facet joint pain, or discographies for discogenic pain.
  • EMG as a diagnostic procedure.
  • Wearing lumbar support.
  • Ultrasound.
  • Laser Therapy.
  • Traction.
  • TENS machines.
  • Acupuncture.
  • Nerve blockers, or corticosteroids.
  • Injections

However, it does recommend:

  • Looking at: work-related factors, psychosocial distress, and patient expectations.
  • Supervised exercise therapy.
  • Exercise programs that do not require expensive training machines.
  • Group exercise.
  • A short course of spinal manipulation for chronic low back pain.
  • Brief educational interventions.
  • Mulitdisiplinary biopsychosocial rehabilitation.

What the article doesn’t really mention is the interaction between the massage therapist and the patient.

While the above information is from the European guidelines when we look at the updated overview of international clinical guidelines they are consistent in recommending a focus on the identification of red flags (which we have written about HERE) and ruling out specific diseases. The only time medical imaging is recommended is when a serious pathology is suspected.

However, consistently across all of the recommendations is that patients should be reassured they don’t have a serious issue, and they should remain active.

Beliefs Regarding Pain

Sometimes it can be difficult to convince a patient they need to remain active, as they become fearful of moving because they associate it with pain.

In fact, there is a hypothesis where those experiencing low back pain fall into two different classifications: confrontation or avoidance, and this is determined by a persons fear of pain.

Those who confront their pain view it as a nuisance and are quite motivated to get back to normal activities. Whereas those who fall into an avoidance response tend to reduce physical and social activities, have a more prolonged disability and have adverse physical and psychological consequences. There is actually a correlation between avoiding activities because of the expectation of pain rather than actual experience or feeling of pain during activities.

There is even speculation that fear avoidance during an acute episode of low back pain can be a prognostic tool in identifying those who are more prone to developing chronic pain and may be the most important factor in determining the transition from acute to chronic low back pain. 

These fear-avoidance beliefs are even consistent for patients with work-related low back pain and the time it takes for them to get back on the job. Most return within one to two months after injury, but those who take longer are less likely to return to work.

Before I became an RMT, I was an industrial first aid attendant in a sawmill and I can remember having discussions with WCB (workman’s compensation) rep about employees returning to work. He told me their studies had shown if someone went 18 months without returning to work post-injury, they were likely never to return to work (I’m citing this from memory, I have no data to back it up other than remembering a conversation). So, looking back, this conversation makes a lot more sense to me now as many people returning to work were worried they would get reinjured on the job again.

Part of what contributes to fear avoidance beliefs is well…us.

All too often it is the messages patients get from health care providers who still rely strictly on explanations around pain being the result of tissue damage along with structural, anatomical, or biomechanical problems (yes these still play a role but there are other factors to consider as well). This is further reinforced by practitioners who confidently express their methods and services are the only way to relieve pain. 

So, we then have to consider how we can better help our patients with this increasingly common issue. The first step is; reassurance.

Providing Reassurance

As we have been discussing, peoples perception of pain has a massive effect on how they deal with pain.

One study shows that reduced feelings like helplessness, catastrophizing, pain being harmful and disabling, along with increased belief in control over pain can predict positive treatment outcomes.

Unfortunately, a lot of these feelings are due to things people have been told in the past (often by practitioners) that their back is ‘weak from a past injury’ or their pain is a result of genetics, lifestyle, or some other physical trait. These beliefs also bring about concerns they will reinjure or damage their back even more with activity.

There is strong evidence that these views are directly related to interactions with clinicians who also have high levels of fear-avoidance beliefs. Part of the difficulty with this is when patients go see multiple practitioners and are getting a different story from each one, this results in more frustration and an increase in those negative beliefs.

However, if we start to use language and descriptions that reassure and empower the patient, we can start to positively influence their pain beliefs. 

Once red flags are ruled out we can reassure the patient how things should get better over the next few weeks because the symptoms are benign in nature and this issue quite often resolves itself. More importantly, reassure that they do not have a serious disease! Along with this, we should endeavor to offer some level of education to the patient about their pain and how to self manage, otherwise, a dependence on the therapist could develop, where the patient always needs to be taken care of.

We need to start changing the narrative patients are given. 

When someone comes in who has had an x-ray or MRI and is stressed about the results I like to say something to the effect of:

“Don’t let that freak you out too much, if they took an x-ray of me right now it would probably look similar, yet I’m not experiencing any pain, your back is just sensitized right now and we just need to calm it down”.

Or when someone with chronic pain comes in I’ll say something like:

“Since we know pain is a safety and protection mechanism, your tissues have been protected for a long time now, which puts them in a safe place, your chances of re-injury is minimal”.

Now, this isn’t always going to be easy because they could be getting different messages from different practitioners. So, it may take a while to get your message across. But, for that patient who is afraid to sit down because they fear re-injuring their back, this is a good start.

While these are just a couple of examples I have used with people, they are just examples and won’t necessarily work for everyone. We need to tailor our message for each individual according to their beliefs and relationship with pain. We also need to build up our therapeutic relationship with them and provide appropriate homecare to decrease their dependence on us while reinforcing self-efficacy. These patients are wanting to be heard, have a better rapport with their practitioner, be given reassurance and education, so they know they are going to be okay. These are things rarely given by ‘primary care’ practitioners because they are given such a small amount of time with them, so this creates a valuable opportunity for those of us fortunate enough who get to spend on average an hour with each patient. Even though the clinical guidelines on low back pain could not recommend massage therapy, when we look at what they do recommend, Massage Therapist should be at the top of the list.

Leave a comment below with the language you use, or things you say to reassure your patients, we’d love to hear from you.

She Added Massage And That Made Migraines Unbelievably Better

When I was 5 I started suffering from debilitating migraines.  I remember having pain from my waist to my head, wrapping around the side of my face and settling behind one of my eyes. 

Usually I woke up in the middle of the night in severe pain, close to vomiting before I even realized what was going on.  By the time I was 6 I had an EEG to rule out epilepsy, a CT scan to check for an aneurysm and a variety of other tests to find out the source of my pain.  All the tests came back negative and I was told I would “grow out of them.”

Spoiler alert: I didn’t.

In fact I spent about 20 years having some level of pain 24 hours a day.  However, my parents instilled a sense of agency in me very early on.  I understood I was going to have pain, but I wasn’t in danger, and that I had a choice to make.  I quickly learned how to keep living while managing the headaches and pain to be minimally impactful on my life.  I completed a Master’s in Physical Therapy, held a stressful job, and lived an active life.  

The fact is not all headaches are created equal. 

I was eventually diagnosed with chronic daily headache (headache pain more than 15 days a month), migraine without aura and tension-type migraine headaches.  There are too many types of headaches to review in this setting, and the patient should always have serious conditions such as epilepsy or aneurysm ruled out. 

However, the National Headache Foundation is a good informational resource for both you and your patient

Decreased Headache, Increased Sleep Quality With Massage

For most patients with severe migraines, prophylactic medication will be the first line of treatment.  Anti-seizure medication such as Topomax or anti-depressant such as Amitriptyline are the most common.  Some patients will have full resolution of their migraines, but most will have a decrease in frequency or intensity only. 

This was the case with me.  I still had close to 15 days a month with migraines, but minimal intensity and only about 4 migraines a month that required additional pain medication.  For me that was a win, but still meant I was in pain a lot of my life!  This led me to find massage therapy as a treatment.  Massage allowed me to have some days without any pain and decreased intensity on the days I did.  

An interesting thing happens when you have a chronic condition for 37 years.  Medicine tends to shift regarding the “why.”  Migraines used to be contributed to a rapid vasodilation followed by vasoconstriction and treatment was based on blood pressure (prophylactic propranolol) and making sure we avoided this change as much as possible.  Now childhood migraines are attributed to a version of sensory overload and sensory integration issues. 

I had a neurologist tell me I had a “special brain.”  My brain wants to process everything around me, and get a picture of how everything relates to each other and not just what is immediately in front of me.  This causes an overload in environments that are noisy, with lots of lights and smells.  Some kids have behavioral issues; I had migraines.  This idea of equating migraines to a “sensitive” nervous system made me start looking into massage therapy as a management technique to decrease my underlying pain and continue to try to decrease my overall headache days.

The Journal of Headache and Pain published a systematic review of manual therapy and randomized controlled trials in 2014.  The most RCTs were performed on patients with tension type migraines.  The systematic review found manual therapy including massage to be an effective treatment for tension migraines, reducing the headache frequency and intensity better than usual care by the general practitioner.  In a 2011 study, massage therapy was found to reduce pain intensity by 71% compared to the control group.  Massage therapy also improved sleep quality for migraine sufferers.  

So how does massage help with migraines?  Well just like with any massage, it works on the nervous system.  If my migraine is being triggered by upregulation, massage is an excellent intervention to modulate my parasympathetic nervous system.  The benefits of massage range from the actual touch factor, to the patient resting for those moments on the treatment table, to neuromodulation, to improved sleep hygiene, all of which translate into less pain and migraine days.  It’s important for the patient to feel empowered to give feedback regarding depth, strokes and intensity of massage to continue a beneficial and collaborative environment.  If a massage is painful or perceived as damaging, it could increase the patient’s pain.  And please avoid nocebo language! 

It’s important your patient reflect on possible triggers for their migraines and address those as well.  With that being said, life involves unavoidable stimulus and stress.  Massage therapy can help and is a viable and a researched treatment option for patients with chronic migraines. 


Chaibi and Russell: Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. The Journal of Headache and Pain 2014 15:67

Chaibi A  Tuchin P  Russel M: Manual Therapies for Migraine: a systematic review.  The Journal of Headache and Pain 2011: 12: 127-133

Lenssinck ML, Damen L, Verhagen AP, Berger MY, Passchier J, Koes BW (2004) The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain 112(3):381–388

Yancy J  Sheridan R  Koren  K  Chronic Daily Headache: Diagnosis and Management.  American Family Physician  April 2014: 642-648.

Is Pain Really A Math Equation?


In the January 2019, Pain Journal published an article comparing pain to the Bayes rule in math.

PAIN Symptom Perception, placebo effects, and the Bayesian brain. It suggests the brain can follow a theory of probability in math known as the Bayes rule.  In statistics/math, the rule looks at the likelihood of a given hypothesis.  It takes into account prior evidence, current evidence, likelihood probability of other related hypotheses and makes a prediction.  The brain generates a top-down, out of our awareness, neurally encoded hypothesis about the state of us and the world. So cool!

This top-down hypothesis is met by its bottom-up sensory inputAny mismatch between the two results in a “coding error” or “prediction error” and the brain revises it’s hypotheses and prediction rules for next time.  These hypotheses include those built in from evolution and the person’s personal experiences.  Throughout our lifespan, they are constantly changing and updating to help predict the next set up sensory inputs.  The implication of this theory is that we perceive not how the world actually is, but the brain’s best guess of it. This definitely makes sense when we think about visual perception.

In the case of chronic pain, the brain puts a high emphasis on the hypotheses generated by the brain and less precision on the sensory experience.  Slight and otherwise harmless stimulus (or bottom-up experiences) cause the brain to misinterpret these as contributing to the pain and continue to modify the hypothesis to include these.  Individuals without chronic pain would tend to ignore these inputs as “noise.”  Conditions such as anxiety, threat, and catastrophizing have a tendency to worsen symptoms by maintaining vigilance to these predictor hypotheses.  

So how does the Placebo Effect fit into this theory? The Bayesian perspective states relief of symptoms is not necessarily due to restoring bodily function but more about the lack of interference from the bottom into the hypotheses.  As sensory input diminishes the hypothesis again changes.  This change, however, seems to be slower if the patient does not have external cues that the change is happening.  It’s almost like the brain ignores the improvement as “noise” unless there are other cues to say it’s time to revise the hypothesis.  This may be why avoiding nociceptive language AND encouraging our patients that they are RESILIENT and CAN DO their important activities is so important.  Your body is getting better so go ahead and revise your hypothesis!  This may also be why the placebo effect works.  Experiments where the patient was given analgesics in a manner that did not let them know the medications were supposed to help reported significantly less pain relief than those who were told what they were receiving.

I don’t think the article was saying anything we haven’t already approached with pain science.  However, I appreciate this statistical analysis way of looking at it. Maybe it’s because I live in Seattle and there are tons of tech-driven people here, but I feel like I have one more analogy to help my patients.  AND I don’t actually have to calculate any statistics!