The way the majority of our healthcare system treats pain is based on a 400 year old paradigm from the French philosopher, mathematician, and scientist Rene Descartes, and is described in his classic picture of a man with his foot by a fire.

According to Descartes, if you put your foot too close to a fire, a message runs up the little tube toward the brain and we feel pain.  The thought process behind this simple model is the basis of most of the treatments for musculoskeletal pain used by health care providers today, no matter what condition they diagnose a patient with (e.g. lower back pain, tennis elbow, plantar fasciitis, etc.) They are looking for the ‘fire’ (the pain generator).

While this model seems to makes sense on the surface, basing treatment on it unfortunately hasn’t resulted in great outcomes. This is evidenced by the rate of chronic pain in America, which has doubled between 1998 (1 in 7 people) and 2014 (1 in 3.5 people) despite using this paradigm more than ever before.

Here is how we currently treat pain according to Descartes’ model, and why it hasn’t worked:

  • ‘Avoid the Fire’ This is the classic fear avoidance model. For example, if bending hurts, are we never going to bend again? This model doesn’t work, because if you continually avoid movement (with the exception of an acute injury) then your pain will actually get worse in the long run. We now know in the vast majority of cases that movement is great for pain, and sometimes pain is actually produced in the rehab process when regaining motion.
  • ‘Put out the Fire’ The modern day analogy is we give drugs, injections, etc. We have never drugged or injected as much as we have done in this country. 99% of the world’s hydrocodone is used in the United States. 90% of the world’s opioids are used in the United States. Epidural steroid injections are also on the rise. Despite our attempts to ‘put out the fire’, pain is going up. The model is flawed.
  • ‘Cut the Tube’ If we cut the tube the message will never get from the fire to the brain. So what do we do? We do surgeries, nerve ablations, etc. If Rene Descartes was correct, spine surgeries should have 100% outcomes, correct? This is not the case. At least 1 in 3 people walk out of back surgery with the exact same pain they had before surgery. It can’t be as simple as cut the disc out and the pain goes away or fuse the spine and the pain goes away. There has to be more to it.

So what do we do, then? First, we need to understand that there is much more to pain than a tube running from a body part to the brain. We have learned more about pain in the past couple decades than we did in the previous thousand years, and research has shown us that the more you know about how pain works the less you actually hurt. Next, we need to classify pain into treatment specific subgroups and treat according to those subgroups. One size-fits all treatment approaches haven’t resulted in a lessening of our pain problem. We need to discourage fear and promote healthy movement. When we get smarter about treating pain the rate of chronic pain will decrease. The more we rely on a 400 year old model the more the rate will continue to increase.

Source: The Webinar ‘Teaching People About Pain’ by Adriaan Louw, PhD, PT, CSMT accessed from