FC2O Episode 21 – Dr Nick Penney Show Notes

Dr Nick Penney

3:04. Introduction

  • 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?

  • Increases breadth

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:

  1. Apprenticeship
  2. Application
  3. Attention
  4. Awareness
  5. Acceptance
  6. 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”

29:55. Application:

  • Working within the limits
  • The body saying “this is enough”, rather than “this is damaged”

31:27. Attention

  • The Salience Network (The pain neuromatrix)
  • Is paying attention to the pain helpful?
  • Threat to survival can àthe pain being dropped to zero
    • Warfare
    • Sharkbite

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
    • Distr-Action Techniques
  • 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

52:40. Awareness

  • 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!

58:47. Acceptance.

  • 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

1:02:22

  • 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
    • Gut sensation
  • 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 www.drnickpenney.com


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 link.

*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.