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Pain Medicine in Medical Curricula

Pain in medical school


“Ninety-six percent of medical schools in the UK and USA, and nearly 80% of medical schools in Europe had no compulsory dedicated teaching in pain medicine”
“On average, the median number of hours of pain content in the entire curriculum was 20 in Canada (2009), 20 in Australia and New Zealand (2018), 13 in the UK (2011), 12 in Europe (2012/2013), and 11 in the USA (2009). Neurophysiology and pharmacology pain topics were given priority by medical schools in all countries.”
Stop and consider, just for a moment, how many hours in total an entire medical school curriculum may consist of… and the vanishingly small % that 11-20 hours may represent…

Link to the paper

Check out the open access article here:

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Pain Education – A future perspective

Since David Butler joined us in le Pub Scientifique Home Brew (May 2020), he set the scene for a new wave in his professional life. A wave that reflect on the previous revolutions in healthcare including education. He made his point clear. Education has been underestimated widely and needs reconsideration on how its been used as a therapeutic tool. We have collected some highlights from Dave’s talk about the missing bit – the educational science and future possibilities in the paineducation field.

Carol Dweck

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Explain Pain – The Final wave


Relive: David Butler

Learning how to learn before we learn.

Has anyone taught you how to learn?

If you agree you, your family, clients are likely to have been victims of a learning experience. And you may have passed on your limited or faulty learning strategies to children, friends and patients. We have probably had learning errors for our lifespan. Is learning increasingly becoming a survival tool in the world of today? E.g. Medical knowledge doubles every around 73 days and half life if knowledge is shrinking. Think of virus research today! (Densen er al. 2011).

Our error with Explain Pain – I told them all how to put the lifejacket on, but did they learned it?

Dr. David Butler

If you see a client twice a week for half an hout that is 0.59% of the week. Sport coach with athletes are estimated at around 1-5%. What happens in the rest of the time? And in the chronic pain clientele, the processes constructing pain and inflammation, and long term medications are likely to affect learning. Educational psychology is one of those areas that rarely been intergrated in healthsciences. There is som much to learn. Start build a frame work or toolbox.

Educational science has broadly two areas. The learning and instruction area is definitely the biggest but a second area, the science of conceptual change is less common but probably most valuable in health. The most fundamental difference is that the conceptual change field focusses on the nature of existing knowledge (Vosniadou, 2017). This is also known as ‘androgogy’ – which refers to methods and principles used in adult education. Pedagogy on the contrary is obviously the better known big brother. Patients will bring their existing knowledge to the clinic too. And especially on health, patients bring a huge amount of experiences, beliefs en knowledge along with them. You can’t blame them. Healthcare providers have shown to be a big resource for common misconceptions too.

What is the ideal learning strategy or technique for adult learners in pain and for their deliverers? We need to address this question if we want to improve it. A philosophy that fits the context is the concept of constructivism which comes from the wider scope of learning theories. The learner is nog a passive recipient of knowledge, that knowledge is constructed by the learner. Therefore Self Regulated Learning seems to provide the ideal framework for paineducation. The Self stand for – you ultimately do it to yourself, its not done to you. The regulation parts are regulations of movements, exercises, cognitions, emotions, time, contexts, etc. Resources before, during and after the learning experience. This is getting seriously the next wave in the paineducation world. More will come soon!

Written by Bart van Buchem

The learner is not a passive recipient of knowledge, that knowledge is constructed by the learner.
David Butler
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The Rollercoaster of Professional Life – still evolving

By David Butler,  November 22, 2016

I wrote the first version of this over 3 years ago and I still get contacted by health professionals who want to discuss their similar rollercoaster journeys. Here’s an update on my ever-evolving roller coaster.


The first wave

When I emerged proudly with my degree in the late 70s, all packed with Maitland style manual therapy, I was convinced I could fix all and sundry and I often opened a clinical conversation with “what can I fix today?” (I feel ill saying it now!) Anyway, it all worked well for a few years but then I noticed that “it” was not delivering the goods so well. Unbelievably some patients dared not get better. Things were feeling professionally grim, career changes were pondered, but then, proud and erect, fresh from New Zealand, Robin McKenzie rode into town, maybe even on a white horse!

The second wave 

Wow – this was it! How silly was I to miss the disc and the novel notion of actually getting people to treat themselves and to give your thumbs a good rest. People started getting better again, my practice was full of lumbar rolls, the “Treat your Own” books and models of discs and I was on a roll too. This McKenzie approach worked wonders for a few years, but then the outcomes began to taper off, some patients wouldn’t improve, some wanted the old fashioned hands on that I had almost given away and a now familiar professional grimness emerged again. What next?

The third wave

I heard about a year-long Maitland post graduate course in South Australia and I reasoned that there must be more to it than I’d first thought, so I signed up for the year. I made it through a bit wounded, but the old “I can fix anything” returned and I went into the outer suburbs of Adelaide to ply my trade, wriggling and cracking joints and doing the new teasing nerves stuff. People got better and complex problems seemed to dissolve. But would you believe it – it happened again – the clinical outcomes tailed off with what I now recognise as centrally sensitised states, overuse syndrome and complex regional pain syndrome. I pondered a career change. Perhaps professional surfing?

The fourth wave

By now (late 80s, early 90s) I was becoming a bit older and wiser and trying to think more deeply about things – so I thought –“stuff the others – I’ll try and work it out myself”. And so I went off on the “neural tension” bandwagon – the idea of the physical health of the nervous system and mobilising nerves. I did some reading, had a few thoughts, stood on the shoulders of a few others and even wrote a couple of books. This was it I thought! Life will be easy from now on as we wriggled and glided and teased nerves from head to toe. Patients flocked in … but the old diminishing outcomes emerged again, even for something I had helped to invent. Grim days – coffee was coming into fashion I pondered becoming a barista and investigated what it would take to become a marriage celebrant.

The fifth mini-wave

I was getting very wary now – the early work of Vladamir Janda was being updated and researched, particularly at the University of Queensland and once obscure bits of anatomy such as transversus abdominis, obturator internus and short neck flexors were now the new targets and the “with it” practitioners had ultrasound machine to view muscles. I went to the courses and gave it a go but my heart wasn’t in it. Waves can be exhausting, and the outcomes were eluding me again, just like my transversus abdominis. I tried the taping stuff too, but like a focus on a single muscle, it just didn’t make enough sense.

I drifted off into the world of pain and neuroscience and am still happily here. No magic, just a lot of hard work using neuroscience to fuel educational and imagery therapy and the good parts of the historic waves I’ve ridden. I thought I may have reached nirvana with the brain, but now I realise that neurones are only 10% of the brain and as the rest is immune cells, so there is long way to go.

I am still on this fifth mini-wave – trying to keep up with the world of brain plasticity, neuroimmunological balances and recent research and concepts of DAMPS (danger associated molecular patterns) and BAMPS (behaviour associated molecular patterns) and even CAMPS (cognitive associate molecular patterns) among others, all identified by Toll Like Receptors which can ratchet up their behaviour and keep enhances immune responses bubbling. It’s infectious science.  But …

Uh oh – a sixth mini-wave beckons

I never thought this would happen, but I peering back at the tissues where I started all those years ago. The brain is so trendy that the scientific and some of the clinical world seemed to forget the rest of the body. I have been trimming my nails in anticipation of a return to the flesh! Not giving up the neuroimmunology of course but things like how can we dance with the different receptors in tissues, deal with the immunocompetence of the meninges, or indeed most tissues, and the simple and undervalued licence to touch is sacrosanct – even if just touching a hand while sharing knowledge. I notice and try and understand the trend towards predictive processing and Bayesian thinking, and find it fascinating but I am a wary old bugger. After all – all the talk was about phenomenology a year or so back but it seems to have gone out of favour. Are some of our colleagues onto their next mini waves

Three thoughts

1. I look around now at the course advertisements in the back of the journals and it seems the new roller coaster is still driven by dry needling, loading joints and lifting weights, someone called Pilates, and now mindfulness has become trendy – even yoga is on the up. No doubt some people are flying with it, and good on them, but not me – I am too war weary to get on the roller coaster again but I am sure there is something in it like there is in everything and if your professional paradigms are wide enough and trending towards biopsychosocial then there is a rational place for everything. The waves are not a loss if you can absorb them.

2. What bugs me is that it took so long to realise that it was I myself who was probably the main variable in outcomes – not the techniques. I am not saying that massaging patients with a wet salmon will help. However the interactional power needs better analysis and understanding and as Pat Wall would say “in the end, if the majority of the outcomes are based on placebo, do not fear, but work out what it was in the placebo which gave the outcome”.

3. But what saddens me is that I now see a rapid and enforced rollercoaster in young therapists just out of college – youngsters with that precious, must be captured mindset of wanting to change the world. Yet increasingly employment is all about the dollar, the speed, the getting patients back and thus treatment processes inevitably based on singular biomedial paradigms. There is no time to work out for themselves what this professional rollercoaster of life is all about. We all need to work it out ourselves in some way. If not – we face professional burnout. I am looking forward to wave 7 soon!

– David Butler

Original post is published on NOIJAM.COM

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Dr. David Butler at Le Pub Home Brew

David Butler

Assoc Professor David Butler, B.Phty, M.App.Sc, EdD

Understanding and Explaining Pain are David’s passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI. David is an Adjunct Associate Professor at the University of South Australia and an Honoured lifetime member of the Australian Physiotherapy Association.

Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley, Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, “Explain Pain Supercharged”. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests.

David Butler will be taking us on the rollercoaster ride of his professional life. You will have an opportunity to interact and ask questions or just sit back, relax and enjoy from the comfort of your own home.

Ever considered how your professional life has evolved? Or where your profession is heading? What were the meaningful interactions, people or publications? 

Is it true that he invented the radial nerve neurodynamic test on the ‘dunny’? Is Explain Pain still a working title for a book that has greatly influenced many professions? Do metaphors hold the answer for stimulating behavioural change for someone in pain?

We will hear how Shiraz has shaped our pain knowledge, nudity has nurtured friendships, and that bushfires might just end it all….(this event was live on 2nd of May 2020)


Butler DS (1991) Mobilisation of the Nervous System, Churchill Livingstone, Melbourne (translated into German, Japanese, Spanish, Korean, Italian, Portuguese)

Butler DS (2000) The Sensitive Nervous System, Noigroup, Adelaide

Butler DS 2005 The Neurodynamics DVD and Handbook, NOI Publications, Adelaide

Butler DS, Moseley GL 2003 Explain Pain Second edition (2013) Noigroup Publications, Adelaide. (Translated into German, Portuguese, Dutch and Spanish)

Moseley GL, Butler DS, Beames, T, Giles T (2012) The Graded Motor Imagery Handbook. NOI publications, Adelaide.

Moseley GL, Butler DS (2015) The Explain Pain Handbook: Protectometer, Noigroup, Adelaide

Moseley GL, Butler DS (2017) Explain Pain Supercharged, Noigroup Adelaide

Articles and chapters:

Simionato R, Stiller K, Butler DS 1988 Neural tension signs in Guillain Barre syndrome: two case reports. Australian Journal of Physiotherapy 34: 257-259

Butler DS 1989 Adverse mechanical tension in the nervous system: a model for assessment and treatment. Australian Journal of Physiotherapy 35: 227-238

Butler DS, Gifford LS 1989 The concept of adverse mechanical tension in the nervous system, Part 1. Testing for ‘dural tension’. Physiotherapy 75: 622-629

Butler DS, Gifford LS 1989 The concept of adverse mechanical tension in the nervous system. Part 2: Examination and Treatment. Physiotherapy 75: 629-636

Graham GJ, Butler DS (1992) Whiplash in Australia: illness or injury? Medical Journal of Australia 157: 429. letter

Butler DS (1994) The Upper Limb Tension Test Revisited. In: Grant R. (ed) Physical Therapy of the Cervical and Thoracic spine 2nd edn. Clinics in Physical Therapy, Churchill Livingstone, New York.

Butler DS, Slater, H (1994) Neural Injury in the Thoracic Spine. A conceptual basis to management. In: Grant R. (ed) Physical Therapy of the Cervical and Thoracic Spine 2nd edn. Clinics in Physical Therapy, Churchill Livingstone, New York.

Shacklock, MO, Butler, DS, Slater, H (1994) The Dynamic Central Nervous System: Structure and Clinical Neurobiomechanics. In Boyling, JD, Palastanga, N, Grieve’s Modern Manual Therapy, 2nd edn, Churchill Livingstone, Edinburgh

Butler DS, Shacklock MO, Slater, H (1994) Treatment of altered nervous system mechanics.  In Boyling, JD, Palastanga, N, Grieve’s Modern Manual Therapy, 2nd edn, Churchill Livingstone, Edinburgh

Slater H, Butler DS, Shacklock MO (1994) The dynamic central nervous system: examination and assessment using tension tests. In Boyling, JD, Palastanga, N, Grieve’s Modern Manual Therapy, 2nd edn, Churchill Livingstone, Edinburgh

Butler DS (1996) Nerve. In: Zachazewski J, Quillen J, Magee, D (eds) Athletic Injuries and Rehabilitation, WB Saunders, Philadelphia

Butler DS, Slater H (1995) Physiological responses to injury: nerve. In: Zuluaga M et al (1995) Sports Physiotherapy, Churchill Livingstone, Melbourne

Gifford LS, Butler DS (1997) The integration of pain sciences into clinical practice. The Journal of Hand Therapy. 10:86-95

Butler DS (1998) Commentary- Adverse mechanical tension in the Nervous system: a model for assessment and treatment. In: Maher C (ed.) Adverse Neural tension reconsidered. Australian Journal of Physiotherapy Monograph No. 3.

Butler DS (1998) Integrating pain sciences into Physiotherapy: wise action for the future. In Gifford LS (ed) Topical Issues in Pain. NOI Press, Falmouth.

Coppieters MW, Butler DS (2001) In defense of neural mobilization.
Journal of Orthopedic and Sports Physical Therapy. 31:520-1

Coppieters MW, Butler DS (2002) In defense of neural mobilization. Part two. Journal of Orthopedic and Sports Physical Therapy 32: 125-126

Nee RJ, Butler DS (2003) Nerves. In Kolt & Snyder-Mackler; Physical Therapies in Sport and Exercise, Harcourt, London

Butler DS 2004 Ongoing low back, leg and thorax troubles, with tennis elbow and headaches. In Jones MA, Rivett DA (eds) Clinical Reasoning for Manual Therapists. Butterworth Heinemann, Edinburgh

Butler DS, Tomberlin J 2006 Nerve.  In: Zachazewski J, Quillen J, Magee, D (eds) Athletic Injuries and Rehabilitation, WB Saunders, Philadelphia

Nee RJ, Butler DS 2006 Management of peripheral neuropathic pain: Integrating neurobiology, neurodynamics and clinical evidence. Physical Therapy in Sport 7: 36-49

Butler DS, Coppieters MW 2007 Neurodynamics in a broader perspective. Manual Therapy 12(1) e7-8

Coppieters MW, Butler DS 2007 Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Manual Therapy 13: 213-221

Wilson D, Williams M, Butler D 2010 Language and the Pain Experience. Physiotherapy Research International 13  DOI: 10.1002/pri.424

Louw A, Diener, I, Butler, DS, Puentedura EJ (2011) The effect of neuroscience education on pain, disability, anxiety and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation  2011: 92: 2041-2056

Louw A, Butler, DS, Diener, I, Puentedura EJ (2012) Preoperative education for lumbar radiculopathy: A survey of US spine surgeons. Int J Spine Surg 6: 130-139

Louw A, Diener, I, Butler, DS, Puentedura EJ (2013) Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiotherapy Theory and Practice  29: 174-194

Louw A, Diener, I, Butler, DS, Puentedura EJ (2013) Development of a perioperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil 92: 446-52

Wallwork SB, Butler DS, Moseley GL (2013) Dizzy people perform no worse at a motor imagery task requiring whole body rotation: a case control comparison. Frontiers of Human Neuroscience. 7: 258

Wallwork, SB, Butler DS, Fulton I, Stewart H, Darmawan I, Moseley GL (2013) Left/right neck rotation judgments are affected by age, gender, handedness and image rotation. Manual Therapy 18:225-230

Bowering KJ, Butler DS, Fulton IJ, Moseley GL (2014)  Motor Imagery in people with a history of back pain, current back pain, both or neither. Clinical Journal of Pain 30: 1070-1075

Wallwork, SB, Butler DS, Wilson DJ, Moseley GL (2015) Are people who do yoga any better at a motor imagery task than those who are not? British Journal of Sports Medicine: 49: 123-127

Von Piekartz H, Wallwork SB, Mohr G, Butler DS, Moseley GL (2014) People with chronic facial pain perform worse than controls at a facial emotion recognition task, but it is not all about the emotion. J Oral Rehabil doi: 10.1111/joor.12249

Moseley GL, Butler DS 2015 15 years of explaining pain. J Pain, 16 (9), 807-813 doi:10.1016/j.pain2015.05005

Breckenridge JD, McAuley JH, Butler DS, Stewart H, Moseley GL, Ginn KA. (2017)

The development of a shoulder specific left/right judgement task: Validity & reliability.

Musculoskelet Sci Pract. 2017 Apr;28:39-45. doi: 10.1016/j.msksp.2017.01.009.

Pate JW, Hush JM, Hancock MJ, Moseley GL, Butler DS, Simons LE, Pacey V.(2018)

A Child’s Concept of Pain: An International Survey of Pediatric Pain Experts.

Children (Basel). 2018 Jan 15;5(1). pii: E12. doi: 10.3390/children5010012