Transforming Chronic Pain Care with Psychologically-Informed Practice

Eric Marquette

Hello and welcome back to the Fall 2025 podcast. I’m Eric, and today, we’re taking a big step deeper into the realm of chronic pain—specifically, what it really means to manage pain from a psychologically-informed perspective. If you caught our last episode, we talked a lot about nerves—how they stretch, get compressed, and respond to stress, right? Well, building on that, today we’re going a bit broader, looking not just at what’s going on with the tissues, but at everything around the pain—what we call the biopsychosocial model.

Eric Marquette

First, a bit of context: about a quarter of patients, 25%, will develop chronic pain, and for roughly 8%, it becomes something that truly impacts their day-to-day functioning. That’s not a small group. And more and more, the research tells us it’s not just the joints or the nerves we have to think about. It’s the psychological factors, the social factors—stuff like anxiety, belief systems, even socioeconomic influences. That means living in a place with fewer resources, or experiencing discrimination, or financial strain, can have a measurable impact on pain and recovery. It’s not just about what’s going on inside the body—sometimes the outside context is just as important.

Eric Marquette

The ICF model illustrates this really well; it’s not linear, it’s a web: health conditions, body functions, environment, personal factors, all linking up. I remember I once saw a patient living in a rural area—a good hour from the nearest physio clinic. This wasn’t just about transportation; it influenced how we set up their care plan. Their context—limited access, time constraints, maybe a bit more isolation—all shaped what we could do, how often, and even their expectations. If you’re only looking at the physical signs, you’re missing half the story.

Eric Marquette

So as therapists, or really just anyone working with people in pain, we’ve got this responsibility to consider all those variables. Social determinants like income and housing matter. Psychological contributors matter. If we don’t pay attention to them, if we just chase symptoms with a single tool, we’re probably leaving a lot on the table in terms of outcomes.

Eric Marquette

Now, when it comes to actually figuring out which patients might have these extra hurdles—the so-called “yellow flags”—the good news is, we’ve got a solid toolkit. There’s the Pain Catastrophizing Scale, which, if you’re not familiar, is a quick way to see how much someone is ruminating on their pain—sort of in a loop, convinced it’ll never get better. Scores above thirty on the PCS are significant and definitely raise my antennae.

Eric Marquette

Then you’ve got the Tampa Scale for Kinesiophobia—that’s all about fear of movement. If someone scores, say, above thirty-seven? That’s moderate fear of moving, meaning we need to look at those beliefs directly. And then there’s the Pain Self-Efficacy Questionnaire, that’s looking at how confident a person feels managing their pain themselves, with forty as a sort of high benchmark.

Eric Marquette

I also want to mention the OSPRO-YF, the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Tool—it’s a bit of a mouthful, but it gives a global overview, which is quite handy for picking up on issues that might slip through otherwise. All of these tools are just conversation starters, really—but they’re essential to get us beyond the surface symptoms.

Eric Marquette

I recall this one case—a patient had a really high PCS score, way up in the forties. And instead of just telling them to soldier on with exercises, I paused and used some open-ended questions from this patient-centered communication framework. Things like, “What worries do you have about becoming more active?” or “How do you cope when pain gets bad?” The difference was almost immediate—they shared a lot about how pain had taken over their decision-making, avoided situations, and even changed their sense of identity. That one conversation shifted our whole plan. Point is, these assessments aren’t just forms; they’re the launch pad for honest, productive discussions.

Eric Marquette

And a quick aside—don’t get boxed in by the numbers. These scores help but it’s that interaction, that genuine back-and-forth about beliefs, concerns, and daily struggles, that gets you to the real work. Sometimes I get a bit over-focused on the cut-off points and have to remind myself, the dialogue is what matters. Anyway, before I get carried away—assessment is much more than data collection. It’s the bridge to patient-centered, meaningful change.

Eric Marquette

So, let’s say you’ve identified some yellow flags or psychosocial challenges. What next? Here’s where Psychologically-Informed Practice—PIP—and Pain Neuroscience Education—PNE—become indispensable. The idea isn’t to just “educate” patients, but to actually help them reframe the way they see and respond to pain.

Eric Marquette

Motivational interviewing is huge here. Instead of prescribing a program, I try to guide the conversation so the patient is empowered to see the change as their own. It's about getting them to talk about why being active could matter, and helping them link day-to-day steps with their real goals. It's never as easy as just, “Go for a walk.” Sometimes, you get resistance—like, “I've tried before and failed.” But you dig into, okay, what worked, what didn't, and tie it back to what they actually value.

Eric Marquette

Another practical piece is graded exercise or graded exposure. It sounds fancy, but really, we’re talking about starting with what a patient can tolerate—say, walking for five minutes at a comfortable pace—and then slowly increasing it, session by session. If they hit the goal, you nudge it up; if they don’t, you hold steady or problem-solve together. I had a patient once who was genuinely afraid of squats—like, convinced it’d blow out their back. We started with a nearly weightless box and lots of reassurance, some structured feedback after each try. Over time, the fear came down, and their confidence went up.

Eric Marquette

Graded motor imagery is another great approach, especially when pain seems out of sync with tissue healing. I remember a woman who’d basically stopped using her left arm after an injury. Through imagery exercises—just picturing movement at first, later progressing to mirror therapy—she gradually built up tolerance. Paired with movement and positive reinforcement, she got from barely moving her arm to doing tasks she’d given up on.

Eric Marquette

Now, PNE—pain neuroscience education—rounds this all out. The core message? Pain isn’t always about harm. That “alarm system” metaphor is powerful. I’ll explain to patients, “Your pain system is just a bit overactive, like a car alarm that goes off with a light breeze.” It’s not about ignoring pain, but re-interpreting what it means. Using language like “hurt does not equal harm” really helps patients move past that fear-avoidance cycle.

Eric Marquette

In fact, there’s strong evidence all this—PIP, PNE, and collaborative approaches—can bring down pain intensity, reduce disability, decrease healthcare use, and, just as important, restore a sense of control. It’s not about waving away structural causes, but about zooming out, seeing the bigger picture, and working together for sustainable improvement.

Eric Marquette

Alright, that’s gonna wrap us up for today’s journey into psychologically-informed pain care. If this sparked any questions or you want a deeper dive, well, stay tuned—there’s plenty more ground to cover as we keep bridging the gap between the evidence and real-world, compassionate care. Thanks for listening!