Show and Tell: Education strategies in physiotherapy

June 10, 2019

Note: This blog post is more clinician/health professional oriented but can give you some insight into how and why we do certain things at NPP if you’re just generally interested. If you have any questions feel free to shoot me an email at

Here at Newcastle Performance Physiotherapy we recognize that effective communication and education is the bedrock of good physio treatment. Now, when clinicians and clients think of education they might picture a conversation, a diagram, a lecture, a blog post like this one. These are all useful educational tools, but when it comes to learning about pain I’m going to propose that they’re only half the story. All of those examples would fit more or less in the “tell” category of educational strategies, using words and images to build an improved conceptual understanding of pain or how to manage it.

“Show”, of course, would be the second category of education. This is done by creating actual reference experiences in the clinic or in the gym that reinforce concepts and give concrete examples of what we’re trying to explain. Often it’s most effective to both “show and tell”. We’ll have a client move a certain way, perform an exercise, or perform a manual therapy technique with them to alter their pain while linking it to the various concepts we’re trying to help them understand.

To give a concrete clinical example we can take a few target concepts from Butler and Mosely’s Explain Pain Supercharged and apply them to a patient with a persistently achy and weak shoulder that doesn’t like flexion or abduction. They don’t have an acute traumatic incident and don’t exhibit red flags for serious medical problems.

Target Concept #1 “Pain relies on context”
Show (Example): Pain decreases and range of motion increases with a cue to squeeze a dumbbell, or creating the widest arc possible, or supination + ER, scap retraction/protraction,  or light tactile facilitation around shoulder or scap, or tactile pressure on upper trap/posterior delt/ant delt/pec minor, or closed chain movement instead of open chain, or an external target to reach towards.

Tell (Explanation): Pain can often be produced as a protective response to different movement patterns or contexts. Any of the above examples are not enough to dramatically change the way the structures of the shoulder are loaded, but are often enough of a change in context to reduce the pain output in response to movement. Context can take the form of a whole number of different variables such as load, speed, range of motion, desired movement outcome, locus of focus, expectations, environment, fatigue etc.

Target Concept #2 “We are bioplastic”
Show (Example): Pain decreases and range of motioning increases following sustained isometric contraction or consistent graded exposure to painful movements in the correct doses throughout the session. Any of the tools from target concept #1 can also be used to demonstrate this concept.

Tell (Explanation): If we can find things in the clinic that change your pain and increase your movement, we can begin retraining you to tolerate the movement without the accompanying pain response. Sometimes it can be a matter of moving in a way that is similar to the painful movements but different enough in context, sometimes just gradual exposure to the painful movements is enough. Either way, if we get the dosage right we can retrain the system to no longer perceive those movements(contexts) as threatening or warranting a pain response.

Hopefully that provides some insight into how we can think about the whole clinical experience and how it relates to client education. Unfortunately this blog was all tell, but if you want the showier side of things feel free to come by the clinic!