What can Drake teach us about bottoms-up and top-down approach?

In the world of rehabilitation and health care, pain has often been quantified through the bottoms-up approach. With the bottoms-up approach, we see pain as being processed from a potential stimulus. This is where we usually put the blame on a specific tissue/s. When we look at it from this lens, pain is driven by a stimulus. The greater your pain is, the greater the stimulus that triggered it. While that approach holds a lot of merits especially when there is a clear mechanism of injury…there is a lot of interplay with the nervous system that can rightfully change the output. Now, this is where Drake comes in.


Drake has had his share of heartbreaks, ex-es, hard days and long nights. In recent news, he’s found out that Kiki didn’t love him, and she wasn’t riding. He’s always suffered and it’s evident:

“You’re still the one that I adore, ain’t much out there to have feelings for.”
-Drake, Own It

“I know you still think about the times that we had.”
-Drake, Marvin’s Room

“You could have my heart or we can share it like the last slice.”
-Drake, Best I Ever Had

You may be wondering, how the hell does this go about helping me understand pain science? Let’s say Drake pulled up to the club with OVO. He’s chillin’, sippin’ some champagne and then someone catches his eyes. This woman is drop dead gorgeous and he has no choice, he approaches her. He buys her a drink and they’re hitting it off until she gently caressed his arms. To an ordinary individual, this would be fine…in fact in the bottoms-up approach, we can’t possibly see this stimulus providing any discomfort. Then it happens…


In split seconds, the nervous system begins to process the stimuli. Drake’s somatosensory cortex activates which processes light touch as well as the location of the stimulus. This sensation feels oddly familiar the nervous system thought as the hippocampus began to light up which is where your long-term memory is stored.2,3,4 “This touch…it feels like Nikki…wait more like Rihanna…or was it Keisha?”. These memories are bringing back emotions which are brought on from our amygdala and insula.1,2,3,4 As all of this is happening so fast, our pre-frontal cortex, anterior cingulate gyrus and other parts of our brain take in all the contextual factors.2,3,4 The nervous system realizes that we are in potential danger to be heartbroken once again. The brain sends an output of heartache and Drake retracts his arms thinking to himself…

“Bad things
It’s a lot of bad things
That they wishin and wishin’ and wishin’ and wishin'”
-Drake, God’s Plan

That my friends…that’s the top-down approach. This helps us explain what Drake already understands. That sometimes…there might not be any real danger but there can still be pain. That sometimes non-threatening stimulus can be perceived as threatening depending on the context. We need to take the whole individual into consideration and begin addressing some of the different factors that come into play which can heighten the output whether its emotions, false beliefs, misconceptions, coping strategies, self-efficacy, thought viruses, etc.1,2,3,4

Image result for top down vs bottom up processing pain scienceThere are people who are terrified of training after they had a minor set back or experienced some soreness following a session. They’ll completely stop the activity altogether without seeing a knowledgeable health care practitioner to rule out anything that could be of potential danger(very unlikely in this case of training). They’ll remember all their friends telling them how deadlifts can “break” their back or maybe squatting past their knees will leave them crippled. All these false beliefs, misconceptions, and previous experiences can influence the output of the nervous system. If your body feels like it’s in danger, it’s going to let you know even if there isn’t anything inherently harmful happening…such as when you’re performing deadlifts or squats.

Sometimes friends, families, and clinicians don’t give great advice about training especially if they haven’t read past an abstract on a paper or have any formal knowledge on strength and conditioning. Remember a wise man once said:

“Should I listen to everybody or myself?
Cause myself just told myself
You’re motherfuckin’ man
You don’t need no help.”


1.) Sawamoto N, Honda M, Okada T, et al. Expectation of Pain Enhances Responses to Nonpainful Somatosensory Stimulation in the Anterior Cingulate Cortex and Parietal Operculum/Posterior Insula: an Event-Related Functional Magnetic Resonance Imaging Study. The Journal of Neuroscience. 2000;20(19):7438-7445. doi:10.1523/jneurosci.20-19-07438.2000.

2.) Pelletier R, Higgins J, Bourbonnais D. Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders. 2015;16(1). doi:10.1186/s12891-015-0480-y.

3.) Lumley MA, Cohen JL, Borszcz GS, et al. Pain and emotion: a biopsychosocial review of recent research. Journal of Clinical Psychology. 2011;67(9):942-968. doi:10.1002/jclp.20816.

4.) Butler DS, Moseley GL, Sunyata. Explain Pain. Adelaide, South Australia: Noigroup Publications; 2013.

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