15 years of Explaining Pain – where have we been and where are we going?

Neuroscience was clearly my favourite course at uni – I loved it so much I was learning for fun, not for exams. I don’t recall ever studying for a neuroscience exam – it all seemed to magically stick in there – as if there were tailored docking stations in my brain just waiting for their particular neuroscience nugget to lock in. I found it fascinating. At once unbelievably complex and elegantly simple. I loved other subjects too – anything about how humans actually worked – biology, psychology, beerology – but neuroscience turned me on the most.

Fast forward to working in a busy sports and manual therapy practice, and with a chronic pain management programme. This was about twenty years ago. ‘Pain education’ (the gate control theory with some trimmings) had spent some time in the sun but was a bit on the nose because, as Fordyce said, ‘education to behaviour change is like spaghetti to a brick’. The evidence was gathering that ‘back schools’ were at best useless and at worst iatrogenic. The biopsychosocial model was gaining serious traction and multidisciplinary pain management programmes, applying cognitive-behavioural principles, were considered the ‘gold standard’ in chronic pain management. In the midst of all this, the most rewarding clinical experiences I was having involved me carefully explaining to someone, and using my clinical skills to convince them, how we thought the system worked. We could explain, on the basis of solid science, even way back in those times, that even though their pain is brutal, distressing and 100% bona fide real, and it feels like their body is broken and about to explode, crumble or slip out, that there are biological processes that can make that happen. When they would ‘get it’, I could watch as they slowly changed the course of their own rehab in response to their new understanding. It seemed to me at the time that it was the most effective thing I could do. I went searching for the evidence and came up blank. Worse than blank perhaps.

One of my jobs was to conduct exit interviews for people who had completed a ‘gold standard’ CBT-based pain management programme. A very common conversation went like this:

LM: How was the programme?

Participant: It was really very good. The staff are lovely. Jane the physiotherapist makes very nice brownies! I was so proud of Dimos – the way he has improved on the treadmill, and Andy on the stair climbing – he is doing real well…. (pause)………I mean the programme was not really for me, because I have real pain.

In one 6-month period, this startling reflection was volunteered by over 50% of everyone I interviewed! They had just spent 3 – 4 weeks, 8 hours a day, thinking that everyone else in the programme thought they had pain when really they didn’t (because why would they be doing a psychology programme if their pain was real?), and that they themselves were in the programme by mistake because they knew that their pain was completely real. When I suggested that many others felt the same way and questioned why do they think they are alone in having real pain, they would say ‘I know my pain is real because I can feel it’.

These experiences fanned the fire of me wanting people to actually understand how and why they can be in horrible pain yet not in horrible danger. I realized then that my clinically uplifting experiences, which were more or less Explaining Pain, might actually be a useful thing to do, if we could do it really well, even though the literature was not very positive. Or so it seemed. Serendipity would have it that about this time I turned up at a conference to listen to this fellow called Dave Butler. A larrikin for sure. He swore in conference lectures. He wore rather un-physiotherapist clothing. The main things I remember now about that lecture are: it was funny, provocative, sensible, fascinating and unpopular. It was imploring us to consider things above the foramen magnum. I was hooked and inspired.

Dave and I had been on a pretty similar journey so it turned out – he much more accomplished and knowledgeable than I.  So, I set out to become more knowledgeable – going to a five day course with Dave and Louis Gifford and reading my guts out, shouting pain physiologists to lunch, having peppermint tea with pain psychologists and wine with anaesthetists, and two years later I started my first ever randomized controlled trial of Explaining Pain. I trained people up and tricked the control group clinicians into thinking that they were the active group. Assessors were blinded. Patients were blinded to which treatment was actually on trial. The results, on pain and disability, were encouraging. We did more RCTs and some experiments. Once the data were in and clearly positive, I teamed up with Dave to write the book – Explain Pain, now in its second edition.  I had no interest in writing the book before the idea had been properly tested – that seems a bit naughty to me.

Now, over 15 years later, it is time to take stock of what has become a new field – Explaining Pain. In our recent perspectives piece available pre-publication in the Journal of Pain, David and I reflect on the journey that Explaining Pain (EP) has made from pretty humble beginnings to being cited in evidence-based guidelines around the world.  There are top notch research groups on each continent innovating with EP and testing it and YouTube, Twitter and Facebook all have a sprinkling of EP-type things. In our paper, Dave and I describe the theoretical grounding of EP, the common misconceptions of EP, the behavioural evidence to support EP including a systematic review of new literature, the limitations of EP, the rip-offs and the replicas, and the challenges we all face in implementing EP strategies. Finally, we make suggestions for where the field might head next.  In the next few posts, I will cover some of these aspects, drawing heavily on the paper. You could just read the paper instead, by going here 15 Years of Explaining Pain – The Past, Present and Future or downloading the pre-publication PDF.

Read the second part in this series of blog posts here.

About Lorimer Moseley

Professor Lorimer Moseley is a clinical scientist investigating pain in humans. After posts at The University of Oxford, UK, and the University of Sydney, Lorimer was appointed Foundation Professor of Clinical Neuroscience and Chair in Physiotherapy, The Sansom Institute for Health Research at the University of South Australia. He is also Senior Principal Research Fellow at NeuRA and an NHMRC Principal Research Fellow.

He has published 190 papers, four books and numerous book chapters. He has given over 120 keynote or invited presentations at interdisciplinary meetings in 26 countries and has provided professional education in pain sciences to over 9000 medical and health practitioners. He consults to governmental and industry bodies in Europe and North America on pain-related issues. He was awarded the inaugural Ulf Lindblom Award for the outstanding mid-career clinical scientist working in a pain-related field by the International Association for the Study of Pain, was runner-up for the Australian Science Minister’s Prize for Life Sciences, and won the 2013 Marshall & Warren Award from the NHMRC, for the Best Innovative and Potentially Transformative Project.

Link to Lorimer’s published research hereDownloadable PDFs here.

Reference

Moseley, G., & Butler, D. (2015). 15 Years of Explaining Pain – The Past, Present and Future The Journal of Pain DOI: 10.1016/j.jpain.2015.05.005

Comments

  1. I have a couple of questions (1) how do people move to thinking that the information does apply to their pain and not just everyone else? and (2) how *can* you tell how serious the threat of tissue damage is?
    I’ve studied some health psychology at uni and in theory I accept the idea behind EP.
    I experience different types of chronic pain. For example, there’s a bit of lose bone in my knee that moves around, sometimes locking my knee, this leads to painful sensation and the pain seems to accurately mark the movement of the lump. A few years ago a PT said to me that I wasn’t doing any damage walking on my painful knee. I just didn’t believe him! This seems like a useful pain message with longer consequences if ignored.
    On the other hand, I get general myalgia (which high creatine kinase seems to indicate is also related to tissue damage) but this responds quite well to meditation and Distraction. I worry the other way that I block out useful protective messages.
    Once you accept that pain is an interpreted sensation how do you decide whether to respond to perceptions of pain in the moment?

  2. Great work guys. Every day we learn that there is so much more we have to learn. You challenge us to keep the passion going. Every single patient individually that improves when chronic pain is their bedfellow is a bonus- when a lot of them get better you feel like you want to throw a party but then there’s always the next one suffering badly and isn’t responding that pulls you down to earth and grounds you. Promise me you’ll never buy a winery and retire will you!

  3. Lorimer,

    You and David and the EP interventions of the biopsychosocial model have revolutionized my practice, particularly of those in chronic pain but I have also used the educational talking points with “regular orthopedic patients” who aren’t deemed to be chronic. When I take off on this journey and challenge people’s beliefs, I can almost feel their intrigue and “is this guy kidding” type reception of the material. However, with a charismatic attitude and little dose of humor and a shot of evidence, they typic receive it well and almost crave more. For what it’s worth man, thank you. Thank you for seeking out knowledge like you did and developing EP with David. Your work is going to continue to help the medical system save many a people from becoming “hysterics, malingerers, and train wreck cases.” We’ve all felt like we’ve seen him and they are challenging, but they don’t have to be. All we need is a crack in their armour of defensive beliefs and constant thought viruses and I believe that EP and a cognitive behavioral approach will work. My wife rolls her eyes now when I keep talking about pain science, but I guess that’s the mark of an eager clinician with a message to share with the world. I am excited to see what happens with healthcare in the next 15 years as a result of this developing area of research and education.
    Best regards,
    Steve (Seattle, Washington, USA)

  4. Lorimer and David, thanks for the concise and balanced review. It was very inormative and helpful to hear how EP stacks up next to CBT. I for one as I am sure many other rehab providers that dabble in pain have wondered what’s so different about EP when compared to the potpourri of other psych treatments. Hearing in your own words where these other pieces fit or do not fit with EP was the strength, iMHO, of the article in The Journal of Pain. The proliferation of pain techniques that have spawned since EP was first published are in no doubt in debited to your pioneering work even if this is rarely acknowledged. From a research perspective it takes a lot of gall and many years hardwork to try to move humans incrementally forward. I think it is important that as consumers of research we must use this as our starting point when forming our own critical appraisals of another’s work. I will eternally have questions if pain in some cases is ever truly recoverable and to the extent that meaning modulates all or part of this experience. We now know that it is, just how far we can take that we’ll just have to see.
    What i find philosophically curious is how a belief, for example that pain can be modulated by verbally communicated meaning, which existed in some form long before EP, but with advent of a belief bolstered by the authority of research can in turn modulates patients and clinicians to tackle painful problems in new and novel ways never before attempted on this planet. The very fact that this belief may stimulate humans to reach beyond their potential may allow them both to achieve something so far unseen during human history–actively shaping one’s own threat detection system. In other words science may not only be retrospective analysis but a feed forward procces that shapes the very same subjects it attempts to study at the same time–especially in such a plastic species such as human beings. When understood in this light then it makes sense that much of the potential of EP may rest not so much on if it is possible but how well we as a species commit to the very fact that it is.

    Cheers Eric

    To the best of my ability I see my experience as a painting. This painting which sometimes contains both pleasure and aversive sensations (that meets the requirements of what others might describe as pain) are simply colors

  5. LORIMER says:

    These are such lovely comments – I am chuffed indeed. I am more accustomed to getting somewhat hammered on web and social media, so these comments are brilliant. I am grateful you took the time to make them. There is no doubt that we all face serious challenges in deciphering the massive amount of pain-related scientific discovery, getting it across to other people, whether they be patients, carers, clinicians or policy makers, keeping our minds and bellies open to surprising discoveries, and doing all this in a way that stays true to what we value most, deep in our guts. I applaud all of you who are taking on that challenge and I encourage you to take stock every now and then, as Dave and I have in writing this article, because it reveals a shift in our world that is hard to detect on a week by week or month by month basis. The tide is clearly turning and that is because of folk like you. So, keep it up!

  6. Ken Wenz says:

    Great article, great work. What you are doing is very difficult because you are trying to take this huge ingrained rut of misinformation and convince (through educating) people of the truth. All the while fighting the battle of the same misconceptions, bias, secondary and tertiary gain of patients and medical folks. It’s like trying to change peoples political or religious beliefs. It’s solidified, myelinated, a done deal with many patients and health care workers. It must be exhausting. Try as I might I run across the same battle and hopefully help folks by trying to explain pain, and give them references and encouragement to by your books and make the effort to understand. I have had a few patients come into my office with your book in hand. I wish EVERYONE would read and understand it.

    Ken Wenz Reply:

    BTW…I also enjoyed the pre publication piece….great read!!!

  7. Congrats (or “cool grass” as my keyboard wants to autocorrect me) and thank you for all those great talks, of which several I have attended and a couple have been personal: sitting in on an assessment at Fit For Work at least a decade ago, as well as listening to you chatting with Michael Nicholas in the man’s office (feeling like a fraud), and once giving you a ride back from a talk in Canberra several years ago; and most recently at a conference in Terrigal, where yet again I turned to people sitting beside me and said with absolute confidence “you’re going to enjoy this”.
    “Cool grass” on making a difference!

  8. John Barbis says:

    Yo L,

    congratulations on a great 15 years. That Butler guy- I don’t know. He is a bit strange. Kudos to you both making a great contribution to the field. TGD