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Back (Pain) to the Drawing Board: Pain Education as a Treatment—A Chat with Lorimer Moseley

4 March 2019

PRF Interviews


Lorimer Moseley, PhD, is professor of clinical neurosciences and chair in physiotherapy at the University of South Australia, Adelaide. A pain scientist with a background in physiotherapy, neuroscience, and psychophysiology, Moseley’s research group examines the role of the mind and the brain in chronic pain. Moseley is also passionate about pain education and care in rural communities. He spoke recently with Lincoln Tracy, a research fellow from Monash University, Melbourne, Australia, to discuss the causes of back pain, the need to incorporate pain education into the treatment of back pain, the Pain Revolution, and more. Below is an edited transcript of their conversation.


What causes back pain, and what makes it such a complex problem?


The first part—what causes back pain—is a very important question, and I wish I could give you a better answer. As a community of researchers, clinicians, and sufferers, we have identified a few factors that clearly seem to cause back pain. The most obvious ones are different types of tissue injury—fractures and bruises and joint sprains, for example, but there are many cases of back pain that don’t seem to involve a specific injury. What’s more, even when there is a specific event, it is very difficult indeed to know what, if any, tissue injury occurred.


The second part—what makes back pain such a complex problem—is the more challenging question. Back pain is complex in part because it is so important to protect the tissues of our back—they do, after all, protect the spinal cord. From my understanding of pain, any credible evidence that the back is in danger is capable of contributing to back pain. There are factors from every aspect of our lives that might provide this credible evidence that our back needs protecting—what you’ve ever learned in life, the expectations that you have, the relationships you have with people you do or don’t like, the way your nervous system and immune systems work, right down to how individual cells and genes in your body act. For me, it is mind-blowingly complex—both intimidatingly and excitingly so.


We have established a treatment community around treating back pain that, to a certain extent, has become part of the problem. The way in which we treat patients, the way in which patients are financially reimbursed for certain treatments, the way we as clinicians are reimbursed, the policies the government has in place—all of these aspects of the treatment community add to the complex nature of back pain.


What are the current treatments for back pain, and what are their limitations?


Whatever model a practitioner uses to describe pain typically directs the treatments a patient receives. Physiotherapists may believe that there is a problem with the back tissue. Consequently, they will often seek to change the way someone moves—to change strength, endurance, or skill level—in order to reduce whatever problem they believe is resulting in pain.


Then you have other clinicians who excel in putting nerves to sleep through injections. These clinicians believe that warning signals from a “danger detector” cause a person’s back pain. They attempt to turn the danger detector off by injecting anesthetic into the area or burning the nerve they believe is sending these danger messages. Psychologists will have a different model, and therefore a different treatment. A psychologist may believe that a person’s back pain results from the way in which that person thinks or behaves. Consequently, the psychologist may deliver treatments that get people to change the way they think about their pain or how they act when they have pain. A sociologist might attribute pain to lifestyle or sociodemographic factors, such as where you live, and will therefore try to address those things.


I am currently one of those people who believe that our understanding of pain, of what it is and how it works, also contributes to back pain. As a clinician, my most effective treatments have always been those in which the client gains a more accurate understanding of their problem, particularly of the idea that pain is a protective feeling and that our pain system learns over time. Not surprisingly, I have worked hard to learn how we can give people this understanding. The more I know about the system, the more impressed I am by the irresistible force of healing, by the irresistible compulsion of our system to learn. Obviously, I become more compelled to be a better teacher. I know I have a long way to go.


The range of available treatments, and the fact that so many of them don’t seem very good, reflects our naïveté about the true complexity of back pain, but perhaps also about the person. In reality, all of these treatments may play a role, but some treatments may play a role for more individuals than other treatments may. There is limited evidence to support any one treatment for a group of patients with back pain. Most of the treatments I mentioned before are, on average, a little bit effective. What we need to do is work out which treatments work for whom, and how we can combine these treatments to create a more effective approach for each individual. For me, the most important thing is to make sure that a solid understanding of biology and neuroscience informs the modern treatments we use for back pain.


So you advocate for pain education as a treatment. How is this different from other treatment approaches?


For 25 years, we have known that there are good ways, and bad ways, to treat back pain. There have been ongoing recommendations from leading back pain researchers for a greater focus on pain education. Most clinicians are not aware of what pain education means, or how we can use pain education as a treatment. It drives me nuts. In my opinion, we misunderstand education simply as providing information, regardless of how we provide it. In the waiting room of any general practitioner or physiotherapist, there are a whole lot of brochures that patients can read. However, we know that more often than not people do not read these, and when they do read a brochure, they often do not take in the information. It is almost as if the brochures are designed to put people to sleep rather than to engage with patients. I know that my own approach to education has been primitive and naïve, and I am working hard to improve it—I remain committed to this because I see, time and time again, that when people understand what pain science currently says about pain, they make better decisions about their health. The challenge we all face is how to give everyone this understanding.


We know that greater engagement helps with being able to learn the content. There is a large amount of knowledge on how we can effect conceptual change for people. Yet, remarkably, this body of knowledge has hardly been incorporated into healthcare in general, let alone pain care. In the recent call to action from world experts on back pain, all of whom I have a great deal of respect for, and some of whom I have collaborated with, it just seemed to repeat what was said in the previous call to action. The idea of education is great, but we haven’t really got stuck into it very well.


The call to action promotes the idea of the need to get patients with back pain moving and to consider psychological therapy. While these are good things to do, I would be confident in saying that most clinicians, and patients for that matter, would have no idea why you would go out and exercise and start psychological therapy when you have hurt your back. They view pain as a marker of tissue damage, so why would you do something that hurts, or change what you think? It makes no sense. This is a very common situation. Clinicians and patients alike are not going to use contemporary care unless they understand the research and rationale behind it.


How can we implement the education approach for treatment of back pain?


There has been a lot of change in a small portion of the community with regard to this. There has definitely been some recognition of better ways to provide an understanding of contemporary science, and there have been changes in clinical guidelines that reflect this. At the end of the day, guidelines are never going to change practice. I have given a lot of thought to these issues and, for a long time, have been trying to push the integration of contemporary pain science education with pain care, primarily through organizations or society bodies with a prime interest in delivering treatments to patients.


We need to get to the grassroots—the public. By reaching out to the public, with humility, respect, and collaborative intent, we can change their understanding and expectations of what happens with back pain and their expectations toward providers and treatment. In the past, I have described this as a whole-community approach. There are many barriers to it, but it is time we faced reality on this one. If we collaborate with people and/or organizations, such as insurers and governments, who have real skin in the game—who are losing money because of back pain—then we can use their massive resources to help get the education message out there. Adding this bottom-up approach component will pair nicely with the top-down component.


It was fantastic that 2018 was the International Association for the Study of Pain Global Year for Excellence in Pain Education. This was a fabulous initiative, and congratulations to all who were involved in it. I place great importance on the bottom-up—the grassroots—approach. That is where my focus is.


Is this bottom-up approach what led you to establish the Pain Revolution, which aims to change how people understand pain in rural and regional communities in Australia?


Yes, the Pain Revolution is one example of this approach. The Pain Revolution is an exciting strategy that has worked incredibly well so far, and I believe it is a model that we can keep building on. What makes this approach different is that we try to embed understanding and knowledge within local communities, with the goal that the public will use this knowledge to seek out high-value care, rather than low-value or potentially risky care. Our vision is that every Australian will have the knowledge, skills, and local support to prevent and overcome persistent pain, and we seek to give people resources to master their own pain, and to give clinicians the resources to deliver high-value care.


The problem of persistent pain affects rural and regional Australia to a much greater extent than in metropolitan areas, and that is where the focus of the Pain Revolution lies. In each community, we aim to identify local clinicians whom we can train and mentor in pain education. These local educators can then engage and deliver this education to the public through existing relationships—through knitting clubs, surfing clubs, shooting clubs, or whatever aspect of the community where these relationships exist. It is a very new program; at this stage the main markers of its success revolve around feedback and some limited quantitative data coming in from these communities. In the longer term, we will be able to look at things like surgery rates and prescribing patterns.


The Pain Revolution engages with the public in rather unique ways, doesn’t it?


A weeklong outreach tour is our flagship event, and we have designed it as a highly strategic project. We aim to tick off the characteristics of a successful community engagement event—create a stir, get media attention, and do something novel. The Pain Revolution Rural Outreach Tour brings together a group of 25 pain experts who participate in a rural cycling tour. Each year we cover about 850 kilometers. We stop in a number of rural towns, and provide free seminars on pain to the public and local healthcare professionals. This attracts attention from the local radio stations and newspapers, which means that most people in town have heard about the Pain Revolution by the time we leave. Our main initiative, however, is the Local Pain Educator program, which is a scalable and, critically, a sustainable strategy.


To date, I think that the Pain Revolution has been very successful. We have received emails from a number of general practitioners from the towns we have visited telling us that their patients have been asking about the Pain Revolution. This is fantastic, because then we can link the GP with the local pain educator in the community. The Pain Revolution is entirely not-for-profit, and we are running on a shoestring budget—most of our work is done by volunteers, and all of it is done by truly dedicated and passionate people. Financially, we rely heavily on donations for our cyclists on the tour, although as the effects are appearing, we are getting government and industry support. Other countries have the same issues, and we are talking internationally with people who want to replicate the model. Who knows—in 2020, maybe we can have a Pain Revolution Tour from Paris to Amsterdam for the next IASP World Congress?!?


What questions should people with back pain be asking of their GP or physiotherapist?


First, they need to realize that they are not alone—they are not the Lone Ranger. We have a website called tamethebeast.org, and it emphasizes the three questions that we think consumers should be asking their healthcare professional. The first is, How do I know my pain system is being overprotective? The second question is, What can I do to retrain my pain system to be less protective? And finally, the third question is, Am I safe to move even if it hurts? Our research shows that the answers to these three questions are the most pivotal aspect of patients turning their journey around. It is important to remember that this is a journey; there are no quick fixes. The challenge that we have is getting to enough clinicians so that when patients ask these questions, they are met with answers rather than blank stares.


How far do you think pain education has come over your career, and how much work is still left to do?


That is a great question, but I do not know the answer. My immediate response is to say that we have come a long way. Yet I am not sure what the endpoint is. What I would love to see is that when people have an acute experience of pain, they have a healthy respect for the irresistible force of healing, the great ability of our pain system to protect us, and the incredible capacity of this system to learn and recover. If people across the world can have that as a grounding when they are in pain, then we will not need people to be educated because they will already have an accurate understanding.


It is important to keep in mind that the field has only been trying to explain pain biology—really explaining it in a fun and engaging way—for 20 years. With time, we will continue to get better at explaining it. If we can continue working on this, then eventually most patients will be able to see a clinician who has a good understanding of modern pain science and the ability to transfer this knowledge to their patients. Once we get to this point, pain education will be much more effective, and the outcomes for patients will improve dramatically. I do not know how exactly we get to that point. I just want to keep working on the disconnect between what we pain researchers know and what people who are not pain researchers think when they are in pain.


Lincoln Tracy is a research fellow at Monash University in Melbourne, Australia.

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