Pain and the brain: Closing the gap between modern pain science and clinical practice

Pain scientists have been urging clinicians for decades to ditch the traditional biomedical approach and adopt a multidisciplinary and multimodal methodology to chronic pain treatment.

This latter approach considers the biological, psychological and social factors that affect the patient's perception of danger. Evidence-based treatment includes a combination of pharmacological and non-pharmacological techniques, including pain education, physiotherapy management and mental health support.

"We have developed a four-steps process that brings together all these ideas (drawn from modern pain science)," says Professor Benedict Wand, a pain scientist at the University of Notre Dame.

The first, fundamental step of this process, he says, is modern pain neurobiology education, which helps people gain a less threatening understanding of pain.

The second step is helping the person feel safe to move, while the third step includes an active progressive rehabilitation that gradually loads the body so that movement continues to feel safe. Lastly, the focus shifts towards making the body stronger.

The biomedical model in which most health professionals in Australia have been trained describes pain as a direct consequence of tissue damage - the more severe an injury, the stronger the pain. In this model, pain provides an accurate measure of the state of the tissues, and it can be 'fixed' by providing pain relief.

"We originally thought that pain was a simple readout of noxious information from the body," says Wand. "But that is certainly not the process that underpins complex and long-standing pain experiences."

Decades of research in pain science have led scientists to believe that the level of pain is not an indication of the level of tissue damage. Instead, scientists have discovered that pain is a vital mechanism that happens in the brain (and not in the tissues) to protect us from more severe injuries.

When we get hurt, pain receptors send a "possible threat" signal to the brain, which then evaluates the danger of the threat by drawing information from current and past experiences and the state of the mind.

If the brain does not perceive the circumstance as dangerous, it will not cause pain. If we are anxious or frightened, our brain might perceive the situation as dangerous and produce pain to protect us.

"An interaction between incoming information from the world around you and held information - things that you already think and feel and believe - gives rise to an experience of pain when you judge your body to be under threat or needing protection," says Wand.

In one study, scientists placed an ice-cold rod on the back of volunteers' hands while showing them either a red or blue light. The rod was at the same temperature each time, but those who were shown the red light, which in our imagery represents danger, reported more intense pain than those who saw the blue light.

In another experiment, volunteers put their heads inside what they thought was a "head stimulator". In front of them, researchers manoeuvred an "intensity knob". The volunteers reported levels of pain that correlated with the intensity on the knob, although the stimulator was doing nothing at all.

These studies suggest that pain is not a response to real danger or physical damage but to perceived danger, says Professor Lorimer Moseley, a pain scientist at the University of South Australia. Consequently, psychosocial factors that alter our perception of threat play a crucial role in the level of pain we experience.

When pain becomes chronic, it is less about physical damage and more about a pain system that has become excessively protective. A physical cause of the pain might never be found in scans, yet the pain people feel is real, says Moseley.

While lack of access to multidisciplinary pain services is a countrywide issue, rural and regional areas are severely underserved.

Pain Revolution is an organisation set up to close the gap between modern pain science and clinical practice in rural and regional communities. The organisation has established a Local Pain Educator Program that trains rural and regional GPs and health professionals in modern pain science and management. In turn, they support their communities by providing pain education to the public.

With another project called the Local Pain Collectives, Pain Revolution helps rural and regional health professionals establish community-based, interdisciplinary networks to build their skills in contemporary pain education and management.

"Two essential ingredients for recovery from persistent pain are learning and movement," says Moseley, who is also CEO of Pain Revolution. "There is very strong evidence that movement is medicine. Our muscles, bones, ligaments, skin, tendons - you name it - love movement."

To support its work, Pain Revolution has launched a virtual challenge to raise funds called Go the Distance.

"Go the Distance is challenging everyone to learn a bit more about pain and get moving, and walking, running and cycling are three easy ways to do it," says Moseley.

The initiative has replaced the annual Rural Outreach Tour, which had previously been the major Pain Revolution fundraiser. "Like many events in 2021, COVID has meant that we had to find an alternative to the tour," says Moseley.

The initiative will be held in October, and it challenges participants to walk, run or ride as far as possible to support people who suffer from chronic pain and often don't receive medical care that is based on the latest scientific evidence.

If you want to help, support Manuela Callari, who has taken the challenge, by donating here. If you want to sign up as an individual, or join a team, go to painrevolution.raisely.com.