Welcome back to the Healing Pain Podcast with Lorimer Moseley

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Welcome to the Pain Science Education Podcast, where we discuss ways to treat and reverse persistent pain. I’m your host, Dr. Joe Tatta, a licensed physical therapist and founder of the Integrative Pain Science Institute, where we train practitioners on whole person pain care. This podcast also serves as a public health campaign to support those living with chronic pain. This podcast is for informational purposes only, and it’s not intended to be a substitute for professional medical advice. Hey there, friends. Welcome to this week’s episode of the Pain Science Education Podcast. On today’s episode, we speak with globally renowned pain researcher, Professor Lorimer Moseley. Lorimer is a clinician, a scientist and educator whose research investigates the role of the brain and the mind in chronic pain. He’s a professor of clinical neurosciences and a foundation chair in physiotherapy at the University of South Australia. He has authored over 400 research articles and seven books on pain. He also leads a nonprofit organization called Pain Revolution, which you can learn more about by going to the website PainRevolution.org. On today’s episode, we discuss new ways a clinician can deliver pain science education and how impactful this approach can be for people living with pain. A special note before we begin today, Professor Moseley will be presenting a live course in my hometown of New York City called Pain Science in Practice. The course will take place on October 12th and 13th. Please make sure to log on and check that out. I’ll be in attendance for the weekend’s festivities. So if you’re attending, please stop by and say hello. OK, without further ado, let’s begin about the new science of pain science education with Professor Lorimer Moseley. Hey there, Lorimer. Thanks for joining me this week on the podcast. Can I join? Pleasure. Excited to talk to you about pain science, pain research, pain educational, great things, pain that you’ve been involved in for quite some time. Gave you a good introduction to today’s episode earlier. Of course, many of the physical therapy and physiotherapy professionals know you, but we also have people who follow the podcast who are other health professionals or people with pain themselves, just give them an idea of how long you’ve been studying pain for, explaining pain, and really kind of what keeps you, you know, fired up and engaged with this type of work.

You ask that question with the slight implication that I’m old. And as you were asking, I was thinking, I can’t be old enough to get questions like that just yet. So I became a physiotherapist in 1992. I started working as one in 1993. It took me a year to get started. I drove trucks for a while instead. I played in a band instead, but then eventually I ran out of money. So I was a physiotherapist working clinically for eight years and then I started a PhD. So since about 2003, I’ve been in a combined role of treating people with chronic pain and researching chronic pain. from a sort of neuroscience and how does the brain make pain? Why does the brain make pain when it doesn’t seem to be serving any useful purpose and that sort of stuff? So I guess that’s in different roles up to 30 years. I’ve been doing the stuff. I think another part of your question was sort of broadly, why do I do it? Would that be fair to summarize like that?

You wear lots of different hats at this point.

Challenges in Pain Education

Yeah, I do. I guess I’ve I’ve always been an explorer, and it’s an extraordinary privilege to live in this time and place in which I can get paid to explore the human experience. And I think that that interaction between being an explorer and finding humans is probably the most fascinating of the things that I’ve ever come across. I find myself quite fascinating, I don’t know if that’s quasi-narcissistic or something, but we’re such complex organisms and so adaptable and efficient at protecting ourselves and I think My fascination with humans, my natural sort of explorer self, my lived experience of having brutal disabling pain for years, all of those things combined and still give me the oomph, you know, they still give me the fire in the belly because I’m gobsmacked. Do you have that word, Joe? Gobsmacked? Now we do. Here and now. You do now? So gob is mouth and smacked is like you’ve been smacked in the mouth. I’m very, very surprised still at the challenge that faces so many people with chronic pain to access contemporary information and understanding. Our research in the last few years has really fired me up more than ever with the potential power of understanding and how bad we’ve been as health professionals conveying that understanding. And when I say we, I genuinely mean me. I’ve been a significant part of the pain education movement and I wasn’t very good at it. But I thought I was. And now that we’re actually getting quite good at it, the contrast in what we’re doing and the outcomes is cool. Anyway, how’s that? A summary for those who have never heard of me, the many, many people who have never heard of me. I’m a pain scientist, educator, clinician. Yeah, there you go.

Yeah, I think it’s, you know, I appreciate the, I think as professionals, we’re, you know, deeply involved in these circles where obviously we’re looking at, you know, neuroscience, pain science, psychology, physical therapy, exercise, health and wellness. And, you know, we’re kind of stacking up all the resources, as they say. But then you go out into the community or that one patient walks in the door to your clinic, um, who doesn’t have maybe, you know, um, a bit of this information and you realize that there really are almost like these two different worlds going out there. But as professionals, we have to be really good at straddling those two worlds, which can, as you, as you mentioned, it can be really tough actually. And these are not skills that you necessarily perfect in a 12 hour weekend course. Right.

Oh, for sure. Yeah. I mean, you would have insight into the complexity more than most, Joe, because you talk to people who have these sort of pointy ends of expertise all the time. And, you know, when you’re at the pointy end of anything, you only see the edge of your bell curve, right? So you get this illusion that you’re in the middle of the bell curve where Whereas you really, you know, you’re obscure in some, it’s not you personally, like people like me, sometimes we’re a bit more obscure than we might like to think because we hang around with people who find the same things interesting and have similar values. But I think your observation that, you know, sometimes we’re having to straddle two worlds is a really astute observation. And I guess I would add the other world is heaps bigger. It’s still heaps bigger than the world that we’re comfortable in, where we all understand what we mean by nociception or even what we mean by fear avoidance or catastrophizing. A good friend of mine used to be in medical advertising and for part of his training, he looked at the average vocabulary for people with and without health training. And on average, the people with health training have 10,000 more words that people without health training have. And we tend to forget that, right? That’s quite profound, don’t you think? There’s a lot of words that we throw in there without realizing.

It is. I mean, I think, you know, pain literacy is someone’s pain literacy. Obviously, pain education is supporting someone’s pain literacy. But, you know, look, in the United States, America is a quite large country with a lot of people. You know, we have over 350 million people here. And the literacy is, you know, it spans different states and different geographies. And, you know, I find professionals have to learn how to take something like ExplainPain, learn it themselves, of course, so that they kind of have a deep, you know, learning and change. But then, how do you kind of take that and start to craft that for, let’s say, a population of people who live in Tennessee, for example, where there are lower rates of pain literacy and there’s also, you know, a growing opioid epidemic, so to speak. But they’re all really, you know, I know this is most of your work revolves around. I’m curious, I guess, as we’re kind of talking about this. Where on your journey did you kind of go from, all right, I’ve studied pain for a while. Um, empirically I have created this course called explain pain and books and resources for obviously, um, professionals, but people as well. When did the straddle come to say, okay, let’s go into the community and try to deliver this in a 90 minute, um, you know, lecture to groups of, you know, 10 to a hundred people, so to speak.

Yeah. Can I change the question slightly?

Yeah.

Just the last bit, I guess. We’re not sure on the format, really, but maybe I’ll get to that by answering the question. Look, I think the first two components of that triad were developing together for me. As a clinician, as a clinical physiotherapist for seven or eight years, I was very self-driven towards understanding biology, and at uni, like college, I think you guys would call it, the biology, the neuroscience, those sort of subjects, they came very easily to me. I never felt like I was studying. I just felt like I was on this exciting journey. I didn’t read novels growing up, but already by sort of year 11, so I was a sort of 15, 16 year old, I was fascinated by biology. I was reading Charles Darwin and Oliver Sacks and stuff like that. And I think, so I’ve always been fascinated by that sort of experimental, the science of consciousness and the science of the human and how we work. My first career was sport and applying some of that magic of adaptation and neuromotor stuff was just really turned me on, like almost in a weird kind of way. not oddly, not sexual or anything, but I really found it so fascinating. So when I started my PhD, my PhD continued that theme. As a clinician, as a physiotherapist working in a chronic pain program, I really found myself thinking, I’ve got nothing for you guys. I, The skills I had did not match very well the biological training I had, even within the same degree. I’d spend time in the bio and the neuro and all that sort of stuff, fascinated, oh, we’re amazing organisms. And this is while I’ve got my own roaring back pain, leg pain, significant challenge to live with, getting excited by the biosciences and getting depressed by the clinical training. That sort of penetrated when I was working in the chronic pain clinic. And I ended up clinically saying to patients, look, I don’t think I’ve got anything much that can help you. And this is why. And I would explain to them why I thought the heroin pain, it was based on biological sciences. And then that would start coming back saying, oh, yeah, look, let’s just keep doing what we were doing last time. I’m feeling a bit better for the first time and I’ve tried this. And it was very interesting to me. And that’s when I decided, well, let’s I’ll test this. This is real. Right. So I think that’s really important that there were three clinical trials before Explained Pain, the book, was ever written or any courses were developed or anything like that. So I feel like that’s something that is really important to know. And I feel really, really satisfied with that pathway. When I started my PhD, I got into the experimental stuff alongside clinical trials. So I sort of almost straddled, at that time, the science and the education around the science. So they’ve developed in tandem. I had research positions looking at brain imaging, neurophysiology, recording. physiological signals and manipulating them with experiments and collaborating closely with people doing experiments on different kinds of animals and stuff like that. So that was going alongside my clinical, how do we get this across? It was always the same thing. How do we, how do we empower people with this knowledge? I just didn’t, you know, I didn’t immerse myself in educational and conceptual change science. I just started with fingers up, being a quotation mark, educating people. But really what I was doing was, as you say, explaining stuff. And that was the most effective tool I had in my toolbox. But now looking back, it was really naive how I went about that. So since my doctorate, I’ve stayed doing that. We just finished a round of studies on cognitive flexibility, which I now think is not really a thing we understand very well at all. You know, I was very interested in that idea. I’m very interested in theoretical neuroscience and modeling how the brain might do stuff. So, you know, they’re sort of still developing alongside each other, I think.

Realizing the Need for Better Skills to Manage Pain

I appreciate you saying that, you know, well, from what I heard is almost like this watershed moment in your career where you’re like, I don’t think I have enough skills to help these people. And, you know, I think that’s a, that happened to me also after training for many, many years. I don’t know if it takes many years to get to that point or maybe some people get there quite earlier. But I actually think that’s a good place for physios to get to on their journey, I think, to understanding psychologically informed care on a different level, I would say.

Yeah, I agree, Joe. And maybe you and I were a bit slow on the uptake, but I do think there was something, a pattern that I that I’m observing, and I’m the first to say our observations reflect in part our expectations, but I don’t have any empirical evidence to support my next statement, which is it seems like physiotherapists and other health professional groups are realizing this earlier than I did. And that is slowly becoming earlier. And I wonder if that actually reflects the changing nature of pre-licensure. training and that the glorious, intimidating, challenging, exciting complexity of the human is starting to come across in some academic settings. And the delay for you when you realize, man, this organism is a bit too complex for my simple strategy now is reducing, perhaps. Yeah, it was a watershed. Was it a watershed moment for you or was it sort of like a slow burn and

I think it was aware of it very early, but the practice settings to support that kind of professional behavior change, if you will, weren’t there, I would say. So I had to kind of work your way out of those work environments into new environments. And I think also to surround yourself with peers that are kind of on a similar journey, I think that’s important as well.

Sure. And do you think that you’ve got the frameworks in place now in the States that facilitate that, or is it still a challenge? Are there lots of little Joes out there who are waiting to come to their watershed moment?

I think we have made some progress in DPT education. Um, I think we have a ways to go. There’s, um, I think there’s an awareness now. And I think awareness is important because then professionals can decide when they come out of school, you know, do I want to, you know, just be a good, um, you know, kinesiologist, so to speak, or do I want to really take on more of. you know, looking at the whole human being in treating, and it’s not just chronic pain, of course, because pain exists in acute settings as well. So I think, you know, these are exciting times we’re living in, right? So we see that professionals now have a choice to be the kind of professional they want to be versus just a very biomechanically oriented physical therapist, shall I say.

Sure, sure. Yeah.

So I know obviously you bring pain education into the community, 90 minute lectures.

That’s right. That was the end of your question. I didn’t get back to that. Yeah. So when did we decide that? Well, I mean, I’ve always enjoyed direct to public stuff around science. And, you know, I’ve been visiting schools for 25 years talking about different sort of cool science stuff. And I’ve done a lot of sports coaching as well, and I’ve found that coaching teenagers and kids is a great opportunity to slip little nuggets of gold into their football, their soccer jersey, while they’re not looking. And so I guess it’s always been something that I’ve thought is a is a modifiable factor in the complex infrastructure of chronic pain. So I guess more formally and recently in 2017, I was in, I think it was the Australian Pain Society meeting. It was a conference anyway. And I was sitting in the crowd up the back as I tend to sit up the back and I remember looking around and seeing the same sort of faces, the same, broadly the same titles for the talks, including me, my face and my talk, and being struck by just how much we know now about what the best thing to do for people with chronic pain is. And I remember I was struck out of this trance, you know, by someone in front of me who turned around and said, enough what? And I had inadvertently said out loud, enough. And what I was thinking there was, let’s go and get this out there to the people. to entire communities, because this is truly exciting, enabling, empowering stuff if we can get it across. And wouldn’t it be amazing if having observed all this data that show that clinical guidelines around the world that clearly say education, active and psychological self-management, do that and don’t do as much prescribing, scans, meds, whatever, do less of that. Clinical guidelines have been saying that for 20 years and your likelihood of getting that care has actually increased over that time. So clinical guidelines are not enough. And I thought, wouldn’t it be fantastic for all those excellent physios and doctors and occupational therapists and social workers who are trying their very, very best to implement good care and to enable people, wouldn’t it be great if their patients turned up wanting that? Actually wanting good care and expecting it. So I thought, you know, enough, let’s try and change consumer expectations and community norms about how pain works. and what good care is. What are realistic expectations? You’ve hurt your back. Well, the realistic expectation is it’s going to take longer than you wanted it to, to recover. On day five or six, it’ll start to spread. It’s not bleeding. That’s some of our research. We’ve done a lot of research now on how people interpret their symptoms. You know, there’s a very understandable neuroimmune cascade that can emerge on day five or six after a very minor tweak, say of a spine. That feels to people, the most common descriptor is, I think something’s bleeding in there.

Like a trickling sensation.

Yeah. Yeah.

I’ve heard that with many patients.

Yeah. Yeah. And how do you interpret that? Well, this is potentially catastrophic. Yeah. But actually, it’s a beautiful neuroimmune response to expand the zone of protection, keep you safe while you heal. It’s beautiful. So wouldn’t it be great if people knew that already so that on day five or six, they didn’t think, I need a surgeon. They thought, I need someone who can give me the right strategies to move forward on this. Can you hear all the doors going behind me, Joe? No, I cannot. So we thought, well, why don’t we go, why don’t we target a community that’s particularly buckling under the chronic pain problem, and that’s rural and regional areas in Australia and actually in North America and the UK, rural and regional as a rule, doing it tougher when it comes to a lot of health problems, including chronic pain. And also those communities have networks of people who are interacting anyway. So can we get into these communities and get enough health professionals to upskill and then start to change their community? So in 2017, we started a charity called Pain Revolution and Pain Revolution does this. So we work with dozens of community government industry partners to first raise money so that we can provide scholarships for rurally based health professionals to learn about pain science, learn about pain education and learn about how to establish networks. So we call them local pain collectives, networks of health care professionals to take them all on this journey to some extent. And then the final thing we we work with them to do is to deliver a community outreach event. And by concentrating on one area at a time, we then bring the Pain Revolution Rural Outreach Tour, which is a, you know, we get 30 to 50 people in Lycra who all raise money to support the next year’s scholarships. And we go from town to town doing demonstrations. We’ve got a thing called the Brain Bus and going to schools and into nursing homes and surf clubs. And so one, One avenue is this sort of 90 minute seminar idea to the general public, where we have some cool science. We always have a lived experience reflection. We got panels and we got a whole lot of resources. We’re still learning how to do that well. So that’s the fifth iteration of the tour is happening this September in Australia. And it’s a different format again, because we haven’t nailed the impact yet. But we’re learning a lot about how to do it. The last decade, we’ve learned a lot from recovered consumers about what are the most important content matters, how are we best to get that across. We’ve learned a lot about understanding how knowledge shifts, how people’s understanding shifts, and drawn on theoretical models more. There’s a model that sort of runs from passive to active, to constructive, to inventive. And we plan exercises even across a 20-minute session. We think about how can we cover that. So we’re way more strategic than we were when David Butler and I wrote Explain Pains. and we go direct to public. And we talked before about those sort of two groups of people, and as health professionals, we can straddle those groups. And the group that is naive to the glorious, complex, challenging, exciting world of pain science, and I think they’re a very big group, but I think we also underestimate them. I had a conversation yesterday with an excellent general practitioner and pain specialist, who described his patients, well, they’re just not smart enough to, I mean, didn’t use these words, but they’re just not smart enough to get it. And our data clearly show, almost everyone is, that the limitation is not with the learner, it’s been with the educator, with us. We’re getting way better at it. Clinically, we’re using virtual reality experiences and getting a hit rate 60% better than we were getting with a good sort of explained paino, in quotation marks, six or seven years ago. So we’re really on a rapid learning curve. And our audit data suggests that when people get it, what is possible becomes just very different. We’re talking recovery. We’re not talking managing better, but pain hasn’t changed much. We’re talking people recovering and describing themselves as recovered. And those sort of observations have led to a whole new… I mean, I talk now about a sensible target for us as healthcare professionals is to instill in people a recovery mindset. Change is not just possible, it’s inevitable. But how we change is the thing we’ve got to be really strategic about. Yeah, so the world’s changed, Joe, and hopefully you can hear the excitement in my voice about it.

It’s really exciting. I mean, what’s exciting is obviously there’s the research to support it. There are, you know, both professional groups as well as the lay person who’s interested in it. You know, as I’m listening to you talk, there, as you know, have been a number of studies on various types of pain education interventions, not just your own, but other professionals who have created their own methods or versions of this, if you will. One side might say, this is all really good. We should keep exploring this. There’s always something new to learn as far as the evidence-based process goes. And the other side says, well, this is just a one small part of recovery, and we’ve kind of taken it as far as we can go. I think the reality to things sometimes lie in the middle somewhere. But I’m wondering if you can start to talk to, is good pain education enough to actually start to change behavior? Because there’s the, the reconceptualization, the belief part of things, which is vitally important. Then there are things that the person has to do, like there has to be some kind of change that the person takes. Have you noticed that delivering 90 minute, you know, sessions to the public is enough to, I guess, trigger that behavior change, if you will?

Explain Pain, Pain Neuroscience Education, and Pain Science Education

Yeah, it’s a lovely question and a lovely description of the spectrum of where people are at who are engaged in, I guess, an education grounded approach. I’m of the first group, and that is that I think we can do a lot better. And there is great motivation being delivered by the data. I love this phrase that I first heard Kevin Vowles use. I love it. You’ve got to dance to the data. Or maybe you guys would say, you’ve got to dance to the data. And the data are clearly telling us shifting understanding of the problem is powerful. and is the most powerful intervention available? There was a really interesting network meta-analysis in BMJ Open by Paulo Ferreira and Manuela Ferreira’s group, looking at all sort of psychoactive interventions for low back pain, which concluded pain education programs get the most sustainable benefits. Pain education plus something active is the best treatment we have. And, yeah, there’s other areas of empirical research that supports good education. And to speak to your question, good education is, in my view, is active. It is involved. So we can’t really, when I talk about this stuff, I talk about ancient education, which is the back school type approach where people were running seminars on the disc and sitting and standing and ergonomics and strengthening processes. Then it sort of went in a little bit to education around the results of research. And so that research, that education was around hurt doesn’t equal harm, move despite your pain, back pain is a self-limiting condition, these sorts of things. Then I would say I was part of the new wave, which sort of aimed at giving people an understanding of the biological underpinnings of this as a way to make the advice make sense, because it didn’t make sense before that. And that broadly, you know, started off being known as ExplainPain. And then it was, you know, the brand of pain neuroscience education became the thing, particularly in North America, you know, very well promoted. And I would describe and that was that was pretty much ExplainPain with a different name and is still the dominant model out there. And I would call that old school pain education. We’re going from ancient to old school. And modern pain education, which our international collaboration has said, we need to differentiate good, hard-hitting, strategic, consumer-informed education. We need to differentiate it from explaining pain. or pain neuroscience education. So suddenly the whole group said, well, let’s try and give it a new name and call it pain science education. There’s currently no randomized controlled trial that has used pain science education that’s published. We’ve got about five going at the moment, this new way of educating. So I’m of the view that the data tell us quite clearly education is the most powerful core of an intervention. But part of your question was, is it enough to just do it and people will change their behavior? And I guess the only way we can answer that question through observation at the moment is, as you say, through contexts that are not clinical. Because in the clinical context, it’s an active journey. It’s no longer a PowerPoint show or a book to read or a lecture or that sort of stuff. It’s way more strategic and involved and patient. And we use this phrase a lot now where we say to patients, you’ve got to do the work. Are you prepared to do the work to learn this? Because without that, there’s no point. We talk about the will to learn and the skill to learn and the thrill of learning all contributing to change. So in a clinical context, the question’s hard to interrogate, but from a public interface context, it’s a lot easier. So because we can’t have those engagements, we really do a show. We put on a performance. and we entertain and what we’re trying to achieve is that the people in that room will leave thinking, I want to learn more about this. This sounds cool. Do we have behavior change? We do from just that single interaction we do in a small proportion of attendance. So our data, one of the questions we ask is, will you do anything different? as a result about your pain problem, as a result of this event. And we get about 65% of people saying yes. then in the, we haven’t done much work following them up, but the work that we’ve done suggests about half of those people actually do do something different. So it’s about three in 10.

Yeah. Which is important because obviously it’s, it’s, it’s, there’s something about that intervention or that interaction that is causing someone to take a different action than they were previously to attending that 90 minute session.

Yeah, absolutely. And sometimes when we take the tour around to town, we go to these small towns and they’re only just big enough to accommodate a tour group, right? But in several towns, I’ve received emails, sometimes quite grumpy emails, from doctors in the town who said, you’re going to have to tell me what this pain revolution is about because all my patients have started asking me, what do you know about pain revolution? So that’s fantastic, right? So we send the doctor a whole lot of stuff and that town shifts. And you get a little blip in stuff like opioid prescriptions, knee replacements. I mean, we only see this in the towns that were small enough to sort of saturate, but we’ve just got a big Australian government grant to do this on a larger scale across a geographical region. And yeah, we’re very excited about that. Yeah, so can I rewind right back to the beginning of your question? Because I think it’s a critical consideration. And my answer’s changed in the last six or seven years. So the question is, is education key? Does it play this tiny role as one thing of a range of stuff? My answer six or seven years ago would have been more along the lines of, yeah, it’s one thing. We’re not that good at it. but it’s the best thing we’ve got. Now my answer would be, it looks to be the critical player in recovery from chronic, at least musculoskeletal pain and the endopelvic pain fibro data are starting to trickle in and they look very similar. And now we’re going into fatigue and the data look very similar.

PTSD, the data look very similar. Yeah. So it’s a trans-diagnostic approach that can help people essentially. Yeah, I think so. I mean, you might have to make some adjustments for social and cultural aspects, but the core of it is there.

Absolutely. Yeah. And I don’t want to overplay where we’re at. We’ve got a lot of work to do and a lot of communities and cohorts that we need to strategically work with to modify. Absolutely. We’ve just started doing work particularly with refugee populations who have lived through significant trauma. And we’ve got to change how we do stuff there and what the core messages are. And that’ll be a five or 10 year journey. But it is a very exciting time to be in this space, in my view.

It is. I’m excited to hear some of the research that’s coming up. Can we talk a little bit about your research now? I know you have the RESOLVE trial, and a good peer of ours, Peter O’Sullivan, has the RESTORE trial. I’ve seen people kind of compare and contrast those two things. Why don’t you tell us about, obviously, your trial first, and what some of the unique findings are in that?

The Importance of Changing One’s Understand of Pain

Yeah, sure. So it wasn’t really my trial, but Ben Wand from Perth put together a standardized implementable program that we could test in a randomized controlled trial that integrated what I would call old school pain education. We started this trial in 2018, I think, 2017. So the protocol was done in 2017. It integrated some of the brain training stuff that we’ve developed over the last couple of decades, and it integrated contemporary notions of adaptation to movement and loading. So it’s a lot of these three pillars that were based around a model that we call the fit-for-purpose model. And the fit-for-purpose model really has been a work in progress for 10 years. That’s been a while, right? No, I wouldn’t call it Ben’s model. I would just call it a model that Ben and I and others like. I don’t know what the providence of that model would be, but certainly Ben deserves great kudos for integrating these things into a standardized deliverable package for a randomized controlled trial. And his approach to that we’ve adapted now for big clinical trial. So RESOLVE was about back pain, chronic back pain. We’ve now finished data collection on a chronic knee pain trial. We’re about to start on a chronic neck pain trial. We’re halfway through for chronic CRPS, phantom limb pain trials, all with versions of the fit for purpose model. The fit for purpose model has three pillars. One is changing your understanding that your body is fit for purpose even though it doesn’t feel like it. So it’s a sort of a slightly nuanced take on classic pain education based on consumer findings that the key concepts to learn are around understanding that your pain system is hypersensitive. And it feels like you’re about to break when you’re not. So the first pillar is understanding. The second pillar is refining the neural mechanisms of sensory motor processing. So that includes things like graded motor imagery, tactile discrimination training, proprioceptive acuity training. You could probably even put in the old transversus multifidus training type concepts. You know, like in my view, All of those things have one thing in common, which is they require the brain to be precise in what it’s doing. And we know that precision in neuroimmune networks is reduced in people with chronic pain. And it makes sense that it is. And when you can improve precision, you have a small clinical effect. So that’s within the larger model. And the third pillar of the fit for purpose model is to ensure that the body is fit for the purpose you want it to perform. So the RESOLVE clinical trial was a comparison of this standardized program that had been put together based on the fit for purpose model, which me and probably others have been playing with for 15 years. Testing that against a very, very strategically designed sham intervention. because we wanted to dance to the data and we wanted to make the treatment, the resolved treatment, work hard for its effect. And the reason we did that, and James McCauley, who’s the project lead on that, and I were very, very particular about that. And Ben was less so because, you know, his perspective was, boy, you might not see an effect. And James and I were both of the view let’s make it work hard so that we know any effect is due to the things that we think should have an effect. Now, James and I, this has never happened in chronic back pain. There has never been a strategically designed sham controlled complex intervention. So Felicity Braithwaite and our group has done some beautiful work on how do we make shams, that are compelling, that are credible, that people are blinded to. So we constructed that. So for RESOLVE, the sham intervention had similar exposure in time, similar attention from the physio. It talked about the brain. People had fake brain stimulators put on their ears and similar interaction with multimedia stuff. So we were very strategic. And when we asked people at the end of the treatment, do you think you’re in the active treatment or the sham, the sham treatment had slightly higher ratings than the other treatment. So it worked, right? Credibility was the same, expectations were the same. So any effect that we see there, we can say this is an effect that’s beyond the non-specific effects of treatment and of being in a clinical trial. And we chose one Primary outcome marker, which is what you should do in clinical trials. If your sample is for one marker, you only look at one marker and you decide which marker it is before you start. And that marker was pain relief at, I think it was one year. And we said if it reaches one as a difference, so difference between the two groups, if it reaches one, the treatment worked. Now we didn’t expect to see that because that’s never happened before. You see effects when you compare to non-shams, for sure. My view on back pain is that we don’t need another trial against usual care or do nothing or anything, because everything works, right? But make it work for its money? We expected the power of that trial would be looking at what’s different about the people for whom it does work compared to the people for whom it doesn’t work, because we won’t see a global effect with such a good sham. But we did see a global effect. So it’s the first sham control trial of a complex intervention that has effectively shammed and shown a treatment effect. So in my view, this is a game changer. In my view, the result of this trial is a true game changer. Now, it’s been really intriguing to me to see the response out there and to see that a lot of people reading about the RESOLVE trial don’t share my view on it. And the main criticism of the RESOLVE trial is it’s a one point change. And there are other trials that have a bigger change. And I would remind any reader that as soon as you hear about a randomized controlled trial that shows something is effective or not, the next question should be compared to what? So if we had have done the RESOLVE treatment versus usual care, it would have been a bigger difference. If we had have done RESOLVE trial versus restore cognitive functional therapy, we’ve got no idea what would have happened. And that speaks to the other part of your question, because we also hear a lot of people say, is cognitive functional therapy and what happened in the RESOLVE trial the same thing? And they’re not the same thing, but my view is they share, at their core, they share the fundamental difference between new wave interventions for chronic pain and old wave interventions. And that is they both target a change in understanding of the problem as the core mediator of progress. Pete’s done amazing, Pete O’Sullivan’s done amazing work developing, a bit like Ben, developing a package and something that he can teach other people to do. But like RESOLVE, it’s centered around change your understanding of the problem. And there are other interventions that also have that at its core. The pain reprocessing therapy stuff out of the States, clinical trial, the control group there was an open label placebo injection. The control group for the restore trial was usual care. Keep doing what you’ve been doing. And I’m really transparent with Pete and with his collaborators where I think that makes the positive impact of cognitive functional therapy in that trial really hard to interpret because I don’t think it’s a pragmatic trial. In my view, it showed that CFT is better than doing nothing. And I was really disappointed that they chose that. control group, and they’ve got their reasons for it, and they argue them really compellingly, and I have very deep respect for Pete, and I think he does amazing work. He knows that I didn’t like the control group, and I don’t think we can conclude anything more from that trial than CFT is definitely better than saying to people, go around, keep doing what you’re doing. And they also target a slightly different group from the group that was in our result trial. The other observation that I have around the response to these new wave trials, so I would say we’ve had three well-conducted randomized controlled trials with different control groups, all centered around changing understanding of the problem. The observation that I think surprised me the most is when people say to me, so why do you think the Restore trial did so much better than the Resolve trial? Because I don’t really understand that question because it comes back to the compared to what. So it’s accurate to say that CFT was, I think, two points better than go away and do nothing, nothing new. It’s accurate to say that Resolve based on the fit-for-purpose model was one point better than a sham control. We can’t compare the two treatments to each other. If we put Those two treatments, the pain reprocessing therapy treatment and the normal trajectory of back pain data from Sarah Wallwork’s excellent paper in Canadian Medical Association Journal, all on the same graph. And no one would say, no one would say, why did one, why did Restore do better than Resolve? If you put them all on the same figure, you wouldn’t ask that question. So how are they similar? They’re similar in that they seek to change understanding of the problem. They’re similar and all through, actually, I don’t know the mediation data from Restore, but the pain reprocessing therapy and the Resolve trial, the effect is mediated almost entirely by a change in the understanding of the problem. That’s powerful. Our audit data of 1,500 people show that when people change their understanding of the problem, their average pain relief in those people is 80%. 80%, like bloody hell. That’s extraordinary. The problem is that only half the people change their understanding. So where’s the problem lie? Well, it lies with us as the clinicians who are not effective enough at working with patients in a recovery mindset towards changing their system. It’s quite a long spiel, but there’s a lot of juicy stuff in the RESOLVE trial. I could talk about that trial for a long time because there’s a lot of really interesting data. But as a scientist, we can only make statements according to the convention of science about the primary outcome. because the secondary outcomes, which were all very consistent and excellent and so exciting, we’re not powered to test all of those. We need to triple, quadruple our sample to say this is true. So what we have to say is, it looks very exciting.

So the secondary outcomes, you’re talking about things like pain catastrophizing or depression, those factors from the trial?

Well, we took it, yes, in part. So we planned and conducted that trial and a lot of, you would need to acknowledge the job that James McCauley does running clinical trials. He’s just a great clinical trialist and that’s why I work so closely with James. We did exactly what we said we’d do. And we select one outcome variable that we say we’re going to hang our hat on this. And as a scientist, you just cross your fingers because if everything changes in the desired way, except that one variable, you have to conclude the treatment doesn’t work. So we did a trial a while ago published in JAMA Neurology on explaining pain in acute back pain. And we hung our hat entirely on one marker, which had a P value of 0.06. Most of the other markers changed in the desired direction, but this one didn’t. So we conclude it’s a negative trial. There’s no effect. It’s a 94% chance there was an effect, but according to convention, it wasn’t greater than 95. So we conclude it doesn’t work.

And there’s a benefit in knowing that too, right?

Absolutely. Yeah. No, absolutely. So that was our one primary. Then we had things that we might call process variables or mediators. So they’re the things that we suspect the treatment might work by, and they included beliefs and understanding of the problem, tactile acuity, catastrophizing, self-efficacy, these sorts of things, and a big chunk of the variant. So the biggest mediator was understanding the problem by a long, long way. And then our secondary outcomes are things like disability, self-reported disability, recovery rate, medication intake, these sorts of things. And in the Resolve trial at 12-month follow-up, we had a 50% complete recovery rate. And that’s from chronic back pain. That’s amazing. So there’s a lot of juicy stuff that is partly responsible for us. We’re getting funded well to explore this further. And part of the reason is that we’re getting a signal in a very noisy world. And yeah, it’s very exciting.

I know that people, of course, want to hear more about this and you’re going to be in the United States, stopping in a couple of different places to talk about all the trials you’ve been involved in and what they mean. But I know you’re specifically going to talk about the RESOLVE trial on that tour, I believe. But can you tell people where they can find you and what that kind of tour is going to be about?

Yeah, cool. I’m very excited about this. I haven’t been to the States for a long time, North America at all. So I’m actually starting in Vancouver. I’m running a two-day course in Vancouver, and that’s at the very end of September. And then the first two weekends of October this year, I’m in San Francisco for a two-day course and New York City for a two-day course. And if you want to learn about those things, Noi Group is hosting that and facilitating that. So I’m not a part of Noi Group, just because that’s a common misperception. But if you want to learn about that, go to noigroup.com. noigroup.com. Yeah, so yeah, definitely talking about RESOLVE Trial, talking about what’s changed in the way in what we teach people about pain, why we’ve changed that, how we do it, the will, the skill and the thrill, the resources we’re developing and really exciting use of virtual reality embodied learning. to enhance pain education. And that’s, for me, that’s a very exciting development. And the data coming in there are suggesting, you know, we’re increasing our expectations again. You know, we’re lifting the bar of what might be possible. And we’re now starting to talk about recovery mindset rather than management or treatment. But we say to people, you’ve got to do the work. And we as health professionals become coaches and advisors, less therapists. Yeah, yeah, but check that out. I mean, it’ll be fun. Certainly be fun for me anyway. It’s the sort of half half entertainment, half learning. But, you know, being very strategic about contemporary learning facilitators within that course. So, you know, I’ll be doing my best to instill the will, the skill and the thrill of learning about pain science and education within the context of the fit for purpose model. captured by, most recently, the RESOLVE trial for back pain.

Yeah. Well, many people know that I’m in New York City and I’m already signed up, so I’m looking forward to… Oh, excellent, Joe. That’s great. Meeting you and getting to, obviously, learn from you would be wonderful. And, of course, there’s a great community of physical therapists in New York City, who I’m sure, and the whole Northeast too, probably, Join you. So I’m excited for that. Everyone can go, of course, check that out on Noigroup.com and you can find the registration to that course there, which I believe is called pain. What’s the course called?

I think it might be called pain science in practice.

I think that’s correct. Pain science in practice. So that’s a good place to point people. And of course, everyone can find your books and resources. We’ll link to them in the show notes. And I just want to thank you for, of course, the work you’re doing and for spending time here with us this evening and you this morning. And of course, people will check you out on NoiGroup.com to learn about your course. And of course, if you have any final words, please feel free to chime in.

Well, look, thanks so much for having me. And Joe, congratulations on the work that you do. and your contribution to the community. It’s massive and we need leaders like you. So you’re a beacon. It’s great. And if we want to suss out pain revolution, just do a Google search painrevolution.org and you’ll learn about our charity and what we’re doing. And there should be one in North America.

Yeah, I appreciate those kind words. And of course, yes, pain revolution.org as well. Um, I want to thank Lorimer for joining us this week on the podcast. Um, make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter, wherever anyone is talking about, um, pain science education and ways to help people recover from chronic pain. I’m Dr. Joe Tatta and we’ll see you next week. Thank you for listening to the Pain Science Education Podcast. To subscribe to the podcast and learn more, visit IntegrativePainScienceInstitute.com. That’s IntegrativePainScienceInstitute.com. Sign up to receive weekly updates and learn about our continuing education courses. If you enjoyed this episode, leave us a review on your favorite podcast platform and share this episode with your friends. Please join us next week as we share more science-backed solutions for treating and reversing chronic and persistent pain.

Important Links

NOI Group: https://www.noigroup.com/

Pain Revolution: https://www.painrevolution.org/

Pain Science in Practice, New York City: https://www.noigroup.com/event/pain-science-in-practice-moseley-nyc/

Teaching Patients About Pain: The Emergence of Pain Science Education: https://pubmed.ncbi.nlm.nih.gov/37984510/

Lorimer is one of the most requested keynote speakers internationally in the field of pain science. His research and creative activity, education, leadership and engagement achievements have been recognised by the Bradley Distinguished Professor Award for preeminent academic staff and the Officer of the Order of Australia, Australia’s second highest civilian honour for ‘distinguished service to humanity at large in the fields of pain and its management, science communication, education and physiotherapy’.

Currently, a Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy at the University of South Australia, Lorimer is also an honoured member of the Australian Physiotherapy Association, an Honorary Fellow of the ANZCA Faculty of Pain Medicine and a Fellow of the Australian Academy of Health and Medical Sciences. He has authored hundreds of articles, multiple books and chapters, and is cited in clinical guidelines internationally. With over 30 years of clinical experience working with people in persistent pain, his community outreach and whole-of-community education initiatives are internationally renowned.