Pain, the brain and your amazing protectometer - Lorimer Moseley

[Applause] thanks mate so this is the third incarnation of the co-adlow lecture um this organization was started uh by Dr Leslie co-adlow some 50 years ago along with his secretary and more importantly or equally he's importantly a consumer at the heart of the start of this organization which was about real people helping real people overwhelmed with the demand in his clinical practice he saw the need to establish an organization such as ours and we continue 50 years and this lecture is in his honor uh so we're an organization very much about adopting a person-centered self-directed approach and about empowering consumers for Better Health outcomes with musculoskeletal care now we're very confident that this year's lecture will continue in that vein we have obviously Laura Mosley Professor clinical neuroscience and Foundation chair at the University of South Australia he's authored more than 300 papers and five book or books on pain and Rehabilitation that's a pretty fair effort you do do other things I'm guessing Lorimer but that's obviously a huge contribution to understanding in this area Professor Mosley is particularly interested in how education about pain can lead to better pain related outcomes and he's exemplified by such initiatives as the pain Revolution tame the Beast and Body in mine on behalf of musculoskeletal Australia thank you Laura Lauren Mythic attending tonight and being with us to convey your wisdom much appreciated [Applause] right wow nice crowd good job am I being Amplified excellent last time I was in this building I I went up the stairs and I went to the toilets on the next level up I don't know if anyone's been to those toilets but certainly when I was there there was a sign out the front or as you walk in saying please use all the facilities to avoid congestion so I did which is quite difficult to do like I like once you're empty you you're empty but um I managed to use all the facilities and I didn't have any congestion so we are in a house of learning and that's that's fantastic but those signs were not there so if anyone's feeling like you're getting you know a little bit stuck in your sinuses I encourage you to go and use all of the facilities so thank you very much for having me here for this really important lecture I think that the any effort to to get a message out to people who will actually benefit the most from that message is something that should be supported and this organization has a has a massive history of of emphasizing that and this lecture captures that so it's a real honor to give this lecture I think it's probably very important for most of you to know something about me most of you probably won't know anything about me I recognize a couple of faces the rest of you won't so here's a couple of things about me my official letters are there and if you put them together with our spaces they say effective support which means I've spent about 25 years researching pain treating people who have it primarily persisting pain and and teaching people what I've learned about it over that time I my main role is as a scientist so I'm officially a clinical neuroscientist which means I study the nervous system and brain of people who who are not in perfect health that's the official rule of that they're in some sort of clinical context in reality I we we can't confine science to one system anymore like the nervous system the nervous system can't work without your immune system in fact for a single synapse to work so synapses when two nerves talk to each other that synapse does not work without a cell from the immune system making it work so we can't really think about Neuroscience on its own anymore so I like to think of myself as a human scientist and pain is probably the human experience that I've been most fascinated by for a long time uh I think it's really important to be fully transparent so I'm not paying for my airfare over here nor for my hotel accommodation tonight nor the Uber that I took here uh nor the party I'm having with all my mates tonight uh that was paid for by you guys and presumably via sponsorship so thank you for for your support of that uh the books that Rob mentioned I'll get royalties for all those books and if anyone's written a book you'll know writing medical books fast and easy money it just comes pouring in I every day I see this ching ching the money just piling up from royalties from medical books uh especially the ones where I negotiated a great deal to not have any royalties at all nonetheless I do I do have uh benefit from that the following companies have paid me money have supported travel to go to conferences or give talks or consult or give me something for free so you can see the first one there I I have slept with the devil um I've done work for a company in in the USA called Kaiser Permanente which is a Cooperative Health provider they have about 160 hospitals around the USA the ioc if anyone wants to walk out now because I've I've done some work for the port power I would understand there's another Drug Company there and I'm very proud to say that micro scooters give me free scooters and the reason for that is because I've recommended them that more than anyone else apparently in the country and when they discovered this I got this really bizarre phone call I answered the phone uh Heights laws here uh is that is that Professor laws I guess technically are you also Lorimer yes are you the scootering Professor yes well we'd like you to be an ambassador because you have recommended more people than anyone else in the country to this great brand of scooters so they gave me a free scooter and now I'm completely conflicted by that because I want you all to go and buy one uh and these people make shirts there you go I'm not wearing one at the moment but the research that I do is mainly sponsored by your tax dollars by the Australian government our national health and medical research Council I also have research currently that's funded by state governments including Victoria uh and the government's overseas and then a lot of the work that we do is of of great interest to insurance companies uh because when you have pain and you cannot work that cost insurance companies a lot of real dollars and and they're just realizing that probably 40 to 50 percent of income protection insurance claims are because people have pain and they have pain resulting from soft tissue injuries that are considered non-catastrophic so many of you will identify with this some of you will have more substantial injuries but the really costly ones for insurers in terms of their bottom line uh back pain knee pain shoulder pain neck pain and on the global burden of disease this is something you touched on Rob there is nothing more burdensome on the planet as term in terms of years live with disability and economic cost than low back pain followed by depression followed by neck pain and musculoskeletal disorders so three out of the top four health conditions cancer comes in at about 14. and diabetes somewhere around there as well so it is a really massive issue and what we do know from Pain science and I'll get to this by the end of my talk uh is that there is a there is a great hope now based on the revolution in pain science and how we understand these things that that burden which is big on our society level clearly but it's really big on an individual level and many of you will will be aware of it on that level there's really There's real hope that we can start turning that around but you're the key to turning that around so I've got a few messages that I'd like to get across and I'm going to guess how long it's going to take me I sort of will depend on how distracted I get with stories but I'll do my very best I think this is a really important issue pain is a critical Lifesaver I went to school with this guy who used to charge five dollars now when I went to school five dollars is quite a lot of money Primary School five dollars for us to jump on his hand uh now in my in my memory I thought wouldn't that just be cool to have the gift of being able to have someone jump on your hand and it not hurt and it didn't hurt him and he could swap hands but his hands were clearly being injured by this and I was one of the people that paid the five bucks and I saved up and I put a phone book on top of the chair that I stood on just so I get a bit higher and now when I think he he died when he was 23 that fellow because he was born without critical part of physiology which is the ability of his tissues to detect Danger we call those things nociceptors now his nose receptors or danger receptors were faulty they they didn't work and there are a few uh famous cases that that have stayed alive through really incredible vigilance on behalf of their parents and and on behalf of themselves but even looking at them they don't look right because they've had so many injuries and because danger detectors don't just tell us about Danger detectors the activity of danger detectors is critical for normal tissue health normal growth things grow in the right way in the right shape if your danger detectors are working you need a lot of other things as well but but danger detectors working and then a side point of that is having a bit of pain is critical for development it's critical for normal functioning and and this mate of mine who I thought oh wouldn't that be great he died because he didn't have these receptors working properly so pain is a it's a critical Giver of Life it's just like a loyal and faithful companion that will will bring into your awareness the possibility that you are in danger and you should do something about this raise your hand if you have ever had pain thank you raise your hand if if you have been aware at any time in your life of that pain being quite helpful to get you out of a potentially dangerous situation great now you don't have to raise your hand for this but have another have a think about this question what if that pain started to prevent you from doing things that you actually probably knew were good for you and trying to overcome that barrier two working weekends ago I had a massive flare-up in a spondyloarthropathy which is a an autoimmune disease that I have and it's very well managed and two weeks ago it went nuts and there was I knowing the best thing for me to do is to is to move but it was so painful to get onto my bike I ride a bike a lot I fell over trying to do it because my system was in this competition of Worlds produce pain you are in danger and cognitively but I think this is good for me and this is a real challenge that all of you face uh and I think we'll get easier the more you understand the more you understand and that's the thing that really gets me excited about my work that aren't we know understanding helps we want pain to be like a faithful and loyal companion that protects you when you need protecting the problem that we hit is that the relationship between pain and injury is a very variable relationship we know that different people have different pain thresholds and I know there's a few clinicians in the room but for those of you who are patients is I'll let you in on a secret that if you tell your clinician you have a high pain threshold they tend to think you don't so don't tell them that even if it's true don't tell them that you look him in the eye and say what do you think about my pain threshold so get them answering this relationship between pain and injury is highly fascinating and I had a neurology Professor when I was doing my physiotherapy degree a long time ago who said when we were leaving the lecture theater once he said and you know young man the worst injuries are often the least painful and I said now that can't be true as we have pain receptors and pain is damage and he said well why don't you go and find out so this is exactly what I did I went to Royal North Shore Hospital in Sydney Sydney's biggest hospital and I took a clipboard and on my clipboard I wrote down a data collection form so one column I got to describe the injury in the next column I got to describe how much they were writhing in pain the next column would be how gory the injury was and the last column was the answer to the question on a scale of 0 to 10 and how sick are you of this question on a scale of zero to ten zero being no pain 10 being worse Possible Pain how would you rate your pain right now who feels like even this even the sound of that makes you want to adopt the off posture uh I know we can't help ourselves can you rate it I remember one one dude in particular coming into the uh emergency room that day I sat there all day and I was alerted by his weird voice because he said no way Giorgio and there was this guy who was walking in to casualty Department like this and he's saying no way Giorgio and he was doing that because he had a hammer stuck in his neck well you know the curly bit that you're meant to get the nails out with that had gone in the back of his neck and was coming out the front that was blood all over amen and I was in third year training so I had already had some clinical training so I said there's a hammer in your neck mate and he said yeah I know completely relaxed so how do we make sense of that severe injury and apparently no pain the way I thought at the time was he's clearly had something like he's clearly had pethidine or morphine or something so I asked him have you had anything he said what do you mean well have you taken anything yeah yeah I have well that would be it what have you had well it's a kilometer from the building site and I was getting a bit peckish I stopped for a egg and bacon roll isn't that outstanding imagine going into the cafe Giorgio look just two reckon bacon rolls thanks he's had no drugs this guy has no drugs in his system but he's got severe injury and he doesn't seem to have any pain so my next conclusion is he is probably just a complete idiot his brain is not capable of making his body hurt but then after I'd been talking to him for 30 seconds filling out my form on a scale of zero out of ten zero he said and he said oh I've got this gag ready and this is what he did in a crowded casualty waiting room he did this he said what am I and he was going between the state the the all the seats and he got up and I said mate you are a Nutter and he said no no I'll do it again Giorgio do the sound effects so he did it again and Giorgio who wasn't coping very well actually he was sort of a big giggly and uh Giorgio did this dude this guy got up the second time and said I'm a hammerhead shark and I thought then he and he's planned it he's planned the joke he's told the story really well he's choreographed it with Giorgio he's clearly not a Brian is very capable of working so I've ruled out a drug I've ruled out a brain that doesn't work so I have to conclude at that stage of my career and understanding and you might relate to this I had to conclude it's shock we would call that stress induced analgesia so the the brain is just not letting any and in the old way of thinking we would say the brain's not letting any pain messages in you relate to that I see a few nods well if that's the case how do you explain what happened next where he has to turn around and he hits his knee on a little coffee table thing the magazines on it he's got a hammer in his neck and he did this ah yeah and the nurse ran over saying my God I'll go with a hammer on his neck screaming at the nurse it's my near you idiot same human same moment in time severe injury no pain mild injury pain just think through that same human same time severe injury no pain mold injury severe pain how on Earth do we make sense of that if pain equals injury and my response to that scenario was all right I've got to find out that was 25 years ago or a bit longer how fascinating is that and how difficult does that make our life if we're treating people in pain but more so if we have pain that we don't understand really really difficult so how does the system actually make this sort of thing happen well we've had a massive Revolution really in our understanding of what pain is Renee Descartes who is a philosopher in the 17th century and who was really really clever and about whom I wrote a song and sang with my kids when they were little little kids it goes like this Renee Descartes was very very smart which is why we sing this song but I must impart he was a jolly old fart and as it turns out he was wrong and once I was seeing that with my two-year-old son at the time and he managed to fart on cue and you know as a parent when when you your child's done something that you know you shouldn't really encourage but you're really impressed by it and I eventually had to say oh good on you Henry that was Henry's not his real name no it is um Renee Descartes had this idea that really pain was something that would be detected in the tissues of the body and sent to the brain so that you get a marker of the state of your tissue so you so you're being told how are your tissues and this is what it feels like and this is the the most common interpretation of Pain still but the last 50 years of scientific progress tell us it's not like that pain doesn't work like that and this is both a really confronting reality but a really exciting proposition if you have pain pain is all about protecting our body tissues it's all about making us do something to get out of pain and it's a brain thing which means we can Now understand and explain findings like this that in violinists fingers on their left hand are more sensitive than fingers on their right hand to painful stimuli to stimuli that could be painful you don't need as big a stimulus for this hand as you do for this one why because you have to protect this one more than this one to play the violin this is a more important part of your body than this hand makes sense now it doesn't make sense if pain is measuring tissue damage or state of the tissues it makes sense if pain is a protective feeling that we get and I could throw you examples like that from research experiments I've been involved with or or collaborators or people I've never heard of have undertaken and we would be here for a week with the amount of data that support that idea and this summarizes it anything that suggests you need protecting takes pain up anything that says yes you don't takes pain down you're talking about the hot water Springs at your place who else just imagine themselves in one of those warm water baths as you're talking that sends a good safety message that data the whole all of the data coming in suggests that you are in less danger therefore it should reduce pain now I don't know if there's any randomized controlled trials that are able to blind people or for whether they're you know make people unaware of whether they're in the warm bath or not that would be pretty hard to do but as a scientist that's what we need for evidence but as a basic scientist trying to understand how does the human work that would be my prediction because that those stimuli suggest you don't need protecting as much so pain should go down have you ever thought about this so remember back when you twisted your ankle because nearly everyone twists their ankle in fact raise your hand if you have ever twisted your ankle great it's probably more interesting just for the raise your hand if you've never twisted your ankle never congrats it's not you're pretty special all right right raise your hand if you have twisted your ankle and you sort of liked the experience of just how swollen it got gets really swollen what's amazing about twisted ankles is that they stop hurting a long time before the the ankle is returned to normal the ankle will take normally six or eight weeks maybe longer for the tissues to be back at Peak condition but most twisted ankles stop hurting a long time before that because they don't their system doesn't need to produce pain to stop them doing stuff so there's no point in producing pain pain is about protection you could do this experiment why don't you do a little experiment here we'll see if we can make this work but but if anyone has an injury doing this please Sue musculoskeletal Australia or the sponsors okay so what I want you to do is just squeeze your your thumbnail one hand on the other don't do this if you have sore fingers but squeeze it just enough just to make it hurt just a little bit remember how hard you're squeezing it okay now squeeze the thumbnail of the person next to you the same hardness okay and what you should all notice is that it hurts more when they squeeze it when I um I once ran this experiment I once ran this experiment squeezing earlobes and that was bad because they came back a week later and half of the class had bruised earlobes it's a bad look but we do a controlled experiments which show that if you apply pressure to your own finger to produce pain if that you rate at about three out of ten if you apply if someone else who is your friend is applying that same pressure even though they're your friend it hurts more and if it's a stranger it hurts in almost intolerably and people will swear it's more pressure that bastard is turning up the pressure so the difference in these scenarios is not the event it's the risk and the risk is what determines how you it tells your brain okay I need you to protect yourself here and the only way I can make you protect yourself here is to make it hurt because it it's unpleasant pain is unpleasant you want you want to stop it many back pains I think the evidence would suggest most back pains that can be brutally painful pass out painful Frozen lying on the ground painful distressing painful distressing for the people around you painful something you rate at nine or ten out of ten might be associated with little or no injury we now know that the data tell us that it feels like you've been blown apart some back pains that have proper tissue damage and some significant injury feel just the same life-threatening injuries where your life is at risk because of this injury are usually pain-free think through that so I'm talking here about a limb being blown off catastrophic trauma and most of you will at least know of a story you might know someone you might it might have been your story that at the time of injury for really for until you were safe you were pain-free once your your life is no longer under threat then you'd normally have a lot of pain because pain is not measuring tissues it's telling you whether or not you should protect and the brain is smart enough to know that if you if if it creates an experience that makes you look after your arm that's been blown off then you'll die so it doesn't create that experience it's very very sophisticated and cool system so we now conceptualize pain as something that provides for us a protective buffer I remember putting up a slide a bit like this sort of talk in France and they said we don't have the word buffer it was being translated in real time and the translator said you know sorry we don't have a word for buffer unless you mean and I said well what does buffer mean and she said well it's the uh the the protective layer outside of a car to protect the car from and then as she was talking she was saying that's what you're saying isn't a buffer I say no no I'm not saying buffer I'm saying so pain provides a protective buffer and the size of that protective buffer varies all the time according to anything anything related to protection so you could either spend the next 20 years of your life getting your head around all the experiments on pain or you could just remember that principle and apply it so if you have knee pain and you're an otherwise normal human and you're participating in a research experiment in in one of our research programs and we took you to a set of stairs and you've got knee pain this is important and we just asked you uh we're going to walk up those stairs how many stairs do you think they're there are there and you had a guess at that you would guess more stairs than if we walked up and said we're not going to walk up them but how many stairs do you think are there and you guess there's fewer stairs because even without you knowing it your brain's already trying to discourage you from from going through a painful situation so your brain tells you there's more stairs than there are but this will only happen if you're human if you're not human it won't apply to you so what what are the important factors that determine the size of the buffer that protective buffer danger messages from the body are really important we have danger detectors through all of our tissues and you can activate those danger detectors by squeezing tissue or by heating it or by freezing it or by putting too much acid in the tissues if you like and that's detected by things that we call danger detectors and nature detectors send a really really important message now I've got to try and read what this said ah I met someone twice today before the talk um I'm looking for you but I can't see you but there twice in one night and what he uh observed about me made me wonder whether or not I should tell this this story can you raise your hand if you've seen a YouTube uh tedx talk where I talked about walking in the bush if you haven't seen it go and have a look at it I'm going to miss that story is that all right did anyone come just for that story okay I've got if I've got time at the end I will but I suspect that I won't what's more important than danger messages coming from the tissues of the body is what your brain thinks those danger Messengers mean and that's a that's a really important reality that that you might need danger messages coming from the tissues of the body to be alerted to an event but what your brain thinks those messages mean is more important now we would hope that if those danger messages are being triggered by a dangerous situation we would hope that the brain concludes yes this is a dangerous situation and you need protecting and that is normally what happens but have a think about this reality and then have a think about your back scan report has anyone had a an x-ray a CAT scan or an MRI on their spine raise your hand okay so maybe half probably a bit more uh you you probably got the report that's in an envelope that says confidential only to be opened by your doctor and you opened it am I right yeah and then you read it and it says things like degeneration it says things like you have a broad based disc bulge pressing on your fecal sack and you might not necessarily know what a fecal sack is I had a patient who described it once as a fecal sack which it's not quite right but the what information you get from the report changes what this this this danger messages mean so we've just finished an experiment with 400 people that shows that if we give them their report and we explain that those things mean normal age-related adaptations they have less pain when they bend over than if we don't explain that so the danger message from the body is critical but what it means is more critical if you've had knee knee x-rays if you like and someone has made the mistake of saying to you it's bone on bone in there that says danger that's that's a critical determiner of meaning so I would I would suggest to all of the health professionals I ever come in contact with unless it is bone on bone in there which you probably really need to go in with an arthroscope to have a look and it's almost certainly not the case don't say it because it looks like it on an X-ray pain is not the only thing so so all of our things that we experience are determined by meaning because the brain is creating these things and I always use these slides and I know some of you who have seen that Ted Talk probably know this but go with it all right because half of you haven't seen it but just raise your hand if you think the square that's got a in it is darker than the square that's got B in it okay great if you if you really don't see it like that you've got a neurological deficit so your brain's not working properly you should see this as darker than this but if we take those out to the side you'll see hopefully they're actually exactly the same but your brain is changing the data for you based on what the whole package means together and you can see this for yourself one of the amazing things about this is what happens when you turn your head on your side so turn your head right or don't if you've got sore neck don't do this don't hit heads careful if you get your head right over right on the side and your eyes vertically aligned it still looks exactly the same foreign if you stood on your head and looked at it upside down it would still look exactly the same because your brain is so capable at attributing meaning and the the experience that you get will reflect meaning we did an experiment that that relates to vision and how different information gives us meaning we got a whole group of people who describe them in ourselves as normal individuals but they did volunteer for a pain experiment they're probably not normal um we should really say this was this experiment was done in a group of psychologically questionable poverty-stricken students but we in each situation just just think about what we did here this is a very cold probe that goes on the back of their hand and we didn't we did not tell them it was cold we just told them it was a it was a probe and there might be different temperatures of the probe and then we showed them at the same time either a red light because it because red means hot and danger or for some of the the trials so some of these stimuli we showed them a blue light and blue means safety and cool for every single stimulus they got the probe was always the same temperature real temperature it was always minus 20 degrees which is very cold but not particularly dangerous for more than a few seconds we asked them a lot of questions but this is what they responded when we asked them about pain so we said did that hurt and if it did how much did it hurt and you can see how much we rely on this horrible zero to ten scale that you all hate each line belongs to a person each person got I think about 10 different stimuli in each condition and the fact that all of these lines not all of them most of them tend to go up in that direction tells us that for for nearly all of these supposedly normal people the same stimulus with a red light hurts more than it does with a blue light because of the meaning we've changed many now you can see this person here this person here they're idiots they don't they don't they don't their brain doesn't process that meaning or perhaps they were colorblind who knows we know that the ability of the system to detect Danger ramps up rapidly and massively in the presence of inflammation so this is why inflammation inflamed joints hurt this is one reason they hurt so much more here's a this is an invertisement for an English DJ who is coming out to get sunburned in Australia sunburn is inflammation of the skin and you've probably all been sunburned and when that warm water goes on your skin it really hurts and that's because of the the shift in this protective buffer you've moved from a a normal size buffer to a really big buffer and that is a beautiful system to stop you putting forces through those tissues that need to heal and it's very effective back to if you've twisted your ankle the day after you've twisted your ankle and you can't put any weight on it there's no way your ankle is in true danger but the system knows I want to be overly protective while we heal and inflammation has that effect and we understand very well how it has that effect we understand the mechanisms we understand some ways that we can interrupt that effect one of the challenges that faces anyone with persisting pain is that our pain system learns it's a rapid learner it's an effective learner we we know a lot about how it learns the the really difficult part of this whole biology of the human is that it learns really well uh the way that I would describe this scenario to people so I spent the first 15 years of my clinical life running pain education classes for people doing a pain management program through a hospital and I would tell them this story which is based on my experience traveling around Australia trying to learn how to play the clarinet a saxophone and I was hitchhiking and I was waiting out the back of a Roadhouse in Northern Territory and someone stopped and shouted out from the their Ute do you want a job mate and I thought I'd been discovered as a as a clarinet player I thought that person had heard me and thought he's good and I've jumped in the Ute and I said where's the job and he said well we need someone to drive trucks around our property in Northern Western Australia so we drove for 20 hours and we got to his property and then my job was literally sitting in the front of a of a truck that when you go to 80 kilometers an hour it just drove itself you just pressed a little green button on the dashboard and it would stay at 80 kilometers an hour and you just had to keep an eye on things and I drove for eight hours in one property but I practiced one tune the whole time and that tune was called ornithology by Charlie Parker Does anyone anyone know Charlie Parker anyone know ornithology please don't tell everyone how bad this is but Ornithology goes a little bit like this was it okay yeah great I'll do it again because you need to remember the sound one more time that's Ornithology and I played ornithology Non-Stop eight hours a day for three weeks driving through the desert sitting sideways in a truck with my elbow on the steering wheel and my back resting against the you know that thing on the um on the door for your arm that hurts your back when your back's on it for a while now I know everyone who's nodding has been kissing in the car I saw your vigorous knotter so that thing that I was there to cut a very long story slightly shorter about about three months later I was playing in a five-piece jazz band in King's cross in Sydney and we were very very good we played the 1am till 3am shift on Monday mornings and we had a there was someone in the club who was a gospel singer from the from the state and she said can I do some tunes with you said sure what should we start with and we started with Amazing Grace and she was amazing she really was she had this voice like chocolate and she did a bit of soloing then it went to the band leader on the double bass and did the soloing and I'd made my way around if anyone had ever been to a club called round midnight in King's cross you'll remember that there was an old Dodge truck prop and I made my way there I was on the saxophone not the clarinet and I sat with my legs out and my elbow resting against the steering wheel and my back on that thing and my sunglasses on playing Amazing Grace and it came to my solo and this is what happened I was in ornithology in the middle of Amazing Grace and I looked over at the band leader and he was doing this he was going I remember looking at my fingers part scared part impressed that they were going so fast and mouthing back at him as I was playing I mailed back I got sacked from that band but that experience is is exactly what happens in your brain when you when your brain keeps playing the pain tune it gets so good at it that it can hijack Amazing Grace [Music] so you might have days where you where you you're doing the same thing you've always done and one day Bang you've done nothing different and you are struck down by terrifying distressing pain that that has got you does anyone relate to that now if we don't understand pain we should conclude you're in a catastrophically structurally to catastrophic situation but because we understand pain we can now say something has caused this flare-up and it's overprotective your tissues are not really in threat because you've done this task you assist you you structure knows how to do it but something has made Ornithology hijack Amazing Grace and the system learns pain so well that what you can do pain-free just goes lower and lower and lower so you sort of have two choices well you've got three but the two that are the most common choices are that you start avoiding that pain because that's the system it's working or you try to beat it think which system you use are those two do you just slowly avoid it more and more and if you do that you would have noticed over years you're getting more and more disabled by your pain it's affecting more and more of your life it's getting triggered by things that are unrelated to your body loud noises set it off you're getting irritable you get sick and your pain comes back if you're doing the the approach I'm just going to beat it exactly the same scenario happens because it is you it's you it's your brain that's producing pain so you can't beat it it's you fortunately there's a third way and that's the most for me the most exciting thing that I've learned in 25 years of pain science is the Third Way of retraining the overprotective system that's learned how to produce pain the challenge that anyone faces with persistent pain is that their pain is overly protective you are overprotected the irony is that your tissues are safer and they feel way less safe and this situation this loyal friend that's that would have saved the life of my schoolmate had had his system worked this loyal friend has become like a raging beast that's controlling your life it's stopping you from doing stuff it's changing Who You Are we now get excited by these realities that learning in the pain system man this might not apply to you at all but if you've got persistent pain you might recognize the stories that I've told learning in the paint system got you into this mess and learning can get you out we now know there's a building body of evidence there's a really strong scientific argument that when we train the system it is possible to in the in the the phrase that we use is it is possible to tame the Beast again to bring your system into being appropriately protective now if your tissues are actually in danger if you have an inflammatory disease if you have some musculoskeletal trauma that's unresolved then it's sensible to have some pain to be able to protect you but so far we as a pain science Community we we can't see any possibility of you having persistent pain and your system not learning if you're human it will have learned so you will be more protected than you need to be and that is a really confronting and uh disappointing message in some ways on its own but right next to that message is that therefore things can be better than they are absolutely so the pain science Revolution offers hope I think it offers genuine uh realizable hope but there's a catch unfortunately there's a catch this is the Hope outstanding outcomes including recovery for many people are possible definitely possible the data tell us this the science predicts this the catch is that it takes time and it takes effort it takes a whole lot of characteristics that everyone who would come this evening has you just got to employ them and get a coach to help you employ them so this is what the paint science Revolution suggests that we we should be promoting in the in the health field about how to how to improve your life when you have persistent pain the first and I think the most challenging is rethinking pain shifting your idea of pain as being a measure of the state of the tissues shifting it into being something your brain's doing to protect you and therefore everything matters so now you have to understand your amazing protector meter this system inside you that is always judging how much to it should you should be protecting yourself this is out of a book that I wrote that you really should all Buy it's it's uh this is an idea of what we call the protector meter and on one side of this are all the things in your life that tell your brain your system is in danger and needing protecting everything in your life messages from the tissues messages from your friends your partner your kids your health professional the things you say the things you do the things you hear I saw a patient some time ago now but but he called himself Roman even though his name was Norman and I said do you want me to call you Roman or Norman so call me Roman everyone calls me Roman all right well I mean why have you seen my x-ray I said one his lumbar spine his low back x-ray was described as having degenerative changes which were actually very normal for someone of of his age but he a lot he likened them to the Roman ruins and that became part of who he was and that's sort of a bit funny right but it's tragic actually because his entire identity was one big what we would describe as a dim which stands for danger in me his name every time he said it people talk to him just told his brain your back's in danger a little reminder your back's in danger and a smart brain should just work a little bit harder to protect his back and if you if your brain's working hard to protect your back the best way to do it make your back hurt give you back pain lock up your back stop it from moving stop you moving reduce your balance make you feel a bit sick if it has to it will protect on the other side of this is what we call Sims so evidence to your brain that of safety in me not danger in me safety in me and the protective media our internal protector meter is is in a constant state of judging dims and Sims the challenge that anyone with persistent pain has and I would probably argue anyone with pain that's not following the ideal trajectory of recovery the challenges identifying what are my dims and what are my Sims how can I find them and we have a phrase that we use with people in pain which which says dims and Sims hide in difficult to spot places you've got to go looking for them this is a version I apologize for this really amateur slide but this was me on a reasonably bumpy flight from Adelaide today this is capturing uh what What's been around for 50 years is called the biopsychosocial model of health and I'm saying protection things that are bio relate to the true health of the tissues of your body including genetics and danger messages and things like that the psycho refers to the things that you know your thoughts your beliefs other feelings that you're having your fears your mood of course none of this apply if you have pain none of this applies if you're not a human and the reason I keep saying that is that it's very common for people to think yeah well my pain my pain is different my my pain is all about that and I would say well if that is truly the case then you are not a human or you're the first human ever discovered who doesn't have this contribution to pain social refers to your relationships your community your culture your access to care and pain sits at the middle I think my Mark is going to stop working and that's not working oh okay everyone we've got here the Citrix Receiver is telling us oh hang on tell your eyes out of a natural I.T guy Payne sits at the at the intersection of these three things in every human and the dims that we have evidence of danger in me and The Sims that we can find evidence of safety in me can be found in all of those places therefore the paint science Revolution says well if you can if you can rethink pain it's a really hard thing to do and you might need to really learn a lot about pain to do that then you can re re-engage with the idea of retraining your system teaching your system to be less protective teaching your pain system to be less protective I think the first thing you need is understanding and and I bet that among you there are people who are thinking no this is not me my pain is different I bet you there are people among you who are thinking well this makes a lot of sense but I don't really understand I'd like to understand more uh and msk's ready for you there are a lot of resources around and there are some of you I imagine who are thinking I've heard this before he's saying it's all in my head and you're contemplating the off posture pain is clearly in your body but 100 of the time without exception it's produced by your brain no brain no pain I used to a long time ago I worked with a rugby union Club and I think some of them there might be an exception to that rule but I think you need understanding and this is something that that is hard to get but there are a lot of resources now out there to help you gain an understanding of it you need to plan okay how am I going to go about this you need patience because it's usually slow although you might just be surprised that it's faster than you think you need persistence because it's a journey this system has learned and has adapted to protect you it's going to need some convincing to reduce that protective buffer you will need courage but in my experience people with persistent pain are some of the most courageous people I've ever met and you'll often need a good coach so that's a good clinician who understands modern pain science who understands high value care who treats you with respect and who gives you the resources to master your situation and the third thing to remember motion is lotion active stuff gradually suppresses the pain system by many mechanisms passive stuff getting stuff done to you doesn't active stuff protects you against a whole lot of other problems that we know are of increased risk when you have persistent pain passive doesn't protect you like that in an overprotective system movement is safe even when it is a bit painful avoiding movement is not in an overprotected system the risk of inactivity is much greater than the risk of activity and if you can lock those things away and get a little by little always do more today than you did yesterday but not much more retrain your system don't try to beat it so this journey back to life we put it to the survey and the survey says everyone agrees everyone who's in this in this game agrees this is the way to go about it it's not everyone sorry all of these official bodies agree and there are more but there are forces of the community who don't and I imagine the more you stand to lose by adopting this model the less likely you are to endorse it this is what I've said pain is a lifesaver pain and injury have a variable relationship pain is all about protecting our tissues danger messages matter but not as much as what they mean our pain system learns modern science offers hope with a catch the hope is life can be better for sure the catch is not without work not without time not without training rethink your pain try and understand your internal your internal protective meter re-engage your system to retrain it get all the help you need to retrain it to go on that Journey and remember that motion is lotion here's some places you can go so obviously go to msk.org.iu they've got this great booklet that was great to see that this is given to all of you it's fantastic pain Revolution is an initiative that I'm involved with um we've got resources for for the general public there things that you can read you can watch YouTube clips those sorts of things if you're really rich you could support us by donating uh only if you've got money left after supporting msk Australia tamethebeast.org is centered around an animation this is a pretty embarrassing animated me uh but trying to just reinforce some of the stuff that I've said tonight and again there's resources on there for you uh I'd like to just say again thank you for having me but um really thank you for you guys for for making the effort to come out and doing this for yourselves uh but also doing this for the community of practice I know there are clinicians in here and part of my job is to keep clinicians accountable to science and to evidence and without you guys engaging in the process that's going to be a lot harder to do so thank you very much and the last thing that I do whenever I travel is I even though it's not far from Adelaide I acknowledge that the beautiful Anna with whom I share my life is at home with our two kids single parenting and she is part of the team that allows me to come and do this I always want to acknowledge that and the Exquisite Charlotte and the adorable Henry not his real name anyway thanks thank you very much [Applause] well I'm absolutely brilliant we feel privileged to uh to again hear from you I know there must be a million questions Lauren has been very kind in saying that he'll answer a few I would suggest however firstly that we go to the microphones got a couple of microphones on either of the two aisles about halfway up and if we could try and keep questions uh from a generalist perspective as much as possible because I know there'd be lots of specific information that that you want as Lauren has indicated there's lots of resources through the initiatives that he's driven and also through what we do at msk um uh if everybody um wants to keep in touch with what we do yes go to the website or fill your details in these cards that are part of the um part of the pain God pack that was provided um so if there are any questions could we have you just go to those microphones because I could restate your question or I could stand close and you could use my mind is that going to be intimidating it's quite close isn't it the Motion Lotion does it have to be aerobic right question uh no no uh we're about to ask for a lot of money to test whether there's any different benefit for a particular painful disorder of whether you go aerobic or not aerobic uh no my short answer is no in fact it ideally it's it's true movement but you even get benefit from imagining movement so I mean this is one of the really remarkable things that when your brand when walking is the best thing but there are conditions let's say of of Upper Limb conditions where there's no arm to move about making your brain operate that arm in a sensible way has analgesic effects so even the brain sending movement commands has some effect on the danger system and and that's reasonably well understood how it does that yeah kitchen over here hello I've got arthritis and I used my understanding of pain to very very very slowly start with five meters of walking and I I now do several kilometers of walking to the point where rheumatologists look at me and say there's nothing wrong with you you're on too many drugs they take my drugs down and the inflammation comes back is that my brain not controlling the inflammation or am I oversimplifying it oh that's a really complex question actually um I I would imagine that that I presume it's like a rheumatoid family about Russia um the immune system in people like you and me is overly overly active right so it's it's overprotective and the reason the question is complex is that I just can't remove the nervous system from the immune system so I think they're really well related but I think that that through partially lack of lack lack of the draw bad luck of the draw and genetics means that our our immune systems are overly inflammatory and those drugs are able to keep a handle on that uh I just kudos to you for for going from five meters to several climb and that's just outstanding but the fact that you get inflamed again when you take down your drugs just tells you that that the protected meter in for the immune system's gone over and maybe the reduction in drugs needs to be smaller or maybe you you need more Sims there uh yeah I don't think you're oversimplifying it I think that uh the reality is that it's complex yeah but well done it's fantastic it's another question Laramie you mentioned um the importance of a good coach I also wondered if you could comment on the value of a of like peers who share positive stories in relation to pain recovery and so on and and the value of that within your sort of schema yeah that's a great question Jen it wasn't planted but uh one one strategy that we're running pilot trials on now so this means that we're we're testing whether we can make this work is that we we use graduates so people who have learned a lot about pain feel like they've got a really good handle on on their Journey on their protected me to manage it well and they become a coach for a new patient so they're not health professionals but we do give them a bit more training and we don't actually know whether that works or not we haven't got far enough on the on the research but there's a great deal of research to support peer support and community of Engagement as well as a community of practice so this this actually also applies to clinicians who work with with people with persistent pain we know that they work better and have greater well-being if they're in a community of practice and I think that just applies it in in life in general and in fact this is how the brain works um you know we these interactions we have with other with other people uh are very important and I think the peer-to-peer support network we've got a lot of credibility uh if if you've been there yourself right uh does that do you agree yeah cool that's another question third question for the evening yes Laura you I'm not ahead at everything you say bar one thing to naught and you always you said always do more than you did yesterday so how do you manage that when if you do something it's a three-day recovery yeah how do you get off the couch or out of bed the next day and do more it's Madness yeah yeah great great question and your question speaks to the corners that I cut in what I was in what I was saying so the first step will always be to find your Baseline uh and and a lot of the time we do this we talk about finding your flare-up line and that can be a real Challenge and and for some people getting out of bed causes a flare-up uh and I've seen people I've seen many people in that situation so the background to that statement is probably important to make that statement more accurate and and the background is once you've found your your safe Baseline then we can apply that principle always do more today than you did yesterday but not much more but we also don't adjust apply it to for example a movement what we have to apply it to is exposure to all of the dims so one thing that that might help to sort of give some meaning to that idea is that that you might be traveling well in a in a loading perspective right so let's say you're walking if we go back to your example and you get to one kilometer of walking and your next increment is is 1.1 kilometers and that flares you up all right and that view might be information someone else that might be you you struck down in bed with severe pain for three days or a week or whatever then what we might have to do is to find another Sim or a group of Sims to add into that scenario so that the dims of the 1.1 don't take you over the threshold so when we say always do do more today than we did yesterday what it means is always do more of of the entire package not just a movement but of all of the dims that you can find and that's where where you've gone but that's that's where the idea of a coach might be really important to help you find these balances and and move those things around I'll take your point your Point's really great and I and I really hope you are now nodding with everything uh on the background of that that it's not a case of now going do more tomorrow than you did today as of tonight because what you what you're doing today might already be over your Baseline you have to find that spot first can you give me some sort of night or shake or it's a night I've got a knife over here hi um my name's Jessica I am para athlete and also diabetes educator recently about six months ago I cut sugar all together out of my diet I have more than 10 grams a day of carbohydrate I've gotten rid of half of my MS symptoms and I don't have probably maybe five percent now of the pain that I had before can you explain to me the relationship between glucose or sugar and pain uh no but I can I can offer what might hopefully sound like an educated response to that really interesting observation we do know that simple sugars are inflammatory we do know that Ms is an inflammatory condition in the nervous system and we know that inflammation makes pain worse uh the the challenging thing we have in the science space is that when we do randomized controlled trials which is the gold standard and we put all of this group of people let's say all this group with persistent paint into a group and say right off sugar and another group and we say all right we're just going to make you think you're off sugar because that's what we have to do then the results don't come out as compelling as the story that you're telling me but it might well be that there's a group of people there who fit the same scenario as you're describing the challenge that we have as scientists is working out how to find those people how to how to do tests that will tell us yeah they will respond to a no sugar diet there's certainly in my view very sound science to explain why that might happen for you from an inflammatory inflammatory perspective there's also I mean you can't do that without knowing you're doing it and there's a lot of there's a lot of good stuff in taking control in in maneuvering your system and having confidence they're all Sims so I imagine how a scenario as good as you're describing it's probably all that stuff together yeah pleasure another question here um hi Laura I'm just wondering if you could say anything about the role of pain relieving medication for people who are trying to get retrain their brain and yet get moving with significant symptoms is is there a role for that or is it out of bounds it's a really a really tough question because my answer has to start with I'm I'm not a medical doctor nor a pharmacologist um my view is in persistent pain there there are some data to suggest that in some types of persistent pain there are medications that are that you can use for a while that take the pain down a little bit um when there are conditions that there are there the system's not working properly then there are really important drugs that change that so change inflammation for example and your example was great of what happens when you go off that and and I take drugs for mine my condition um but when the drug is for analgesia the the harsh reality is that we haven't really got a drug that has very impressive long-term effects your question was about should you take it while you start to train your system uh I don't think you should take it for for that confined purpose but I'm completely accepting of there are situations where if you don't get some rapid relief uh you're going to be more trouble for whatever reason and I think that that if we know there's a mechanism by which we can give you some transient short relief then we should we should probably do that uh the the massive challenge we have is that our best drugs don't last very long for pain and I guess to finish that the there's this statistic called number needed to treat and all that means is that if you if you gave someone a drug to get 50 drop in pain the number needed to treat tells you how many people you have to do that for one of them will get the response but wouldn't have got it on a good placebo now if you can't follow that the number needed to treat for complete relief of pain of cutting your head off is one which means that everyone who cuts their head off will have pain relief and no one who thought they would will have it the the best drug we have for neuropathic pain has a number needed to treat of so the lower the number the better right has a number needed to treat of about five or six for neuropathic pain an intensive education and exposure program uh has a number that you need to treat about three and a half so uh that suggests that it's more effective long-term to do the ladder now those two things haven't been compared in a randomized controlled trial I'm taking data from two different pools and pulling them together so I'm always reluctant to say no because I think it saves lives sometimes but I don't see any mechanism by which it will solve the problem just the last two questions this one on this side and we'll finish up there thanks hi my name is Adam um I'm a I've suffered a spinal cord injury a couple of years ago firstly I'm lucky enough to have a a good coach who I can actually see here at the moment Andrew how long does it normally take for patients generally to go through the motions of finding uh their triggers for their pay and neuropathic pain Etc what would be the average time frame that someone would expect to find their triggers that's a tough question Adam uh no idea it's so variable in I would only really go on my own clinical experience and for the last 15 years I've seen four or five patients one-on-one consults a week so I'm you know there are clinicians in this room that I know who would have a better cohort but I would I would always say to people uh months to years if they've had a long history of persistent pain if you've had injury to your nervous system particularly the central nervous system then things are way more complex because the the actual Hardware has been damaged so I think that might be even more challenging however I've I've had patients who overnight literally overnight I've had other patients who I might see 10 years later who who had a really tough Journey for eight years and then obviously patients 10 years later who are still in trouble yeah I want to be really transparent with that so I wish I could give you a better idea the more honest answer that question would be longer than you wished yeah thank you all right the last one over here thanks Ellen thank you thank you for really inspired I've got a student which I'm hoping you'll be able to answer which is imagine this lecture theater was full of people with very very low health literacy um a presenter who's far less entertaining than yourself people that don't speak much English and you want to start them on their journey and start with the understand bit would you have two or three really inspiring messages that can help us rope in people so that come along the journey with us because getting them to that top level of the understand but it can be such a challenge and we know that if they persist and have all the other supports hopefully some of them will get to the end but getting them in that first little part of the journey so it's probably challenging but yeah oh it's it's massively challenging um and we look over the last 10 years we've we've spent six million of the Australian government's dollars on that sort of question and we're slightly closer to answering it than we were but and that's where stuff something like pain Revolution we're really focusing on that and I think I think really it's a case of us all singing to the same song sheet having a lot of a lot of Pathways different types of media short sharp Clips having no one in in your your sphere as a patient you know or someone in pain in your sphere who doesn't understand modern science so you imagine the challenge that we Face to get to that situation a typical medical degree will have four hours of pain science training in it uh yet sixty percent of the patients on average that see a doctor are seeing the doctor for pain so you know you're talking to you're talking to the converter but at the same time I I think that's this is just one one form of access right uh well what what we do know from empirical data is that most people underestimate the capacity of other people to understand modern pain science uh by a long way testing a five this this time the best thing we now know that people from uneducated and any literate to educated people change their understanding of pain just a little bit and watching that once just a little bit so I guess more I would I would respond by saying uh we keep going because we'll get there I reckon thanks Helen Laura Moore on behalf of muscular Australia thank you very much for what has been an inspiring speech and obviously you know we're all part of this journey now and really thank you very much for giving us your time on behalf of muscular School illustrator thank you very much thanks a lot thank you very much

Channel: Musculoskeletal Australia

Views: 221,230

Keywords: Pain, Lorimer Moseley, chronic pain, persistent pain, musculoskeletal, arthritis, back pain, fibromyalgia, neuroplasticity

Id: lCF1_Fs00nM

Length: 83min 10sec (4990 seconds)

Published: Wed Dec 05 2018