Contemporary Pain Education

Contemporary pain science has revolutionised how we understand pain and persisting pain in particular. There are entire textbooks and university courses dedicated to pain science and its implications, but perhaps the minimum number of key things that health care professionals should know is five:

1. Pain most often serves to protect us and promote recovery, not to provide a readout of tissue health.
2. All pain is real no matter what is causing it.
3. The degree of protection offered by pain changes moment to moment and the longer you have pain, the more protective it gradually becomes - the processes that underpin pain (let's call them 'the pain system') become more sensitivie. Once the system becomes 'uber overprotective', the effect of pain flips - it stops us doing the things we need to do; it prevents recovery.
4. There are many factors and processes that contribute to pain.
5. There are many ways to change pain and 'retrain your pain system' back to a normal protection setting.

This is the key trigger in my own journey towards integrating effective pain science education into care pathways. In the mid 1990s I found myself really frustrated with this - there is compelling evidence that chronic pain is associated with increased sensitivity of protective systems, there is compelling evidence that activea nd psych therapies and self-management are the best treatments we have, but THEY MAKE NO SENSE if we still think pain is providing a readout of tissue state. So, I was one of a few people thinking this way at the time, all motivated in one way or another with the sensible prediction that if people knew WHY those treatments were the best and it does not in any way shape or form undermine the realness, intensity or horribleness of their pain, then they might just 'buy in'. This is the platform from which explaining pain emerged. The better we get at providing consistent, compelling, engaging and memorable education, available in a range of formats and from a range of sources, on how pain really works and how the pain system responds to training, then the better buy in we will get. On a personal health professional level, my frank advice would be to become a great and inspiring educator; get your knowledge up to speed; get curious yourself about how pain actually works; practice the curly conversations with consumers who are hearing 'it's all in your head' when you are not saying that at all; link up with colleagues from across disciplines to learn from each other and to support each other in bringing contemporary understanding out of the journals and textbooks straight into your clinic - it is tough to be at the front end of transformation so you might as well find other people doing it; see if you can link up those with a lived experience of recovery through knowledge and empowerment with those who are facing the daunting journey from the front end. Be brave, bold and open minded about it because the best data we have suggest that health professionals including psychologists don't find it any easier to switch their understanding from old, disproven models of pain to modern models of pain, than consumers do. In some ways, us health professionals have more to lose.

Great question. I have been researching this in one way or another for 25 years and we are getting better at it, but still have a way to go. It is difficult to know how best to summarise all that work here, but some key discoveries along the way include: education is all about learning, yet most health education has been about the provision of information. Our data clearly show that when people actually do learn a contemporary understanding of pain, they tend to have much better outcomes. Our data also show that the best educators (until recently at least) were getting about a 50% hit rate. That is, 50% of people were 'provided the information' but didn't get a shift in knowledge. That discovery made us double our efforts to get better answers to the question you have asked. The last 10 years has seen a series of iterations of what we call 'key' or 'target' concepts that seem to be important to cover when it comes to pain education. I am currently working with communications and advertising experts to break it down more without losing the key bits - that is a work in process so 'watch this space'.
What we do know is that helping consumers understand does require you to understand it - and don't take that for granted because most health professionals don't and our early work in 2003 ish showed that psychologists were lagging behind most other health professionals on this - that was still the case around 6 years ago but I really hope and expect that it is changing slowly. We also know that you can make the content fun, engaging, relevant and that you can employ proven learning strategies to help it stick. The tough news though is that, like every other clinical skill, you need to build your own knowledge, skills and practice time to improve.

I really appreciate this question because there is a common myth out there that elite performers - athletes, muso's, dancers etc - are somehow 'unhuman' when it comes to pain. In my experience with elite athletes, pain literacy is similar to the rest of the population, but the tendency to view pain as a readout of tissue state is probably more rigidly held. This might be because the health team around elite athletes tend to hold this view pretty rigidly too. There are of course exceptions to this rule, and I am basing this on my experience over the last 20 years - there is not much empirical data out there that I know of. With regard to what might enhance/advance pain education in these contexts, I think it is through the athletes themselves - particularly in team sports - when they return to high level play after a long period and attribute it to their enhanced understanding of the problem, this is influential around the playing group. Also, if coaches and management see the performance dividends of including quality pain education in rehab, then they are also likely to endorse and integrate it into usual practice.

A really interesting question this - both for its intent and its wording. First to its intent - there is probably a stronger relationship between the duration of a persisting pain state and how long it takes, or how easy it is, to get back to a normal life, than there is between the diagnosis itself and how long or easy these things are. We can also think about the complexity and context of different presentations. As a pain clinician, early on I found that I had least to offer people with complex regional pain syndrome, brachial plexus avulsion injury, spinal cord injury and headache. The challenging nature of those conditions was important in triggering my own interest in research - I spent years trying to develop better approaches to treating these conditions (actually - not for headache but for the others). Now I feel much more confident with those conditions, from a clinical perspective. Second to the wording of the question. I think this speaks to a journey I have taken and I think many are taking, although it is a tough journey to take as a clinician or scientist - that is the idea that pain is an entity that can be resistant to therapy. Hang in with me here because I think this is important and not just semantic. We tend to consider pain as though it is a thing that exists within but separate to, the sufferer. I think this is why the idea that 'the pain' is resistant therapy makes sense at all. I think pain is a conscious state that is being produced by the organism in order to motivate beneficial behaviour. I think it doesn't exist separate to the sufferer but is simultaneously a state and product of the sufferer. I have held this opinion for decades and spend some time thinking about it, but even still, I struggled to write the first half of this answer without inferring the same stuff. So it is tricky indeed. To conclude this verbose answer - regardless of the pain state, I think providing as much understanding of the problem as we can is an important part of intervention, which means the more complex situations will be more challenging. So will the situations that have clear disruption of the pathways in the nervous system that usually transform or transmit nociceptive data - eg a frank injury or disease to a peripheral nerve, a tumour or disease that disrupts central nervous system structures, a highly inflammatory state that messes with danger detector thresholds and behaviours - all these things make treatment more challlenging.

I believe that there are psychological factors involved in every single pain episode. Some will immediately reject that proposal, but perhaps less so if we consider that psychological factors are those factors associated with the storage and processing of information by the brain. Take this example - you stub your toe but you are about to get run over by a bus: psychological factors are involved in you not having toe pain until you are safe from the bus. Complex regional pain syndrome is not different in this way to every other pain and persistent pain in particular. One way to understand why we can confidently conclude the psychological factors may be contributing to pain is to consider pain a protective response that occurs at the very highest level of the organism - in consciousness. Therefore, anything 'below' that level that is relevant to protection can influence pain. Researchers around the world are busy investigating a range of factors that modify pain and they include previous experiences, thoughts, understanding of the cause, injustice, worry, expectations of the future, pictures in your mind of what the body looks like under there etc etc

With respect, honesty, humility and patience. There are several 'skill based' approaches that most readers will be familiar with and I am no expert in. My own view is that the key variables are those four.

Any pain can be conceptualised as the organism's approach to an unsolved problem - to protect the back. There is overwhelming evidence that a range of factors often contribute to anyone's pain. Back pain is no exception. It is not at all surprising for a pain scientist to hear stories like this - it makes total sense and the previous question speaks to it - it is all about total evidence suggesting protective behaviour is required vs total evidence suggesting it is not. We talk about 'DIMS' and 'SIMS' - evidence of 'danger in me' vs evidence of 'safety in me'. Add into that complex (altough ultimately functionally simple) situation the reality that most - yes you read that right - most back surgery for pain is not indicated by sensible clinically reasoned evidence - then the scenario is even more sensible. Unfortunately in many states in many countries, being recommended surgery for back pain is based on outdated and disproven diagnostic thinking, so it is not a very reliable sign that someone has a particularly vulnerable or fragile back. We have a long way to go......

In any jurisdictions, this is no longer the case. In jurisdictions that place evidence, consumer outcomes and risk reduction at the heart of their decision making, surgeries are becoming less common. However, the determinants of what care consumers receive are not limited to the best options for them. This doesn't just apply to surgery - we could ask the same question with regards to active, self-management strategies being overlooked in favour of passive, professional-delivered interventions. Health care is complex and has many stakeholders, not just the consumer. Sometimes, surgery is the best thing to do. Often it is not. Clinical guidelines the world over put these three things on the top of the list for the prevention and management of a range of common chronic pain problems: education, active and psychological strategies, self-management skills. According to evidence, they deserve to own the podium.

Fibromyalgia is a tricky condition to understand and it is associated with a range of signs and symptoms other than pain. Some make contemporary approaches to recovery challenging - for example the 'fibro fog' - trouble concentrating and doing demanding intellectual thinking makes pain education more challenging. However, taking this into consideration usually means elevating your respect, honesty, humility and patience as a clinician - the techniques that are effective for chronic pain - GOOD contemporary pain education, CBT, exercise-based stuff, sleep management etc etc - are still the way to go.