What is the future of pain management?
This is a blogpost from our teacher in Neuroscientific Pain Modulation course, Lars Avemarie. This course is held in Gothenburg, Sweden the 13-14th of October. You can buy your ticket online in our Anmälan button. If you have any questions regarding the ticket or about the course, do not hesitate to connect with us.
__________________________________________________________________ Many health professionals believe that when patients have pain, it means that there is something is wrong in their body, in the place where they hurt.
This core belief is based on what is popularly called the “biomedical” model of pain, that postulate that all illness and symptoms arise from an abnormality in the body (1). It leads the health professionals to the solution logical solution, that if they remove the abnormality the patient will be pain-free.
Unfortunately, this conclusion is wrong, especially when pain lasts longer than the normal healing time. Both modern pain research and neuroscience has shown us that, when you have pain, it has more to do with your brain and nervous system (2), than the actual state of your tissue, or any abnormality in your tissue.
Pain is not as simple as health professionals believe. Pain is a multifaceted experience that is produced by multiple influences and factors (3). Pain has a lot more to do with your brain and nervous system than with your muscles, tendons, and joints. A testament of the major role the brain has one the pain experience is phantom limb pain. Phantom limb pain is when you have pain in a limb that has been amputated, often because of an accident or a disease. Phantom limb pain is intractable and disabling in almost a third of cases (4).
As shortcut into understanding what the last 30 years of pain research and neuroscience have shown us, is a statement made by the legendary Danish professor Dr. Finn Bojsen-Møller: “It is fundamental to the body’s self-protection ability that pain begins before reaching the breaking point. Without the painful experience, there is no possibility of keeping the body and tissue intact and whole (5).”
We are now in a position when we never had more knowledge about pain, and there have been a substantial shift in what we know pain to be. We should let our clinical reasoning and treatments be informed by all of the pieces of this complex jigsaw puzzle, that pain is. We have to stop ignoring this new research-based view of pain because it does not conform to our choice of modalities, treatments or our ideology and worldview. We should use all the pieces of the jigsaw puzzle, we have right now. Not only use our favorite jigsaw pieces, which we had 10 years ago, or equally wrong, we shall not base our treatments upon how we wish the jigsaw puzzle may turn out to be in 10 years.
An essential part of a modern pain management approach that is informed by modern pain research and neuroscience that unfortunately often is missed and overlooked is knowledge of pain modulating factors. That being knowledgeable about what multiple factors that influence and modulate pain.
An in-depth review of the many different factors which modulates pain can serve as a strong and fundamental starting point for an updated approach to the treatment of patients with pain. Prof. Moseley stats that pain modulator fit into three categories: prioritization, meaning and transmission/processing (6). Scientific knowledge of what factors modulate pain and the strength of the modulation and interaction of the modulating factors can serve as a great stepping stone to develop better clinical reasoning informed by modern pain research.
What health professionals know about pain modulators is however often shallow knowledge, and they unfortunately often lack a comprehensive scientific perspective on pain, as noted by the Institute of Medicine (7).
“Unfortunately, many health care providers lack a comprehensive perspective on pain and not infrequently interpret the suffering of others through their own personal lens. Misjudgment or failure to understand the nature and depths of pain can be associated with serious consequences—more pain and more suffering—for individuals and our society.” Relieving Pain in America, Institute of Medicine
So the future of pain management is to use this gold mine of scientific knowledge we have about pain to inform our clinical reasoning, and to use all the current available pieces of this jigsaw puzzle that complex musculoskeletal pain is.
As Prof. Moseley says, "out with the old, and in with the new" , and the new stuff is really cool…
1. Wade DT, Halligan PW. Do biomedical models of illness make for good healthcare systems? BMJ. 2004 Dec 11;329(7479):1398-401.
2. Moseley GL. Reconceptualising pain according to modern pain science. Physical Therapy Reviews. 2007; 12(3):169-178.
3. Melzack R, Katz J. Pain. WIREs Cogn Sci. 2013; 4(1):1-15.
4 . Giummarra M. Augmented reality for treatment of phantom limb pain-are we there yet?. Lancet. 2016 Dec 10;388(10062):2844-2845. Epub 2016 Dec 2.
5. Bojsen-Møller, F. 2001. Bevægeapparatets anatomi. 12th ed., Denmark: Munksgaard.
6. G Lorimer Moseley. Teaching people about pain: why do we keep beating around the bush? Pain Manage. (2012) 2(1), 1–3.
7. Relieving Pain in America, Institute of Medicine, Committee on Advancing Pain Research, Care, and Education. National Academies Press, 2011