EP 15 years in: historical and theoretical underpinnings

This is my second post based on a perspectives piece David Butler and I wrote for the Journal of Pain. You can get the gist of it by just reading the bolded sentences.

It is some time now since John Loeser adapted Engel’s biopsychosocial model to fit it to the lived experience of chronic pain. From my perspective as someone who had experience on both sides of the chronic pain fence, it seemed to be focused on the impact of pain on the life of the sufferer. There is a bucketload of evidence to support that now – from Fordyce’s work on behavior therapy to Keefe’s on coping skills and Vlaeyen’s on fear avoidance – that one’s life is modulated by much more than the pain itself seems to me do be a done deal. This wide range of cognitive-behavioural therapies (CBT) share common theoretical assumptions about the interactions between environmental events, cognitions and behaviours. Not least among these is the idea that symptoms and behaviours can be cognitively mediated and can therefore be improved by modifying problematic thinking and inaccurate beliefs.

Perhaps a controversial point we raised in the article was this: that somewhere, between the establishment of the biopsychosocial model and the rapid rise of CBTs as the dominant non-pharmacological treatments for chronic pain, a shift occurred towards the idea that ‘pain is unavoidable – suffering is optional’. CBT aimed to manage pain, rather than to change it. The coverage of pain-biology related material in the CBT literature seemed to focus on this idea of ‘pain is now unavoidable so it is now time to learn how to cope with it. I found this situation quite confusing – ‘pain can be modified by our beliefs and behaviours’ seems inconsistent with ‘pain cannot be relieved by modifying beliefs and behaviours’.

I also think that this approach of ‘conceding that we can do nothing for pain’ seems inconsistent with what we now know about the underlying biological mechanisms of pain – that pain is fundamentally dependent on meaning. This understanding of pain, that it reflects an implicit evaluation of danger to body tissue and the need for protective behavior, was foreshadowed in the gate control theory[1], articulated more fully two decades ago[2], but is only recently gaining significant traction.

I wonder if this journey has suffered a hiccup recently with the widespread endorsement of ‘central sensitisation’ – a ‘disease within the CNS’ rendering pain relief impossible. I think this view contrasts with fundamental concepts of pain being something one feels and the inconsistent link between brain changes and clinical presentation[3].

Perhaps ironically, EP provides very strong justification for taking a CBT-based approach to rehabilitation and that is where my journey with EP began – to convince people that their pain was dependent on a potentially vast mix of inputs that suggest your body is in danger. In the last post on this I touched on my astonishment at realizing that half the people doing a full-on CBT programme spent the whole time thinking that they were the only one in the group who had real pain. In the article, David and I contend that the absence of strong biological justification for CBT might have contributed to it being no more effective for decreasing pain and disability in people with chronic pain than other active treatments are[4] (although, importantly, CBT programs on the whole do relieve pain[5]). It is deflating news that, in a recent Cochrane overview of multidisciplinary pain management programmes, the long-term effects of CBT for chronic pain came out somewhat underwhelming[6].

But is this really all that surprising? Why might someone in pain engage with treatment aimed at their thoughts, beliefs and behaviours, if they believe their pain is an accurate marker of tissue damage or of another disease process afflicting their spinal cord and brain? It seems to me that scientific evidence compels us to extend the idea of helping people live well with pain, to the possibility of helping them live well with less pain, or perhaps without any pain at all.

So, the theoretical underpinnings of EP are the experiments on animals and humans that clearly show pain to be modulated by a wide array of variables. EP is grounded in (i) the notion that pain is a conscious feeling that motivates protective behaviour, not a discrete biological event that occurs when tissue is truly in danger, (ii) the relationship between true danger and perceived danger is modulated by the sensitivity of our protective system, and (iii) understanding these things decreases perceived danger and therefore pain, and positions a biopsychosocial approach to rehabilitation as the best approach to rehabilitation.

About Lorimer Moseley

Professor Lorimer Moseley is a clinical scientist investigating pain in humans. After posts at The University of Oxford, UK, and the University of Sydney, Lorimer was appointed Foundation Professor of Clinical Neuroscience and Chair in Physiotherapy, The Sansom Institute for Health Research at the University of South Australia. He is also Senior Principal Research Fellow at NeuRA and an NHMRC Principal Research Fellow.

He has published 190 papers, four books and numerous book chapters. He has given over 120 keynote or invited presentations at interdisciplinary meetings in 26 countries and has provided professional education in pain sciences to over 9000 medical and health practitioners. He consults to governmental and industry bodies in Europe and North America on pain-related issues. He was awarded the inaugural Ulf Lindblom Award for the outstanding mid-career clinical scientist working in a pain-related field by the International Association for the Study of Pain, was runner-up for the Australian Science Minister’s Prize for Life Sciences, and won the 2013 Marshall & Warren Award from the NHMRC, for the Best Innovative and Potentially Transformative Project.

Link to Lorimer’s published research hereDownloadable PDFs here.

References

1. Melzack, R. and P. D. Wall (1965). “Pain mechanisms: a new theory.” Science 150: 971-9.

2. Wall, P. (1994). Introduction to the edition after this one. Editorial. TheTextbook of Pain. P. Wall and R. Melzack. Edinburgh, Churchill-Livingstone: 1-7.

3. Sullivan, M. D., A. Cahana, S. Derbyshire, et al. (2013). “What Does It Mean to Call Chronic Pain a Brain Disease?” The Journal of Pain 14: 317-22.

4. Williams, A. C., C. Eccleston and S. Morley (2012). “Psychological therapies for the management of chronic pain (excluding headache) in adults.” Cochrane Database Syst. Rev. 11: CD007407.

5. Morley, S. (2011). “Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges.” Pain 152: S99-106.

6. Eccleston, C., A. C. Williams and S. Morley (2009). “Psychological therapies for the management of chronic pain (excluding headache) in adults.” Cochrane Database Syst. Rev.: CD007407.

Comments

  1. I was hoping for a response. Explain pain often works well when working with patients in persistent pain and seems to work well with patients prior to having surgical intervention in minimizing the risks of developing persistent pain.
    I realize there are times when explaining pain to a patient in pain is counterproductive (if not done well or if there are other pressing needs for the clinician and / or the patient).
    Could you provide a framework for this?

  2. Hi Lorimer, thanks so much for your important work. The Explain Pain books are extremely helpful in my daily practice with patients and the research work and articles you have written have provided me with a framework in which to work with many of the patients I see with complex needs. Having read your review of what Explain Pain is and isn’t, I am looking for some clarification. Explain Pain is not simply saying move despite the pain, it is providing the conditions in which the clinician and the patient feels that it is safe to move. Would this be accurate? The paradigm shift that pain is not an accurate indicator of tissue damage is a starting point. I really appreciate your continuing emphasis that it is not just caring about the process of explaining pain but that caring about the patient in pain is the key. BIM is a brilliant venue. Thanks again.

  3. Hi all – John – sorry I have not responded to your email – I can see you are keen to get a response from me however! Fair enough of course. Let’s not do it here tho’, it is unrelated to this post. Stay tuned re email.
    Thanks to others for contributions – I wrote my response when there were only three but posted it after some of the others -did not mean to ignore!

  4. insightful, honest, thought-provoking, excellent…….. essentially no change from the usual. thanks again Lorimer!

  5. John Quintner says:

    Lorimer, in an important Topical Review recently published in Pain, you and Johan Vlaeyen argue that chronic pain is a conditioned response “to the multisensory and meaningful events that routinely coincide with, or preempt, nociceptive input.”

    You go on to argue that “imprecise encoding of these multisensory and meaningful events leads to overgeneralization of the response, such that an adaptive and protective process becomes maladaptive, distressing, and disabling chronic pain.”

    Essentially, you are proposing to extend the “associative learning framework of pain-related fear to an approach that has pain itself as the response, rather than a stimulus.” I think everyone would agree with you that (the experience of pain) is indeed a response.

    But can you provide evidence that any of our sensations (including pain) can be conditioned (as opposed to an unconditioned) responses?

    Reference: Mosely GM, Vlaeyen JWS. Beyond nociception: the imprecision hypothesis of chronic pain. Pain 2105; 156: 35-38.

  6. Folks you have got to read this article INCLUDING the comments from people below the article:
    http://www.huffingtonpost.com/kat-gal/what-to-never-say-to-people-who-suffer-from-chronic-pain_b_7633418.htm

    l wish I had it in me to give thoughtful, scientifically correct, empathetic, effective comments to all the misinformation. The best thing to do might be to just say nothing and give a link so folks can buy “The Explain Pain Handbook.”

    How would you all answer some of the comments made in the article and the responses??? Here is an opportunity to educate (and stir up a hornets nest…people are passionate about their pain).

  7. Lorimer says:

    Thanks for commenting folks. John – I take your point here, but I would contend, on the basis of current evidence at least, the BPS is a bit like democracy – it is full of problems, but it is the best system we’ve got (this should be cited – probably Churchill – but I don’t know it). The idea of flipping the model is a sound proposal in my view but, as EG points out, that will be tricky indeed. I don’t endorse the hierarchy in the BPS that you seem to endorse – that it implies bio is first or biggest, then psycho then social. I suspect you, and you would not be alone here, would see social as first or biggest right? I have tended to throw them all in as important to consider, each influencing the final pathway to different extents depending, ultimately, on the strength of their neuronal substrate (I can here Mick Thacker lamenting my neurocentricity here – perhaps you will be too John). A final word on BPS – I actually find the B bit offputting because the P and S bits are also, in my view, biologically mediated. Perhaps TPS would be more appropriate – tissuepsychosocial. Pinot noir conversation perhaps.

    To EG – interesting angle indeed. I need to contemplate that more but I certainly resonated strongly with one aspect of it – that of the vested interests we all have. I am a card-carrying believer in bias. I reckon it is unavoidable. To imply that I might be seeking (in your words) “the same prize that the current top dogs are enjoying” is, in my view a fundamental truth (although I don’t think those ‘dogs’ are necessarily ‘top’ – perhaps they are in one system of measurement – their influence over the lives and clinical pathways of people – but I do not seem them as above me on any other scale I care to endorse. This is not critical at all, just me voicing my view that that one system of measurement is not the most important one to me). I think we are all driven by protection – or what I prefer to describe as ‘to love and be loved’ (cringe-worthy i know). I think there is an alternative explanation for some of the resistance too – you state that “Some accept this challenge willingly, because they love getting to the truth. Most prefer safety. There’s a clear lock on the whole system. Fear is the one critical element.” I don’t think it is fair to conclude those who do not accept this challenge willingly are those that do not pursue the truth – this is where the true complexity of our biases makes interpreting behaviour and indeed thoughts and beliefs really difficult. I completely understand however, and this I think is one of your main points, that if one perceives anything to be threatening, regardless of whether it actually is or not, then one will seek to protect against it. That brings me full circle to your ultimate point – that my own journey reflects seeking of protection (or my cringe trigger ‘to love or be loved’). The final clarification I wish to make on your point is that I do not think these ideas are ‘mine’. These ideas are those that I think, with my own resources and the influences upon me in action, are the best ones to support. That decision is, in my view, fundamentally dependent on my own values, skill set and….potential to benefit from supporting them. This, in my view, illustrates that I am human. Your encouragement and reminder to intentionally remain cognisant, to endeavour to ‘see’ all the elements in play, is much appreciated, so thank you.
    Finally, John W – my response to this behind the curve-ness and the possibility that things will change – things are clearly changing already and Louisiana will surely be part of that change sooner or later. One need only look at the rapid commercialisation around the world of people with their own EP triggered products, the shift in balance between commercial and non-commercial considerations, to see that the powerful hand of the market economy is joining in the arm wrestle. I expect with that strength behind it, things will move more quickly from herein.

    John Quintner Reply:

    Lorimer, BPS is not a scientific model. It is better seen as a framework for discussion or an aide memoire between clinician and patient. I think this was Engel’s original intent. Unfortunately, pain medicine has tended to privilege the biological approach to people in pain, whilst paying lip service to the other two domains. The socio-psycho-biological approach can work on three levels: WHAT IS HAPPENING IN THE PERSON’S WORLD? – WHAT IS HAPPENING TO THE PERSON? – WHAT IS HAPPENING IN THE PERSON’S BODY? Carr and Bradshaw argue this case quite convincingly. Yes, it is tricky!

  8. I like the idea of working through the stages with someone with chronic pain.
    First goal to help them live better with their pain, second to live better with less pain, and then thirdly living better without any pain.
    It can easily be argued that no one has yet fully achieved the third goal so we all fit somewhere on this spectrum.
    Managing chronic pain is really the fundamental challenge we all face. Life.

  9. John Ware, PT says:

    So then, according to the data showing that it takes clinical research on average 17 years to become incorporated into widespread clinical use, we should be celebrating the extant implementation of EP concepts in PT clinics across the globe in mid-2017, no?

    I know of two PTs within a 30 mile radius who even know what EP is. One of them is me. Why are we so far behind the curve? That or the next two years are going to be quite momentous for PT in southeast Louisiana.

    KW Reply:

    Are there any physicians in the USA that know about EP?

  10. “Some accept this challenge willingly, because they love getting to the truth. ”

    EG,
    That’s the impression I get from Dr. Moseley. Truth can and will step on many toes. Fear of retribution and loss of income are quite real….I’ve seen it in my own practice. Moseley is courageous in my opinion in that he consistently promotes the truth about pain even though lots of folks don’t want to hear it (and oddly enough may be harmed by it from an income perspective). It may be naïve to believe this but I’m still hoping that if one believes and does the right thing that somehow, someway, there will be a way to survive and make a living. At least one can sleep at night knowing they are seeking the truth and trying to do the right thing.

    Moseley is a true hero IMO. It takes a lot to go against popular thought, secondary and tertiary gain, and just plain rude and nasty people…..and not give up. There is satisfaction in getting towards the truth, even if the money is not great. Somehow I think he will survive even if others ignore or attack him. He’s too darn smart. His concepts also explain many difficult situations we see clinically and seem to be able to explain pain in a way that makes sense.

    I would love for Dr. Moseley to work on the second most difficult thing to explain behind pain: The thoughts and emotions of women! I just can’t grasp that concept. The book could be called “Explain Women.” That would certainly require a socio-psych-biologic perspective. Man would that step on some toes. : )

  11. Hi Lorimer,

    Your models for chronic pain pose a threat to those who currently hold the top spot in the medical and therapy worlds. The top dogs stand to lose a lot of status and income if they open themselves up to the evidence you have provided. I think everyone here understands that much.

    Since status and income provide safety, how can you expect professionals to open themselves up to feelings of danger? Such feelings of threat could well lead to all manner of health issues, including the possibility of chronic pain itself.

    What you’re asking doctors and physios to do is make themselves more vulnerable to danger, and hence, suffering and pain.

    Some accept this challenge willingly, because they love getting to the truth. Most prefer safety. There’s a clear lock on the whole system. Fear is the one critical element.

    Say one day your ideas get world-wide acceptance and praise. Say this results in a huge boost in your status and income. With this comes greater feelings of safety, and therefore health and well being for you and those close to you. Part of your mind is well aware of this fact!! Given this, can you see that you are seeking the same prize that the current top dogs are enjoying? Safety, comfort and well being?

    Your approach has a raw and rigorous truth-seeking quality to it, which is attractive to me. But there’s other elements at play which need considering, imo.

    EG

  12. John Quintner says:

    Lorimer, thanks for the update but something is missing. In 2008 we found that in its application to people in pain, the BPS framework inadvertently leaves out the person in pain and too easily defaults to biomedical reductionism [1]. Therefore I cannot agree with you that a biopsychosocial approach is the “best” available one for rehabilitation. In a very cogent paper Carr and Bradshaw [2] argue that it is now time to “flip” the pain curriculum and replace a bottom-up “bio-psycho-social” approach with a top-down “socio-psycho-biological” one. I would appreciate reading your comments on their recommendation.

    References:

    1. Carr, D.B. and Y.S. Bradshaw (2014). “Time to flip the pain curriculum?” Anesthesiology 120: 12-4.

    2. Quintner, J.L., D. Buchanan, M.L. Cohen, J. Katz and O. Williamson (2008). “Pain medicine and its models: helping or hindering?” Pain Medicine 9: 824-34.