On a misty autumn morning in Australia’s Royal National Park, just south of Sydney, a peloton of nearly two dozen cyclists tackles a 3,740-foot ascent. When they reach the highest point of the day’s 45-mile ride — the first leg of a weeklong journey — they’re rewarded with cookies and candy from support staff, followed by a downhill glide along a sandstone escarpment. Far below them, waves of the Pacific barrel toward shore and explode in clouds of foam.
The group is not training for an athletic event. Instead, the 21 cyclists and their support crew have united to promote an unconventional pain management approach. The team wants to start a revolution. The road ahead is a long one.
Australian physical therapist and pain scientist Lorimer Moseley, 48, got the idea for the annual ride because he wanted to connect with other practitioners, and patients, to change how they thought about and treated chronic pain, particularly in rural areas where access to care is limited. The first Pain Revolution outreach tour hit the road in 2017. Covering more than 500 miles of southern Australian roads, the cyclists spent their nights in small towns and hamlets, offering talks on pain science and its practical application. The response was so enthusiastic that Moseley and his University of South Australia colleagues developed a formal training program for local pain educators. The inaugural class convened in 2018.
Chronic pain is a common and expensive problem. In the U.S., 1 in 3 Americans deals with the condition. The price tag of treatment — including medication, surgery and other often invasive options, as well as lost productivity and additional costs — runs more than $600 billion annually. Moseley and his colleagues believe, however, that much of what we spend on chronic pain — not just money, but also time, energy and quality of life — could be saved.
The solution that they advocate, which has its share of critics, is essentially to retrain the body’s pain system, particularly the brain, to be less sensitive. According to the Pain Revolutionaries, that process begins by understanding that pain is the brain’s response to perceived threat.
All Aboard the Brain Bus
“If a part of your body seems to be in danger and needs protecting, then your brain will make that part of your body hurt,” says Moseley.
He became interested in the brain-pain connection after sustaining a near-fatal snakebite on his ankle while hiking in 2000. Moseley recovered, but months afterward, a twig brushing against his ankle caused him to experience extreme pain. He realized that his brain had concluded, incorrectly, he’d been bitten again.
“All pain is very real,” Moseley says. “But there are many situations in which pain does not seem to match the amount of danger your body tissues are truly in. . . . Pain depends on your evaluation of danger and the likely benefit of protective behavior, not on the true danger level or the true benefit of protective behavior.”
Contrary to what most of us have been told, says Moseley, there are no “pain pathways or pain messages.” Instead, he says, there are peripheral nerve endings all over the body that send signals to the brain, which makes a judgment based on what seems, given all data on hand, to be in the organism’s best interest. But that judgment is not infallible.
The Brain Bus, a white Econovan sporting a Pain Revolution logo, is waiting for the cyclists when they reach their Day One destination, the seaside city of Wollongong. Part of the tour’s educational outreach, the bus is loaded with exhibits and experiments that illustrate the brain’s fallibility. It’s already drawn a crowd of health care professionals, patients and family members.
“Your brain can be tricked, [which can] shape perception,” says clinical pain neuroscientist Tasha Stanton, part of the Brain Bus team.
She demonstrates with an experiment on a local physical therapist. The woman is seated at a folding table, with her left hand positioned behind a curtain. In front of her, a fake, rubber left hand lies next to her real right hand. For a few seconds, Stanton gently caresses both her real left hand and the rubber one. The woman’s surprised squeal reinforces Stanton’s point: Her brain has registered the sensation of being stroked on the fake hand as if it were her own.
The rubber hand experiment and other Brain Bus exhibits use audience engagement to highlight the brain’s sometimes iffy judgment. A large chart on display nearby might not be as flashy, but it’s arguably more important: Two mountains, each sliced horizontally into three different zones, illustrate the core of what Moseley and the Pain Revolution preach.
Imagine an individual’s activity, whether it’s getting out of bed or running a marathon, as a hiker trekking toward a summit. One of the mountains represents a pain system with normal sensitivity. The bottom zone is pain-free. Above it is what Moseley calls the protect-by-pain line, when the brain determines, based on available data from peripheral nerves, that a part of the body is in danger of being damaged and needs to be protected — so the brain starts to make it hurt.
There’s a narrow buffer zone between that protect-by-pain line and the line above it, the “tissue tolerance line,” where actual damage to the body part may occur if the activity continues.
The other mountain on the chart represents people with chronic pain. The top line, tissue tolerance, is a little lower, due to the initial injury, than that of a person with normal pain sensitivity. But the protect-by-pain line is much lower, leaving a large buffer zone between them. For these brains, benign sensations from ordinary activity may be misinterpreted as threatening, causing pain to kick in. In other words, when chronic pain patients experience flare-ups, says Moseley, it’s usually not because they have reinjured themselves, but because their pain systems are hair-trigger sensitive.
Tag, You’re It
The idea that the brain can get oversensitized is not new. In the mid-1960s, for example, the brain was seen as a mass of neural networks. The more a specific network was used, the more sensitive it became. Later work described the phenomenon of central sensitization: Long after an injury has healed, the central nervous system remains persistently overreactive to stimuli — like Moseley experiencing agonizing pain at the same site months after his snakebite.
How patients think of their chronic pain, even how they and their health care team talk about it, can also play a role in how they experience pain. Moseley recalls a patient who consistently referred to his back as his “Roman ruins.” The patient even kept a photo of Rome’s crumbling Forum above his desk. A physician he consulted pointed to structural problems on his MRIs and X-ray reports, without acknowledging that these were typical of an aging spine. Convinced that his spine could “go” at any time, Mr. Roman Ruins’ brain created a neurotag, a network of brain cells that fire together to produce, essentially, a conditioned response. Because he felt and acted as if he had something seriously wrong with him, and the people around him reinforced this idea, the patient repeatedly strengthened that neurotag.
Numerous studies have documented that connection between an individual’s expectation of pain, formed through both previous experience and the way the anticipated pain is discussed, and the subsequent intensity of the pain response. The actual mechanisms underlying pain expectation and perception have been difficult to identify, however.
In November in Nature Human Behaviour, researchers reported on the first model to correlate pain expectation and response with specific neural activity. Using brain imaging, the team found that individuals who expected greater pain showed more neural activity in regions of the brain involved in fear and threat response, even before they experienced the unpleasant stimulus used in the study — a painful but harmless application of heat to their arms or legs. Once the stimulus was applied, participants cued to expect higher levels of pain reported higher pain ratings, even when they actually received low-pain levels of heat. Their brains also generated greater activity in areas associated with pain.
Surprisingly, the researchers found that for individuals anticipating high levels of pain, receiving a low-pain stimulus did not change their expectation for the next round: They still anticipated a lot of pain, and that anticipation was reflected in their brain activity, including the pain response.
Moseley and his colleagues believe, however, that thanks to the inherent plasticity of our neural networks, a brain that becomes oversensitized can, over time, relearn normal sensitivity. And that’s where the Pain Revolution focuses.
The researchers think that the way to return chronic pain patients to normal function — to raise their lowered protect-by-pain line — is a combination of awareness and activity. Pain educators help patients understand that their pain is, as Moseley puts it, “an output of the brain designed to protect you. It’s not something that comes from the tissues of your body.”
The educators encourage patients to gradually increase physical activity, and not to let a little pain stand in the way. Over time, the patient retrains their pain system, including their brain, reducing oversensitivity.
At a local surf club in Wollongong, Pain Revolution cyclists, still in their black and polka-dotted Lycra, are working the lobby and meeting locals. Among the team is David Butler, an associate professor of pain science at the University of South Australia and the founder of the Neuro Orthopaedic Institute in Adelaide. The support staff and educational content lead for the cycling tour, Butler plays an even larger role in the Pain Revolution itself. He collaborates closely with Moseley on Explain Pain seminars and handbooks for practitioners and their patients. His inner showman emerges when he takes the stage to address the entire group.
“You and I hurt when our brains weigh the world, weigh everything going on, inside us and out, and judge that there is more that is dangerous to us than safe,” he says. “Equally, we will not hurt when our brains weigh the world and judge that there is more safety out there than danger.”
Butler runs through the factors that he and Moseley believe make people vulnerable to chronic pain by producing certain neurotags. The stimuli that create these tags can be either internal — your thoughts and beliefs, physical changes in your body — or external, ranging from places you go to things you see, smell and hear.
The key difference between these tag-producing cues is whether the brain perceives them as signs of danger or safety. A “danger in me” stimulus (DIM), which produces a danger neurotag, could be the ominous whirring of a dentist’s drill, a whiff of burning rubber or your inner voice proclaiming you’ll never get rid of those love handles. “Safety in me” stimuli (SIMs), which build and strengthen safety neurotags, might include hearing your favorite song, getting a massage or feeling in control of your life.
If the scale tips hard, if there are too many DIMs, your brain may conclude that you are in jeopardy. It may ultimately trigger an inflammatory response that, in turn, can result in pain. To convince your brain cells that you don’t need protection, the scale must be rebalanced. This is best accomplished, says Butler, by pursuing SIMs, the experiences and activities that “open up that drug cabinet in your brain,” spurring the production of endorphins and other feel-good chemicals such as serotonin and dopamine. Knowledge through education and understanding is the “master key to the drug cabinet,” says Butler.
Watch Your Language
While working with patients early in his career, Moseley observed that the attitudes health care providers displayed, and the language they used, could actually worsen their patients’ discomfort. Terms such as degenerated, desiccated, stuck, bone-on-bone, jammed, out of alignment, locked and twisted can color a patient’s self-perception of pain.
Instead of describing pain with such daunting and imprecise language, says Moseley, it should be reframed as a smart, protective mechanism that sometimes goes off the rails. Pain is modulated by context, expectations and experience, so what the practitioner says to the patient makes a big difference.
Phrase to forget: “I know what you’re going through.” Consider instead: No, you don’t. Replace with something like, “I can listen and try to understand what you are going through.” Phrase to forget:“You must be a bad/poor/slow healer.” Consider instead: Reinforces negative self-perception. Just don’t say it. Phrase to forget:“Learn to live with it.” Consider instead: Honor and acknowledge the individual’s current condition and attempt at coping before offering another approach.
Focus on Pain, Not Blame
While the Pain Revolution rolls on, not everyone is going along for the ride. Many peers remain skeptical, and studies have yielded inconclusive results.
In 2016, for example, The Journal of Pain published a systematic review of various back pain treatments, including both exercise and cognitive strategies like those promoted by the Pain Revolution, as well as combinations of the different methods. The review showed little difference in outcome.
Other critics, such as Canadian professor of spine biomechanics Stuart McGill, believe Moseley, Butler and their colleagues are too focused on the brain’s role in chronic pain.
“Both Lorimer and David, while they’re good scientists, they have a very brain-centric view of the world,” McGill says. “And this is natural. Scientists find what they look for.”
Moseley, says McGill, “studies the brain, and he finds things out about the brain and the neuroscience side of things. But that doesn’t mean by default that the brain is the ultimate variable for helping a patient with back pain.”
Instead, McGill believes that all back pain is rooted in actual tissue damage that can be detected through careful and thorough physical assessment. Moseley and Butler’s work is interesting, McGill says, but adds, “I haven’t seen any convincing evidence that helps me with the patient in front of me.
“When I perform an assessment with enough detail and rigor, I am shown what the mechanism of their pain is,” he explains, “and I find exactly what motions, postures and loads trigger their pain, and what activities take it away.”
For McGill and other skeptics, their greatest concern with the Pain Revolution approach is that enthusiastic followers will misinterpret Moseley and Butler’s science, particularly if they are short on clinical experience and expertise. These well-intentioned but misguided Pain Revolutionaries could, contends McGill, make the patient’s situation worse by leading them to believe the pain is all in their head.
Other peers are more optimistic. Beth Darnall, a pain psychologist at Stanford University, believes the Pain Revolution and Explain Pain initiatives offer a more comprehensive approach to managing pain.
“I’m a fan of the Explain Pain wisdom because it is so accessible,” says Darnall. “These messages around what pain is, and how it’s a product of the brain, and how an individual can learn ways to best control their pain experience, this equips and empowers people to have the best control over their own suffering, and that translates into fewer doctors and fewer pills.”
She adds: “It’s not to the exclusion of medical care, and it’s not necessarily to the exclusion of pharmacological treatments. But . . . everybody wins when the patients are educated, when they understand which choices can best support reduced pain and increased function and best outcomes.”
More of the field overall may be coming around to Moseley and Butler’s approach. In 2018, The Lancet published a pair of papers, plus a related opinion piece, that challenged current treatment guidelines for chronic low back pain, including spinal fusion surgery, opioid therapy, cortisone injections and nerve ablation procedures. The authors suggested instead that physicians tell chronic back pain patients to exercise or remain active, and to seek counseling to deal with the psychological aspects of managing chronic pain.
That was a step forward, says Moseley, but something important was missing. Accessible neuroscience education for the patient and the practitioner — just what the Pain Revolution and Explain Pain projects offer — must come first. If a person believes, as many back pain patients do, that hurt means harm, “telling him to exercise or remain active is futile,” says Moseley. If he doesn’t understand what is going on in his brain, “it’s daft to think that an exercise program alone will resolve chronic pain.” If he’s instructed to seek counseling, without that understanding, says Moseley, “he’s going to feel like his health care practitioner doesn’t believe him, leaving him frustrated and angry.”
The Road Goes On
A couple of days into the Pain Revolution cycling tour, after a grueling, non-stop climb, Simon Summers, a Ph.D. student taking part in the ride, is trying to deal with a cramp in his low back. His brain is issuing furious protect-by-pain messages.
Moseley takes advantage of the teachable moment. “Imagine that you have reached a threshold at which you begin to trigger positive adaptation in your body tissues,” he says. “You’re a fit, healthy guy. Be confident in yourself and courageous in pushing things a little, in the knowledge that your system will protect you.”
In a few minutes, Summers is back on his bike and pedaling.
But convincing people outside the Revolution of the brain-pain connection remains an uphill task. While the peloton stops in Canberra, Australia’s capital city, some members attend a panel discussion called “The future of pain management beyond codeine.”
The topic is timely: A couple of months earlier, the Therapeutic Goods Administration, Australia’s FDA equivalent, ordered pharmacies to remove over-the-counter codeine products from their shelves. The idea was to avoid a U.S.-style opioid crisis, but many Australians have long relied on codeine to manage chronic pain. Now that the shelves are empty, the people who used the products want to know what to do.
The audience of some 200 people includes practitioners, researchers and policymakers, as well as patients, some of whom express skepticism over the role of the brain in their chronic pain. Well-trained local pain educators, Moseley believes, will be key to bringing these patients around to his approach — and these health professionals seem eager to join the Pain Revolution’s ranks.
On the last full day of the tour, the cyclists trade urban Canberra for sheep pastures punctuated with rows of poplar trees. In wind gusts reaching nearly 50 mph, they climb more than 9,000 vertical feet, crossing over the Snowy Mountains to the hamlet of Corryong. No forum is planned in this town of 1,200, deemed too tiny to draw a crowd. But 22 health professionals from outlying areas show up anyway, thanks to what Butler calls the “bush telegraph.” To feed everybody on such short notice, local residents throw a massive potluck dinner.
The next day, the cyclists cross the broad Murray River and complete their course. They’re already planning for next year’s Pain Revolution tour: more than 400 miles on the back roads of Australia’s island state of Tasmania. There, the prevalence of spinal fusion surgery for low back pain is seven times higher than it is in South Australia. Opioid abuse is also rife, and the need for pain education is profound. The Pain Revolution is in high gear, but it still has miles to go.
[This article originally appeared in print as "Tame the Pain"]