Clinical Trials of Chronic Back Pain - Is There a Clinically Important Signal?

In this episode, Pain Scientist, Clinician, and Distinguished Professor at the University of South Australia, Lorimer Moseley, talks about pain and research.

Today, Lorimer talks about his many streams of research, assessing cognitive flexibility, and his MasterSessions. What is cognitive flexibility and how does it affect pain?

Hear about the social determinants of pain, COVID's impact on Pain Revolution, the complexity of chronic pain, and the responsibility that comes with doing pain research, all on today's episode of The Healthy, Wealthy & Smart Podcast.

Key Takeaways

• "One of the biggest determinants of your health in the US is your zip code."
• "[Cognitive flexibility is] the ability of your system to change its behaviour when the task requirements or conditions change."
• "If you're going to label something, it should be what it says it's doing."
• "[chronic pain] is one of the most burdensome health conditions in the world."
• "There's genuine, realistic, scientifically-based reason to hope things will keep improving for people with chronic pain."
• "Love and be love."

More about Lorimer Moseley

Lorimer is Bradley Distinguished Professor at the University of South Australia. He is a pain scientist, clinician and educator. He has made seminal contributions to how we understand pain and why it sometimes persists and has developed treatments that are now considered front line interventions in clinical guidelines internationally.

He has authored 370 research articles and seven books. His contributions have been recognised by government or professional societies in 13 countries.

In 2020, he was made an Officer of the Order of Australia for distinguished contributions to humanity at large in the fields of pain science and pain medicine, science communication, pain education and physiotherapy.

He lives and works on Kaurna Country in Adelaide, Australia.

Suggested Keywords

Healthy, Wealthy, Smart, Physiotherapy, Pain, Research, Cognitive Flexibility, Chronic Pain, Perception, Responsibility, Recovery,

Notable Mentions

Caitlin Howlett.

Dan Harvie.

Pain and Perception, by Dan Harvie and Lorimer Moseley.

Epiphaknee, by Lorimer Moseley, David Butler, and Tasha Stanton.

Participate in research (it takes just 20 minutes).

MasterSessions.

To learn more, follow Lorimer at:

Website: https://www.tamethebeast.org

https://www.painrevolution.org

https://people.unisa.edu.au/Lorimer.Moseley

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Read The Full Transcript Here:

00:03

Hi, Lorimer, welcome back to the podcast. I'm so excited to have you back on.

00:08

Good. Thanks for having me.

00:10

And so today we've got a lot to cover, because we are going to be talking about some of your current projects, new developments that maybe happened since 2021, where you had well over 30 publications. So you had a very, very busy year, I would say. But as we go, as we kind of go through and talk about some of the things that you're working on, I just want you to let me know if there's anything that you're like, Whoa, hey, I can't talk about that. Or if there is reason to be a little vague, because things might be ongoing trials and things like that. So we'll definitely keep that in mind. Now, let's say you've had a lot of publications over the last year, what are some current projects, or discoveries or developments that really stuck out for you in your most recent research?

01:08

Ah, nice question. Um, one of the things about being a scientist in a clinical field is that here, it's not often that you get a revolutionary discovery, it's quite unusual. So what I think the things that I'm most excited about are not, not so so much particular papers, although there, there are some really tiny phones, there's one that's not published yet, but will will be out in the next couple of months that I'm particularly excited about. And I can allude to that. But I think sort of like these, these streams of research in which I'm involved that are turning me on a bit, the moment and one of those is a continuation of the whole explain pain thing. But over the last sort of four or five years, we have discovered, we've looked really closely at but at the the outcomes of clinical practice in where people are delivering great educative interactions and, and I've had a fair degree of, of influence over them. So I feel really confident that I did, they're supposedly doing well. And those data from a big cohort of people suggests that, in about half of the people with chronic pain, they see they have this shift in understanding of the problem, but a real flip. And it's in a predictable way, you know, shifting towards really deep in your belly can conceptualizing pain as a protective feeling that's being produced for a reason. And we need to work out what that reason is, and it will almost well, it will certainly not be a single reason, there'll be all these little contributors. So real flipping, understanding. And, and I guess, understanding that as pain persists, the system becomes over protective, and, and really embracing that as a reality. And that's a really hard thing to do. But those those half of the people who do it has great outcomes a year later. That's a for me, that's a really exciting discovery. The half of the people who don't don't have great apples. So for me, again, it's a really exciting discovery. The problem is that we're only winning in half the people. You know, we're only nailing it in half the people and the interventions good across seems to be good across everyone. So clearly, our markers are what's good intervention, they're not accurate. So my gut feeling about that was not accurate. So we've been looking deeply at how, how can we expand that group from half to bigger and, and unexpectedly for me, doubling down on the on the criticality of learning. So I've been learning a lot about learning. And that's been infiltrating our research and infiltrating the whole way we go about helping people with chronic pain or at risk of chronic pain. And so I'm really excited about that. And we're seeing its scientists talk about seeing a signal amongst the noise. And in chronic pain, there's just so much noise, right? Because chronic pain is this truly, in my view, truly bio psycho biggest and it's more or less social thing. And if we can intervene and see a signal in that group, that's a really exciting development. And

05:03

I, I'm more excited than I was maybe seven or eight years ago about the potential power of of new and better ways to get people to give people understand. And I started banging on about this in conferences and stuff maybe three or four years ago. And I have this slide that that is intentionally slightly provocative, particularly to the physical therapy world. And that sort of pain science education world, I think in in the US the brand name as popular as paid in neuroscience, education, p and E. These are all brand names, right? PMA expired pain is a brand name. So I like to avoid the brand name. So I call it sort of pain science education or modern pain education. So this slide is meant to be slightly provocative, in say, has education become the objective, instead of learning being the objective, and I think for me, education became the objective. And that was a mistake that, that I made. And I think my research made that mistake, and my clinical practice probably made that mistake. And my own outcomes over the last 10 years, and I get I keep really tight audit data, I can see the benefit of my own development as a, as a clinician, educator, and probably as a human on outcomes. So I'm excited about that, for sure. And I can give a little, a little teaser to the paper that we expect to come out the next couple of months in a big journal near you, which looks at a clinical trial of chronic back pain, where we have done two things that I think are really unusual for our field. One is we've tested, I think, a new complex intervention. And it's made up of less new interventions, but they're all sort of put together into a package if you like. And the other thing that was different that we did that, that are Yeah, I think I'm really proud of the team led by James McCauley is the senior author on it. And Ben once and I were important in sort of formulating the treatment, but Ben's been really critical. But we were all very keen to make the control group the best placebo intervention, we could. So we put a lot of effort into credible brain targeted treatments, matching the educative component. And testing whether people had different expectations or perceived credibility or beliefs about whether they are in treatment or not. So from my perspective, it's a very tight trial. And James and I were fully expecting that we would not see a signal in this. But we would be interested in secondary analyses which tell us mediating effects like what, even though there wasn't an overall effect, where what worked, what what might have been helpful. So that's what we were expecting, but in fact, we saw a clinically important signal. And that's very unusual in back pain trials. It's if you have a control group where you've got a waiting list or usual care, or you've gotten there's been a couple of trials published slightly, or you've got open labeled saline injections, you know, these treatments that will have some sort of effect, but they're no match. Right? So you're not really asking, are the particulars throughout this treatment? Important? All of those treatments will show a signal they all they always do they show exactly the same signal. I've done those randomized control trials. So that's one thing, you can design a trial in a way that you'll show signal. But it's a bit meaningless to us as real world clinicians. Or you can design a trial that we would call an explanatory trial that says, Okay, we've kept all of these things the same in the two groups and the things that we kept the same were as much of that nonspecific therapeutic alliance engagement, credibility expectation, which, which I think is a big part of the whole pain science education thing. So I do think we have to monitor that. You might hear my dog the other

09:38

room. Right. All right. We're pet friendly around here. What's exciting

09:42

about that is that it means there's some sort of delivery bandwidth to be won, I think it might be this new piano that I discovered even better. Yeah. So anyway, so that will be coming out. I can't say anything more about that, but, but it's a really exciting development. And we've got we've got a few trials that are testing versions of these sorts of things for for different conditionals. But uh, going at the moment and the way we're constructing the education component and integrating it with the movement and loading and anti inflammatory component. So that is three pronged approach. Really exciting for me, as I, you know, I've been doing this for quite a while that feels like, I still feel like a kid. But, you know, I have been researching for a while. And this is a really exciting time, I reckon, in the chronic pain world, because I think we're starting to chug forward again, I feel like the field was stalled a bit. But jumping forward. That's one thing. And then then on the other other side research streams, one of our team called Dr. Emma Karen is doing really difficult and really important, work really well investigating the influence of social determinants of health on chronic pain outcomes. First focusing on low back pain. She's published a couple of systematic reviews, and mixed method study on that, that is pretty intimidating. For those of us trying to move the the outcomes in a positive direction, because as we were talking about before, caring that the social determinants of health are very powerful, and they're powerful in back in back pain and pain outcomes. They're really hard to shift, you know, they're very hard to do much about so. At our field, the pain, field musculoskeletal, the the sort of arthritis field has or has engaged with, it's way better than then the non Arthritis, Musculoskeletal pain, pelvic pain, Fibro fields, we, you know, it's remarkable how little attention, it gets the biggest social and when we talk about the biopsychosocial model, we nearly always conceptualize that as a smallest session and the people around you social, which is important. But we haven't really integrated the biggest social Yeah, the world in which you live in your access to health care, illiteracy. Poverty.

12:29

Yeah, that sort of stuff. Absolutely. And I think you kind of hit the nail on the head as clinicians, oftentimes when we talk about the bio psychosocial, we think of the socials, what's your support system at home? You know, do you have, you know, can you get to, can you get to therapy? Do you have access to therapy? But what we're not asking is, do you have access to other medical care? If you need it? Do you have access to fresh foods and vegetables, which we know can play a part in, let's say inflammatory responses in the body? Do you have access to a pharmacy? Do you have access? I mean, all of these things make a huge difference, you know, or do you? Is your social part of that bio, psychosocial? Are you working three jobs and raising children and not having time to fit some of this stuff in? Right? So social part becomes a really big S for a lot of people. Certainly in the United States, like I said before, one of the biggest determinants of health of your health in the United States is your zip code.

13:37

Yeah, it's remarkable.

13:40

So social determinants of health is is high priority. And I think maybe people shy away from it, because it's can be so overwhelming. So I don't know what you guys are finding research wise, if there are way and how you can address that?

13:56

Oh, it's it's overwhelming, for sure. And I totally understand why there is a reluctance to go there. And there are also I think there's very complex ethical considerations about going there. We've we've been planning a study in the northern suburbs of Adelaide where I live, which is an area that's really different to the say, the inner suburbs of Adelaide with respect to all that sort of predictable social determinants. But one question that we've had to look in the mirror about is if if we develop this so we're working on developing a screening tool. If we start to identify people that have significant unmet social needs, and we can't do anything about it, is that is that a ethically defensible position? Yeah, we were able to say to people, okay, we know what the problem is, you know, this, you can't have because we got no mechanism Have of meeting that need. So it's quite a challenging area to move into. Because if you if you imagine that the understanding and overcoming persisting pain is a very slow step by step journey. And now we really have to imagine that instead of going in a straight line, we're almost going in a circle, and we're making slow step by steps of the entire circumference of the circle, you know, and you move a little bit, then you have to stop and move a little bit more somewhere else. Otherwise, you're going to break. And the people who suffer when you break will be the same people, you know, the, the more vulnerable people. So it's a really challenging field. And yeah, I can't, I'm excited to be getting dragged along by Mr. and her colleagues on on this. But I'm also so impressed with how, how robust the approaches to it. So yeah, there's a couple of her papers out already and more, more coming. And I think there'll be really influential in the field. Because no one there are people there. There are people who are engaging in this, but very few people are thinking to themselves, I'll take on that challenge. Yeah,

16:28

yeah. Very, very difficult.

16:31

It's relevant to it's really relevant, or I guess my interest in it was sparked by our work with pain revolution, which is an outreach project program for rural areas. And it sounds like it's similar in the US. But there's there's areas in Australia not far from big cities, what we would call a big city of Adelaide a million people. There's areas two hour's drive from Adelaide that cannot get a GP or a physio, or a psychologist or an occupational therapist, to worth it. And they've got, you know, wanting four of them have a persisting pain problem that affects their lives. There's no, what do we do? What do we do about that. And so pain revolution is, is really trying to ultimately build workforce capacity. In giving people health professionals have some description, when I care what description, in fact, we were, were looking for money to try our non healthcare professional, being coached and becoming a rural coach. But the idea of that is that if people we know I think from other areas of the pain field that if if a healthcare professional of any persuasion, understands deeply contemporary pain, Science and Management, and takes a defendable, scientific, and now evidence based approach, then outcomes can be better for sure. And outcomes will be promoted by engaging in in care locally, the moment the only model we've got is a fly in fly out model, which is where, you know, the health professionals go from the city and spend a day in the country and come back a month later, in my view, of very limited benefit. Or we've got a full five model where the patients, that consumers come down to the city. And in many cases, that's a 810 12 hour drive. Get an assessment? Yeah, there's no there's no way of training those people or providing effective care for these people. So yeah, yeah.

18:55

And I, you know, yeah, no, no, you know, it this, this conversation about this kind of rural outreach and, and maybe training someone who's not in the medical field, reminded me of a documentary that I saw, Oh, gosh, I can't remember the name of it, if I can ever And i'll put it in the show notes. I can't remember it right now. But it was on it was more psychology based around loss and trauma. And there was a woman in Africa, who was not, not a psychologist, she was not trained. But she, she, I think she was trained in some basic coaching skills, but she lived in the community. And people there were more likely to go to her because she understood the community. She was part of the community and they had really good outcomes. So I'm wondering even if training someone who is not a medical professional, but if it's possible to train them even in you know, you don't have to be there in person, but would that person because they're part of this rural community, maybe have better results and someone just flying in for the month and flying out where you have someone who knows the community understands the struggles, and maybe has known some of these people their whole lives. You know, we talked about therapeutic alliances and trust and beliefs. So with people they're more likely believe someone who's part of their community than someone who's doing a fly in fly out. I don't know, it just reminded me of that documentary.

20:24

Yeah, I totally get that. And I guess we were really embracing that in, in one aspect with pain revolution, because we're training rurally based healthcare. And that was the impetus you know, they're connected to their communities and their communities are really well connected more so than certainly in Australia, in the cities. You know, you're the physio, if there is a physio will be on the sideline at the Netball day or the football game, way with the consumer, you know, these, these people's normal lives and accessibility and those things that I think reduce the power differentials that that contaminate a lot of healthcare interactions. Was it a part of our drive to drive pain revolution rurally, to tap into this already, and you know, the vision that we state, the pain revolution is that all Australians and I think we're going to change that to all people will have the skills, the knowledge and access to local resources to prevent and overcome persistent pain. And that's the real emphasis that we embed the knowledge and skills locally. And, you know, that's, you know, I've been talking to 1010 years about recovered consumers being coaches, not the healthcare person, but recovered consumers, because they have all this knowledge and expertise that no one else can have. Right.

21:56

They're very deep understanding of pain.

21:59

Absolutely, yeah. And pain, and not not only the lived experience of pain, but the lived experience of recovery. And I think that's a untapped massive resource. But there are significant regulatory medico legal barriers to us just pushing forward on that, that we're still negotiating. So that's yeah, that's been at least a decade. My perspective. But paint ray of is is so exciting. It's, it's really cool. Like, we are doing it on a shoestring. And I think we now at the end of this year, we will have, I think we'll have about 35 Local pain collective. So these are networks of healthcare professionals around geographical regions that get together, learn more about how pain works, and the best ways of treating it collectively problem solve pain, rave feeds them. curricula, but really, it's a collective problem solving facilitated group. And yeah, I think the panorama was responsible for delivering around about around about 400 community outreach sessions, amazing Australia, in the middle of COVID.

23:17

I was gonna I was gonna ask, How has COVID affected? What pain revolution has been able to do, let's say last year, as opposed to previous years?

23:29

Yeah, it's, well, it's had its impacts, for sure. And depends where you live in Australia. So two of our states have had a longer period of of living in a COVID world I guess. And in those places, there's there's been no face to face. stuff. They are 2021 outreach tour that we do. So we run this circus that gets a lot of attention raises a fair bit of money on our level of what a fair bit of money is, it's got in the commercial sector be like someone's bonus for the week. But in our sector, it keeps us alive. And we go from town to town, and we run these public outreach and health professional outreach events. We're all dressed up in library, we ride our bikes, and it's all this cool thing. And that's part of a wider program with two other projects that dovetail into that dedicated to the region. And we didn't run that in 2021. And we won't run that in 2022. And that's a big hit for us because it's our main fundraising Avenue. So that's that's a real challenge. Some states in Australia have had basically no COVID And one state still basically there's no COVID Western Australia they They pay us closed to the rest of Australia in the world. And I think they're aiming to reopen in February. Tasmania has recently reopened and they're starting to get cases. But now we're where I live. We are, we're at the beginning of our wall of Omicron. And we really don't know what this year looks like. So we don't have the experience that a lot of places do. And we're very grateful for that. But we also clearly like deer in the headlights at the moment. Federal governments are going everything. Rules are changing all the time, we and you know, we're not as prepared as you would expect us to be having had a month's notice. So that will impact pain revolution for sure. The we're a really small outfit we have I think we have 1.5 full time equivalent staff delivering hundreds of programs, or events, and we're very resilient. And yeah, well, yeah,

26:11

we'll you'll get this done. And And if people want more information, they can go to pain. revolution.org, correct. Correct? Yes. All right. So pain revolution.org, if you want more information about what pain revolution is doing, and maybe how you can help or contribute, if you so if you see if it if it aligns with what you believe in, then I suggest go for it because it is a very worthy cause for sure. And now, it's kind of switching gears a little bit something that we were speaking about sort of before we hit the record button here. And it's a concept that I had to kind of look up a little bit before our talking here. And it's that concept of cognitive flexibility. I think it's interesting. I think it's worth talking about. So I will hand the mic over to you to sort of talk a little bit more about what that is, and how does cognitive flexibility fit in with people living with pain and maybe with practitioners treating those living with pain?

27:21

Yeah, well, thanks. And again, yeah, I feel like I don't actually actually do much of the good work, it feels a little bit like because this work is has been done by Caitlin halat, who's a PhD student about to finish and has a background in psychology. We embarked on a new direction probably three years ago, with with a really sensible prediction, I think that possible contributed to not recovering after an acute episode of pain based on if people familiar with Bayesian or other predictive processing models, based on the idea that the outputs that we generate predictions and the system is influencing itself according to predictions, then we need to update the internal models of the models in order to resolve so if I was to cover that really quickly, if we, if we said, when you bend over and you don't have pain, that what what could be happening there is that your brain predicts that this will be safe, your brain produces a feeling that's consistent with that mn let's say you tweak the annulus of a intervertebral disc or something, you get no sensitive data that are that are within the sensory load. And I like to say within the Tampa symphony of Dallas, extraordinarily complex, beautifully evolved system of of information about what's happening in the tissues, we get data that says this is not what I predicted. The evaluator for this is not what I predicted. So we update the internal model to say the back is vulnerable in some way, let's say. And then the new prediction is, well, let's make pain. And let's influence the system differently. And then if we go in the other direction, and every time we've been able to get this nociceptive data within the symphony, and then one day you don't I know you've been over and and you don't get that. And now the theory is the system detects that error says Hang on. That's not what I predicted. So it updates the internal model to say the back is less vulnerable. And now your brain doesn't produce as much pain or produces no pay, and then you've recovered fantastic. So one potential barrier to recovery according to that theory is failure to update yourself. Title model. And and that should happen. If, excuse me, that shouldn't happen if you if you don't detect the error. So if for some reason you don't, your system doesn't detect that the predicted data, the predicted data, which was not receptive, in part hasn't been hasn't eventuated. And therefore you don't update your internal models. So on the basis of that, we became quite interested in this broad field of flexibility, cognitive flexibility, which has been defined in many ways. But I guess the way that we were thinking about it was the ability of your system to change its behavior are when the task requirements or conditions change. So in the language of have that sort of Bayesian idea, and to your ability to update your internal model of things. So we started digging around in this field, or Kaitlyn really started digging around in this field. And often in a PhD, you'll start with a systematic review of the literature on a question that's most most aligned with what our hypothesis will be driving. So. So Caitlin took on what we thought would be a reasonably straightforward job to review the literature in cognitive, mental and psychological flexibility. So the barrel phrases that are used, often interchangeably, particularly cognitive and mental flexibility. And with the question that would help us determine which is the best way to assess it's what's the best way to assess flexibility. And there's two broad approaches to assessment. One is self report, questionnaires. And they have they were developed out of a line of research, starting with personality tests in the 1960s. And that's this sort of this long line of stuff. And someone I can't remember who but in the, I think in the 60s or 70s.

32:18

proposed that I think it was empirically based but propose that good communicators perform the answer these sub questions in a certain way. And that research would describe them as positive and flexible people and are good communicators. And then that infiltrated the field. And we eventually got to this situation, we've got cognitive, cognitive flexibility scales, things like that. The CFS or, and there's a few of those, completely independently from that was the development of behavioral tests. The most famous and most common is a thing called the Wisconsin card sorting test. In that, in that test, you you sort cars according to one of three criteria, shape, shape, or number, I think, sorry, shape, color, or number. And the rules for sorting change, and you only realize that change when you make an error. Yeah, that so you put a card in a certain pile, and the tester or the machine goes about anything, what should work, and you have to work out what the next set of rules. And the people doing these studies somewhere in the 80s. Or maybe it was a bit later than that, call this cognitive flexibility. So we've got two independent lines, joining a company flexibility, and then that's then all the whole field just went nuts cross contaminating and all that. So Caitlin has now published and once just been accepted last week, to systematic reviews that are massive. And she had to contact authors for nearly every single one of these studies to get data, asking the question How well do those two approaches to testing 100 Flexibility correlate? Because if the system the same thing that should correlate quite well, one of those systematic reviews is in Healthy People. And one is in people with a diagnosis clinical groups. And in both of those studies, there is absolutely no relationship between those two approaches.

34:39

So you have two different tracks on how to assess cognitive flexibility, and there is no correlation between them.

34:47

Not at all. And actually a lot of the tests, there's no reliability data for them. Now, there are some cognitive psychologists who won't be surprised at that finding. And they're the informed one Who, who have been working in this field? I guess. But for people like Caitlin and I and the rest of the team on this project, where clinically, it's such an attractive hypothesis, right? Like if if people can't change their, that if people don't easily change their beliefs, explicit beliefs, their implicit beliefs about the vulnerability of their body, what pain means that the targets of pain, science education, then we know those people who don't, don't change some of those targets of pain science education, don't do as well, when we know that. So it's such an attractive hypothesis that they might be less cognitively flexible. But the barrier with hit is so how do we find out? Because we don't actually know what any of these tests are actually.

35:56

What are they actually test

35:57

measuring? Yeah, yeah. So so the direction for that, and I've asked for money haven't got it yet to do that is to devise a a new way of assessing the ability to change your decisions when there is some sort of risk evaluation involved, because I think for, for pain, I think we talked about the meaning of things being important for painting. And I think one way to distill the meaning is about just a risk profile, that every nanosecond, our system is evaluating risk, and its risk, that determines our feelings. And I would categorize pain as a feeling bad. So my anxiety, fear, fatigue, lead to the toilet, lead to a thirst, all these things, in my view, feelings generated on the appraisal of risk. And, and if we don't have any risk, in an evaluation of our ability to change your behavior, under changing circumstances, and I'm even, I'm nervous to use the phrase cognitive flexibility now, because I know that whoever he is that there are three or four main ways that you understand that. And some of those would be totally different from otherwise. So I would prefer to say, if we keep assessing the ability to change your behavior, according to changed demand or environment. without risk, then I think we might not capture what we need to capture for understanding a potential contribution to the development of chronic pain or recovering from initial pain. So so that, you know, that was one of those, one of those PhDs where it's such an important discovery, actually, and and Caitlin's contribution to the field is very important. But it won't get the citation impacts and the Roth IRA. Because what the country contribution says is, hang on everyone. Why, you know, there are a whole journals dedicated to this. But what is it? What is it, we almost have to go back and start again and say, Okay, let's get really clear on what we're talking about. Let's use these phrases. Anyway, so but that's relevant to the very first question, what are you most excited about? I guess I'm, you're tired to be excited about, clearly, deflationary discoveries like that, but they're so important. They're really important, and they're harder to publish. But they shouldn't publish, in my view, they should publish top journal. In your face. Journal. Yeah. Well,

38:49

it's, it's like, yes, it's sort of this deflated response, if you will, to, to the systematic review, but it is important because it's important to use the right words, and to if you're going to label something should be what it says it's doing. Otherwise, why are you doing these tests? And why are you you know, labeling someone as very highly flex cognitive flexibility or low cognitive flexibility when you don't really know. And then exactly, so how do you then so then your treatment, I look at it from a clinician standpoint, how do you formulate a treatment plan around something that's, that's not accurate or unknown? So I think it makes it really difficult but it's it just underlines the importance of this kind of research.

39:41

And oh, go ahead. No, I was just gonna say I think that um, it Kayla's research doesn't doesn't tell us that these tests are uninformative. But what it does tell us is that we don't We don't know exactly what they what they mean. So that speaks to your point exactly Karen, that that. So what do we do about it? That's a difficult thing, because we don't actually understand them well enough, I think. But can I put in a plug for? Yes, a research project of Caitlin. So final project for a PhD that we desperately need participants form? Yeah. Because it's an online study. Okay. And it's, it's to do with this kind of flexibility. And we need people without pain, as well as people with pain. Well, that's a lot of types of it. But basically, everyone, anyone who has 20 minutes spare. It would be great if they just went and did Caitlin's experiment online. And maybe I could send you the link.

40:48

Yes. Yeah, you send me the link, I'll put it in the show notes. And also put it out on social media. So that girl can can take this online study. So if it's people with or without pain that takes in quite a lot of people, like you said, like, one? Yeah, so I'm assuming she wants a robust number.

41:11

We need lots. Yeah. Because we think the signal will be small amongst the noise. Yeah, but yeah, if we did it, and then ask one of their family members or mate, yeah, that'd be fantastic.

41:25

Yeah, I'd be happy to send you the way about that. Yeah, definitely do. And as I was, you know, as you were talking about this cognitive flexibility, or the ability of to adapt your behavior, and let's say cognitive strategies in response to a changing task, or to a threat or something like that, it, it always reminds me of this experience that I had. So most people who listen to this note that I had a very long history of chronic pain, I think you're well aware of that as well, about 10 years or so of neck pain, chronic neck pain. And it was this was a couple of years after I could say I was recovered, you know, of course, those times when you have flare ups and things like that, but largely recovered. And I was I was at Disneyland with Sandy Hilton and Sarah Hague. And we had waited in this long line, like an hour to go on what I thought was like a jungle cruise. You know, this very, like, get on a boat and cruise around the water kind of thing. Yeah. And we get up there. And all everywhere. Once we get inside, plastered everywhere was date, big danger signs, you know, the yellow dangerous sign, the red X, if you have neck or back pain, you know, this guy. And I was like, you know, so talk about a threat, right? So my normal behavior, and like, my hands were sweating, my heart rate was up, my eyes were dilated. My normal response, I guess, would maybe show my inflexibility would have been to find the nearest exit and leave. Yeah, yeah, get out as fast as possible. Right. And so I think, Sarah, and luckily, I was with two very incredible women who are very well versed in pain science, and I think I am as well, but when it's you, you're you're like, a big, you know, mashed potato, you know. And Sandy and Sarah just looked at each other and looked at me, and I was like, almost shaking. And Sandy's like, Okay, listen, it only tilts about 12 degrees, and it stops and goes, you're in taxi cabs, they stop and go, you're fine. It's this much of a tilt, you'll be fine. And then Sarah's like, yeah, and the person in front of us like six, you know, there's nothing over your shoulders. It's not that dangerous. And they kept playing down the danger. And so I did end up getting on it very, very nervous. And then I got off and I was fine. They were right. Then it allowed me to be flexible enough to then go on another ride after that. Whereas if I went with my original strategy, which would have been to leave, then I wouldn't have done anything else for the rest of the day. Yeah, so that threat, if left to my own devices would have gotten the, I don't want to say gotten the better of me, but I would have reverted back to the behaviors I had during the that sort of 10 years of living with pain.

44:24

Yeah. And, you know, I respect I respect both of those approaches where it makes sense for an organism when you see credible evidence that this is a dangerous situation to take a variety of action. Yeah, makes total sense. And I guess the, I think about the flexibility thing was evident, as Sandy and Sarah are problem solving with you gathering more data. And, and then your choice changed. That's the stuff that seems consistent with in quotation marks flexibility, you know that right? In the face of new data. So the new data, it could work both both ways. And I think there are some people with persisting pain problems where they behave the same way, even in the presence of significant danger cues. And that works against them because they the danger, for example, right, right. Yeah, can work both ways. Yeah, I think I think there's a rich there's there's a rich stream of, of understanding in there somewhere for us to, to uncover. But it does feel a little bit like that's going to require the the archaeologist among us to get out. This is a metaphor, obviously, to get out our brushes and blowers and slowly reveal what that stream of gold is, as distinct from the earth blasters obviously just want to revolutionize in a in a rapid way. And I fit more into the second category. You know, I lose steam on the very slow, the finite, made tool discovery thing. I'm very pleased to be around researchers who are excellent at that. Yeah, it's not so much.

46:25

And I always always think about that. What did I think David Butler said they were what did he call them? Oh, I don't know why I'm blanking. I have the book right here. Super. Ah, I'll think of it. It'll come up. It'll come up later. It's from explain pain supercharged, you know, the graph and everything leads. So if you have more, yeah. Dangerous safety Sims. He called them Super Dungeon Sims. Yeah. Jensen says, so he was like, Oh, I think Sara and Sandy were your super Sims at that moment, which is maybe what you needed? Maybe? I don't know. But like you said, it would have been just as valid as if I was like, I can't do this. It's too stressful. You know? Yeah, it's too dangerous. Too dangerous. Yeah. Because those

47:14

were the cues that you were, you're getting? Yeah, yeah. And just take it off. I always say it's important in a situation like this to take a moment to reflect on the contrast between the resources available to you in that moment. Right. Which, okay, Sandy and Sarah? Unique, exceptional, exceptional resources. Like, yeah, scrub exceptional. Yeah. But even without them, take your own resources. You know, you're informed, you're, you're resourced with intellectual and other capacities and understand how things work and biomechanics, you've got incredible resources, and then just take a moment to reflect on the contrast when you and most people? Yeah. And is it? Is it any? Is it any wonder at all that people face those situations? And yeah, there'd be a lot of people with chronic neck pain, even if they're on a recovery journey, who would get into that situation and their neck pain would flare up, they wouldn't even do the rod, that's right, leave and they kind of flare up and, and the rest.

48:24

And everything that comes after that, go back

48:27

to the doctor, get a new script, you know, and we do we attempt to, or they I think there's a tendency in our field to, to look, look down on that approach in some way. But, you know, as they are, that's substantive people. But it's totally predictable. And an excellent, excellent biological organism doing that. And we have to overcome, we just always have to remember the resource differential.

48:58

Yeah. Oh, that's, I never even thought about that. But that is so true. And, you know, it just goes to show you why people living with chronic pain, why the burden of disease is the high one of the highest in burden. It's the most one of the most burdensome health conditions and diseases in the world. In most countries. I mean, just low back pain alone, the burden of disease in the United States, I think is third, that's just low back pain. We're not talking about oh, a and other knee or neck pain, other chronic conditions. It's third Well, I mean, things might be different now with COVID. I don't know. But um,

49:38

you know, it's usually with disability. And they usually for disability metric for iPads way out in front. Yeah. Yeah. Yeah. I mean, on other metrics to use last year's lost, which includes mortality, then it drops down, right, just a bit.

49:56

Right, right. But you know, it just goes to show all of the things that you that you've been working on in 2021 and that you're excited about coming up, let's say in 2022 and all the incredible researchers and PhD candidates that you get to work with it just shows how complex and complicated chronic pain is. And that one or two sessions of pain science education in clinic cut it for most. No, absolutely. And it just shows the complexity of it and how difficult it is from a research standpoint, a clinician standpoint it is a tackle these problems on an individual basis and society as a whole. So I mean, keep keep doing that. Keep fighting the good fight, as they say.

50:40

That's scary. Because yeah, gobsmacked, nice weeks that I get to do this for a job and I get paid for it.

50:52

Yeah, speaking. And speaking of helping people around the world, you've got master sessions coming up. So you did this in 2021. So now you're doing it again in 2022. It's going to be May 13. To the 16th. Depends on where you live in the in the world. But you want to talk a little bit more about the master sessions, who's involved and what it's all about.

51:13

Well, yeah, that I mean, that was that was really cool. We sewing in 2021. No one's traveling, obviously. And noi group UK put, to me this idea of doing something a bit different. And it was really different like I was so that it it, we had two broadcasts, and they were timed friend friendly time zones for Europe or for the Americas. And then Australia and Asia sort of could go to one or the other with not quite as friendly. So for one broadcast, I was starting, I think at 6am. For another broadcast, I was finishing at about 11pm, something like that my time, but it was really well planned really well resource like they are, I'm in a studio basically, I was in that it was in the NOI group offices in Adelaide, but set up like a studio with a producer and sound people and a couple of cameras and Tim Cox working as emcee does a beautiful job on that. And we had a team of people downstairs ferreting around for the papers I was mentioning and all that sort of stuff. And it we were we didn't know how it would go because it was it's not like it's not like a zoom conference. Or, or cause it's really quite different from that there's a fair bit of interaction and it went, it went really well was really good fun, really well received. And the feedback has been overwhelmingly positive. I, I was joined by two people for 2021. social pressure Tasha Stanton came to speak. And she so she did a about a 30 minute talk. And then she and I chatted for about 45 minutes and and then we open it up to q&a and and that conversation between Tasha and I and then the other person who contributed that our two people were Mark Hutchinson, who's professor of everything. Adelaide University, one of the one of the exceptional communicators on neuro immunology, related to pain and defense, personal defense. And so same sort of format with him. And then with David Butler, who everyone knows, if you don't know, David, you, you're missing a key part of life you should have. So it was amazing. It was yeah, it was a really well, it's lots of comments like, I never thought online education could be like this and that sort of stuff. So that was really positive. So in 2022 in, and I think the dates you mentioned are probably the Americas day, so that we're doing to broadcast again, where we got feedback that we're responding to, so the schedule is changing slightly. Mark Hutchinson and Tasha are both coming back to do longer stints. And then we're also having in people with really interesting research and great clinical engagement. So for example, Dr. Jane charmers who's done some excellent work in pelvic pain. So she'll come and she'll do a talk and then we'll, I sort of interview them. So it's the massive sessions are a massive amount of work for me because I need to have my head around everyone else's stuff as well. So I can ask meaningful questions, but the, the feedback is is about how useful those conversations are as well. So yeah, so this Jen channels there's Haley leak, Haley leak has has started working with investigate what people who are recovering from paying value in learning about to publish one paper on that in pain, a beautiful paper, I think that I think should shift research direction of a few groups. Haley also has the probably unique among pain scientists brag point of winning the Australian survivor 2021. So she, she survived. And part of the reason for her survival, I think was her deep understanding of how pain works. And there was some great episodes where she there was one where she I think she was standing on like Pogi point things, Poles, they were all doing this with a with another thing coming slider down lower and lower for six hours.

56:08

And lead athletes x s as people have already fallen out and and so she's she's actually done an incredible job in disseminating modern understanding of pain to the wider community because they've all said, How did you do that. And she's able to talk about her understanding of pain. And pain does not mean damage pain is because it was a thing. So no wonder the host is making these comments like that they're trying to rev up my payment system. So incredible impact and she's got a high profile among the people who watch on Survivor on telly. So she's able to integrate that experience with her research. And she's very interesting person. So she's she's coming Sarah wall works doing really interesting work with younger kids. Looking at how how we can engage with young kids on everyday paints in a way that will help them be resilient later. So really fascinating work that she's doing. And then I'm on there as well. So I think I'll cover about half of the time. And it's great fun. Yeah. And you know, people go look at the reviews and all that sort of stuff. But yeah. Love people to to get involved in that. That's in that's in May. Yeah.

57:30

And is there? You may not know this, but is there like a cutoff date for signups? Or can you sign up like the day before? If you wanted to?

57:39

I think there's a right shift. Okay. I think there's an early bird, right. I think I actually don't know much about that sort of stuff. But they they do have to. I mean, the earlier they get a feel for numbers that they they're able to judge sure how to do it, because it takes a lot of bandwidth and all that sort of stuff.

57:59

Right? Yeah. All that behind all the behind the scenes production stuff. You're the On Air talent, you don't have to worry

58:05

Exactly. Worry about any of that. But But noi group, if they get annoyed by it, they'll learn everything

58:12

about it. Yeah, yeah. And again, I'll put the links in the show notes here. And we'll put it out on social media as well. So that if people are interested, then I highly suggest signing up because it what a great, what a great lineup. And it's not until May. So you have plenty of time to shift your schedule and try and figure out, you know, kind of block the time off so you can be part of it. And one other thing, I believe this is true, you can correct me if I'm wrong. But if you if you're in the Americas, and you you paid for it, you live in New York City, let's say I pay for I live in New York City, I can also watch the other, also get the recordings of the other broadcast.

58:55

That's correct. So you get both and you you don't have to be there live watching it in bed. But if you're not you, you're not engaging in the q&a and all that sort of stuff. Yeah, but you get access to both broadcast and you get access to the thing called the Padlet, which is it was an amazing resource from the first time because this is all of the stuff that the team downstairs is getting while the master sessions around. So let's say Professor Mark Hudson mentions this are really exciting new study from so and so which show this then someone downstairs will get that study put the paper on the Padlet. So it's some incredible resource as well. And they have access to that. I don't know for how long afterwards

59:40

Yeah, yeah, but you but you have it Well, it sounds amazing. And I think it's so great that this is probably something if not for COVID Maybe you would not have done and it's made a big impact, right so

59:54

and and when COVID no longer what it is I'd prefer to do it this way.

1:00:02

Yeah, yeah, amazing. Amazing. And now, I don't want to monopolize any more of your time. But is there anything that we didn't cover that you were like, Oh, I really want the listeners to know this or, or is there a big takeaway?

1:00:18

Ah, I think the takeaway is, it's really consistent over years, actually. Whenever I have an opportunity like this to chat, with such an informed and, and clever interviewer, like you, I'm always struck by how, how important people like you are for our community, because I see my role sort of knowledge generation and, and dissemination in sort of conventional ways, you know, books and articles and things like that. But we need people like you, to spread it, to play the critical role and getting it out to the, to the world in a way that's accurate and engaging and, and it's people like you who put in so much so much effort for your community. And whenever I think about takeaway, I just am reminded of of the potential benefit we can still bring to humanity by doing this chronic pain thing better. And we have made progress, know that we made progress. But it feels to me like were climbing up a really, really tall mountain. And now when we look back, we can see we've actually come quite a long way. But when you look ahead, there's still still a bloody big mountain. So all of these things would have hope. I think there's genuine, realistic, scientifically based reason to hope things will keep improving for people with chronic pain, that will people will have better outcomes. So that's my take home. But can I give a plug to a book that I'm an author on? Yeah, it's a self plug. But I'm not the main author. So Dan Harvey, a truly innovative scientist. And I don't say that lightly. There's not many innovators out there. But Dan Harvey is an innovator. And he's the first author on a book called pain and perception. And the Americans can get that through IPTp. Elsewhere, you can get through no group. And it's a I think it's a beautiful book. It's all about understanding through illusions, and sensorial experiences, more about how pain works, sort of like a coffee table, book waiting area book. The feedback has been fantastic. So yeah, I'm really excited to be involved with that with Dan. And I'll just mention another book that's available in in North America, but not in Australia. And it's called Epiphany. And test Stanton has joined Dave Butler and I to, to write a consumer focused book around the osteoarthritis.

1:03:17

And I will say, I, when I first saw this epiphany, it's not how you would normally spell epiphany. It's, it's, it's an what do they call it? It's an acronym an acronym? Yes. So it's explaining pain to increase physical activity in knee osteoarthritis.

1:03:39

Correct. It's spelled AP IPH a knee,

1:03:45

right? Yeah, very clever. Cuz I was like, epiphany. What did I say? Episode? I don't even know. What's epiphanies? And you're like epiphany. I'm like, oh, yeah, that definitely makes more sense. That definitely makes more sense. But yes. And we'll have we'll have links to all of this stuff, again, in the show notes. And, you know, one last question and talking about, you know, all of the work that you do that isn't in very important work, and it can impact not one or two people but millions of people living with chronic pain. So do you as a researcher, how do you deal with maybe feelings of overwhelm with the responsibility that that place is on your shoulders? Or do you think about that at all? Or am I just projecting what I would feel if I were in your position?

1:04:36

I think you're projecting. I don't, I don't feel overwhelmed in the slightest. I don't feel any sense of responsibility to humanity. That's, that's changed because of what I do. I feel I feel that I have a responsibility. I don't know if I feel I have responsibility. I want to use my resources and my knowledge and my skills, and my connections and my relationships to, to be the best Lorimar I can be if that makes any sense and, and the values by which I judge that are not at all on chronic pain outcomes. I'm a very sort of process driven person, I want to make sure that today I did the best thing I could do. And I don't have any illusion that I, I could use outcomes as a marker of, of how well I've lived my life. Because I just think there's too much noise for, for me to have a measurable signal in the world. So I want to make sure that in this moment, I'm being authentic and true and real. And today, I'm doing my very best, I do my very best. But I do that, because I like myself more when I'm doing my very best. But I feel any burden to humanity. That's different from the burden that I think anyone who grew up in my in my world and life with my skill set, and my influences would have.

1:06:24

Yeah. And I think that's great, universal advice for for anyone. And, you know, normally when we finish the show, I always ask people, What advice would you give to your younger self? So I don't know if any piece of what you said would be maybe part of that advice. But is there anything else that maybe you would give to a young a young Larmour? fresh out of university for first time University, not? Subsequent?

1:06:48

Yeah. I think that I would, I think there would be advice, I don't think it would be remotely relevant to my work, I think it would be love a beloved, look for that, and express and, and value that with the entire depth and breadth of your being. And for me, that includes being a neuroscientist and paying dude with a extraordinary fortune of being able to do the things I enjoy doing for work and resonate with my values and all that sort of stuff. And ultimately, I think we're such a sophisticated organism that, that we may want to one one day discover that it's all just to love and be loved. And I don't know, great advice.

1:07:43

Great advice. Thank you. I'm sorry, not a sage. But no, no, it's amazing advice. I appreciate it. Thank you so much for taking the time out to come on and talk about all the stuff you have going on. And is there a place where people can find you? If I don't know they have questions, websites, something like that.

1:08:07

Yeah, so finding and I've got a homepage at the University of South Australia they can find out about personal pain revolution is doing some good stuff on Annabelle, what we're doing that I I get a lot of emails and I just can't possibly respond to them.

1:08:26

We're not here to give out your your emails, or your personal phone number or anything but I think pain revolution, Oregon and the University of South Australia are great ways for people to find out a little bit more about you because as we said, before we get on the air you are not on social media. So there is no Twitter handles or Instagram or tic TOCs none of that stuff. None of that. So people can find you again, pain revolution.org or University of South Australia's website or you can just do a Google go to ResearchGate read all your papers. There's plenty of ways to find out more about your research and and what you have coming up. So plenty of ways to do that. So again, thank you so much for coming on. I appreciate it.

1:09:12

Oh, thanks so much for having me. You're a legend. Keep it up.

1:09:17

Thank you. Thank you so much and everyone. Have a great couple of days and stay healthy, wealthy and smart.