Pain can be felt anywhere in the body, but it all originates in the same place: the brain. Lorimer Moseley, a professor of clinical neurosciences at the University of South Australia and a specialist in how the brain produces pain signals, joins us today to talk about how pain is created as a protective strategy. Your brain, which is constantly monitoring your environment for signs of danger vs safety, sends pain signals when it detects a painful stimulus (a process called nociception). Moseley studies how to retrain the brain when it continues to send pain signals long after the damaged tissue has healed (or, in the case of phantom pain, even after the damaged tissue is gone).
Phil Stieg: Today our guest is Lorimer Moseley, a trailblazer in the field of contemporary pain science. He is the founder of Pain Revolution, a nonprofit committed to transforming pain management through educating patients and health professionals on cutting edge techniques.
Through his leadership of the Body in Mind research group, he works to unravel the intricate relationship between the brain, mind, and the lived experience of chronic pain. Let’s learn together about the science of pain, as well as some helpful and surprising techniques for pain management.
Lorimer, thanks for being with us today.
Lorimer Moseley: Thanks so much for having me.
Phil Stieg: So let’s start with the obvious question. In your mind, what is pain?
Lorimer Moseley: That’s the obvious and probably most challenging question. From my perspective, what is pain is the feeling that I have when I know I’m in pain.
In our field, we’re very keen to point out the difference between pain, which is the feeling we have, and nociception, which is the capacity of the tissues of our body to detect dangerous situations. So the word itself, nociception, if you think of noxious chemicals, they’re dangerous chemicals. So nociception means danger detection or danger reception.
So this difference between nociception and pain is exemplified with headache, I think, because we absolutely know there are no nociceptors in your brain. There is no capacity in there to detect the danger like there is in the rest of the body. But we get headaches, and we get headaches right in the middle of our skull, in the middle of our brain. And if we have a head injury, sometimes we get pain in the right place and still neuroscientists are perplexed. How? How does the brain work that out? Yeah, it’s remarkable, isn’t it?
Phil Stieg: So is that linked then to your concepts that this DIM and SIM — the danger in me and the safety in me — is that linked to this comment?
Lorimer Moseley: Yeah, it is. I think that for people who will be unfamiliar with the DIM SIM approach to chronic pain recovery, it was inspired by what you in North America call “dim sums.” Yeah. So in Australia, they are called “dim sims.”
We were trying to have an easy way to get across the idea that when it comes to pain, when it comes to pain, everything matters. So we do have data from your body. We call that the nociception data. But we can think more broadly. The information coming from your sensory system into your brain can be consistent with danger and it can also be consistent with safety.
And then we think about, well, what else is the brain considering when you have pain? This is every single human who has pain. The brain is also considering your general health at this moment in time. It’s also considering your previous experiences in the world, all that information you have stored. Like what does red mean? What does blue mean? But also, what does back pain mean? What does a doctor mean? What did my parents think about this? All these sort of unconscious stored data.
We know that your brain is always sampling the current environment and we know that your brain is trialing different beliefs and behaviors. And so we can think about all of those things have the capacity to give a danger message or a safety message. And if it’s a danger message, we just use the acronym that it’s a signal of potential danger in me, which is DIM. And if it’s safety, it’s the acronym is this is a potential signal of safety in me. So pain then becomes the balance DIMs versus SIMs.
Phil Stieg: So, you talk about the psychological factors and how they affect your perception of pain.Explain the red light experiment that you had.
Lorimer Moseley: One of my favorite experiments in part just because it’s simple. So in this experiment we were very interested in how powerful some information that we get in life that’s not actually about danger, it’s not from receptors in your body, but it’s from things like vision or sound. How powerful are those cues in determining our experience?
So we did an experiment called the Red Light Blue Light experiment, although participants didn’t know we were calling it that. The experiment involved putting a very piece of metal on the back of a participant’s hand and we’re asking them how cold is it how painful is it? How hard are we pressing, how big is it? But what we’re really interested in is the answer to the question how painful is it?
We don’t mention that every single time they receive a stimulus, that stimulus occurs together with a visual stimulus. And the visual cue was just either a red light or a light blue light. And we chose those lights because they have great meaning to us when it comes to temperature. Red is always associated with hot and danger and blue is always associated with cold and safety. So we thought, well, what happens if we just give those cues? We don’t mention them, they’re just there.
And what we found is that the pain experienced from exactly the same stimulus was at times twice as painful if the red light occurred than if the blue light occurred. On average, the difference was about two and a half points on a ten point scale. Now that’s a big difference.
There were some people for whom, with the blue light they reported no pain and with the red light they reported pain eight out of ten. And that’s a very severe pain. There are other people who reported the same level of pain in each situation. And in scientific terms we describe those people as idiots (laugh) because their brains are not picking up on these cues that everyone else is picking up on.
What that experiment showed, I think in a really compelling way is that it’s never as simple as it seems. Even when you accidentally put your hand on something hot, your brain will be sampling every piece of data available at that moment, both from your world at that time, but also the data you have stored to put this into context. Because the red light, blue light only works because you’ve already stored all this information about red and blue inside your brain.
Phil Stieg: Could you explain to us the concept of phantom limb?
Lorimer Moseley: Sure. Can I explain it with a story?
Well, I was hitchhiking north of Adelaide. I’d been waiting a long time for a lift until eventually a car reversed the wrong way down the highway. And when it pulled up, a cloud of dust emerged and a voice came out of the dust saying, do you want a lift, mate? And as I went to sit down, I almost sat on his prosthetic leg. And he was driving the car with one leg. And the car we call it a manual car, which means you have three pedals. And he had one leg.
Phil Stieg: We remember that in America.
Lorimer Moseley: Yeah. So one leg and three pedals is obviously a challenge. And we got to the first stop and all of a sudden, out of nowhere, he was gripped with what was clearly a terrifying, distressing leg pain in thin air, where his leg used to be. And he was screaming, pointing at the clutch pedal, which is where he felt his leg to be. And he was saying to me, Get my leg, get my leg, put my leg on.
And here I was, quite a young person, not accustomed to people with phantom limb pain. And I sort of put his leg into position. He was hitting me on the head, saying, Get your head out of the way. I have to be able to see my foot. And when he could see his foot, he got a screwdriver out of the visor. And he got me to push into a certain spot on his prosthetic leg with the screwdriver so he could see it.
And then I could see his knuckles relax on the seat. The blood came back to his face and his pain had gone away. And I said, what was that? What happened there? And he explained that sometimes, without warning, his phantom limb pain hits him like a truck. And the only way he relieves it is by seeing this screwdriver going into the painful part on his prosthetic leg.
What amazed me about that was two things. One is you can have pain in thin air where there is no body part. So that’s phantom limb pain, that the brain is producing pain in a body part that no longer exists and that he can relieve it by visual information that makes sense of pushing onto the painful body part on a prosthetic foot. And the second part of that made me think, wow, so the terrifying complexity of phantom limb pain is matched by the terrifying opportunity and possibility of a brain that can do extraordinary things.
Phil Stieg: So, as you’ve said, pain is in the brain, but then too many people hear that it’s all in your brain, forget about it. How do you deal with that conundrum?
Lorimer Moseley: Yeah, I now say, look, pain is actually not in your head. It’s not in your brain, actually. And this may seem to contradict everything I’ve said so far, but I think that it’s critical to understand that pain is in your body, but it is made by your brain. I still say, yeah, your pain is in your back or your pain is in your knee, but it is being made by your brain. And in fact, every single back pain in the history of humanity was made by that person’s brain. And if that is the case, then do you think that you’ve had this back pain for years? For example, do you think we should still only be focusing on your back? Or should we expand the viewfinder and think, what else is your brain considering here? And what has changed in your brain and nervous system and immune system since this started eight years ago or nine years ago? What’s changed?
Phil Stieg: Or your emotional life…
Lorimer Moseley: Yeah, absolutely. Your emotional life. The number of people that I see whose pain flares in coincidence with things like time of year, people’s birthdays, world events, it’s remarkable. And once you can see that pattern, then it’s a lot easier to accept that you’re a complex, beautifully self-protecting organism.
(Interstitial Theme Music)
Narrator: Wouldn’t it be fantastic to live a life completely free from pain? Though it may sound great, it’s in fact fraught with danger. Just ask the people who actually don’t – and can’t, feel pain at all.
A rare genetic mutation can cause a condition called Congenital Insensitivity to Pain or CIP. People with CIP have an otherwise normal sense of touch – they can sense things like warm, cool and pressure on their skin – but they appear insensitive to nearly all forms of pain. Jo Cameron, a woman in Scotland who was discovered to have CIP, described giving birth to her children as feeling like “a tickle”.
While you may think being impervious to pain is a super-power, CIP is actually a very dangerous condition. Pain is the body’s way of protecting itself from injury. One of the reasons scientists believe CIP is so rare is because so few individuals with the disorder live to reach adulthood. And those people who survive their childhood accidents must learn to constantly monitor their body for damage. At 65, Jo Cameron needed to have her hip replaced – not because it had caused her pain, but because she hadn’t noticed anything was wrong until it was severely degenerated.
Another common factor in CIP is the inability to feel fear or anxiety. This too can have dangerous consequences.
Dr. Geoff Woods, a pain researcher at Cambridge University, reports that “Of the CIP patients he’s worked with in the UK, so many of the males have killed themselves by their late 20s by doing ridiculously dangerous things, not restrained by pain.”
Stephan Betz, a participant in a study of CIP in Germany, shares his perspective this way:
“People assume that feeling no pain is this incredible thing and it almost makes you superhuman. For people with CIP it’s the exact opposite. We would love to know what pain means and what it feels like to be in pain. Without it, your life is full of challenges.”
(Interstitial Theme Music)
Phil Stieg: Why do you think that the world, certainly in America, has veered so severely towards you’ve got pain, going to give you a pharmacologic answer. Here, take this and it’ll go away. I don’t know if it’s true in Australia.
Lorimer Moseley: Yeah, I think you guys are leading the world in this. But one factor that I think we have to respect is that when you are in pain, you desperately don’t want to be in pain anymore. That’s the whole point. That’s why pain is so effective, right? Because you want to get out of it. So you want to solve the potential danger. So if you’re in a situation as a healthcare professional and you understand that someone in front of you desperately wants to relieve this situation and you have the potential of doing that in 13 seconds with a script, then everyone is happy about that scenario.
So I think that’s one of the drivers and as pain persists, they become less effective, right? And it’s easy to hang on, well, maybe this one will we change the dose or we add this extra medicine or looking for the quick fix. And I think both parties are looking for the quick fix.
Phil Stieg: I haven’t personally done a scientific study. However, I’ve noticed since I began viewing the hospital and what I do as a wellness opportunity, the day of surgery, after I’ve operated on somebody’s brain, I say, you’re going to get out of bed, now you’re in the process of wellness. I’ve made you better. And taking that very positive approach with patients – they get out of the hospital faster, they don’t go to rehab anymore, and they’re not popping as many pills for their pain.
Lorimer Moseley: Yeah, I love it. I love it. And I think that whole idea of being well and being on a journey towards wellness all the time is a really nice message. We’re doing a lot of work in the general public now, trying to preempt chronic pain, trying to turn off the tap. Right? And we’re trying to do that by giving people the mindset of recovery and adaptation and that principle of biology that we call bioplasticity, which just means ability to change. We don’t say change is possible. We say change is inevitable. But how you change is not. And let’s work out how we can guide the biology of the human, guide the change towards wellness.
Phil Stieg: What, in your mind, are the exciting pharmacologic and nonpharmacologic tools that you’re bringing to the treatment of pain now?
Lorimer Moseley: Well, my caveat there is that I’m not a pharmacologist, I’m not a medical doctor. I don’t get excited about any pharmacological agent when it comes to chronic pain. And the reason for that is the evidence. So we don’t have a drug that on average helps people more than a placebo unless it comes with intolerable risk. There’s just no drugs. And the drug companies will confirm that they have pulled funding because they’re not discovering any new molecules. They’re repackaging old molecules.
In the non-pharmacological space —and this will reveal both my bias and conviction — I see the data coming in over years, building and building to say when people understand that pain is complex, that it is changeable, and that recovery is a journey associated with learning and patience and persistence and grit and a good, informed team, they do very well. When they shift their understanding of what the problem is, the problem is not a broken body or a faulty alarm somewhere in their body. And that’s how they’ve been treated, right, for a long time. So the treatment has been let’s cut it out, let’s fix it, let’s remove its nerve supply or let’s just numb the whole system with a drug.
But when people flip their understanding to say they have pain system hypersensitivity, that can be slowly trained over time and then they start the process, a year later, those people on average have gone from five and a half out of ten to one out of ten pain. But you ask them what was the goal of your intervention, of your journey? And none of them say rapid pain relief. They all say to slowly retrain my body and brain to be less protective again.
What’s the most exciting thing in our field at the moment? It is driving towards better education strategies that work more often. So we’re doing virtual reality stuff, giving people experiences to convince their brain there is a possibility here of slowly retraining things towards recovery.
Phil Stieg: How is what you’re doing different than cognitive behavioral therapy?
Lorimer Moseley: I love that question. I’ve got two answers to that. One is that what I’m doing started because people didn’t think cognitive behavioral therapy applied to them because they had real pain. And why would they be doing psychology if they had real pain? Because real pain equals real injury. That’s the way we thought about it. We had to find a way of persuading people that cognitive behavioral therapies are a sensible thing to do for chronic pain because no one thought they were.
What we’re trying to do with modern pain education that we would call pain science education, is we are trying to go a level deeper. So rather than tell people this is a strategy that will help, this is a way of thinking that is better than your old way of thinking, we go a deeper level. I just want to tell you, I want you to understand how your system works. Because what we see is that when people understand how they work, then they make different decisions. They choose different interventions. They almost automatically go to, for example, a mindfulness-based exercise to reduce their pain because it makes sense to them to do that.
Phil Stieg: I would suspect, given your stature in the field, that you get two types of patients. One that they’ve been told, I can’t do anything for you. Go get some help from somebody else. And the other patient is the one that they’ve seen somebody, and they said, “you don’t have pain. Get out of here.”
I think that it’s really important for people to understand that pain is real. How do you go about reassuring them that their pain is real, and then how do you redirect their thinking so they don’t feel badly about themselves or inferior because they have pain?
Lorimer Moseley: Yeah, I think that chronic pain has got to be one of the most invalidated health conditions on earth.
Phil Stieg: Right.
Lorimer Moseley: And I think that reflects the very reason that we started to get excited about education about pain as a core intervention for people with chronic pain. Because when my journey here started, before I even did my PhD, this is in the 1990s, I was given a contract with one of the state governments here to interview a whole lot of patients who had been through chronic pain management programs. And two amazing things came out of that.
One, most people in those programs thought that they were in the program by mistake. It was amazing how many people would say, it wasn’t really for me because I have real pain. And that, to me, reflects that it made no sense to them, let alone the health professionals, that they could have severe, unrelenting chronic pain without evidence of ongoing tissue damage in their body. And that’s the big kahuna disconnect. As long as we hang on to this idea of pain equals damage, pain equals pathology, then we as health professionals are going to invalidate someone’s experience if we can’t see evidence of the damage.
So that’s why we thought, well, what happens if we’re able to reassure people in a very comprehensive and intentional way that we understand how and why you’ve still got pain even though your body is no longer in need of protection.
Phil Stieg: How do you go about doing that with your patients?
Lorimer Moseley: In answer to that question, what do we do? Well, actually we don’t go straight to encouraging people to work on tolerance at all. We go straight towards helping people understand. So we have a lot of resources and books and videos and try to teach health care professionals how to do this in a way that enables patients and that empowers patients because it is groovy. The science of recovery in chronic pain is cool. It’s extraordinary and it’s difficult.
It’s difficult to get your head around when we’ve been living in an existence where pain equals damage and structural pathology. So how we do it practically after we are satisfied that people understand that their body is actually fitter for purpose than it feels like it is. That’s the key thing that it feels like you’re broken. But if you’ve got a lot of pain system hypersensitivity, that feeling is a trick that your brain is playing on you. But you can’t just snap out of it, right? You can’t do that because it’s you that’s making the pain as well. And that’s a very challenging thing to get across. It’s becoming easier as the way we all understand pain is slowly shifting towards a scientifically grounded perspective.
Phil Stieg: Dr. Lorimer Moseley, thank you for spending this time with us. It’s been fascinating to listen to you explain pain to us. I’m hopeful that everybody understands that pain is in the brain, and we can control that. And there are nonpharmacologic ways that individuals like you are going to teach us and hopefully help alleviate pain within the world. Thank you so much for being with us.
Lorimer Moseley: Thank you so much for having me.