Back in August 2022, the ABC released a podcast titled “Can you unlearn chronic pain?”.
The podcast is in a series called “All in the mind” and this episode is focussing specifically on chronic lower back pain, which one in six Australian adults experience. In fact, chronic lower back pain is the leading cause of disability worldwide.
In their introduction, they say:
“What if you could dial down that pain — or even extinguish it altogether — by retraining your brain?”
Spoiler: If your pain is caused by an over sensitive nervous system, and not a structural or pathological problem, then yes, maybe you can ‘unlearn’ your pain. Maybe. But nowhere in this podcast do they explain this rather imperative fact. And that seems deceptive, at best. But I’m jumping to the ending. Back to the beginning.
They interview several pain specialists including physiotherapist and pain researcher, Hayley Leake, Professor Steven Faux who is a Rehabilitation and pain physician at St Vincent’s Hospital Sydney, Dr Yoni Ashar, a Clinical psychologist, Pain researcher and neuroscientist, and Daniel dos Santos Costa who was one of the participants in the RESOLVE trial that this podcast talks about.
I’m focussing on Hayley Leake and her work in this article, but trust me, I’ll be covering all of these people’s work and what they say in other articles. There’s just too much here to unpack, its going to take a few blog posts.
They go on to say in their intro:
“This week on All in the Mind, we look at clinical trials that helped some people “unlearn” chronic back pain, and what the reality TV show Australian Survivor can teach us about the power of the brain.”
I give them credit for accuracy by saying “some” people can unlearn chronic back pain. Most of these kinds of podcasts about ‘unlearning’ chronic pain treat all ‘chronic pain’ as the same, one great big thing that can be treated with the same one therapy – pain neuroscience education. One Therapy to Rule Them All you might say. This is clearly fallacious.
What they purport is that learning about how pain works, learning a few basic concepts – that pain is a danger signal from the brain, that ‘hurt’ does not equal ‘harm’, that its safe to move, that just learning and understanding those things will make the pain go away.
There are a LOT of problems with this idea, and I’ve written about them before, so let’s focus on this particular podcast. And the science it is referencing.
Here’s the link to the podcast:
First, Hayley Leake. Australian survivor champion and Lorimer Moseley protégé.
This is the study that Hayley is talking about, published in the Journal of the American Medical Association, in August 2022.
Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain A Randomized Clinical Trial
Here are some more links about the trial.:
The RESOLVE Trial for people with chronic low back pain: protocol for a randomised clinical trial
The RESOLVE Trial for people with chronic low back pain: Statistical analysis plan
About the RESOLVE trial
The RESOLVE trial was a large clinical trial in Sydney, Australia, looking at people with chronic low back pain. There were 276 participants, randomised into one of two groups.
Group A received a program of education and graded activity, gradually moving back into exercises and activities that they’d been avoiding due to fear of causing themselves more damage and/or pain.
The program of education involved hour-long face-to-face sessions, 12 times over three to four months, and a bit of home training in between.
The education was simply having a chat about how pain works, the ‘Explain Pain’ model which says that pain is an output of the brain, that pain is not an indicator of tissue damage, and that it’s safe to move. People were then given a graded exercise program, meaning they were given exercises that gradually increased in duration and intensity. They started with simple stretches before progressing over time to exercises like lifting and squatting.
Group B received placebo treatment. The placebo treatment did not include movement or exercise, or pain education.
To quote Hayley Leake:
“Instead (of pain education and graded exercise), their sessions involved things like waving a laser over painful parts of their body and doing some brain stimulation through their skull, but the equipment wasn’t actually doing anything. It was all fake.”
The programs ran over 18 weeks and the groups were compared over many months. The study found the group that engaged in education and movement did better.
Can no one see the problem here? The great, big fat fly in the ointment???
One group did exercise.
The other group did NO EXERCISE.
This study, like so many more like it, is not a fair comparison. You can NOT conclude from this study that PNE improves chronic pain, only that PNE AND graded exercise improves chronic pain. There is no way to separate the effects of exercise alone, or PNE alone. Yet only PNE is being touted as the amazing new treatment that cures chronic pain. No mention that exercise is essential too!
How can people miss this most obvious fact? How can people still be lauding pain neuroscience education, and practicing it, and not realise that it’s very likely the exercise that’s doing the heavy lifting (excuse the pun).
At the very least, you cannot conclude that PNE is doing anything, in and of itself.
Why don’t they ever do studies where BOTH groups do no exercise? Why didn’t they pit PNE against placebo lasers and magic wands where either BOTH groups got the graded exercise or NO group got the graded exercise?
Because they would have found that PNE does nothing. Nothing at all for pain. As other studies have found. And they didn’t want that.
Of course, if you’re reading the study and thinking about it critically, you will realise this. But most people only read the headline and maybe the conclusion, maybe the Abstract, if you’re really lucky. No one has time, and we trust ‘the science’. And if you’re listening to the podcast, none of this is mentioned, so again, trust the science.
But the science is flawed.
I still believe that what PNE MIGHT do, for a patient who is fear avoidant and too anxious to move their body, it MIGHT make that person realise that its safe to move. If it encourages that person to start to move their body, then that movement will improve their pain.
There are many ways to encourage people to move. PNE is just one. But it’s not very impressive to say that ‘PNE is a way to encourage people to move”. Nope. That won’t get media headlines and clicks. It needs to be “PNE retrains the brain and cures chronic pain!”. That’s impressive! Too bad its not true.
It’s very disappointing that the journalists didn’t look a little more deeply. They essentially let their guests talk without questioning the veracity of their claims. They give them a platform without checking if what they are saying is true, and if it’s helpful. Or if its harmful. And they clearly haven’t read the source studies that they are quoting.
Another Really Important Thing to understand about this, and many other, studies on PNE: Patient selection.
I can tell you which patients are likely to benefit from PNE, and which are more likely not to. And so can these researchers because they select for them.
Firstly, they select people who are fear avoidant, that is, they are afraid of doing damage to themselves, so they don’t exercise. These people are generally highly anxious, and due to this anxiety around movement, they have become deconditioned. They NEVER select people who are already active and following an exercise program
Secondly, they select people who have mild to moderate pain. In this study the average pain score at the beginning of the trial was 5.7 out of 10. I’d call that moderate pain. Not severe. They never include people who have severe pain yet they promote PNE as a treatment for severe pain.
Mild, moderate and severe pain are very different. They have very different impacts on a person’s life and require very different treatments. Obviously treating severe pain is harder than treating mild or moderate pain. And you don’t treat a papercut the same way you treat a severed finger. It is deceptive and extremely harmful to say that PNE can treat severe pain. There is NO evidence for that.
And thirdly, every patient who has any kind of pathology is excluded. Again, they don’t mention this. It’s buried somewhere deep in the text; you have to read every word to find it. And they absolutely do NOT tell the podcaster/interviewer/media that this is only for people who have no known cause for their pain. They don’t mention it in their abstract, certainly not in the headline.
But this is a very important point!
You don’t treat pathological pain, structural pain, biological pain with PNE! But in the real world, that’s exactly what health care professionals are trying to do. Thanks to ‘research’, and media reporting, like this. Which means that people living with severe, daily, pathological chronic pain, pain from serious disease or injury, are being dismissed and told that their pain is simply an output of the brain and/or an over sensitised nervous system that can easily be ‘retrained’.
This is not true. And it’s certainly not helpful.
The definition of ‘chronic pain’ is often quoted as ‘pain that persists for 3 months or more, or beyond the healing time of the tissue’. Meaning that the original injury, the cause of the pain, has healed but the pain is still there.
This is just ONE definition of chronic pain. This is, in fact, Chronic Primary Pain, and PNE was ONLY ever designed to treat chronic primary pain.
There are several other definitions of ‘chronic pain’ – here’s the International Association for the study of Pain (IASP) definitions.
Structural pain is chronic SECONDARY pain. It is much more akin to acute pain that happens every day, than the overused and overapplied definition of chronic primary pain. Chronic Secondary Pain generally does NOT respond to PNE.
Healthcare professionals, and patients, really do need to understand the difference. But nowhere in this podcast, or in the source studies, do they explain this difference, or why it matters.
They are promoting PNE as a therapy in its own right – it’s not – and they are promoting this as something that helps everyone. It does NOT! It treats a very specific kind of person with a very specific kind of pain. And in truth, it does significant harm when applied to the wrong patients.
The podcaster talks about the results in the RESOLVE trial:
“In numbers, on a scale of zero to 10, where zero is pain-free and 10 is the worst pain imaginable, both groups started the trial with an average score of around 5.7. After 18 weeks, the participants who received the fake lasers and brain stimulation reported a slight improvement, an average pain level of 4; such is the power of a placebo. And the group that got the pain education and graded sensorimotor retraining? Their average pain levels dropped to 3.”
So, both groups started with moderate pain, and both groups experienced an improvement in pain. Those who received exercise and PNE dropped to an average pain level of 3, mild in anyone’s terms. Those who received placebo dropped to an average pain level of 4, also mild. PNE and exercise was superior, but by only one point. It would be fair to say both placebo and PNE and exercise reduced moderate pain to mild pain.
I can’t access the actual results. I would have to buy the study to access all the data, and I don’t have the money. Given how deceptive the reporting is thus far, I wonder if they have diddled these numbers too. They reported the initial pain score was an average of 5.7. To one decimal place. Seems strange to me that they are reporting the final pain scores as whole numbers. Begs the question, what if the PNE and exercise outcome was an average of say 4.0 and the placebo was an average or 3.4? I don’t know, I can’t tell. This is pure speculation. But again, they don’t share that data. They choose to obfuscate it. Why allow room for speculation? Just tell us!
Hayley goes on to say:
“We spoke to people who had recovered from chronic pain, and they told us there are three key facts that helped them get better. Number one, pain doesn’t mean my body is damaged. And deeply believing this helped them feel less worry. And they told us it really gave them a justification for why it is safe to move, even despite pain sometimes.
The second thing was that thoughts, emotions and experiences can influence pain. And in some ways, this is a good message of hope because it means there’s actually many places to start if we want to try to reduce pain, we can look at stress and our emotions as a way in.
And the third thing, that you can retrain an overprotective pain system, and they valued this because it helped them have an understanding of what’s going on. If it’s not damage, what is it? Okay, it’s my over-protective pain system, but I do have the ability to retrain that. And that gives a goal of something to do.”
Hayley says this says this in the very next sentence and makes it sound like she’s talking about the same patient group, the same study. But she’s not. This is a completely different study.
You can read that one here:
What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education
About the second study:
There were 123 patients who were treated for persistent pain with PNE. Responses from people who indicated that they felt they had ‘improved’ were analysed.
Stop right there! Hayley says in the podcast that these people had ‘recovered’ from chronic pain.
But the study says, these people self-identified as ‘improved’. I’m sorry, ‘improved’ is a LONG way from ‘recovered’!
Again, deceptive. Twisting the truth. And these are the exact words Hayley Leake used. Hayley is a doctoral candidate working under Lorimer Moseley. Lorimer Moseley has done a lot of work around how much words matter. He and his colleagues are the very original ‘words matter’ people. All of their words are chosen carefully and precisely, this is not a careless slip of the tongue. It is intentional. And it is intentionally deceptive, in my eyes.
Also, no mention of how much they improved. Did they improve a little or a lot? Not important, apparently.
Hayley also implies that everyone benefits, but they only interviewed 97 people out of 123. That is, 97 people felt they had improved. That’s about 79% of people. A solid majority, for sure. But shouldn’t she also mention that 21% found no benefit? And these are people who are carefully selected as being likely to improve with PNE. 21% not finding any improvement is a significant minority and shows not everyone improves with PNE. EVEN when they are perfect candidates for the treatment.
But you’d never know that listening to Hayley speak on this podcast.
I am losing all respect for Hayley Leake. If her science is so great, why does she keep needing to misrepresent it?
This is PR, not science. Isn’t there some kind of rule against this? Is it OK to misrepresent your results in the media for your own benefit? Is this an example of good ethical practice?
I have found several examples of this kind of misreporting and misrepresentation of Australian research studies, by the people who actually conducted the research. Here and here.
And lastly, lets look at the conclusion from the RESOLVE trial. That’s the first one we talked about:
“In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings.”
How can pain relief be both ‘significant’ AND ‘small’? At the same time? Make it make sense.
In conclusion, the two studies Hayley Leake talks about in this podcast are touted as evidence that chronic, or persistent, pain can be unlearned. None of her evidence supports this, and this treatment is being used every day on people living with severe, daily pain (chronic secondary pain) for whom this treatment was never intended and for whom this treatment is largely ineffective. This patient group is arguably amongst the most vulnerable in our society, and live with the most severe pain. To deny them pain safe, effective pain relief and replace it with a treatment that has NO evidence base behind it is a travesty.
How about a little more honesty in media, and in pain neuroscience as well.
NOTE: there are other pain researchers and studies mentioned in this podcast. I’ll be writing up the problems with those next!