MONDAY Lundberg

PAIN IN MOTION
– ADVANCES IN PAIN RESEARCH
MARI LUNDBERG MARI.LUNDBERG@GU.SE
UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

THE STORY ABOUT PAIN…
I am going to tell you a story about pain,

this is my story as I know it and I hope it
will inspire you to write and tell your
story about pain in order to help people
to suffer less from pain

I am not at all from Australia…
• Professor at University of Gothenburg,

affiliated to Karolinska Institutet
• Centre for Person-Centred Care (GPCC)
• Physical therapist since 1992
• PhD in Orthopaedics, BSc in Psychology
• Run the Back in Motion Research Group
• Love to laugh, exercise, read and write
• I like to move it!

…but I have a mission – to bring people Back in Motion

Content to cover today
Why bother about pain?

How to manage pain
How can journalists help to reduce the suffering of pain?

PART 1. WHY BOTHER ABOUT PAIN?

The global burden of pain
1 in 5 patients experience pain

 1 in 10 patients diagnosed with
chronic pain every year
Pain is the most common reason
patients seek medical care
The International Association for the Study of Pain

(IASP)

The personal burden of pain
“When the pain was worst, I took
painkillers and sleeping pills, and I also
drank hard liquor in order to sleep at night.
Just to get through the night, really. I didn't
care if I died, or what happened. That was
what is was like some days, because I was
in so much pain.”
(Lundberg, Styf and Bullington 2007)
Photo by Ekrulila from Pexels

Qualitative research helps you tell a good story
Qualitative research
• encompassing several different research
methodologies for describing and
explaining complex social phenomena that
occur in natural settings
• uses research methods that are different
from quantitative methods with respect to
sampling, data collection, data analysis, (Jette, Delaney, Lundberg 2019)
and interpretation
• aims to better understand the
perspectives and experiences of people
within personal contexts

The consequences of pain
Globally Personally
• Leading worldwide cause of years • Suffering
lost to disability • Depression
• Loss of productivity • Disability
• Financial loss • Loss of identity
• Overprescription of opiods • Work loss
• Premature death
(Lundberg et al 2011- 2019)
(Buchbinder et al 2018)

A call for action – focus on health
Health-care challenge:
move away from emphasis
on a biomedical and
fragmented model of care
Change culture:
Develop interventions to
address misconceptions
about low back pain among
health professionals,
patients, the media, and
the general public

I need your help to
spread the word about
what pain is and what we
can do about it

Clinical question lead to research
Why do some people not

get moving despite the
fact there is nothing
”wrong” with them?
UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY

Another perspective…(of 20 years)

WHAT IS PAIN
Definitions, models and explanations

ABOUT PAIN
An unpleasant sensory and emotional experience associated

with actual or potential tissue damage, or described in terms of
such damage
(The International Association for the Study of Pain)
https://www.iasp-
pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=921
8

New definition of pain
An aversive sensory and emotional experience typically caused by,

or resembling that caused by, actual or potential tissue injury.
• Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors
• Pain and nociception are different phenomena: the experience of pain cannot be reduced to activity in sensory pathways.
• Through their life experiences, individuals learn the concept of pain and its applications.
• A person’s report of an experience as pain should be accepted as such and respected.
• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or
a non-human animal experiences pain.

What is really pain about?
‘‘it makes you crazy ... it

affects you mentally
because you can’t go
along on anything. You
get left behind.’’
(Lundberg et al 2007)

The complexity of pain
Sensory
Sensory (discriminative) Localisation, type of stimuli,

strength, time
Affective (emotional) Anxiety, depressed mood, Cognitive
fear, stress
Cognitive (evaluative) Meaning, cause, previous
Affective
experiences, rumination

Pain – time matters
Acute pain Chronic pain

Acute pain is of sudden onset and is usually Chronic pain is defined as pain that lasts or
the result of a clearly defined cause such as an
injury. Acute pain resolves with the healing of recurs for more than three months.
its underlying cause

Condition Low Back Pain
Time Acute Chronic
Treatment Pharmacological
Non-
pharmacological
Psychological
Education Exercise
interventions

PART 2. HOW TO MANAGE PAIN

From treatment to management
https://www.iasp-pain.org
We need your help

Pain management built on the understanding of pain

Pain management model – ”The Cartesian Way”
Pain a
disturbance
that travelled
along nerve
fibers until the
disturbance
reached the
brain
Painting by André Brouillet, 1887

Pain management model – ”The Gate Theory”
• A non-painful stimuli
(e.g. rubbing) tends to
inhibit the
transmission of
“pain” to the brain by
closing the gate in
which the pain
stimulus travels
(Roland Melzack and Patrick Wall,
1965)

Modern pain management – for (chronic) pain
Targeting psychological factors

• Expectations (placebo)
• Pain beliefs
• Catastrophizing
• Fear
• Depression
Supporting
• Physical activity
• Exercise

Incorrect beliefs about pain still circulating

Evidence based practice for pain management
Pain
Exercise education
Psychological
interventions

MOVE THE PAIN AWAY

Why is movement prescribed for pain?
#1 Physical activity=health
>3 Million studies on

the relationship between
physical activity and health
#2 Pain inhibition
activitation of our
own endogenous pain system
#3 Effective for depression

(With permission from GIH The Swedish School of Sport and Health Sciences)

The meaning of moving
‘‘I am a person who was always busy,

I was never still, I was always on the
road and I loved it. When I could not
do it any longer I felt like a second
class person”
(Lundberg et al 2007)
(Myriam Zilles , Pixabay)

Why don’t people move?
The (cognitive-behavioral) fear-avoidance model
Vlaeyen et al, 1995

Fear of movement a growing area of interest

Have you ever been afraid of moving?
Have you ever been afraid of moving?
Yes=Good, you are normal
No=Let’s talk later…

Definitions

Who is afraid of moving?

Who is afraid of moving?
• Patients with low back pain the

most studied group (Vlaeyen et al 2000)
• 70% of the patients with low back

pain in an orthopaedic setting
report a high degree of
kinesiophobia (Lundberg, 2006)
• More men than women report

kinesiophobia (Lundberg et al 2011)

Fear - linked to poor outcome and function
• E.g tendon rupture • E.g chronic low back pain
Negative correlation between 70% of the patients with low
kinesiophobia and functioning 12 back pain in an orthopaedic
weeks after an Achilles tendon setting report kinesiophobia
rupture (Lundberg et al, 2006)
(Olsson et al 2012) Linked to decreased PA-level
after lumbar fusion surgery
(Jakobsson et al 2019)

Summary – prevalence of kinesiophobia
• There is a high occurrence of kinesiophobia in

patients with different low back pain conditions
presented in the context of orthopaedic care
(Lundberg 2006; Lundberg et al 2009, 2011a, 2011b;
Limbäck et al 2011
What to do about kinesiophobia?

Fear - linked to poor outcome and function
• E.g tendon rupture • E.g chronic low back pain
Negative correlation between 70% of the patients with low
kinesiophobia and functioning 12 back pain in an orthopaedic
weeks after an Achilles tendon setting report kinesiophobia
rupture (Lundberg et al, 2006)
(Olsson et al 2012) Linked to decreased PA-level
after lumbar fusion surgery
(Jakobsson et al 2019)

What to do about the fear?
Targeting psychological factors

• Expectations (placebo)
• Pain beliefs
• Catastrophizing
• Fear
• Depression
Supporting
• Physical activity
• Exercise

Cognitive behavioral
Behavioral medicine
therapy (Åsenlöf and Denison, 2006)
(Beck et al, 1960)
Psychologically Cognitive exposure

informed PT – in vivo
(Nicholas and George 2011) Pain (Vlaeyen et al 2002)
related
fear

Relearning pain
http://changecom.files.wordpress.com/2012/12/classical-conditioning.jpg
Prehabilitation – target risk factors for
poor outcome surgery before surgery
Lundberg et al 2019
Who participated?

What did they do?

Results of our prehabilitation intervention

World Neurosurgery
2019 Jan;121:e77-e88

Next step…
• Screen for vulnerability and then target their risk factors
In collaboration with Professor Jo Nijs (Vrije Universiteit Brussels)

• Develop pain education for children and adolescents
• Test signs of central sensitization in children with hypermobility syndrome
• Collaboration with professor in communication

3. HOW CAN JOURNALISTS HELP TO
REDUCE THE SUFFERING OF PAIN?

Communication and education about pain
Micro: ”Patient”
level
Researchers
Meso: Health care
professionals
Macro: Society

Back to Australia… (pain neuroscience education)
https://people.unisa.edu.au/lorimer.moseley https://www.noigroup.com/

Why is talking about pain effective?

Pain education on the macro level
• Buchbinder et al 2001

Why it matters to me
‘‘One of the things that improves

my mood is exercise, because I
keep doing it and when I leave
here (the physiotherapy
department) I feel better, both
mentally and physically. When I
leave, for instance, I can feel that
it’s easier to walk, that I’m less
tense, so I know that exercise
makes me feel better. It
strengthens my whole self.’’

How to write a better story about pain…
 Tell the patient’s story  Adress misconceptions

 Read qualitative research  Look for ”non-positive results”
(Lundberg et al 2007; Gutke and Lundberg,
2015; Jette, Delaney and Lundberg 2019)
 Go beyond the head-lines
(research methodology – sound?)
 Personcentredness
(or person-centred care)  Spread the word about the value of
(Ekman I et al 2011; Lundberg 2019)
exercise for health and life

Funding
AFA Research Funding,

Eurospine Research Grants,
Swedish Research Council,
Health and Medical Care
Executive Board of the Västra
Götaland Region, Doctor Felix
Neubergh Grants

References
 Lotzke H, Jakobsson M, Brisby H, Gutke A, Hägg O, Smeets R, Lundberg M. Person-Centered Preoperative Cognitive-
Behavioral–Based Physical Therapy for Patients Scheduled for Lumbar Fusion Surgery – A Randomized Controlled Trial.
Phys Ther. 2019 Feb 21.
 Lotzke H, Jakobsson M, Brisby H, Gutke A, Hagströmer M, Hagg O, Smeets R, Lundberg M. Patients with disc
degenerative disease exhibit a low level of physical activity before fusion surgery: a cross-sectional observational study.
BMC Musculoskelet Disord. 2018 Oct 11;19(1):365.
 Lundberg M, Archer K, Larsson C, Rydwik E. Prehabilitation - the Emperor’s new clothes or a new arena for physical
therapists? Phys Ther. 2018 Dec 3. Gutke A, Smeets R, Lundberg M. Prediction of Objectively Measured Physical Activity
and Self-reported Disability Following Lumbar Fusion Surgery. 2019 Jan;121:e77-e88.
 Olsson N, Brorsson A, Eriksson B, Gravare-Silbernagel K, Lundberg M, Karlsson J. Ability to perform a single heel-rise is
significantly related to patient reported outcome after Achilles tendon rupture. Scand J Med Sci Sports. 2012 Jun 21.


MONDAY Lundberg

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MONDAY Lundberg

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PAIN IN MOTION

– ADVANCES IN PAIN RESEARCH

MARI LUNDBERG MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

I am going to tell you a story about pain,

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

• Professor at University of Gothenburg,

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Why bother about pain?

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

1 in 5 patients experience pain

The International Association for the Study of Pain

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

(Lundberg, Styf and Bullington 2007)

Photo by Ekrulila from Pexels

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Why do some people not

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

An unpleasant sensory and emotional experience associated

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

An aversive sensory and emotional experience typically caused by,

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

‘‘it makes you crazy ... it

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Sensory (discriminative) Localisation, type of stimuli,

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Acute pain Chronic pain

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Time Acute Chronic

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

We need your help

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Painting by André Brouillet, 1887

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Targeting psychological factors

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

>3 Million studies on

#3 Effective for depression

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY

‘‘I am a person who was always busy,

(Myriam Zilles , Pixabay)

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Vlaeyen et al, 1995

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

Yes=Good, you are normal

No=Let’s talk later…

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY MARI.LUNDBERG@GU.SE

UNIVERSITY OF GOTHENBURG | SAHLGRENSKA ACADEMY

• Patients with low back pain the

• 70% of the patients with low back