From a culmination of years of research and clinical practice, the Fit For Purpose model is emerging as arguably the most logical, research-based method of helping people with low back pain. [Adelaide West Physio + Pilates](https://www.adelaidewestphysio.com.au/) has written a [great article](https://www.adelaidewestphysio.com.au/fit-for-purpose-model-low-back-pain/) about the model that [Prof Lorimer Moseley](https://people.unisa.edu.au/lorimer.moseley) helped define.

‘Fit For Purpose’ can mean fit for play, fit for performance, fit for competing, fit for sitting … whatever.

Fit for tasks of daily living.

It was born from asking the question ‘what has gone wrong in people with persistent pain’, and addressing each of these key areas using the understanding of these pathologies.

This approach to helping persistent low back pain that was tested in the [RESOLVE trial](https://reality.health/research/19/), published in late 2022.

In the person with persistent or chronic pain, it has been established that there are three aspects, called ‘pillars’ that do not function normally.

The problem of chronic or persistent pain is proposed to occur when the patient 1. has a belief the body isn’t fit for purpose, 2. doesn’t feel fit for purpose and 3. physically isn’t fit for purpose.

Treatment using the Fit For Purpose Model targets each of these, one at a time and sequentially, but sometimes all at the same time.

Fit For Purpose Model

The article calls out the Reality Health VR platform as power way of delivering the key messages associated with the model. 

Our VR platform has been developed in collaboration with Prof Lorimer Moseley specifically for the purpose of helping clients with persistent pain. Prof Moseley was a co-author in the [RESOLVE trial](https://reality.health/research/19/) and co-creator of the Fit For Purpose Model. You can hear him talking about the model with Bart van Buchem from [Noigroup](https://www.noigroup.com/) below.

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Virtual reality and the 'fit for purpose' model

Under the guidance of Dr Dan Harvie, the Gold Coast Persistent Pain Centre has been conducting a research study for patients on the waitlist for their interdisciplinary pain service that uses the Reality Health VR Pain Education platform as a core part of the treatment approach. The study is showing  promising early results, with very high levels of engagement from participants. 
 
At the recent Gold Coast Health Research and Transformation Showcase, Hannah Kennedy and Darren Doherty had the opportunity to showcase the VR Reality Health platform to attendees, and were invited to share what they have been up to with Channel 9 news.

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231123_VRChronicPain_Ch9.mp4

Available for [download here](https://www.petalcollaboration.org/uploads/1/4/4/1/144169171/moseley__ryan_petal_discussion_paper_making_pain_education_better_120923.pdf) from the [PETAL Collaboration](https://www.petalcollaboration.org/) website, this thought-provoking paper delves into the complexities of pain perception, its psychosocial impact, and proposes a holistic framework for comprehensive pain education. Drawing from extensive research and clinical experience, the authors shed light on the importance of a multidisciplinary approach to pain management, emphasising the need for collaboration between healthcare providers, educators, and patients.

Groundbreaking discussion paper

A Paradigm Shift in Pain Education: The paper discusses traditional methods of pain education and advocates a patient-centred approach, including leveraging technology such as Reality Health’s VR platform that empowers individuals to take an active role in their pain management. 

*"One clinical tool that has gained substantial investment and is pushing outcomes forward is that of virtual reality (VR), delivering embodied, active learning experiences under the supervision of non-specialist (or specialist) primary care HCPs or occupational rehabilitation providers. VR is not new to the chronic pain space…but utilising its unique capacity to provide learning experiences, and designing these experiences around key learning objectives identified by recovered consumers to be the most important for their recovery... is a potential game changer."*

The paper goes on to discuss some very promising results from Reality Health client [IPAR’s](https://www.ipar.com.au/) program that utilises the Reality Health VR platform compared to ePPOC’s data for Specialist pain services.

Addressing the workforce capacity and expertise gap: there is discussion on the disparity of the vast number of people living with chronic pain when compared to the number of people with advanced skills in treating this population. There simply are not enough specialised resources to deliver care to those who need it, nor will we be able to train a sufficient volume of healthcare providers with specialised skill sets. The demand for care for all but the most complex presentations are able to be met by informed health providers who have appropriate resources far earlier than would otherwise be possible. 

*“It seems likely that the most impacted 10% or so - those with very complex, very high impact pain conditions - will need specialist pain services. However, all the evidence suggests that the other 90%, with high impact chronic pain, will greatly benefit if they can access an informed health provider who can deliver effective pain education, earlier in their clinical journey”.*

Community Engagement and Education: The authors emphasise the need for community-based initiatives that raise awareness about pain, reduce stigma, and provide resources for individuals dealing with chronic pain. Great examples of these are [Pain Revolution](https://www.painrevolution.org) and [Flippin’ Pain](https://www.flippinpain.co.uk/). 

*“Immediate options to reduce the personal, social and economic burden of chronic pain include: scaling up these programs; working with primary and local health networks to build HCP capacity; delivering effective public messaging campaigns that impart understanding not just around what are the most effective ways to prevent and treat chronic pain, but why they are the most effective; co-designing viable service delivery models that consider local context. All available metrics suggest that if this multiple component strategy, focussed on understanding, enablement and empowerment, shifted just 1 in 20 of those whose life is compromised by chronic pain, it would return on the investment many times over”.*

Finally, an immediate call to action for primary care and occupational rehabilitation (compensable) settings who have *“...a golden opportunity to deliver high quality, credible, consumer-informed pain education, using strategies and frameworks that have been irrefutably proven in educational settings. HCPs report needing such clinical tools and guides to deliver better pain education. Innovations such as VR-based embodied learning programs may be a game changer”*. 


Key highlights of the discussion paper include:

One of our partners, IPAR has incorporated our virtual reality app in its Re-thinking Recovery program that is supporting patients with persistent pain in workers compensation.

They are starting to get some great results with their persistent pain clients that include:
- Increased work hours
- Increase work capacity (lifting and performing over shoulder movements)
- Returning to life activities including playing with children and housework
- Significant improvement in pain catastrophisation, pain self-efficacy and pain interference
- Amazing improvements in general health, mental health, pain severity and recovery expectations

Check out the results [here](https://www.linkedin.com/feed/update/urn:li:activity:7063714792947007489/).

If you are interested in using our VR app in your practice, enquire [here](/?modal=enquire).

A modern **treatment** that trains both the brain and the body has shown important effects on pain and disability in a paper just published in Journal of the American Medical Association.
- Training both the brain and the body together
- Reductions in pain intensity and disability that were clinically and significantly better than the sham control group
- Improvements present at the one year follow up

People challenged with chronic back pain respond well to a new treatment approach that focuses on training the body and the brain together, a randomised control trial run by researchers at UniSA, UNSW and several other Australian and European Universities, has just shown.

This modern approach challenges traditional treatments for chronic back pain such as drugs, manual therapy techniques, surgery and insertion of stimulation devices, by viewing chronic back pain as a modifiable problem of the nervous system, not a structural problem of the lower back.

The study, carried out in Sydney at Neuroscience Research Australia, divided 276 participants into two groups: one who were put through a 12-week course of this new ‘education and sensorimotor training’ approach, and the other who received sham treatments specifically designed to control for common effects in back pain trials.

Their results are published today in the Journal of the American Medical Association, and show that the new treatment offered reductions in pain intensity and disability that were clinically and statistically significantly better than those in the sham group. Improvements were still present at the one year follow up.
Reality Health Scientific Advisor Professor Lorimer Moseley AO, Bradley Distinguished Professor at UniSA, who is recognised internationally for his innovative approaches to treating chronic pain conditions, noted the excitement in the research team:

“These effects are better than those seen in placebo-controlled opioid, manual treatment or exercise programs trials.  We did not expect to see such a clear and sustained difference between the groups - a clinically meaningful effect on pain intensity and disability; their quality of life was better and the treatment is cost-effective. To see these long term benefits raises the stakes for pursuing better outcomes for people challenged by chronic back pain”

UniSA’s [Associate Professor Tasha Stanton](https://people.unisa.edu.au/Tasha.Stanton), also involved in the trial, noted that ‘This is the first new treatment of its kind for back pain that has been tested against a credible placebo treatment.  That’s important because clinical trials that compare to usual care or waiting lists don’t control for potentially powerful non-specific effects of a treatment’.

Professor Moseley identified that the potential impact of this work is substantial “Considering that back pain has exerted a massive [Global Disability Burden for the last 30 years](https://www.iasp-pain.org/resources/fact-sheets/the-global-burden-of-low-back-pain/), we need to use the very latest discoveries in neuroscience to keep devising more effective treatments for this problem. This is a big step in the right direction”.

Professor Moseley said ‘this treatment, which includes specially designed education modules and methods and sensorimotor retraining, aims to correct the dysfunction we now know is involved in most chronic back pain and that’s a disruption within the nervous system. The disruption results in two problems a hypersensitive pain system and imprecise communication between the back and the brain.

The treatment aims to achieve three goals: 1. to align patient understanding with the latest scientific understanding about what causes chronic back pain; 2. to normalise the way the back and the brain communicate with each other, and 3. to gradually retrain the body and the brain back to a normal protection setting and a resumption of usual activities.

[Professor James McAuley](https://www.neura.edu.au/staff/prof-james-mcauley/) from UNSW, described the new treatment “People with back pain are often told their back is vulnerable and needs protecting. This changes how we filter and interpret information from our back and how we move our back. Over time, the back becomes less fit, and the way the back and brain communicate is disrupted in ways that seem to reinforce the notion that the back is vulnerable and needs protecting. The treatment we devised aims to break this self-sustaining cycle.”

[Professor Ben Wand](https://www.notredame.edu.au/about/schools/fremantle/physiotherapy/school-staff/Ben-Wand) of Notre Dame University, the clinical director on the trial, emphasised that by using a program of sensorimotor training, patients can see that their brain and back are not communicating well, but can also experience an improvement in this communication. We think this gives them confidence to pursue an approach to recovery that trains both the body and the brain.”

How this new treatment works

Traditional medical and physical therapies have concentrated on fixing something in your back, injecting a disc, loosening up the joints or simply ‘increasing core strength’. The problem is, there is little evidence that these things actually cause chronic back pain.

Traditional psychological therapies focus on accepting that pain is unchangeable and learning to live well despite your back pain.  What makes this approach different, according to the international team behind the trial, is that it trains the whole system – how people understand their back pain, how the back and brain communicate, how the back is moved and loaded, and the strength and fitness of the back. ‘This study adds to other discoveries of the last 20 years that show that chronic pain is changeable but that it takes both new understanding and a period of retraining to change it’ said Professor Moseley.

The study authors say that more research is needed to replicate these results and to test the treatment in different settings and populations. They also want to test their approach in other chronic pain states that show similar disruption within the nervous system.  They are optimistic about rolling out a training package to bring this new treatment to clinics and have enlisted partner organisations to start that process.

Once the new treatment is available via trained physiotherapists, exercise physiologists and other clinicians – Professor McAuley hopes this to occur in the next six to nine months – people with chronic back pain should be able to access it at a similar cost to other therapies offered by those practitioners.

![Resolve_JAMA.png](https://uat-cms.reality.health/uploads/Resolve_JAMA_83e6ec7af0.png)

Training the body and the brain

Ask any health care professional and they will tell you that pain science education is difficult. How can I get better learning in my patients? How can I be confident that the content is accurate and that I deliver it in a compelling, convincing and accurate way?
Health care professionals, governments and industry are calling for more effective strategies to ensure high quality, scientifically accurate, compelling and persuasive pain education. 

It is one thing to see persistent pain as having tissue-based and pain system-based contributions. It is another thing altogether to know how to guide such a complex protective system towards recovery and to implement it at a high quality.

Reality Health aims to provide the tools to achieve this lofty and critical aim. By developing a platform that fully immerses a client into a non-threatening environment, compelling embodied educational experiences paired with movement and loading experiences that are specially designed to violate expectations to foster deep, operational learning. This is further strengthened when done side by side with a healthcare professional who understands the science, opening the window for a client and health care professional to drive recovery.

Rethinking pain is challenging for everyone 

It is one thing to see persistent pain as having tissue-based and pain system-based contributions. It is another thing altogether to know how to guide such a complex protective system towards recovery and to implement it at a high quality.

Research in this area is emerging. Reality Health is committed to sharing the progress and providing tools that are based on the evidence in this space to ensure great outcomes for healthcare professionals and their clients.

Another way to think about the best treatments for persistent pain is that they target the pain system itself. However, treating bodily pain with education and other strategies that do not target the body part that hurts, makes no sense to many [patients](https://www.jpain.org/article/S1526-5900(15)00682-3/fulltext). Therefore, in order to successfully train the body and the brain - the entire pain system - compelling and convincing patient education about how pain works, why pain sometimes persists, and how bioplasticity can be used to reduce pain system hypersensitivity, is critical.

We need to train the body AND the brain

Modern pain education was [developed](https://scholar.google.com.au/citations?view_op=view_citation&hl=en&user=O9a6ieoAAAAJ&citation_for_view=O9a6ieoAAAAJ:IjCSPb-OGe4C) to align how health care professionals and people in pain understand pain with a scientifically based understanding. Modern pain education has a few names - ‘explaining pain’, ‘pain neuroscience education’, or ‘pain science education’. 

There is compelling [evidence](https://www.tandfonline.com/doi/full/10.1080/09593985.2016.1194646?casa_token=OqR3o2kEKwEAAAAA%3ALPjy5ZPs5vb0wzr5D5HimJyoE6PG60pX7MscOcx9rYePBsHVcP6QTgIRoF6sgnHzCXDMB7Rj3Jwsfes) that pain science education reduces pain-related worry, increases self-efficacy, increases participation in active and psychological rehabilitation, increases global perceived effect of care. Notably however, these results reflect ‘average responses’ and the health care professionals that deliver the education are trained and mentored. There is also compelling [evidence](https://pubmed.ncbi.nlm.nih.gov/26761387/) that when patients learn a modern understanding of pain, they can have excellent outcomes. One study in over 800 patients with a range of persistent pain conditions, mean duration of over 5 years, pain levels dropped on average from 5-6/10 to 1/10 over the following year, in those patients who adopted a modern understanding of pain.
 
There are two very important considerations on this excellent result however:
1. All patients participated in modern pain science education, but only half of them learnt the key concepts. This means we need more effective pain science education strategies. 
2. Pain science education was followed by a rehabilitation program that trained both body and brain, and was tailored to patient goals and objectives. This confirms [evidence](https://pubmed.ncbi.nlm.nih.gov/30831273/) that pain science education alone does not induce large changes in pain and disability.

Good pain science education seems critical

There are now several [randomised controlled trials](https://pubmed.ncbi.nlm.nih.gov/34678468/) that show reduction in pain and disability from treatments that combine modern pain science education, based on ‘[explain pain](https://www.noigroup.com/shop/)’, with brain and body-targeted rehabilitation. Some randomised controlled trials compare treatment to doing the same thing participants were doing prior to the trial, others to a single [open placebo injection](https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694), others to sophisticated [sham interventions](https://pubmed.ncbi.nlm.nih.gov/27939089/). 

Two very important findings have emerged:
1. There is building evidence that compelling education plus a program of brain and body training is effective and arguably the most effective treatment we can offer people with persistent pain.
2. We desperately need to improve our education and provide compelling, convincing and memorable ways to learn modern pain science and to integrate learnings in movement, loading and functional exposure.

Pain science education + brain and body based training = pain & disability reduction

The first step to improving education is identifying what content is important? One [approach](https://journals.lww.com/pain/fulltext/2021/10000/what_do_patients_value_learning_about_pain__a.12.aspx?casa_token=KqHPdo33yjAAAAAA:WgT-lc_QVbsB9c327CI-Tad7zxXtkVFoBl68wZOgUntfkROLeqXlY03dAuZIvJ3DQB4wG9bD-__XMRSfpmm52b-P) to this critical question has been to consult people with persistent pain who have recovered. That approach revealed concepts that these people identified as being key to their recovery: 
1. Pain is protective
2. Multiple factors can affect pain
3. Persistent pain is overprotective - “pain system hypersensitivity” 
4. Pain system hypersensitivity can be retrained over time.


Recovered patients are experts

There are now several randomised controlled trials that show reduction in pain and disability from treatments that combine modern pain science education, based on ‘explain pain’, with brain and body-targeted rehabilitation.

Bioplasticity refers to the inbuilt capacity of our biological systems to change. Bioplasticity is just like neuroplasticity but involves the entire body and brain. It is such an integral part of humans that it would be more accurate to say that change is not only possible, it is inevitable. The question then is no longer ‘Is change possible?’ but ‘What sort of change will happen?’ [Read more](https://www.iasp-pain.org/publications/relief-news/article/time-to-embrace-bioplasticity/) on this idea here.

Bioplasticity is a significant contributor to the development of persistent pain. We can clearly see this at work because as pain persists, the pain system becomes more sensitive. This results in two clinical observations: [allodynia and hyperalgesia](https://journals.physiology.org/doi/full/10.1152/physrev.00025.2008). 
Allodynia is when a stimulus that is normally not painful becomes painful. The easiest way to think about it is as a ‘lowered pain threshold’. Hyperalgesia is when a stimulus that is normally painful becomes more painful. This increase in pain might mean more intense pain, longer lasting pain or a larger area of pain.

In persistent pain, allodynia and hyperalgesia occur for stimuli that are mechanical, thermal, psychological, social or contextual. For example, a stressful environment, a reduction in general health, a worrying diagnosis, are not usually enough to result in pain, but with marked allodynia they may be. This situation is called pain system hypersensitivity.

Bioplasticity explains the problem

Pain system hypersensitivity changes moment to moment and over time. With the right understanding, and training, it can be gradually decreased. This is why education, psychological and active strategies are recommended as first-line treatments for preventing and treating persistent pain, across clinical [guidelines](https://link.springer.com/article/10.1007%2Fs00586-018-5673-2) internationally.

Bioplasticity offers a solution

Bioplasticity refers to the inbuilt capacity of our biological systems to change. Bioplasticity is just like neuroplasticity but involves the entire body and brain. It is such an integral part of humans that it would be more accurate to say that change is not only possible, it is inevitable.

Over 30 years ago, Patrick Wall, arguably the parent of modern pain science, lamented the failure of health care professionals to embrace a scientifically accurate understanding of how pain works. He [wrote](https://psycnet.apa.org/record/1987-24240-001?fbclid=IwAR0F7dmTi1RX7XV8IVIjNyPC8iowb1gaHdnU9Rv6HEn2Za98e_mXCpLfcTo) - ‘mislabelling nociceptors as ‘pain fibres’ was not an elegant simplification but a most unfortunate trivialisation’. Read a wider commentary on this quote [here](https://www.futuremedicine.com/doi/10.2217/pmt.11.73).

![Rectangle 220-2.png](/uploads/Rectangle_220_2_6189b33add.png)

At that time and, remarkably, to this day, many health care professionals still hang on to what some describe as the ‘old way of understanding pain’. This is not unusual in health care - a similar reluctance to embrace the true complexity of humans as evidenced by swathes of data, was lamented by another giant in health care - [George Engel](https://www.nejm.org/doi/pdf/10.1056/NEJM198204013061311) - almost 50 years ago. He proposed the ‘biopsychosocial model’, which was adapted to pain care by John Loeser and is now [discussed](https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach), and widely [advocated](https://www.researchgate.net/profile/Kelley-Bevers/publication/309623595_The_Biopsychosocial_Model_of_the_Assessment_Prevention_and_Treatment_of_Chronic_Pain/links/59342746aca272fc5540df41/The-Biopsychosocial-Model-of-the-Assessment-Prevention-and-Treatment-of-Chronic-Pain.pdf), internationally.

Old ideas about pain persist

Tens of thousands of scientific articles on pain have been published in the last 30 years. Together they show that pain is much more complex than previously thought. They also provide a picture of how pain works and what happens when pain persists - a picture that has exciting implications for prevention and treatment.  

This modern scientific understanding of pain emphasises the important protective purpose of pain and the dynamic nature of a complex and highly integrated pain system. The understanding is in some ways very logical (what good would a pain system be if it only alerted you to a problem when it was too late?), but in other ways it is truly revolutionary. Importantly, it is leading to better outcomes for people with persistent pain than were thought to be possible even 10 years ago. 

Our education partners NOIgroup publications have several fully referenced [books](https://www.noigroup.com/shop/), in several languages, that summarise modern pain science and its implication for care. 

Scientific understanding has transformed pain care 

To this day, many health care professionals still hang on to what some describe as the ‘old way of understanding pain’. This is not unusual in health care - a similar reluctance to embrace the true complexity of humans as evidenced by swathes of data, was lamented by another giant in health care - George Engel - almost 50 years ago. He proposed the ‘biopsychosocial model’, which was adapted to pain care by John Loeser and is now discussed, and widely advocated, internationally.


About 1 in 5 people live with some kind of chronic pain (pain that lasts longer than 12 weeks). The most common is persistent, or chronic, back pain. About 1 in 10 people are considered to have ‘high impact persistent pain’, which means that their persistent pain substantially reduces their ability to work, study, socialise and contribute to society. Show me the data? [USA](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6146950/), [Europe](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878786/), [Australia](https://www.sciencedirect.com/science/article/pii/S0304395900003559?casa_token=oT9_-fH_HuQAAAAA:Y1FfYNe-EbXlQYJvDhDRaxP9lheAzLCcipqr74pATHsiaDaX3e6Hn9NLkq3sO0jCcbbmFKB-cG4), [UK](https://bmjopen.bmj.com/content/6/6/e010364?cpetoc), [India](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6199848/).

Persistent pain is very common

The ‘[Global Burden of Disease study](https://www.healthdata.org/gbd/2019)’ involves more than 7,000 researchers in over 156 countries and territories. They collect and analyse data on premature death and disability from more than 350 diseases and injuries in 195 countries. Chronic pain exerts the biggest burden of any health condition in terms of years lived with disability. [Show me the data](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext)?

Persistent pain impacts lives

The economic burden of persistent pain is massive - in some countries, persistent pain costs the economy more than cancer and diabetes [combined](https://pubmed.ncbi.nlm.nih.gov/22607834/). Having persistent pain elevates the risk of a swathe of developing cancer, diabetes, cardiovascular disease, stroke, depression, suicide, opioid addiction; it elevates the risk of death by any cause by between [10% and 50%](https://www.thelancet.com/pdfs/journals/eclinm/PIIS2589-5370(21)00483-1.pdf).

The cost of Persistent pain

The economic burden of persistent pain is massive - in some countries, persistent pain costs the economy more than cancer and diabetes combined. Having persistent pain elevates the risk of a swathe of developing cancer, diabetes, cardiovascular disease, stroke, depression, suicide, opioid addiction; it elevates the risk of death by any cause by between 10% and 50%.

"Over the last 25 years, scientific progress has seen a transformation in our understanding of how pain works and how it is best treated.
"

Reality Health - Latest pain science research

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"Over the last 25 years, scientific progress has seen a transformation in our understanding of how pain works and how it is best treated. "

Over the last 25 years, scientific progress has seen a transformation in our understanding of how pain works and how it is best treated.

Latest pain science research

If you are a clinician and would like to talk to us about using the Reality Health platform in your clinic, either email us at enquire@reality.health or complete our enquiry form by clicking the button below.


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Interested in using our platform?

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A great explanation of the 'Fit for Purpose' model that Prof Lorimer Moseley helped define

Study shows promising early results with high levels of engagement.

New Discussion Paper Endorses Revolutionary Approach to Pain Education

Reality Health app in-clinic results

RESOLVE Trial for Chronic Low Back Pain - NeuRA

Rethinking pain is challenging for everyone

The evidence based biopsychosocial approach to treatment

Bioplasticity - the cause and the solution

The evolution of our understanding of pain

The impact of persistent pain