Ask the Doctor (2017–…): Season 1, Episode 5 - Pain - full transcript

Like it or not, pain is a part of life.

But while for most of us, thankfully,
it's short-lived,

others battle chronic pain
on a daily basis.

Globally, one in five of us
suffers from chronic pain.

So in this episode,

we're going to explore some new ways
of treating an old problem.

Ow!

[Renee]
And we ask the agonising question...

why do we feel pain?

Sandro takes one for the team...

- How are you today?
- A little nervous.



[Renee] ...to demonstrate
cutting-edge neurological techniques

to manage chronic pain.

[Sandro] Have you done this before?
[Segar] Many times.

[Renee] And using virtual reality...

- Oh, my gosh!
- [laughter]

[Renee] ...I discover how chronic pain
can be alleviated

through mind-bending trickery.

[Tasha] When we actually manipulate
how their body part feels,

it takes away their pain.

Oh, that's so weird!

[theme music]

[Shalin] When you think about it,
pain is pretty weird.

I mean, why does stubbing your toe
hurt so damn much,

but then you read about people
losing entire limbs



without experiencing any pain at all?

It raises a couple of very interesting
questions...

what is pain,
and where does it come from?

And I'm going to try and answer
these questions with this needle.

Now, of course,
it's been fully sterilised,

not that it makes what
I'm about to do any easier.

Ow!

Now, let's take a look at
what actually just happened.

When the pin pierced
the surface of my finger,

it caused damage-sensing nociceptor cells
to be activated

and fire a signal towards the spinal cord
and brain.

The signal itself isn't pain,

it's really just an alarm
to let the body know

that something dangerous or damaging
has happened.

It's a highly complex process

that determines if and how much pain
a person will feel.

And even though it seems like
the pain I felt

from jabbing myself with that needle

was coming from my finger,

in truth, the whole sensation
was perceived as pain...

by my brain.

[Renee] Pain medications
are many and varied,

but which pill should you take
for which pain?

Ibuprofen works by reducing inflammation,

so it's useful for pain such as headache
or muscle sprain.

But it can be risky for people
with asthma, stomach ulcers,

and the elderly.

Aspirin acts similarly to ibuprofen

and can reduce
your blood's ability to clot,

so your doctor may prescribe it
if you're at risk of a heart attack.

Paracetamol can reduce inflammation
and pain,

but is much gentler on the stomach.

However, it can cause liver damage
if too much is taken,

so never exceed the recommended dose.

With a number of treatment options
available at your fingertips,

we asked you the question...

what helps you feel better
when you're in pain?

[Sandro] Pain is experienced by
many of us on a daily basis.

And whilst there's a perception that women
have a higher pain tolerance than men,

it's actually women who report
being in chronic pain more often.

Scientific studies show contributing
factors are sex hormones and genetics.

Yet many feel us blokes
are the big complainers

about small amounts of pain.

I guess it's time for me
to put that to the test.

I'm in Sydney to find out firsthand
how my brain responds to pain,

and I'm a little nervous about
what's involved.

I'm about to undergo a brain imaging MRI,

but before I can be scanned,
I'll be served a large dose of pain.

- Hi, Sylvia. Sandro. Lovely to meet you.
- Sandro. Nice to meet you.

[Sandro] It will be inflicted on me
by Dr Sylvia Gustin,

a senior neuroscientist and psychologist.

She's been studying the brain's
response to pain for 20 years.

[plays smooth sax tune]

So it's no surprise in the evening
she relaxes with a soothing sax.

Normally Sylvia and radiographer Segar
scan the brains of chronic pain sufferers.

But using their latest research

in understanding how the brain reacts
to pain,

they hope to address ways to come up with
treatments that don't include drugs.

And today, I'm their guinea pig.

My name is Segar, the MRI radiographer.

So I'm in your capable hands today.

Yes, you are indeed. How are you today?

A little nervous, but usually
I'm sending someone off for an MRI,

not myself, so, um...

The bit I'm really nervous about,
of course, is the pain,

which is coming in the form of
a saline solution, or saltwater.

At some stage you'll let me know

when you start putting the
hypertonic saline into my leg, or...?

We will not let you know that.

No, it will just start to happen?
Wow, I'm glad I asked that question.

Yeah, because this is how pain starts.
Pain starts suddenly, yeah?

- OK.
- So you're without any warning, yeah?

Right, so this is your hospital gown,
and so we get you changed.

- Is that it?
- Yes.

- There's no more?
- No more. All there. [laughs]

- It's gonna be cold.
- [laughter]

[Sandro] Not only am I nervous,
but now I'm doing it in a paper dress.

Wait, why isn't Shalin doing this?

- Pretty stylish.
- OK, let's start.

- We're going to get your glasses off.
- Let's do it. Great.

- Can you see without your glasses?
- Blind and in pain, excellent.

- So now... [laughs]
- Let's do it.

Before the scan begins,
I'm having a cannula fitted.

It will be used later to administer
the saline solution...

- Was that very painful?
- Ah, didn't feel a thing.

...which, when directly injected
into muscle rather than a vein,

will induce quite severe pain.

[Sylvia] If there is anything
and you want to stop the experiment,

please press the buzzer
and then we stop immediately.

[Sandro] OK.

[Segar] Is everything alright with you,
Mr Sandro?

- Yep.
- Good.

We're going to ask you
to check the buzzer.

[buzzer beeps]

- That's it.
- Right.

So, when you will start feeling
the pain in your right leg,

then please press the buzzer one time.

And if the pain stops,
just press about five to seven times.

[Sandro] What do you mean, "pain stops"?

Ah, if you don't feel pain anymore.

[Sandro] OK, but what is the...
If that's... I'm confused.

If I don't feel happy
and I want to stop the experiment,

what is the signal?

Oh, if you want to
stop the experiment...

- Are you planning to stop the experiment?
[Sandro] No.

- OK.
[Sylvia chuckles] OK.

[Segar] Right, um,
if you want to get up from the scanner,

just continuously press.

[Sandro] OK.
[Segar] Sounds good?

[Sandro] And Segar,
have you done this before?

[Segar] Many times.
[Sandro] OK, great.

[Sandro] So, clearly I'm nervous.

- Thanks, buddy!
[Segar] Yeah.

[Sylvia] Do you have any pain at the
moment, Sandro, from the cannula?

[Sandro] No. None.
[Sylvia] OK, that's fantastic.

We will look into your brain,

what's going on now
while you have no brain...

While you have no pain. [chuckles]

OK, we'll start now.

[Sandro] My heart's racing
and I'm starting to sweat,

so I'm wondering if that's what
will be showing up on the scans?

[Sylvia] So, what we are now seeing here
is actual slides of the brain.

Ah, quite a little bit of activation here,

I think because Sandro
is a little bit scared, yeah?

He doesn't know exactly what is coming.

So there is quite a little bit
of activation in the prefrontal cortex.

- Shall I step inside?
- Yeah.

- To do the...
- Yeah, yeah, I think so.

[Sandro] And now for the part
I've been dreading.

Ooh! Ow!

[buzzer beeps once]

[Sylvia] OK, the pain has started.
Sandro buzzed one time.

[buzzer beeps three times]

And now it's increasing, yeah?

[Sandro] I can feel cramping
and sharp pain slowly spreading

as the saline works its way
through my muscle.

It really hurts.

[Sylvia] Oh, wow. Now we can see there's
a lot of red blobs that are coming up.

That means the brain is very active, yeah?

In particular we see in
emotional pain processing areas,

but also in somatosensory areas.

[Sandro] The somatosensory cortex,

the part of the brain that processes
physical feelings,

is registering my leg pain,

and that's because its job is to detect
touch, temperature and pressure stimuli

and turn them into danger signals
where needed.

This response is now showing up
alongside other active brain regions,

the emotional ones,

which were triggered by
my nervous anticipation.

[buzzer beeps five times]

Thankfully, after five minutes or so,
the pain subsides.

So we know now
that the pain has diminished.

[Sandro] And everything
goes back to normal.

We can't see there any more
activity in the prefrontal cortex

or emotional brain processing areas

because I think he's very happy now
and he's very relieved it's over,

and he knows, "Now I can come out
of the scanner and I've done it."

- Cool. A bit sweaty.
[both laugh]

A bit sweaty from the stress, I think.

So, Sandro, you've done well.
Well done.

Thanks very much, Sylvia.

So, how's the pain at the moment?
Is it gone, or still a little bit?

No, the pain's mostly gone now.

- Mostly gone.
- Yeah.

When we started the experiment,
on a scale from zero to ten,

so, zero means no pain,
and ten, the most imaginable worst pain?

Yeah, like, it crept on quite suddenly.
Sort of hit two, three quite quickly.

OK, two, three. And then as it increased?

Yeah. And then I think it got to
probably about eight or nine.

- Oh, wow, that's--
- Or, yeah, maybe seven or eight.

- No, no, no, you said... No, no, no--
- But it was pretty...

- Yeah, it was pretty sore.
- No, it was, definitely. It's...

[Sandro] Now, the big question.

Am I a total wimp?

Um, I would say you are somehow
in the average, yeah?

- OK.
- There are a little bit more brave people.

- Yeah? But there are also--
- I'm not surprised.

[both chuckle]

[Sandro] So, women might be
more prone to chronic pain,

but with that performance,
I think I've just levelled the field.

Well, I think the anticipation
was probably in many ways

worse than the pain itself,
but either way,

I will not be making a regular habit
of putting myself through pain.

Of course, there's a big difference

between the five minutes
of acute pain I underwent

and the chronic pain
patients that Sylvia usually scans.

So, it looks like I have a brain.

It's quite a good-looking brain,
I would say...

[Sandro] Chronic pain is a condition
where discomfort from injury or illness

doesn't shut off,
even though the incident has passed.

So I'm really interested to see
how my brain compares.

So, in particular
what we have seen today

- was activation here in thalamus.
- Mm-hm.

[Sylvia] And then we have seen activation
also in the primary somatosensory cortex,

and what we have actually seen in you,
before we started the injection, yeah,

we have actually seen quite a bit
of activation here...

- In the prefrontal area.
- ...in the prefrontal cortex.

- And that makes sense, doesn't it?
- Yeah, because...

- Yeah, a bit anxious.
- ...you've been a little bit anxious.

So what you're saying is that we've seen
sort of two patterns of brain activity.

One is relating to the pain in my leg.

Then we also saw some prefrontal activity

that was probably more related to
me having insight into the fact

that something was coming
and being a bit nervous

- and being a bit, probably a bit chicken.
- Yeah.

And so we see that lighting up,

and then we actually see the pain centres
lighting up. That's interesting.

So how would this look different
if it was chronic pain,

that is long-term pain,

as opposed to pain
that only lasts a few minutes?

[Sylvia] So, in people with ongoing pain,

our research showed that they have
structural function biochemical changes.

- And one area is the thalamus.
- Mm-hm.

[Sandro] Among other things,

the thalamus relays sensations
from the peripheral nervous system

to the cortex of the brain,
a bit like a boom gate.

It's one of a number of regions

Sylvia's team have found misfires
in chronic pain sufferers.

Another is the medial prefrontal cortex,
which regulates emotions.

[Sylvia] This might mean that
your medial prefrontal cortex

has lost its ability
to dampen down your emotions,

- and therefore everything gets amplified.
- Wow.

So the more you anticipate pain,

the more you think about pain,

somehow the more is the increase in pain.

So the pain increases your emotions,

the emotions increase your perception
of the pain,

which increases the emotions again,

and you end up in this cycle of both?

[Sylvia] Exactly, yeah.
- Right.

This idea of a self-perpetuating,
or vicious, cycle

could explain the plight
of chronic pain sufferers

whose symptoms sometimes inexplicably
last for months or even years.

So these insights into
the emotional side of chronic pain

could shed light on more effective
treatments in the future.

[Renee] We recently put out a question
on social media...

how do you manage your chronic pain?

[laid-back rock music]

Wait, did you think I was
smoking cigarettes?

I'm Indian,
and we love burning the incense.

[sitar music]

But what has smoking cigarettes
got to do with pain?

Not only is smoking
the leading cause of lung cancer

and leaves us smelling
less than desirable,

but there's new evidence to suggest

that smokers are at greater risk
of back pain than non-smokers.

The cigarette smoke reduces blood flow
to the spinal region,

making it more vulnerable to injury.

So this could be another good reason
to quit those ciggies.

[Renee] The complexity of chronic pain

is something medical professionals are
gaining more understanding of every day.

Dr Nick Christelis
is a pain specialist physician...

who also likes spinning tunes.

[record scratching]

[Nick] Chronic pain is huge.
It's a massive problem.

It affects all types of people,
young and old.

In this clinic we see up to about
a thousand patients per year

suffering from some form of chronic pain.

[Renee] Dr Christelis helps his patients
with a three-to four-point plan,

starting with medication,

but building to ultrasounds
and nerve-scrambling therapies

to block pain signals
before they get to the brain.

Pain medications only help
some people some of the time,

up to about 30% of the time,
which is not a high number.

Invariably, if medications don't provide
a good form of pain reduction,

then we would move on to
other forms of therapies,

and this includes blocking off a nerve
using an injection.

Sometimes we can burn nerves,

sometimes even just heat up nerves
to provide longer lasting pain control.

That gives us a short window of
opportunity to rehabilitate the patient.

[Renee] It seems pill-popping alone
is no longer the simple solution.

Now, medication and nerve therapy

are incorporated into a wider program
of exercise and rehabilitation.

A lot of people come in and say,
"I'm exhausted.

I'm exhausted physically
and I'm exhausted emotionally by my pain."

So these advanced techniques

need to be combined with
a holistic pain management approach,

otherwise invariably they don't give us
the success we're looking for.

[Renee] This new holistic approach to
pain management is gaining momentum,

in part thanks to this
rather special creation.

It's a travelling science lab on wheels,

known simply as the Brain Bus,

and I caught up with it on the
Great Ocean Road in Victoria, Australia,

along with its creator, Lorimer Moseley.

He's a professor
of clinical neuroscience...

and he also likes bubblegum milkshakes.

Professor Moseley's so passionate
about chronic pain,

he's dedicated his life
to educating people about it.

What do you think are the real
major causes of chronic pain?

Well, chronic pain is so complex,
Renee, it really is.

And I think the major causes are learning
within your nervous system, actually.

I mean, there's a lot of causes of injury,

but most injuries heal,

and then the nervous system sometimes
keeps sending danger messages

up to the brain,

and we know that whenever
the nervous system does anything a lot,

it gets better at doing it.

[Renee] This is exactly what
Sandro learned back in the lab.

Some people's pain response
goes into overdrive,

with an added psychological element.

How's this for a stat?

If you hurt your back,
and someone tells you you need an MRI...

that makes you less likely to recover.

Not getting the MRI,
being told you need one.

[Renee] To help get this message
out there,

the Brain Bus is a travelling
community resource

created to support patients of
chronic pain on their road to recovery,

and it does it by demonstrating
the power of the mind.

- Hi!
- Hi.

- Tash?
- Yes.

- Renee. Nice to meet you.
- Lovely to meet you.

- And you must be Dan?
- Yes.

- Nice to meet you, Renee.
- Nice to meet you, guys.

- What an awesome bus.
- I know, right?

[Renee] Dr Tasha Stanton
and Dr Dan Harvie

are at the helm of this
innovative pain experiment

with some... unusual props.

[Renee] You've got, like, a hand.

[Tasha] Yes, this creeps some people out.
It's a rubber hand, so all good. [laughs]

[Renee] OK, so,
she carries a rubber hand around.

That's... interesting.

I've never done virtual reality before.

Ooh. Oh, my gosh.

This test is a starting point,

showing how easily
our brains can be tricked

by things that aren't really there.

Why am I slurping?
I don't even know why I'm slurping!

It's an important step in understanding
the role perception plays in chronic pain.

- Ahh, I spilled my coffee!
- Don't spill it on yourself.

[laughter]

[Renee] This is impressive,

but their next trick shows how
whole new body parts can be imagined.

- So I just put that there?
[Tasha] That's perfect.

- Sorry, playing with your hands.
[Tasha] Not at all.

So now I'm going to get you to
put your other hand behind here.

Yeah, that's great,
and your other one on this side.

And I'm just going to drape this
over the top of you.

- So I can't see my--
- Exactly.

So, we're going to make it so that
you cannot see your hand.

That's not my hand.

So, with my real hand
hidden behind the screen,

they plan to trick my brain into thinking
old horror hand has replaced it.

I really can't see this one working.

[Tasha] And what we're doing is, we're
going to see if you can lose your hand.

And all I'm going to do is,
I'm just gonna stroke it with the brush.

[Renee] While Tasha is stroking
the fake hand,

she's also stroking my real hand.

I know this is happening,
yet strangely, the illusion is working.

[Tasha] Yeah,
and where is your hand located?

It feels like it's here.

- That's so weird.
- It does, doesn't it?

So, because you're seeing your hand
being touched

and I'm touching your other hand behind
the screen, same place, same time,

your brain then decides that
this has to be your hand.

- But that's not my hand.
[Tasha] That's not your hand.

My god, I had to check it wasn't my hand.

That's so weird. You're not my hand!
You're not my hand!

- [exhales] OK.
[Tasha laughs]

[Renee] Brain Bus two, Renee zero.

Let's see if I can be muddled
by the mirage machine.

I'm not sure if you're going to
chop my head off or something.

Yeah, that's fair enough. [laughs]

- I promise it's safe.
[Renee] OK.

[Tasha] If you can put your right hand
into the machine here, in the bottom bit.

- In here?
- Yep. And you should be able to see it

- if you look in this top mirrored portion.
- Yep.

- Definitely my own hand.
- Perfect.

So, what we're gonna do today is we're
gonna see if you have stretchy fingers.

Now, can I get you to make a fist
and point at me with your index finger.

I'm just going to grab the end
of your finger here

and I want you to just keep watching
what happens to your finger, OK?

[Tasha] Oh, that's interesting.
- Oh, that's so weird!

[Tasha] I knew it!

[Renee] Well, this is bizarre.

Oh, my gosh! [laughs]

Of course, rationally,
I know this can't be happening,

but my brain feels as warped as my finger.

[Tasha] So, what we do in this illusion,
it's combining vision and touch.

- It's messing with your brain.
- Yep.

And we see that in people
with chronic pain,

that often their perceptions
of their body part are impaired.

Explains why when you talk to patients,

and you try to tell them
that something isn't true,

they're often like,
"Well, but it's real for me."

[Tasha] And also I think that's the power
of X-rays and imaging,

is you're seeing this visual image
and it can be incredibly powerful.

[Renee] Yeah, definitely.
[Tasha] Yep.

[Renee] It's certainly impressed me,

but then, very fortunately, I'm pain-free.

And how about patients with chronic pain?

I mean,
do you deal with those sorts of people?

Yeah, I do. So, we have various studies

that are looking at people
with chronic pain.

The ones I work with the most
are painful osteoarthritis,

and we do some really cool illusions
with them that, basically,

that changes in front of their eyes,
in real-time video,

what their body part looks
and feels like to them.

And what we found is that
they're analgesic.

So when we actually manipulate
how their body part feels to them,

it takes away their pain.

See if there's anything interesting
in the cupboard to your left.

[Renee] It's incredible to think
such simple illusions have the power

to take pain away without medication.

[Tasha] It's crazy, isn't it?
- Yeah. I just can't believe it.

I'm glad you liked it.

[Renee] The Brain Bus,
and Moseley's pain revolution,

is really exciting,

and it's bringing relief to people
who really need it.

People like Dave Jones.

Dave's no stranger to chronic pain,

but has taken a multi-disciplinary,

multi-modal approach
to his pain management

using brain training techniques,
exercise and meditation,

among other strategies,
to get it under control.

But not until he'd already spent
nearly 17 years

suffering the agony of chronic back pain

after falling onto a slab of concrete
at work.

So, you've actually tried
a lot of different treatments,

I believe, over the last sort of 17 years.

Can you sort of take me through
some of them?

Oh, physio, osteo,
chiropractors, acupuncture.

I reckon I've been to see
just about everybody

except for that bloke with the fish
and the smoke and the igloo

- that chants a bit.
- It was at least interesting.

Yeah, it would have been made for
an interesting adventure, but anyway.

Yeah. So, obviously,
during this whole period,

you've been taking medications.

Do you think they've been helpful?

[Dave] Not really.
They just mask the symptoms.

And I was very aware of the addictiveness

of a lot of the things
that I was being given,

and I didn't want to go down that track.

[Renee] But it wasn't just
the physical pain

that was having an effect on
Dave and family.

How has this whole process affected
your relationship with your wife?

It's made it really, really difficult,
and, uh...

Sorry. [chuckles]

[Renee] No, that's fine. That's fine.
Take your time.

Um, I'm very lucky that Kaylene's
an extraordinarily calm person,

so she's been incredible with her support.

- She deserves a medal.
- [chuckles]

[Renee] It was Dave's wife, Kaylene,

who encouraged him to read the research
of Professor Moseley

and apply both a physical and emotional
approach to his pain management.

[Dave] Armed with the information I got,

I've developed a heap of little mantras
that I say in my head.

[Renee] Mm-hm.

[Dave] And I've maintained my physio
and a lot of my exercise.

Basically I just keep telling myself
in my head

that I shouldn't be having that pain,

because the accident I had
was 17 years ago.

So I just keep initiating that
and initiating that in my head,

and it seems to not let the pain episode
escalate out of control.

It seems to maintain it.

[Renee] And do you still have pain?

[Dave] I live with the pain still,
but on a lower scale, and it's manageable.

I sleep at night,
I can go out and kick a footy,

I can do things, but it's manageable.

[Renee] Chronic pain is a complex problem,

and while some people benefit from
medication or things like surgery,

for others,
it seems there's something else going on.

And research is showing that
that thing might be our brains.

Dr Gustin's work,

although still in its infancy,
is exciting.

You can see how one type of brain activity
would reinforce the other.

[Renee] Understanding
the brain's response to pain

will help develop more bespoke treatments
for chronic pain sufferers in the future.

And it's amazing to think that something
as simple as mind management techniques

could help ease the agony for so many.

And how does the future look to you now?

Oh, the future's looking great.

Just amazing. Amazing.