The term ‘paradigm shift’ is bandied around freely in medicine – and other sciences – these days. It suggests a sideways shift in the direction of thinking in any particular field of endeavour. Originally proposed by the science philosopher, Thomas Khun (hence the term ‘Khunian paradigm shift’), it was meant to show that big advances in science come from stepping outside traditional thinking and carving a new, and sometimes obtuse, path.

The notion of Lifestyle Medicine is a type of paradigm shift (albeit a small one). But within the field lifestyle medicine, there are a range of shifts occurring, which only make sense within the broader category of changes in population levels of disease.

Chronic pain is an example: Traditionally the thinking has been ‘dualistic’ – either a straight medical treatment (drugs/surgery), or being sent off to a psychologist or psychiatrist with a note to say there is no obvious organic reason why this is happening, so it must be ‘in the head’.

The need for a paradigm shift in this way of thinking was brought to light at the national pain summit in Canberra. Headed by long-term pain specialist Professor Michael Cousins from Royal North Shore in Sydney, the summit concluded that this dualistic and linear approach has to be replaced with a more holistic view, taking account of the patient’s life history, emotional and relationship status, thinking patterns, lifestyle and actions, as well as any biological aetiology.

This has come about through acceptance of the fact that much chronic pain has no biological basis, and some biological pathology (eg. disc rupture) does not cause pain for some people. X-rays for lower back pain often make the problem worse, and in some contexts (eg. war,) that pain has a totally different manifestation than in other contexts. This adds to the suggestion that there is more involved than just nociceptors and neurons.

The pain summit demonstrated, perhaps for the first time to many practitioners, how widespread (at least 20% of the population) and costly (a direct cost of ~$34 billion) chronic pain is.  Specialist pain units are overwhelmed (a) because of the extent of the problem and (b) because of the inadequacy of primary care (and sufferers) to adequately manage, or self manage, the problem.

While chronic pain has undoubtedly been with humans for eons (can you imagine the joints of the retired gladiators or crusaders???), most experts agree that the prevalence has increased markedly over the last 2-3 decades. Why should this be so?

One reason is the ageing population. However, this is not the entire explanation, because younger age groups are increasingly diagnosed with chronic diseases. Early involvement in contact sports could also be exacerbating the situation. Orthopaedic surgeons are undoubtedly going to be in high demand from ageing professional sportspeople who have endured injuries throughout their careers.

Another, more insidious, driver however, is the very thing behind the growth in overall chronic disease prevalence – our modern lifestyles. Not coincidentally, non-specific chronic pain is associated with obesity, lack of sleep, inactivity, smoking, poor nutrition, stress, anxiety etc. Some recent findings on ‘inflammatory’ pain as a sub-section of neuropathic pain may help us understand why.

Low grade, chronic, systemic inflammation (‘metaflammation’, or metabolically related inflammation) has been associated with many forms of the modern, industrial lifestyle. It is as if our immune systems react to this ‘new’ lifestyle, as it would to a bacteria, or micro-organism with which it has not evolved. This immune reaction occurs mainly in the vascular endothelium (although the liver and other organs are also affected). But inflammation of microglia, which play an important intermediary role in the neurovascular system, suggest that de-sensitisation of nerve junctions from the inflammation within neurovascular tissue could result in chronic pain messages being lodged in the brain, without any obvious stimulus.

Norman Doiges revealing book The Brain that Changes Itself, considers the possibility that such connections can not only be easily formed, but might be amenable to alteration through ‘de-programming’. Understanding the patient’s psycho-social history, lifestyle and thought patterns, adds to any biological implications from such non-specific sources of pain.

How can primary care help? The best thing to do is make positive lifestyle changes, including self management. Drug treatments have limitations. Surgery can be effective at the deep end of the pool. However, the effectiveness of lifestyle management, including psychological and behavioural treatments, and improvements in nutrition, have yet to be fully tested. If, indeed, chronic pain does have an inflammatory basis, with a lifestyle mediating cause, a paradigm shift might be a refreshing change in managing what is becoming a ubiquitous national problem.