The following is a summary from the 45th Annual Scientific Meeting (ASM) of the Australian Pain Society (APS), which took place in Melbourne from April 13-16, 2025. Since 2019, the ASM has featured a named plenary lecture drawing inspiration from the International Association for the Study of Pain’s (IASP) Global Year Against Pain, an advocacy effort to raise awareness of pain. The IASP chose 2025 to be the Global Year for Pain Management, Research, and Education in Low- and Middle-Income Settings.
Dr Tie Parma Yamato, a research fellow in the School of Health Sciences at the University of Sydney, and Dr Saurab Sharma, the chief clinical research scientist at the Michael J Cousins Pain Management Centre at Royal North Shore Hospital, were given the honour of delivering the named lecture in 2025. The pair shared insights from their careers on how pain management, research, and education can be advanced in low-resource settings.
Dr Sharma started the lecture by explaining the rationale for the changes in language, where references to low- and middle-income countries has been replaced with low- and middle-income settings. While the former is certainly included in the latter, the expanded definition also refers to disadvantaged populations in high-income countries, including – but not limited to – culturally diverse communities, First Nations people, refugees, and people living in rural and remote settings.
Focusing on a broader definition is critical, according to Dr Sharma, due to the increasingly disproportionate burden of pain in low- and middle-income settings.
“Only 5% of all clinical trials that are published on the area of global health are coming from low- and middle-income settings, which hold 85% of the world’s population. Similarly, there is exclusion of cultural diversity, with only around 1% of all clinical trials in Australia focusing on Aboriginal and Torres Strait Islander people, he said.
“Furthermore, clinical research and trials often exclude culturally diverse individuals, which means that most of the treatments we have don’t really apply to these individuals. But most importantly, for many of the low- and middle-income countries, there aren’t any policy documents for musculoskeletal or other chronic pain conditions. So, the clinicians there remain unguided on how to treat people with pain in their country and context.”
Many of the barriers to undertaking research in low- and middle-income settings relate to research not being a priority due to other pressing issues (e.g., famine, war, etc.). Having research sit lower on the priority list means there is less funding available to support a research-specific workforce and fewer opportunities to teach health professionals about research. Language is also a big sticking point, as reliable and validated tools in local languages are few and far between.
To highlight some of these issues, Dr Sharma walked attendees through some of the work he undertook about setting pain research priorities in Nepal, his home country.
After conducting a systematic scoping review into the state of clinical pain research in Nepal where research gaps were identified and prioritised, the first area of focus was pain assessment. This work involved testing four commonly used pain scales to determine which were more preferred and more accurate.
“Surprisingly for you, but not for us, the numerical rating scale was least preferred while the FACES rating scale was most preferred. Furthermore, the numerical rating scale and the visual analogue scale were associated with the most error,” Dr Sharma said.
Dr Sharma and his collaborators used these findings to guide the translation and validation of several tools to assess pain, function, and quality of life for people living with pain before using these in the next two priority areas: treatment and high-quality epidemiological studies.
The team developed educational resources for people with back pain and other pain-related conditions, which were based on a strong curriculum that also contained local patient stories, metaphors, and original artwork. This approach was later adapted to three different language groups in India, meaning the resources could be used by over 800 million people.
The final area, high-quality epidemiological studies, involved a lot of leg work as Dr Sharma and the team completed a census in a village from the rural, mountainous regions of Nepal. Their census showed one in two people experience chronic pain.
“We were also lucky enough to squeeze in one question around low back pain in the National Health Survey of Nepal, and we found that activity- or work-limiting back pain was present in one in four people, which is quite a massive burden.”
Dr Sharma has recently received funding from the NHMRC to co-design and test culturally appropriate treatments for five different culturally and linguistically diverse populations in Australia. He hopes that the interventions that come from this work can lead to future research partnerships in countries such as Vietnam and China.
Dr Yamato’s part of the presentation related to her work undertaking pain research in Brazil. Despite its population of over 200 million people, the country faces several social and health challenges.
“About 6% [of the population] are unemployed, which is roughly the combined population of Sydney, Melbourne, and Brisbane. Nearly 13% of Brazilians – more than the entire population of Australia – live in rural areas, and a significant number of adults have not completed primary school,” Dr Yamato said.
“Over 160 million Brazilians do not have private health insurance, and yet 80% of the doctors work in the private sector. This means that just 20% of the country’s doctors are responsible for caring for 75% of the population.”
Like Dr Sharma, Dr Yamato started by setting a simple research priority – a cross-sectional study to estimate the prevalence of disabling musculoskeletal pain in children and adolescents. The study of nearly 3,000 participants found 27% of children and adolescents had experienced disabling musculoskeletal pain in the past month. This initial work led to a subsequent study estimating the costs of musculoskeletal pain in children and adolescents over the course of a year.
“The annual societal costs per child was around $177, which represents three percent of the minimum wage in Brazil.”
Some of Dr Yamato’s more recent work – the KITE and the BRINCA cohort studies, both of which are currently under review – have attempted to develop the first models to predict the onset of and recovery from musculoskeletal pain in children.
The first cohort study saw Dr Yamato and her colleagues follow nearly 2,000 children who were pain-free at baseline for a period of 18 months. The incidence of musculoskeletal pain at 18 month was 22%, and the associated predictive model showed good specificity but low sensitivity.
The second study was similar, but here the researchers followed nearly 700 children with pain at baseline for 18 months to determine predictors of recovery. While the majority of patients (86%) recovered over the follow-up period, the recurrence rate was still quite high.
“Flexibility is essential when doing research in low- and middle-resource settings,” Dr Yamato said.
“For example, missing data is a significant problem. In low- and middle-resource settings, people may not be able to attend a session or follow-up due to many barriers such as the costs associated with transportation. Furthermore, universities often lack basic infrastructure [necessary for research] – for example, the university I was at didn’t have Wi-Fi.
“Designing research in low- and middle-resource settings often needs to be designed from the ground up. We had to translate and validate all the tools before we could do the longitudinal studies. We also faced issues like students being unable to attend school due to violence during the pandemic. This kind of local reality must be carefully considered when planning research.”
Dr Yamato’s point about considering the reality of designing and implementing interventions in low- and middle-income settings was further emphasised when she shared some of the work done by her husband, Dr Bruno Saragiotto, in a project that explored testing three different implementation strategies for delivering an online pain education program through the Brazilian public healthcare system.
“Before running their Randomised Controlled Trial (RCT), they did a qualitative study to ask how the population would like to receive the intervention. Many people don’t have access to the internet in Brazil because the data is very expensive, and they do not have enough storage on their phones.
“[However], most of the mobile providers in Brazil offer free access to WhatsApp, and because of that, they delivered the whole intervention via that platform. In this context, no other apps or platforms would have worked… I think this is a great example of how the context strongly shapes how interventions should be designed and delivered.”
But despite the challenges, Dr Yamato highlighted that opportunities also exist.
“People in low- and middle-resource settings tend to be very motivated and hard-working. Research in Brazil mostly happens out of goodwill, and it relies far more on determination and our natural willingness to support one another rather than relying on funding or government incentives.”
Dr Yamato concluded the plenary lecture by reiterating what Dr Sharma spoke about during its early stages, highlighting that pain is a global priority, and that research needs to be embedded into the culture of healthcare systems even in places where resources are limited.
“People living in low-resource settings are not the minority. They’re actually the global majority, and I am sure that the dominant voice has something to contribute too.”
Dr Lincoln Tracy is a senior research fellow at Monash University and writer from Melbourne, Australia. He is a member of the Australian Pain Society and enthusiastic conference attendee. You can follow him on (@lincolntracy) or check out some of his other writing on his website.
Australian Pain Society 