Chronic pain is more than just a pain signal

Professor Dirk De Ridder on "BurstDR":

How natural brain signals inspired a new approach to chronic pain

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A Belgian pioneer in the international development of neuromodulation

Professor Dirk De Ridder, co-founder of BRAI3N, was instrumental in the development of BurstDR: an advanced form of spinal cord stimulation for the treatment of chronic pain.

In an interview with the international trade journal Orthopedic Design & Technology , Professor De Ridder explains how the concept originated, how BurstDR differs from traditional spinal cord stimulation, and how scientific research has further refined the technology over the years.

The technology's name contains a direct reference to its origin: the letters DR in BurstDR stand for De Ridder.

Chronic pain is more than just a pain signal

Pain primarily serves a protective function. It warns us of damage or danger and prompts us to adjust our behavior.

With chronic pain, however, the pain system remains active even when that constant warning has largely lost its original protective purpose. The pain then becomes more than just a physical experience. It can also affect daily functioning, sleep, concentration, mood, and quality of life.

People with chronic pain therefore often experience more than just the sensation of pain itself. They may also deal with:

• fear of movement or new pain;

• a constant alertness to physical signals;

• worrying about future pain;

• feelings of powerlessness;

• emotional exhaustion;

• a decrease in social and professional activities.

In the interview, Professor De Ridder distinguishes between two dimensions of pain.

On one hand, there is the sensory "painfulness": where is the pain located, how intense is it, and what type of pain is being experienced?

On the other hand, there is the "suffering" that accompanies the pain: how much emotional significance is attributed to the pain, and what impact does it have on the patient's life?

According to this view, effective treatment for chronic pain must therefore address not only the physical pain signal but also the broader networks that determine how burdensome and threatening the pain is perceived to be.

What is spinal cord stimulation?

Spinal cord stimulation, also known as SCS, is an invasive neuromodulation technique. Mild electrical signals are delivered to the spinal cord via an implanted system.

These electrical signals change the way pain information is transmitted from the body to the brain and processed.

Spinal cord stimulation has been around for several decades. Traditional systems primarily used so-called tonic stimulation: a regular and continuous pattern of electrical pulses.

That type of stimulation mimics one of the ways in which nerve cells communicate with each other. However, the nervous system does not exclusively use regular, tonic activity.

Nerve cells can also fire their signals in short, organized groups. This is called "burst firing" .

The inspiration behind BurstDR

The concept of BurstDR originated from the idea that neuromodulation should mimic the natural functioning of the nervous system as closely as possible.

Professor De Ridder refers to the Catalan architect Antoni Gaudí, who was strongly inspired by forms and structures from nature in his designs.

The core idea was similar:

When we want to influence a biological system, we must try to speak the natural language of that system.

While conventional spinal cord stimulation primarily mimics tonic activity, BurstDR was developed to mimic burst firing.

Burst activity occurs in the brain and nervous system, among other times, when a stimulus is salient, relevant, or meaningful. It serves as a powerful communication signal that can influence other neural activity.

By mimicking such a natural signal structure, BurstDR aims to modulate pain processing in a more targeted way.

Not just the pain, but also the emotional impact

According to Professor De Ridder, a key difference from traditional stimulation is that BurstDR was designed to influence both the lateral and medial pain pathways.

The lateral pain pathways are primarily involved in the sensory characteristics of pain, such as location and intensity.

The medial pain systems are more closely linked to the emotional and motivational aspects of pain: how threatening does the pain feel, how much attention does it demand, and how much suffering does it cause?

Research into BurstDR reported not only changes in pain intensity, but also described improvements in the emotional and mental impact of chronic pain.

One of the aspects studied is pain catastrophizing. This refers to a state where someone constantly thinks about the pain, feels helpless, or expects the pain to keep getting worse.

Pain catastrophizing does not mean the patient is imagining the pain. It is a real neuropsychological process that can heighten focus on pain and increase the perceived burden.

A form of stimulation that also influences these emotional pain networks can therefore have a different clinical impact than a treatment that focuses exclusively on the physical sensation of pain.

The "less is more" principle

BurstDR was initially administered continuously and at relatively high stimulation amplitudes.

However, further scientific and clinical insights led to an important change. With BurstDR, it turned out that more stimulation did not necessarily produce a better effect.

The starting point therefore became:

“Less is more.”

In practice, this principle was translated into:

• lowering the stimulation amplitude;

• intermittent rather than continuous stimulation;

• administering the lowest effective dose;

• increasing the precision of the stimulation.

With technologies like FlexBurst360, stimulation can be tailored across different body zones.

This development is part of a broader evolution in neuromodulation. The goal is not to deliver as much electrical energy as possible. The goal is to influence the right neural network, with the right pattern, at the right time, and at the lowest necessary dose.

Ten years of further development

BurstDR was first approved for use in the United States in 2016 with certain spinal cord stimulation systems. Further technological developments and new applications followed.

In 2019, approval was granted in the United States for low-dose BurstDR neurostimulation using systems that do not require regular recharging.

In 2022, the Proclaim Plus system with FlexBurst360 was introduced. It allows stimulation to be tailored across up to six different areas of the torso and limbs.

In 2023, U.S. approvals followed for specific patient groups, including patients with chronic pain due to diabetic peripheral neuropathy and certain patients with chronic back pain who are not candidates for corrective surgery.

These approvals apply to specific systems and indications in the United States. They should not be automatically extrapolated to other countries, systems, or patient groups.

From scientific hypothesis to clinical technology

The story of BurstDR is an example of translational neuroscience.

Translational neuroscience seeks to translate fundamental knowledge about how the brain and nervous system function into clinical applications that can help patients.

The development process involves several steps:

1. understanding how nerve cells process information;

2. formulating a hypothesis on how a disrupted network can be influenced;

3. developing a stimulation pattern that aligns with that hypothesis;

4. clinically testing the technology;

5. further refining the treatment based on the results.

In 2023, Sven Vanneste and Dirk De Ridder published research in the scientific journal Brain Stimulation on the influence of BurstDR on the balance between pain input and pain suppression in the brain for chronic neuropathic pain.

This research supports the idea that spinal cord stimulation does not only work locally at the level of the spinal cord, but can also induce changes in the way the brain processes pain information.

BurstDR and BRAI3N:

invasive and non-invasive neuromodulation under one vision

BRAI3N approaches neuromodulation as a broad and integrated field of treatment. We do not limit ourselves to non-invasive techniques, but also embrace the possibilities of invasive neuromodulation.

BurstDR is an invasive neuromodulation technique in which electrical signals are administered via an implanted spinal cord stimulation system. Within BRAI3N, this expertise will be offered alongside our existing non-invasive neuromodulation techniques, including transcranial magnetic stimulation, transcranial electrical stimulation, and neurofeedback.

The development of invasive neuromodulation is being carried out in collaboration with Professor Jean-Pierre Van Buyten, anesthesiologist and pain specialist. This collaboration is organized within BRAI3N and in partnership with AZ Vitaz in Sint-Niklaas.

Although invasive and non-invasive neuromodulation differ technically, they share the same scientific vision: to influence a disrupted brain or nerve network as precisely, effectively, and individually as possible.

Several principles are central to this approach:

tailoring the treatment to the neural network involved;
approximating the natural functioning of the brain and nervous system as closely as possible;
stimulating no more than is necessary;
continuously evaluating treatment results against scientific research;
taking into account both physical symptoms and the broader impact on the patient's functioning and well-being.

By bringing invasive and non-invasive neuromodulation together within one center of expertise, BRAI3N aims to offer patients a broader and more integrated treatment perspective. The focus is not on a single technique, but on determining which form of neuromodulation best aligns with the symptom profile, the network involved, and the individual patient.

Professor Dirk De Ridder's contribution to the development of BurstDR aligns directly with this vision: making neuromodulation increasingly targeted, personalized, and biologically grounded.

A continuous evolution

Even after ten years, BurstDR continues to evolve.

Future research could, among other things, study how other stimulation parameters can be further optimized, how stimulation can be targeted even more precisely, and whether different forms of stimulation can be combined.

The most important lesson from the development of BurstDR is perhaps that innovation does not arise solely from developing more powerful technology.

Sometimes progress comes from a better understanding of how the nervous system itself works—and then stimulating it with less energy, greater precision, and a more natural pattern.

As Professor De Ridder summarizes it:

“With BurstDR, ‘less is more’ is the starting point.”

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Source

Based on the interview “Meet a Pioneer of Modern Neurostimulation for Pain Relief,” published by Orthopedic Design & Technology on June 25, 2026.

Scientific reference:
Vanneste S, De Ridder D. BurstDR spinal cord stimulation rebalances pain input and pain suppression in the brain in chronic neuropathic pain. Brain Stimulation. 2023;16(4):1186–1195.

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