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[Physio Discussed] Pain management in practice with Dr Lorimer Moseley and Dr Tasha Stanton

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In this episode, we discuss pain science and all of its complexities. We explore: 

  • The definition of pain and chronic pain
  • Pain in total knee replacement recovery
  • Patient and therapist expectations and their role in pain
  • Perception and awareness in pain
  • Language and visualisation strategies and resources in pain
  • Spinal pain
  • Role of pain in knee OA
  • Importance of education in pain management

Professor Lorimer Moseley is a Bradley Distinguished Professor at the University of South Australia. He is interested in pain and other protective feelings. He has written over 400 scientific articles and 7 books. His foundational discoveries and outreach initiatives have led to awards in 15 countries. He leads the non-profit Pain Revolution and in 2020 he was made an Officer Of the Order of Australia for distinguished contribution to pain and its management, education, science communication and physiotherapy, to humanity at large. He lives, works, and rides a very cool e-scooter, on Kaurna Land in Adelaide, South Australia.

Associate Professor Tasha Stanton leads the Persistent Pain Research Group at the South Australian Health and Medical Research Institute (SAHMRI) and is co-Director of IIMPACT in Health at The University of South Australia, Adelaide. She is a clinical pain neuroscientist, with original training as a physiotherapist. Her research focuses on pain – why do we have it and why doesn’t it go away? She has a specific interest in chronic pain, osteoarthritis, pain science education, and novel technologies, such as virtual and mediated reality, to enhance exercise engagement.

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Our host is @sarah.yule from Physio Network

SPEAKER_01:

Thank you so much for having me. Tasha is a clinical pain neuroscientist with original training as a physio, with research focusing on pain. She's received over$7.3 million in competitive research funding, has published more than 110 peer-reviewed journal articles, and she has been a keynote speaker at more than 100 national and international conferences. Laura Mimosley is a clinical scientist investigating pain in humans. After posts at the University of Oxford, UK and the University of Sydney, Lorimer was appointed Professor of Clinical Neuroscience and Chair in Physiotherapy at the University of South Australia. He is also Senior Principal Research Fellow at Neura and an NHMRC Principal Research Fellow. He has published over 310 papers, six books and numerous book chapters, and he's given over 150 keynote or invited presentations in meetings in over 30 countries. His contribution to pain science and rehabilitation has been recognised with awards from 12 countries. Today's episode is jam-packed with so many practical insights and concepts that all of us should be pondering as clinicians. I hope you enjoy this conversation as much as I did. I'm Sarah Yule and this is Physio Discussed. Lauren and Tasha, I'm very excited to talk to you both today about all things pain science. So welcome to you both.

SPEAKER_02:

Thank you. I

SPEAKER_01:

think a logical place to start, perhaps, is in defining pain and chronic pain, and perhaps we can explore where the evidence sits currently.

SPEAKER_02:

Defining pain, there was this psychologist called Henry James who wrote Principles of Psychology, two volumes at the turn of the 20th century, I think. It was about attention, but you could apply it to pain. There's no point defining attention. Everyone knows what it is. Yeah, I feel a little bit like that around pain because we all know what it is for us, right? With a very small percentage of the human kind who doesn't experience pain or they don't experience it. They don't seem to. It's certainly not related to tissue threat and stuff like that. But aside from that, officially pain is all about, I think the official definition is something along the lines of pain is an unpleasant sensory and emotional experience associated with actual pain. or potential tissue damage, or it's been updated now to say that is normally associated with actual or potential tissue damage. And the things that people draw out in it is that pain has these two dimensions to it that I believe are inextricably linked together, and that is that it has a location, a sensory sort of dimension, and it has an emotional dimension. And the easiest way for me to think about pain is to always have those things together. So if it's not unpleasant... For me, I'd like to find another word for it.

SPEAKER_00:

Fantastic answer. It's right along the line of whether or not I still feel it's unpleasant. It probably is because I'm still wincing when it's occurring. But no, I definitely agree with how you've framed that. I certainly think one of the areas that's quite interesting to consider is when we think about how we define chronic or persistent pain. We use lasting three months, but that does feel a little bit just picked out of the air. I don't think there's necessarily something wrong with having a definition like that to standardize the literature. But it is really interesting to me. Often, if you see someone who's had pain and it's been there for three months, it might be a very different picture than someone who's had pain lasting years. So perhaps we see that differential weighting between sensory and emotional as it impacts your life more. But that's where I find it, I think, quite fascinating to consider individual presentation and how that's personalized for each individual in front of you.

SPEAKER_02:

That is a bit of a challenge though, isn't it? don't you think?

SPEAKER_00:

The good pain that

SPEAKER_01:

people talk about.

SPEAKER_02:

Yeah, that's exactly the language, isn't it, Sarah? It's a good pain. But I do wonder if that's about our extraordinary ability to predict the future and to weigh up things that we might think are good for us. But the way I think about pain, if you describe it as pain, it's pain, even if you think, oh, yeah, I want to have this.

SPEAKER_00:

Because that holds to like, Athletics too, doesn't it? When you think of people that push themselves to the limit and that hurts, that's not a fun circumstance, but yet there's benefit, there's reward. But yeah, I think it's still pain, isn't it?

SPEAKER_02:

Yeah, but it's curly, right? Henry Jones would have loved this. Because attention is so relevant to pain. Attention is the same, that we use the tension to describe all these different things. I run an exercise in our pain programs here where I just get people to define pain themselves. And there'll be 150 people in the room and there won't be two definitions that are the same. Some of them are very different. The point of that exercise is to say, this is us. We're a pretty homogenous group of educated, health-informed people who We don't even have similar ideas on what pain is. How's it going to be to make presumptions about what someone's experiencing when they say they have pain? And that chronic thing, yeah, I agree. It's like, you know, in two months and 27 days, if the third month is February, you've got acute pain and then you wake up the next morning and you're a chronic pain patient. It clearly doesn't work like that.

SPEAKER_01:

I think those are great points. The context to it seems to be quite relevant as well. I know people tend to intuitively know when they sort of say it's a good pain versus it's a bad pain. And it seems to be the context that they've often attached to it.

SPEAKER_02:

Yeah, I agree. I heard someone say the other day, in fact, his name is David Munro. He runs NICA, which is the National Institute for Circus Hearts here in Australia. They're such an interesting group of people, right? Circus performers. who hang by their hair or do stuff. And he was saying that often they don't talk about acute or chronic, they talk about same or different. Is it a different pain? Which is another interesting angle on it, I think. And I wonder if that's what does happen. If you've got that soft tissue massage, there is a time when you think, no, stop it. It's different. It's different.

SPEAKER_00:

Yeah. Well, we explored that a little bit. I wish I... I can't remember the exact findings, but with people who are undergoing total knee replacement surgery, because it's that idea that you have these whole trajectories of how people go after they've had their surgery. Some do really well, but some had, you know, really severe pain beforehand, and they still have it afterwards. Some have less pain beforehand and more pain afterwards, like all these different trajectories. But yeah, we were really interested in understanding, like, is it that for some people, they still come out with that same pain, which might predict that something that you had prior to the surgery wasn't resolved by the surgical procedure versus a different pain might be more related to something that occurred with that surgical procedure. But it was a smattering of different responses. So it was really interesting that even within quite an established procedure that you're doing that is really advanced so much, you just get such a different response in people.

SPEAKER_02:

Is there much conversation in the knee replacement world around knees hurting afterwards and it effectively being phantom pain because the knee's gone?

SPEAKER_00:

Yeah. So, I mean, certainly that's some of the way that we viewed it looking at setting up some of those studies. But I think there's a little bit about this idea of the forgotten knee or the knee that coming back to attention, it's almost like semi-neglect or extinction where you do have to attend a lot to it. And so, then that... when things are going well, it's almost like we don't notice our body. You have this perceptual, almost transparency of your body that you don't have to attend to, and it just works. Whereas suddenly you get a circumstance where to make it function as you'd like, suddenly you have to attend so many resources to it. And so it's almost like it's this forgotten need, which I think actually potentially works quite well within a paradigm of almost like phantom limb, because it's like, You're not theoretically getting that same sensory input back to say, yes, it's there. It is your knee.

SPEAKER_02:

Tash, after a knee replacement, is all the synovium still there and stuff? Like, could you still be having all that nociceptive stuff?

SPEAKER_00:

I'd probably have to look into that more myself, truthfully. I think sometimes it can be, but it probably depends on the type of replacement that they have, because some of them will have the unicondylar ones, which then you would suspect that there would still be existing synovial tissue on at least one side. But yeah, no, it's a great question.

SPEAKER_02:

Okay, I've gone off topic there.

SPEAKER_01:

Far off topic.

UNKNOWN:

Sorry.

SPEAKER_01:

It sort of sounds like with what you've spoken to about attention, it makes me think of when we don't actually think of being able to breathe with both nostrils, but on the day that our nose is blocked, we fondly reminisce about all the times our nose wasn't blocked.

SPEAKER_02:

Yeah, isn't that interesting? You do not notice it, do you?

SPEAKER_01:

Exactly

SPEAKER_02:

right. Being a proficient manufacturer of hay fever, I have this experience quite regularly. Fabulous.

SPEAKER_00:

Has that been on your CV?

SPEAKER_02:

Yeah. My most impressive achievement.

SPEAKER_01:

Going all the way back, I'm curious to just explore where the concept of our expectations, either as patients or just humans, expectations around the context of what we experience, how that plays into our experience of pain.

SPEAKER_00:

I mean, I think it plays a huge role. We see from some of the epidemiological literature that people's expectations of recovery, of surgery, result of just general, how they'll go with certain treatment, often have really decent links to where their outcome actually ends up. And Laz, you can probably speak to this best, but within some of the new perceptual theories and things like predictive processing, there's some thought behind the fact that your expectations of things actually change the way some of that sensory information that's coming from your body is sampled, such that they inherently change the processing and the experience itself.

SPEAKER_02:

It's groovy stuff, isn't it, that? And it's actually that idea's been around since Thomas Pais, I guess, maybe even before Thomas Pais, which, I don't know, that's 1800s? I can't quite remember. Priest, a Methodist priest, I think, and was wondering about stuff and came across this idea of how maybe even noticing in his own experiences of the world that what he expected to happen does seem to influence what feels like it happens. But to your question, Sarah, I guess the idea of expectation to me implies, and I think to most people, implies an awareness that you expect this. And I think as physios or as health professionals, we need to be quite careful about that because people don't like anyone inferring they're expecting the worst or they brought it on themselves, those sort of implications. And I'm aware of some of those studies that really emphasise what people think is going to happen in a health context often does happen, but that's often because people have a good judgment early on of trajectories. When you go deeper though, that stuff that Tash was alluding to, then I would often flip the language into predictions instead of expectations. If it's not sort of metacognitive where you can observe, oh, I expect this, then I like to think about, it's the same idea, but just with a different different label. It's pretty compelling. I visited the Grampians Health and Barwon Health Psychologist Day last week. And actually, even better, at the Health Professionals in Performing Arts Conference on the weekend, I ran this thing that I called the Nociception Choir. And it's a great way of understanding the extraordinary complexity of somatosensory input into the spinal cord. And it is astonishing. And I use the phrase, the symphony of data. arriving from every single cubic centimetre of our body all the time. And arriving into the brain, Dan Harvey, an outstanding scientist here at UniSA, quotes this stat. I've got no idea where he got it from, but it's pretty cool. Even if it's wrong, it's pretty cool. And that is that there are 100 billion signals reaching the brain every second. Now, let's say it's only 1 billion. That's still, many would argue, and probably the scientific community has accepted now, is 10%. is too many signals to interpret. So the brain becomes very good at accumulating data over the course of life to recognize what's probably going to happen next. And we use this phrase around being fit for the very next moment rather than experiencing things like pain because you're not fit for the moment. Actually, the contemporary thought would say it's probably more likely that your brain is saying you're not fit for the very next moment according to what should happen. And And it's a whole different way of thinking about how pain works and why pain is produced. But when it lands, we've got data from health professionals where we say, what helps you be more confident delivering biopsychosocial care or delivering pain science education or stuff like this? And one of the things that comes up is really understanding the idea that pain almost has an objective. And it's not just to alert, give you a readout of something. It's to change your behavior. There are people who criticize that. A very small number of people criticize that very aggressively, that idea that pain is protective. But I think it's a very compelling model. Anyway, I've gone off track again and hogged it.

SPEAKER_01:

No, wonderful points. Do you have some additional thoughts there, Tasha?

SPEAKER_00:

I think you brought up an excellent point, Liza, that idea of explicit expectations and calling them in this model predictions, but also these ideas that There are things that we aren't necessarily aware of that can really quite profoundly change what we experience. And so I think kind of even having examples about and understanding that can also make it scientifically plausible that my pain is going to differ when I'm in this situation, when I'm doing this sort of thing, even if nothing has changed yet. in the periphery. Like it starts to make sense. Like we often in some of the presentations that I'll do, I use the rotating mask illusion where you see the rotating mask and it looks to you like it's changing direction. But in fact, it isn't. It's just that we've learned that faces curve outwards and our brain refuses to see that error. So it shifts what you perceive, which that's remarkable. And it's powerful. So I think that there's a lot of things that actually kind of go on underneath our awareness that can really shape what we feel. But even I think just understanding that that exists is actually a really important part of that journey towards understanding how to empower and engage and re-engage potentially with valued life activities that were really nervous and really scary before. But understanding, okay, there could be some things I could do about this. Let me think about what my individual contributors are. to danger to safety, all of these aspects that ultimately determine whether or not we need to be protected by something like pain. So I don't know, I think it's the more that we get into the depth and the complexity, the more excited I actually get because it to me is where a nuance of a situation can actually be explored potentially within a scientific framework and that will have clinical translation because there's ways then to extend that to a clinical scenario. And as Loz mentioned, I think we often see that just even the mere understanding of some of those bigger concepts can be really shifting in people's journeys towards improvement or even recovery from pain.

SPEAKER_01:

Those are fantastic, fantastic points. And I feel like I've got a lot of questions coming from what both of you have just said. An example that I probably have seen many times before is that whole discussion around having the conversation around correcting perceptions and the language that someone comes to you with. And the best example I can give is my detested analogy of the lumber disc being like a jam donut because it just, you see the impact that that has on people and it just induces this feeling of fragility. But I've noticed that even once you've sort of picked a different analogy to sort of say, actually, we're a lot stronger than a jammed donut. There's this disconnect between, obviously, the brain lacks the evidence to go, well, show me. And I'm curious as to what both of your thoughts are as to how, as clinicians, we should be trying to not just say, well, actually, jammed donut's not the right thing to say, but actually how we prove to patients or the humans we see that that's not the case.

SPEAKER_00:

I feel like the first bit is just acknowledging that is not easy and that almost everyone has had those same experiences where you just feel like, oh, I'm not making traction. Like, I don't quite know what to do here. I don't think I have the answer. I think that some of the things that potentially are useful is, and depending on kind of the level at which they're coming to this conversation, is maybe to explore what would be evidence that your disc is like jam donut. What would be evidence that would give us some certainty that it's not? And perhaps we could think through some of those different things. And they may be activities, they may be symptoms that they feel, which we probably have less control over those symptoms. But I think some of that almost underpins some of the work where, you know, exposure therapy can be like trying to get people to do something that they really thought that they couldn't do, but you based on your evaluation, you are quite certain that's safe. That takes a lot of trust. That takes a lot of building. But perhaps there's also those kind of cognitive strategies as well to just create many little experiments with people to be like, all right, let's go through this. Let's test these assumptions that we hold and see where we come out. But it is hard.

SPEAKER_01:

Those are fantastic points. It's almost like the brain needs votes on the board to to go, well, that sneeze that happened, that was proof, but all of these other things that happened, that was the evidence against.

SPEAKER_00:

And I think it's hard because anything that's negative or adverse, it's weighted heavily. And rightfully so, it helps us survive. But I think certainly some of the work that's done by Anne Mulders, she's a researcher out of Belgium, often really shows that people who have persisting pain, they're actually okay at learning danger. It's much more difficult to learn safety. that is often compounded by anxiety. So that is a really, I think, interesting therapeutic avenue that would be, I think, really relevant for us as researchers to consider. Fantastic points.

SPEAKER_02:

I do wonder whether the fact that it's such a visually recallable event is part of the problem. There's pretty good evidence that neural networks or neuroimmune networks, some of the principles that govern the way they work include the precision with which the neurons in that network communicate. And the visual system is a very precise system. So if someone's got a visual representation of the jam donut and they've integrated into their idea of their back, that might be a particularly robust internal model of whether I'm fit for the very next moment. Equally though, if we can use the visual system to break down that model. And I think we only need to undermine it enough for an error between what should happen and what did happen to be detected by the system. And when it's detected, the system might change its model. So it's not, you know, it sort of slowly becomes, oh, that's not even thinking, but, oh, that's less like a jam donut. And then we try and undermine it again. And we can use visual data to do that with... or drawings, we've spent a lot of time trying to get accurate anatomical images of intervertebral discs. I even hate saying disc because it's not a disc. It's not actually disc-like. Yeah. Anyway, that's another rant that I could easily go on. But it's very hard to even find images. Even on this big worldwide web, there's all these images that are metaphorical. that show these clear delineations between the disc and the vertebra that look very slippable. Or there's anatomical photographs, which you can't comprehend anything because it's all grey because of formaldehyde. But actually, I got right into this a little while ago, and that histologically, the fibres in the ligaments that make up, and we talk about the LARF, the Living Adaptable Force Transducer, being made of ligaments. All around the outside, just like the ligaments on your ankle, only much stronger and heaps more of them. And those ligaments histologically, when they enter the vertebral body, there is a point at which they become a trabecular thing, like, you know, those bars of bone. But you can't work out what point that happens because it's such a gradual thing. So there's no real connector there. It's a transformation or a transition between ligament tissue into bone tissue and slowly happens over the course of the structure. So if you have the capacity to present those ideas or to draw that sort of structurally ligament-like stuff, we should be able to use the same precision to undermine the previous jammed donut model. What about having a more accurate drawing on your clinic wall? of an intervertebral disc than the little red jelly bean that's sticking out the side of the skeleton or the big red slipped thing. Just get something a bit more accurate. And it's just up there. You don't even have to talk about it. But we could reframe intervertebral discs into meet your living adaptable force transducers. They're amazing. And undermine the internal models of your disc is about to go or it's disintegrated or you've got no disc.

SPEAKER_01:

I couldn't agree more. Thank you for those points. It's sounding like obviously we have the toolkit of our words, which I'd like to get to in a moment too. But when you describe using the visual system to break down those models, do you think as clinicians there's a role for us in guiding people through visualization with those models? So sort of trying to describe what you've just described, but also almost replace that visual construct? Yeah.

SPEAKER_02:

It's a great idea. So you're suggesting that you run someone through a visualization exercise, picture your disc beautifully strong, full of ligaments, stuff like that. Yeah, that sounds like a great idea. It feels to me like if you could plant some examples in there first. As a virtual reality platform, I've been involved with Does This and has this massive... You've got the goggles on and you can go and walk around a lumbar spine that's massive and it's moving and you can see these strong ligaments. And the narration in the background is all about strength and power and stuff like that. It's a similar concept. Yeah, we should have a really good psychologist here to answer that question. Makes sense.

SPEAKER_00:

I think that's a really interesting point because I certainly think the route that we've probably gone down with visualization has more been related to the body and its movement and almost trying to improve the precision or like the accuracy with which people are dealing with sensory information coming from that body part. So, you know, being better able to localize touch, being able to know where it is in space and trying to create that Because I think it can be sometimes, or the theory behind it can be hard to kind of show people, let's say if they're actually doing a movement, that they're safe and they've done it well, if they're also getting really kind of imprecise information theoretically from that body part. But I've not thought about visualization in that term. So that's a really interesting idea. I think you're going to do a PhD.

SPEAKER_01:

I suppose it's extrapolating off that evidence around the mind to muscle connection and the sorts of things that we would have patients or athletes think about as you're doing a movement. And so I think if we're using exercise as an example of a repeated example to the patient's brain that a movement is safe, throwing in a nicer analogy than a jam donut for them to mull over whilst they're doing it maybe adds to that reinforcement. I don't know.

SPEAKER_02:

What I understood you to be talking about is almost visualization of anatomy. Yeah, and people sort of do that a bit, don't they? They talk about move this and you can almost feel that. I can imagine David Butler doing this beautifully. You can feel the lubricant coming into your joints. And on the VR thing I mentioned, you can see the lubricant being released into the joints. And the narration talks about that. You know, every time you move, you just lubricate things a bit more and

SPEAKER_01:

I suppose it's one of those things where it's looking at the elements of a good explanation. I think sometimes what we do as physios is really challenging given the complexity of the information and balancing simplicity with essential detail with adequately addressing what's actually quite complex but not overwhelming can be really hard. So I'm curious as to your thoughts around how we navigate pain science and Because I feel like in my clinical time, there's been times where I go, I feel like that really landed and other times where I go, I think I butchered that explanation. So I'm curious as to your thoughts around the power of words and our explanations.

SPEAKER_00:

Yeah, that's such a good question. One of the things that we found really interesting when we were looking at this in the context with people with knee osteoarthritis is that there was like somewhere, obviously there's quite a few conceptions, things like bone on bone and wear and tear that can be quite challenging and scientifically actually might, but it's not supported by the current evidence. But one of the things that we noticed was that it really was way more listening. and asking questions of them because there was a tendency that we would kind of just vomit up all this information and you kind of just see people sitting back being big eyed and not having, knowing what's really going on. Why is a physio telling me all this stuff? But I guess really exploring with them in a bit deeper level, the extent to which some of the things that they thought were influencing what they're doing. So asking, does that make you think twice about undertaking exercise? Does this, like really kind of delving to see because sometimes people they might hold those beliefs and they might not be linked to, like they might be very okay to do an intervention like exercise. So they may not be things that we need to tackle right away. They might be things that we build up to, but in some cases they are, and they're actually a key cornerstone. One of my PhD students who she's just getting close to finishing, her name's Monique Wilson. After she did her undergraduate, she worked clinically as a physio in private practice and ran into similar challenges as to what you're bringing up, particularly when time is tight and you're having people that might be paying and expecting certain things for their interventions with a physio. And she's done some really cool stuff to basically create and working with co-design with different people with pain as well as physiotherapists to try to create resources that might take advantage of some of the times that aren't in an appointment. So she's developed this resource that we're just about to test it early next year, which involves kind of these infographic cards, but also this personalized calendar that then you can kind of input all these different resources that you're sort of like, hey, Tuesday, you're going to watch this video if you'd like. Do you want it short? Do you want it long? And just categorizing all the available, what we would consider credible resources and having that so it's like a library that you can put in and use and also just developing different models. So maybe if we're having training troubles, why is there a role for us as clinics to have patient partners where they're peer mentors who have actually done really well through something and they're actually part of our system and we're saying, hey, it sounds like it's a bit hard. Would you like to talk to someone else who's been through this just two months ago? And we have these links. So I think I'm feeling quite excited about exploring those different strategies that we can use, but absolutely acknowledging that they are challenging conversations to have.

SPEAKER_01:

All great points, that listening, seeking to understand. I think that the resources sounds fantastic because then at the very least, you're offering a consistency in what you're delivering.

SPEAKER_00:

Yeah, that's right.

SPEAKER_01:

Lorimer, your thoughts? I'm very eager to know as well. I

SPEAKER_02:

have so many thoughts on this and I was sort of hanging back because I thought if I start, I'm just going to consume up way too much time. I absolutely agree with what's been said and with all of those perspectives. I think that the evidence to support pain education done badly is really compelling. There are 85 clinical trials published that involve like a classic pain science education, that blurting stuff out either on its own or in conjunction or embedded within a reactivation type idea or manual therapy or whatever it is. And on average, they say, yeah, this is all right as a treatment. I reckon we've got a crisis of sorts out there, particularly in the workers' comp space, where education is an intervention and network meta-analysis by Manuela Ferreira's group out of Sydney a year or two ago concluded that it is the most effective treatment long-term that we have for chronic back pain, though other chronic pains have been tested in that. So we have this intervention that is possibly, it's certainly among the best interventions we've got, and most health professionals don't think it's an intervention. Actually, I don't think it's one, which I think is just extraordinary. And that may be because of the things that you've observed, that it's really hard to do. You often get the f*** off posture, you know, you get the, are you saying it's on my head? Yeah. And I think that what that tells me as someone who was around as this approach developed and has been involved the whole time, that my naivety here has been really problematic. And, you know, I always feel like I need to apologise to the field for my naivety, not my intent. I wasn't, you know, mal-intented. You know, it historically wasn't very good. And we started to realise, well, it was good, but it certainly wasn't great or outstanding. And we started to realise this probably 10 years ago. And a big chunk of my research group's intention has just gone to making education better. Because what we also see is that when people change their understanding of the problem, truly transformative outcomes become possible within physiotherapy practices, within pain management clinics, exercise physiology, psych practices, almost everywhere. Once people understand pain in a way that's more aligned with contemporary understanding of how pain works and what it does and what affects it and how your system changes, the follow-up data are amazing. The problem is that we only get that in the old techniques. We only get that half the time. So some of the stuff that Tash has been talking about that Monique's been doing and in your group, Felicity Braithwaite, Tash, and we've got people in our group, Hayley Lee, Carolyn Berryman, Emily Moore, pursuing better content and strategy. And we've got a lot of data from a lot of consumers, a total of 500 recovered consumers who have been asked, what was the most important bit of education for that allowed you to recover. And from that, we've picked out that the process has spat out four essential pain facts. And they now form the core of educational interventions, but the education just doesn't look like what it looked like even seven or eight years ago. These sort of things that you were talking about, Tash, are critical, co-designed resources. We use sequential art. I mean, the book that Tash did excellent work on around NeoA is to totally different type of book, you know, it gets people, it's informed by contemporary education and it's something that physios can walk their patients through and I would suggest learn a lot on the way. This is totally, we're transforming the field at the moment and it's the clinical trials with new strategies that are only starting in the last year or two that won't finish for five will tell us whether our hopes are realised but To me, it's a no-brainer that if there's compelling evidence that bad education is one of the best treatments we've got, good education should be better and physios should be driving this. I find it gobsmacking at times when physios are actively standing in the way of this because they have some notion that it threatens their other skillset. But in my view, it empowers, supercharges their other skillsets. And wouldn't it be great if we were all talking about the recovery opportunities in people with chronic pain instead of we're going to hope they manage well for the rest of their pain ridden life. But the evidence doesn't support that perspective anymore. It really doesn't. Well, in my view, and there'll be people who would argue with me there, but I think 85 clinical trials in education, they've got meta-analyses with 3 million people. saying which strategies are good and which are bad. And until very recently, we don't use those strategies in health education. We give people pamphlets.

SPEAKER_00:

Same PhD student, Monique Wilson, did a survey that was all of Australian physios. It's over 300 people that responded to the survey. And they were ones that had received training in pain science education, either through university or through a postgraduate course. And they were very good with pain knowledge. But when we asked them about different types of educational strategies that you might use, it was a blank response, basically, or it talked about resources or things like that.

SPEAKER_02:

Tash, wasn't it 75% of those people, this is what I understood from mine, couldn't name one strategy?

SPEAKER_00:

Not one, yeah. And so as an example, like one of the things that we did within our OA book, because there's such a different story of what we understand osteoarthritis to be, is we use like technique called holistic confrontation, where you present the old, and then you immediately kind of present and challenge with the new and just kind of say, this is so different. And we're not kind of working up to it. We're just slamming it. But those types of things, they're Certainly not things I think that until I read more about it, I wasn't aware of some of these aspects. So I think there's a real, there's actually such an opportunity for us to take some of this, you know, educational literature and strategies and really create that feeling that when you're going into that intervention, you're kind of not going with that like slightly foreboding feeling of being like, oh God, this could go really bad. But you're going in with that feeling of like, I have like three to four different ways that I could go about this exact same thing. And I'm going to do my best to read that person. But then it feels intervention-y, doesn't it? Because you have these different strategies. And I think to me, that is one of the aspects that I'm really quite excited about when we think about ways that we might be able to do this better.

SPEAKER_02:

Yeah, I agree.

SPEAKER_00:

Yay!

SPEAKER_01:

I have many questions from all of this. I'd love for you to both tease out, I think... Firstly, Lauren, you mentioned bad, bad pain science and good pain education and great pain education. I think there will be some physios listening, driving home going, I wonder if mine's in the good category or the bad category or the great category with the context of say like back pain or knee OA. What does good, bad and ugly look like and great?

SPEAKER_02:

It's probably not fair for me to use those labels because Right. I'd probably actually say, I mean, I did use those labels. I mean, I would say bad education is education that's incorrect and done badly. Well, it's probably worse education would be incorrect and done well. But then if you go up the rungs, incorrect and done badly, then correct and done badly, and then correct and done well. And it's not like a flip, you know, like you go from one step, oh, now I'm doing good, but I think we can always get better. by using some of these tactics that Tash has alluded to and that are all over in the OA book and the Resolve Back Pain book. And I think that, you know, what is it, in answer to your, or in reflection on your contemplation, Sarah, I wonder if there's physios driving home thinking, I wonder how good I am. My answer to that would probably be not as good as you think. And part of my journey has been realizing I'm not as good as I thought I was. And what that means is that I'm not, it's not landing. enough people. And I would confidently say I'm better at it now than I was a year ago, let alone five or six years ago. And the outcome data of the people I see is supporting that idea. But what does it look like? I think that it's, in my view, it's almost too hard a question to answer without a couple of days because it's learning how to help people learn. And I guess one way that I've pitched this, and it might be like a quasi self-flagellation at the mistakes that I made. But I think that pain science education has become, in no small part because of someone like, people like me, it's become a thing you do. It's the thing, education. But actually, what we're trying to achieve is learning. There's a big group of people internationally now who are embracing this challenge to say, let's make education great again. Mega. I'm going to get hats. Let's make... Pain education, great, by focusing on learning. What is it we want people to learn? How are we going to get them to learn? Tass just said, you know, I might have four ways to get this across. What lands? Oh, no little tricks like repeat word for word the things that land. And there's a whole lot of tricks. Some of them are pulled out of cognitive behavioral therapy. Some of them are pulled out of conceptual change theory, learning paradigms, education, neurophysiology. And good education is education that has more of those in it. And The thing I'll finish on is I really like the metaphor of moving away from what you described, Tash, is that we just blurt it all out to continually thinking about the fork in the road, that we give learners an opportunity to make a decision between two options that will promote their understanding of something. And that's a hard thing to learn how to do. And I would say to all physios out there, do you remember the first facet joint you went looking for or the first time you thought, is the multifidus or transversus turning on or, you know, remember the first time we did all that where a nag was a snag, it was the same thing. All of that. Well, I think it's the same with this and we have to practice and we've got to make mistakes. So we should be practicing on each other as well as patients remembering that they're more vulnerable than us. You know, like I think we need to have that attitude and as physios, like I'm not a particularly physiophilic person. I think all the health professionals have got heaps to offer. But as a physio, we are in a really good position to utilize the stuff that we're legally allowed to do, the skills of knowing how bodies work, of how tissues heal, of how loading occurs, utilize all that and become great educators, great teachers along the way. Anyway, that's my next rant. That's my third rant of this podcast. I hope it doesn't turn your podcast into a

SPEAKER_00:

rant. Rants are good. If you are reflecting on it, you're probably already a step ahead. Because I mean, that is actually one of the ways you learn and that you get better is by reflecting upon past experiences and thinking, what can I do better? What did I do well? Celebrating those achievements, but then being very open to new opinions and new ideas of how you might go forward. One of the things that I wonder in my mind might fit that so-called bad pain science education Again, I don't think it's the intent behind it, but the outcome that occurs where we've done this big educational intervention and we've merely shifted the one sole cause from the tissue to the nervous system. And I think to me that sometimes can occur and it's a hard balance to get. But I think remembering that we're describing processes of adaptation that are occurring in the body and that did occur for some reason, things like sensitization, It's our friend in acute pain. It's a very good thing. And sometimes it is our friend in persistent pain. But remembering that these are adaptive states or potentially maladaptive states of the body, but that we don't want to just move it up to say, well, the problem now is in the nervous system. We are individuals that are remarkably complex with many different things interacting. And actually, the point in my mind of probably good pain science education is to appreciate and celebrate that complexity, but understand the extent to which we can also use that complexity to help our systems and ourselves as individuals improve. So it's a very hard balance, but to me, that feels quite important because otherwise I think we're just still shifting that same idea of like the one cause as soon as I fix this, I'm good. And we often don't see that to be the case. We see it to be complex.

SPEAKER_02:

I love that, Tash. It's common, isn't it? I've got central sensitization pain. These sort of phrases. I saw a patient some time ago who explained that to me and I asked her, what does that mean? She said, oh, the pain's now moved from my back into my spinal cord and it's a matter of time before it reaches my brain. And she was packing up the farm and moving into the city for her palliative journey. So that was an absolutely catastrophic interpretation of what I imagine was probably a well-meaning pain educator. almost capturing that problem that year. I mean, for her, I think it was both shifting the site and then giving it like a cancer-type characteristic. It could have been me that delivered the first education, not the second one. We all make these mistakes. I could reel off patients where I thought I'd done well and I just made them worse with the stuff I tried to teach them.

SPEAKER_00:

It's

SPEAKER_01:

that check-in that's so Italian, isn't it?

SPEAKER_02:

Oh, yeah.

SPEAKER_01:

So it's sounding like... Between what both of you have said, there's three components to it. It's, as you said, Laura, it's getting it correct, which, Tash, I think the component of that is that idea of are we doing more than just shifting from the tissue to the nervous system and then doing it well. So whatever we're teaching, doing it well, and then as clinicians, reflecting on

SPEAKER_02:

I'd like to modify the first component of that away from correct into as close as what's currently understood to be the situation. I know there's not a word for that, but, you know, we make it scientifically based because that'll change as well. And it may not be correct, actually. It may just be our approximation of it at the moment. We hold lives in our hands, don't we, as health professionals. And as soon as we do that, I think we have a responsibility to do our very best. And therefore, we might not need to blurt out a whole lot of deep understanding of how we currently think pain works. But I think we should try and understand it as well as we can because the person in front of us is challenged by that. Yeah. So, I think, yeah, definitely, maybe not correct, but, you know, as accurate as possible.

SPEAKER_01:

Yeah.

SPEAKER_02:

How we do it. And then, yeah, I love that self-reflective practice reminder, Tash. That's fantastic.

SPEAKER_01:

I'm curious where you see consistencies in us as clinicians, perhaps just missing the mark in the way of that scientific accuracy. Do you think there's stuff that's slowly getting, it started off really accurate and our explanations are perhaps getting diluted into something that's not as accurate? That's probably a very long question or answer, and the science is a whole other podcast.

SPEAKER_02:

It may not be a systematic, usual thing, decline. But if I was in the spirit of that question, Sarah, I think I would say, I think a lot of us when it's not landing, and there's good data out of the UK, out of Cormac Ryan, Jamie Watson, King, Robertson, these people looking at what are the experiences of clinicians and patients when they participate in modern pain education. There's good data to suggest that if we're struggling and with it. We tend to fall back on our own inaccurate understanding of things because we're confident handing that over. And if we're anxious, we go into what all organisms do, and that is we protect ourselves and we go into the space in which we're confident. And so it may not be, I don't know, Tash, you might have a different perspective on this in the NeoA stuff, but it may not be a particular, this is what drops off first. It might just be, it's hard. And When it's hard, we all tend to go to that which we know we're comfortable with.

SPEAKER_00:

Yeah, I don't know if there's one thing in kind of the osteoarthritis space, but one thing that I did notice was, and I think it's a very relatable thing, is when people were getting people that come in, patients that came in that, you know, on a scan and image, it is pretty end stage. It's a person that you might be considering surgery for, but it took time. a while for people to be really convinced that this was safe. Like, is this safe really for my patient? And that was a really interesting journey to see people go down. The question that we always need to ask as clinicians, are we taking people into dangerous territory? How confident are we that this is okay? And I think what was really lovely to see is particularly We did a clinical trial and they had pilot participants where they were kind of practicing everything and we were listening to things, recording and giving them feedback. And some of the things that came back after those pilot participants is they just said, people can do so much more than I thought they could. And that was, I think, actually such an important reflection and moment to really understand. take time with, because this is a trained health professional. They have 15 to 20 years of experience, but we have such a specific narrative about osteoarthritis. And once a joint's worn out, we probably need to be a bit careful about this. And that just sort of went against almost everything that they have potentially experienced or had been taught, but also they'd never had that opportunity within a controlled way push to see, is this true? So it is a bit tangential, but for me, that was actually one of those really important things that we can still potentially kind of get it wrong if we're not sure, because people pick up on that. Like we are very good at reading when people are not quite sure what they're telling us. And so for that aspect, I think of assuredness and confidence was a really, really big shifting factor.

SPEAKER_02:

There's a great study that's relevant to that by Katja Wieck from Oxford, where she was delivering laser stimuli to the feet of supposedly normal, healthy volunteers. They randomly allocated one location on the foot to get the instruction, this, we've examined the skin here and this is safe. And the other location on the foot, we've examined the skin here and this is probably safe. And then they looked at pain report and brain activation in imaging to those two conditions. And there was a significant difference between those conditions in that The word probably put in there, increased average pain report, and was identifiable with enough of a systematic difference in brain activation to say, oh, well, that brain part's probably on average involved in that distinction. But that's just the word probably. Wow. That's cool, huh?

SPEAKER_01:

Pretty powerful. Probably, I think, maybe all the words we use to soften things. Wow. I feel like we could all keep talking for a very, very long time. But before we wrap up, I'd love to ask each of you for perhaps one key takeaway. I know that'll be a challenge that you'd like our audience to perhaps implement into their practice tomorrow or consider on the drive home or wherever they

SPEAKER_00:

are. I feel like mine is a general one, but it's be curious and be continually working open to learning and taking on new things. Because if you're curious about why something's hard, first of all, you're not judging yourself. There's no shame. There's no feeling guilt over not doing it well. But if you approach something from a curious mindset, then suddenly you're on this adventure to figure out for you why a certain circumstance is hard or why a certain patient presentation is particularly challenging in a short appointment or whatever the situation might be. But I think it's pretty easy to Be in situations where you feel like you might not be doing as good as you are. And if it's approached with more of a negative mindset, I think it's where we get defensiveness. I think it's where we get challenges where that can't possibly be true. I'm not taking this on. And I just think that curiosity keeps us really humble and it keeps us willing to learn from others and from the patients that are coming in. So very general piece of advice, but that's what I would suggest. But grand advice nonetheless.

SPEAKER_02:

I would say rewind the podcast and just listen to what Tash said again.

SPEAKER_01:

Why not? I think it's a stellar point. Thank you both so very much. There is a full necklace of clinical pearls in that conversation. So very much appreciated. And thank you. Thank you.

SPEAKER_02:

Pleasure. Thanks for having us on this show.