Transcript
Speaker: One of my particular frustrations as someone with lived experience of of pain and um also as a clinician that works in this space is like, I'm sick and tired of hearing but pain is complex, pain is complex, pain is complex, which is true. Don't get me wrong. But like patients that come and see me and me personally, I don't want i don't want to know my pain is complex.
Speaker: What I want is like simple, actionable solutions or things that I can do to to help my situation. In recent years, there's been a trend for more mechanism-based classifications and then mechanism-based treatments, but but but you're not treating a mechanism, you're still treating a patient.
Speaker: think about chronic stress or you know anxiety or whatever, and we we understand this concept of low-grade inflammation being being been potentially relevant in chronic pain states that that can be influenced by having things like chronic stress, poor sleep.
Speaker: But low-grade inflammation then has its effect, vi again, via different mechanisms. But one of those mechanisms is going to be that... This podcast is not personalized medical advice. Consult a health professional before acting on anything discussed.
Speaker: Just give me 30 seconds before we start. Whether you're a clinician wanting better outcomes for your patients, someone living with chronic pain, or supporting someone who is, thank you for being a loyal listener.
Speaker: Most regular listeners haven't hit follow yet. If that's you, please tap it now. It tells the algorithm to show this to more people it can help. And that's the single biggest thing you can do to help me and my guests on our mission to create a world with a little less pain.
Speaker: Derek, I want to get the most important thing out of the way first. um Albeit short-lived, you do have experience with pain with your with your marathon running. ah tell tell me about Tell me about your marathons and um your personal best.
Speaker: Yeah, so I suppose outside of outside of work, um I love to run. You know, what while I do like the competitive side of running, I think running also just provides me with an opportunity to de-stress and time time on your own and time to think and all of that. So I think the most important thing for me is is that aspect of running. Some people might not believe that given, you know, when you when you run competitively, they they often think it's all about that. But ah through my own injuries and times off running, I think you realize the importance of just being able to go out and and and and run. So I suppose um' my forte is probably over the longer distances. So
Speaker: i'm I'm a marathon runner, and although I do dabble in some of the shorter races as well, particularly the half marathon. ah My personal best is from 2023. We're on low 227, 227.04 in Valencia. So I'm going back to Valencia this December. So hopefully I can i can improve on that. But but but who knows?
Speaker: Yeah, well, you you you think you're ready to back that up and ah make it a bit harder to to beat? Yeah, i'm I'm training well. So you never know with marathon. it can throw anything at you on the day. But I'm being consistent as I advise my patients to be. So um time will tell. And look, if it works out great. And if it doesn't, as I said to you, the most important thing is that I'm i'm able to run and enjoy it.
Speaker: Yeah, yeah. I was ah reflecting on the converting that to ah the pace. And that is incredible. A 329 pace. ah per kilometre.
Speaker: um Yeah, i I don't think I could run a kilometre at that pace, but that's ah very, very impressive. um do ah do some of your best thoughts and ideas come while you're running?
Speaker: Yeah, definitely. it does provide the opportunity to think um and just on ah just on a clear head. So, you know, ah if if there was something bothering me or worrying me, it can it can help with that. But also, as you said, it's time to think and I'm, you know,
Speaker: Yeah. I don't listen to music when I run. um Yeah. So it provides the perfect of ah opportunity to to ponder any thoughts or questions that I have. And sometimes there is a eureka moment and you can kind of answer those questions and sometimes sometimes not. So it depends.
Speaker: Yeah. Tell me, why did you get into the world of chronic pain? um So I suppose it it starts back to my undergraduate training. First and foremost, I was really interested in the physiology side of things. And and I still am to a certain extent, but I suppose I've become a lot more clinical.
Speaker: ah throughout my journey. um So I really love the physiology stuff and I did throughout my undergraduate training and then when I when i finished my undergrad training um the opportunity arose to do a PhD and pain was quite topical at the time and and I ended up doing my PhD looking at the physical activity behaviours and what influenced that in ah in a group of people with disabling chronic low back pain and As part of my research, I had the opportunity every Friday to spend time in um in ah in a pain clinic in one of the ah local regional hospitals, and that provided just
Speaker: a really good opportunity to to be able to sit back and listen to patients tell their stories, very different stories, all with a common theme of having disabling pain. and And I suppose I really learned from a very early stage about, I really appreciated the importance of giving patients time to tell their story. um and and And I developed some of those, what we what we previously might've considered soft skills,
Speaker: and very early in my career and i'm I'm quite appreciative of that. So I just found it fascinating and both in terms of the stories that people they had to tell. But but as you well know, it's a very complex area. It's a very challenging area. So and it's a very rewarding area to to help people regain their quality of life.
Speaker: um And then it just led from there. So I did my PhD and while I was doing my PhD, I was, I was working clinically, um, part-time as well. Um, and then I suppose you just get so immersed in it that, um, you're, you're then working clinically yourself. So you start to further refine and develop those skills. And, you know, it's an area that still challenges me as, as much as it fascinates me. So yeah, um, it's, it's, it's an area that I really enjoy.
Speaker: m And tell me, what was the outcome of your research, your PhD? So as part of that, we looked at measuring um measuring physical activity objectively using accelerometry over a week. um And this was, and as I said, this was in a group of people attending secondary pain services. So they were quite disabled. um And then we looked at a host of biopsychosocial factors that could potentially be associated with
Speaker: um physical activity levels or volume or intensity um over over the week. um and And of course, we we measure the usual things like disability levels as well. And again, looked at a host of correlations between these biopsychosocial factors and disability and physical activity.
Speaker: um From the physical activity perspective, interestingly, um it was depression scores that were associated with objective measures, objectively measured physical activity.
Speaker: um And i suppose disability was a bit more easily explained by a wider range of factors. So things like their level of acceptance, self-efficacy. um And we also used at the time the pain detect questionnaire as a kind of a very crude measure of potential pain mechanisms.
Speaker: we we we found that people that met the cutoff score for a more neuropathic-like pain, now that's that's very much debatable as the as the literature has emerged, what these questionnaires are actually measuring with the with the the newly defined nociplastic pain coming coming on board since then. and But we found that, yeah, that the pain mechanism was associated with the um with the level of disability as well. So um I suppose quite consistent with the with the with the broader literature.
Speaker: oh Yeah, interesting. So you work clinically as well. What's your clinical role at the moment? Yeah, so i'm I'm a full-time clinician. So i suppose i I'm working in the in a local private hospital group, the Bon Secours in Chile.
Speaker: So I very much operate on a self-referral or a consultant referral service. So I still like to see a mix of patients because i try not to lose any skill sets that I've developed. So while while a big portion of my patient cohort has some kind of persistent or chronic pain.
Speaker: I will also see more mechanical type presentations and your sporting injuries as well. I do see a lot of runners and endurance athletes because obviously given my own personal interest, that's, that's an ah and also an area of interest clinically to me. Um,
Speaker: So I like to, as I said, I like to develop and and keep my skills in these other areas as well, which i I think helps me also when when it comes to helping people with with chronic pain, because, you know, there's always transferable skills you can you can learn um because I'm working in in the hospital setting, I suppose I have been exposed to um the broader medical stuff as well.
Speaker: And again, that's really important in terms of my my broader understanding and my screening of patients. You know, i will tend to see people from a rheumatology setting as well. And often I'll see them before they've been diagnosed. So as you well know, things like spondyloarthritis can often go under the radar for quite a long time. And, you know, I'll see them with a diagnosis of chronic pain or some non-specific pain condition.
Speaker: but they may go on to have an inflammatory condition or or another medical condition that has yet to be um diagnosed. So having having that team around me, having access to imaging, having access to the medics, having access to the lab via GPs and everything when needed is is crucially important to to my role, both from a management perspective and and more importantly, diagnostically.
Speaker: Oh, multidisciplinary care is ah so important when it comes to chronic pain. I work in in a um multidisciplinary pain clinic. So with pain specialist doctors and psychologists, dietitians, physios. So probably not as broad as what you you you work in. But um yeah, it's ah important to sort of work as a team.
Speaker: Absolutely. And I think you you know everyone brings a skill set. to the to the to the clinic and we can all learn from each other. I'm i'm ah i'm a big believer in, you know, it's it's an ongoing learning process, isn't it? You know, you're never you're never fully there.
Speaker: Totally, totally. Never fully there. On that note, what how do you explain pain? and where Obviously, pain is evolving in our understanding of what's going on over the over the years and especially in the last, say, 20, 30 years, it has evolved quite, quite, um rapidly, but what's your current understanding of of pain?
Speaker: I suppose it it sounds like such a simple question, doesn't it? um and And you would think that we would have a definitive answer to that. and and and And I know the IASP definition has changed in recent years. I'm not going to be able to state it verbatim at the moment, but it's obviously a very controversial area. um you're You're probably familiar with the recent controversies around you know, pain as a protector or, you know, is pain the protection or is nociception the protection?
Speaker: I always come at it from a clinical perspective. You know, i think when when we're explaining it to a patient, it it first and foremost needs to make sense. um and And we need to be as true to the science as we possibly can. But, but you know, i'm I'm not a physiologist. I'm not an immunologist. i' i'm I'm not a pain scientist per se. So I i I do like the idea that you know pain, at least in in in some of its role, is is is a protective experience that we have. And I suppose I'm borrowing here on some Laura Rosalie's work and and the team in Australia, um but but but also from my own experiences of of of of having pain. So look, you know we're all very familiar with
Speaker: having an acute ankle sprain or having an acute episode where where the pain is probably quite informative and and it and it alerts us to a potential or actual tissue damage, which is part of definition.
Speaker: which is part of the definition um or I suppose more medical scenarios if somebody has an acute appendicitis and they have they have pain that brings them to the emergency room and and and they subsequently have a have a diagnosis that was important to diagnose. So, you know, at at a very fundamental level, you know, to me, pain is is is some way protective um of a future or more tissue damage or um you know, then when it comes to chronic pain, then things change a little bit. And this is where this is where the debate arises. um
Speaker: But again, I think in in recent years, we've seen an emergence around the neuroimmune system and and and and and various mechanisms that somehow make this protective system more protective. We now know that the same system that is activated when you sprain your ankle the the properties of this system can change and and it and it can start to respond to more innocuous stimuli or or minimal stimuli. And, you know, there's various terms that we have developed for that around, you know, nociplastic pain and and those kind of things. But, you know, I suppose from a patient perspective, I i try to reframe pain as this,
Speaker: as this thing that rather than it being an enemy, it's it's it's in some way protective and it has you know it has developed over such a long time from an evolutionary perspective. and And we have a host of these factors that are some way within our control around sleep and physical activity and our thoughts and our beliefs and our worries, et cetera, that can shape how this system behaves. but But I do like to bring it back to you know, this idea that it is the same system that when we have obvious tissue injury or damage that, you know, it's still part of this system so that they don't leave thinking that we've told them it's all in their head, you know, so there's, there's the practical understanding of pain. And then there's this huge emerging body of science and,
Speaker: neuroimmunology that, as I said, I'm not a physiologist, I'm not an immunologist. I have to explain it in a way that that the patient understands. um And that is as true to the science as as we can be, but without becoming, you know, without getting into the details so much that we actually lose the patient. So, you know, I totally get that in many of our situations, how we explain it may not be fully accurate, but But we need to be at the same time sensible that that we don't lose all understanding by trying to be too scientific with it as well.
Speaker: Totally. Yeah, you don't want them to glaze over um in the context of their own problem. There's some things that are relevant to their situation and other things that can...
Speaker: can be left unsaid, which can be a challenging task as a clinician to work out what what needs to be said and what needs to be left unsaid, I guess.
Speaker: Absolutely. what a um Where do modern explanations of pain go go wrong, do you feel, when it comes to ah your clinical work?
Speaker: um yeah I think we need to be careful that we don't lose the patient in terms of trying to explain pain. um If someone comes to see me and you know, their goals are are either to improve their function or reduce the pain. And then then that's where our focus needs to be. and And any interventions, including explaining pain need to be, their their effectiveness is really determined by the outcome.
Speaker: um You know, and I think we get lost in thinking, yes, how accurate is the definition from a scientific perspective? but we lose focus on the actual the the the patient related um outcomes associated with that definition um you know i suppose i'm a fan and i i think you've had peter o'sullivan on on the podcast at some stage have you you know so i'm a bit more of a you know if you look at pete's approach around cognitive functional therapy while while they do talk about explain you know while they do explain pain as part of it
Speaker: it's more it's more framed around understanding your story or understanding your situation so you know how have i got here what are the you know what what are the various aspects of my life both non not both modifiable and non-modifiable that has shaped the systems that that underpin our experience of pain you know that that to me is more about how can i give the patient control of their situation and an understanding of the things that some of the things we can change and there might be some things that we can change that do shape their pain experience. um You know, I don't believe that we need to get we need to get really into detail on the neurophysiology or now and the neuroimmunology of of of pain um rather than
Speaker: what things we can do to change the experience or change the disability that's associated with it. um That would be my clinical perspective on it. yeah I'm not sure what you think on that.
Speaker: Yeah, no, of course. i feel like... um i've always I've said recently that you know it's um it's important that pain education leads to behavioral change and and and if it doesn't, I feel like it's it's void. I don't think the the understanding of pain itself really has much power unless it's connected to a change in, you know, behavior, which, you know, belief can change behavior. Obviously, like if I feel like this building is going to fall down on top of me, I'm i'm going to get out of the house. So belief is a good starting point, but it's it's probably not the be all and end all to actually changing behavior. which I agree 100%. And I think we've seen that in the literature. you know If you look at any standalone intervention, including pain education, and you look at the patient outcomes, you know it it it hasn't been shown to be um significantly better than any other intervention that that that we've used. so and And partly that's probably because exactly as you said, that does it actually change what we're aiming to change that will ultimately influence the the outcomes of the patient. Knowledge is important, but it it's it's how that knowledge shapes what the patient does is probably a little bit more critical. It's not that different than explaining the benefits of exercise, which we see a lot, but then expecting the patient to go out and exercise more.
Speaker: simply on Simply on a belief or simply on an understanding that exercise is important for your health. And, you know, I think it's very clear that that doesn't have the desired effect and in suddenly just getting people to exercise more.
Speaker: and And I don't see pain education being any different to that. which is why I think our explanations need to be patient-centered rather than, you know, just focused on the neuroimmunology. It's one thing that knowing that pain is not a good barometer of tissue injury or damage, but again, you still need to have fine strategies that actually encourages the patient to whether it's to be more active, whether it's to, you know, how do we improve their sleep?
Speaker: ah You know, all of these external life stresses, it's it's it's just giving them a broad understanding that these factors are relevant. But I don't believe that that we need to get down to the level of you know, some of the real deep stuff that that, you know, you or I probably don't fully understand either. This is really complex stuff. So I think we can get lost um sometimes in in just getting too focused on that and and losing the patient.
Speaker: Absolutely. how How do you go navigating in a multidisciplinary team? Like alone, there's probably lots of different belief systems around pain and how it comes about and like nuances within that. How do you go navigating that with some of your colleagues when you're referring patients?
Speaker: Yeah, i think I think having just an open discussion and, you know, realizing that I suppose we we all have different experiences, we all have different skill sets, as I said. So I'm I think we all come at it from a slightly different angle, but we can still very much learn from each other. you know, communication is obviously very important um to communicate both in a respectful way. um And and it's it's not about one person having all the right answers because clearly,
Speaker: we We don't have all the answers yet. So, you know, i'm I'm very much aware that my approach or the current best available the approach based on the evidence, you know, nothing has been shown to be a miracle cure for for chronic pain. So I suppose we need to just be be a be aware of that. um But I suppose I just try to be consistent, um you know,
Speaker: when when you're communicating, whether it be with other doctors or, like you said, dieticians or psychologists, it's it's it's about just having an open two-way communication stream and being receptive to what what other people can offer. um in referral letters, in discharge letters, just just being consistent and and highlighting the things that we we changed. So rather than just saying somebody improved or didn't improve, you know, giving a little bit of background into the things that we addressed, be it sleep or lifestyle factors or physical activity levels, so that, you know, other healthcare professionals see that that the intervention wasn't
Speaker: what I suppose traditionally might have been considered to be ah physiotherapy type intervention where it may have been more, you know, hands-on based. So it's it's just being consistent with your communication, you know, letting people know what things you worked on with patients and what things changed that may have influenced their outcome. And I think over time then people start to, you know, lines of thinking start to join up a little bit. um and other clinicians start to learn the value that you bring to that clinical encounter, as well as you learning where, you know, your skill set might run out and that there may be other people around you that that can offer other aspects of the jigsaw puzzle to help the patient.
Speaker: Yeah, for sure. i want to um i want you to talk, I know you've said it's not all about the neuroimmune contributions, but I know you like physiology and I think it's important When it comes to explaining, like I often use this phrase is like if we could zoom up into the nervous system, we would see changes.
Speaker: Because like, you know, people come in with scans and they're like, their scan doesn't explain their symptoms, right? They might not have findings that that really match what's going on. And they've been told, I don't know what's going on. And and I think...
Speaker: It's important that there's still a there's still some processes that are going on in the body. It's not um just, like you said, in their head. um So if we were able to zoom up into the neuroimmune system, and I know i hope people are gracious to you, Derek, because yeah obviously it's complex and it's evolving, but what are some things that are going on in that that area?
Speaker: Yeah, so I suppose first and foremost, you know, none ah none of the recent works suggest that what's happening in the periphery or in the peripheral nervous system is not important. and And I think that's sometimes forgotten. You know, in recent years, we hear a lot about central sensitization and nociplastic pain and all of these other descriptors. And, you know, they are relevant, of course, but that doesn't mean that, that you know, that there isn't some ongoing peripheral nociception process what What might be causing that again is ah is is a different question. But, you know, we shouldn't just see pain as being this central nervous system phenomenon and where we get changes in the central nervous system. We know that there are lots of things that happen out in the periphery as well. um The IASP task force have have in recent years introduced pain.
Speaker: new terms and redefined other terms. So now we have nociceptive pain descriptors, we have neuropathic pain descriptors, and we have what they're calling nociplastic pain descriptors. So I suppose nociceptive pain is, and again, I like to use analogies and both for clinicians and patients, and and this is your typical ankle sprain. You know, you you sprain your ankle,
Speaker: there's a local inflammatory response. The inflammation sensitizes these peripheral nociceptors and you get typical movement associated pain. So when they invert their foot or ankle, it feels sore. When they don't do that, you know, it has this on and off kind of relationship to to movement. It's predictable. It's usually in line with the severity of the injury. So if someone has a more severely swollen, bruised ankle, they're usually less likely to be able to weight bear on it than somebody that has minimal or no swelling and no bruising. So it has this, you know, the the timeline fits the mechanical response of the pain to movement fits this idea that something is going on in the peripheral nervous system. So I suppose when we're answering your question in those scenarios, we're going to see
Speaker: what's traditionally termed as peripheral sensitization driving that. In the more persistent pain states, it's not to say that these peripheral changes aren't relevant or they're never there, but, you know,
Speaker: as you've alluded to with the with the expansion of the neuroimmunology field, we can see that these nociceptors change how they function via via various mechanisms that I probably won't delve too far into. But, you know, that that same stimulus response in the periphery can now generate a very, very different response um throughout that nociceptor in the central nervous system. um And this will lead to phenomenon like, you know, allodynia, hyperalgesia, um the pain starts to spread beyond the the initial area. So it becomes a bit more widespread, a bit more diffuse. um If we were to zoom into the central nervous system,
Speaker: what' what whats what's happening? um probably Probably lots of things. You know, as I said, there's um there's an explosion of work around what's happening from like like glial cells in the central nervous system and and and their their role in terms of sensitizing um the the the the nociceptive system. um Things like you know reduction and descending inhibition that normally kind of keeps control of that ascending nociceptive system suddenly isn't doing such a ah good job anymore and the system becomes very excitable or hyper excitable.
Speaker: um And this can be independent of what's happening in the periphery. um And to answer why why some of these things might happen, again, the what's happening in the periphery, if it's ongoing, can can can drive these more central changes.
Speaker: But then it gives us an opportunity to talk about things like lifestyle, things like stress, chronic stress, particularly genetics, obviously play a role here. And lots lots of things will probably feed into why we get changes in the property of the of the nociceptive system that might be independent of tissue injury or damage. So we we get both physiological changes in the in the nociceptive system, but we also get, you know, over time with certain pain conditions, we get more structural change, especially with neuropathic pain conditions. So um
Speaker: You know, it's a really, really complex um system or interacting systems. um But I will always go back to, well, how can we influence that? So if someone has, you know, someone has a typically sprained ankle and it's behaving like a sprained ankle, then a lot of the intervention is focused on rehabbing that ankle sprain.
Speaker: Whereas if you have all of these other factors going on and the pain is more diffuse and it's, um it has more characteristic features of nociplastic pain, like meaning that there's allodynia to very light pressure or to light touch. The pain is spreading. It has a mind of its own. It's not clearly associated with,
Speaker: certain aggravating or easing factors, it's more constant, you know, then the emphasis on treatment is it's it's not that the tissue capacity or tissue function is irrelevant, but, but it usually s signposts you to these broader things that are going on. And as I said, some modifiable, some non-modifiable, um, that, that we should be looking at as part of our toolbox when it comes to, um, intervention.
Speaker: Hmm. Yeah, i love how you, as as a clinician, I can see your clinician draw it back to like, well, what are we actually going to do about that? It was one of my frustrations, actually. i did a professional certificate in pain science down at University of South Australia and Laura Mamosley, who you mentioned, teaches into that. And one of my particular frustrations is someone with lived experience of of pain and um also as a clinician that works in this space is like I'm sick and tired of hearing like pain is complex pain is complex pain is complex which is true don't get me wrong but like patients that come and see me and me personally I don't want I don't want to know my pain's complex what I want is like simple actionable solutions or things that I can do to to help my situation um and I can see that you've got you know
Speaker: as a clinician you you see the relevance in of zooming out because patients don't talk in in terms of central sensitization or neuroimmune contributions etc yeah um they just want to know what they can do and i suppose it's a good time to further expand on that point like we you know in recent years there's been a trend for more mechanism-based classifications and then mechanism-based treatments but but but you're not treating a mechanism you're still treating a patient And, you know, the that the peripheral and the central nervous system are one system. They, they you know, they don't behave as as these separate systems. So, you know, you're not, you're never treating just something in the periphery or just the peripheral nervous system without having an influence on the central nervous system, you know. And, you know,
Speaker: and For example, you know, we, you know, think about chronic stress or, you know, anxiety or whatever. And we we understand this concept of low grade inflammation being, being, being potentially relevant in chronic pain states that, that can be influenced by having things like chronic stress, poor sleep, but, but low grade inflammation then,
Speaker: has its effect vi again via different mechanisms. But one of those mechanisms is going to be that it's going to result in peripheral sensitization. It's going to do the same thing that if you sprained your ankle, you know, that that that that probably technically doesn't come under the umbrella of a nociplastic pain mechanism because,
Speaker: it's it's it's winding up a peripheral nociceptor no different than any other inflammatory response would. Now, you probably get other mechanisms like reduction and descending inhibition that feeds into more nociplastic pain mechanisms. So it really doesn't help me in classifying that pain as nociceptor versus nociplastic. What helps me is how do we facilitate that person to reduce their stress levels?
Speaker: Totally. but That's how I would see that. So I don't think knowing if if we have, ah there's some work going on at the moment, I believe, around developing clinical tools to to better define clinically nociplastic versus nociceptive versus neuropathic. and and And that may help to a certain extent, but but but I'm not convinced that that will automatically lead to better outcomes because...
Speaker: The same upstream issue ah like poor sleep, stress, lack of physical activity, worry, all of these things that we talk about, they they can have their effect via multiple mechanisms.
Speaker: And it it isn't one or the other. and And does knowing the mechanism help me in the clinic? Or do I just work with the multidisciplinary team about trying to change whatever that modifiable variable is? that ultimately will will have its effect via many different mechanisms that we we really can't tell in the clinic. We we have no direct measure of nociception in the clinic. You know, that there is no way to measure central sensitization in humans. Like, so how how can this help us in the in the clinic when when I don't have any way of of measuring this? All I can measure is the ultimate impact on the...
Speaker: on the patient's experience. So I think we need to have a better way of, you know, as I said, coming back to the patient, how does this help the patient in front of me? And and how does it help me in terms of designing an intervention or bringing on board other members of the multidisciplinary team that can help us on that journey?
Speaker: Some of our interventions when it boils down to it to to influence these systems that we're talking about are so simple that it can even feel a bit invalidating for yeah know for patients in terms of like, okay, like we know that this is what's going on, so therefore like I want you to get a good night's sleep. i want you to do a little bit more exercise. I want you to stress less. you know like they're They're very simple levers that we have to pull. And when I say simple, it's simple because...
Speaker: you know, everyone knows that they should be doing those things since they were nine years old. yeah But but complex in terms of behavioral change, like habits, habits are very challenging. And I think that's probably where it's a hard.
Speaker: I don't know if you experience this, but personally, sometimes it feels hard to get a little bit of buy in occasionally for some of these things because it i am Yeah, it's it's not, I guess, sexy, for lack of a better word.
Speaker: Yeah, i think I think patients have had particularly patients that have had their pain for a long time, we we need to be careful that we're not talking at them with all of this new information and and kind of almost that, you know, it coming across as people are being blamed for their situation so that they're just not exercising enough or they're too stressed. So, you know, it's it's important to take patients on a journey. And, you know, what one thing I'm not a fan of is in, I don't know what it's like in Australia, but but we talk about,
Speaker: you know, when it comes to patient assessments, we talk about assessment versus treatment. To me, to me assessment and treatment are ongoing things. they're They're not something you do in the first session. The first session isn't the assessment and then everything else is treatment after that, you know.
Speaker: Patients become more trusting of you as time goes on. They'll they'll they'll tell you more about their story and and more of their story will emerge. And, you know, it's it's that importance of that ah communication and that motivational interviewing part where you're you're not you're not telling them just exercise more or just needing, you just need to sleep better um because that, it's quite rude if it comes across like that, but but then you're going to lose the patient because they just feel like they've been blamed for their condition rather than realizing like, look you know, you're you're in a very challenging situation.
Speaker: I can understand and empathize with why, you know, your sleep is so affected. There's all of these other factors going on in the background. But if we can improve on these things, it's likely to help you manage the situation and you're you're likely to feel better rather than the World Health Organization says you need to be doing 30 minutes, five days a week of moderate. And, you know, that it's it's that approach that really bothers me.
Speaker: And I think we need to move quickly away from that real kind of, this is what you should be doing to actually, how can I bring you on a journey from where you are to doing a little bit more? Totally.
Speaker: Yeah, totally. um What were the controversies that you mentioned that you you didn't allude, well, you alluded to, but you didn't go into detail. You said at the start that there's some, um and you might be able to hear the dog getting a drink behind me.
Speaker: Um, there's some, there's some controversies in the pain space. Do you want to touch on them and give your two bobs? Yeah, I suppose the, the biggest controversy has been, I suppose, the, I suppose around the mind body kind of dualism and that, that, that pain is, um, you know, some groups have kind of come down heavy on the idea that pain is an output of the brain or it's an output of the central nervous system. Um,
Speaker: And you know there has been, i suppose, a bit more of an emphasis on on the nociceptive system that nociception is no, so you know, the the whole debate about is nociception required for pain? Is it necessary for pain? And that has where, where that controversy has, has emerged. And and again, i think it's a really interesting debate. um And, and, and, and I'm quite open to the idea that, you know, nociception is involved in some capacity in our, in our pain experiences.
Speaker: Um, but it doesn't change what I do with patients. It doesn't fundamentally alter. you know i don't have that conversation with patients around whether nociception is necessary or required for pain. you know if If I can get the understanding across that the amount of pain you have is influenced by lots of factors, including what's happening in your tissues. That's all I need them to understand.
Speaker: You know, I'm not a scientist in in that, you know, maybe maybe from drug development and other aspects of pain. I totally understand that we need to know what we're targeting and, and you know, certain drugs are going to be targeting this nociceptive system. and And, you know, as the years emerge, i'm i'm I'm sure we're going to get better at that. We we may have better...
Speaker: biological treatments for pain in the coming years. And and I hope we do. and um but But my role as a physio, I don't think that debate helps me. I still listen to the debate because, as I said, I'm respectful of all sides and I've learned from all all of the different and opinions. and and ah And I suppose good science is always about debate.
Speaker: um ah But again, it comes, for as I said, here and I keep coming back to the same point, fundamentally, I'm always asking the question, well, how does this change what I do clinically? yeah um And because I don't really talk about nociception from that perspective, it it doesn't change what I what what i do clinically. i think still the more important messages are that you know pain is not a reflection, a true reflection of tissue injury or damage. And and sometimes it very much is. you know, um and we we need to be aware of when it is or isn't. um
Speaker: And that comes back to the skill set of the clinician and and and and their experiences. So, yeah, like it's it's an ongoing debate, um fascinating in many ways, but, yeah you know, a lot of it will be over my head. As I said, it's quite a complex area from from the neuroimmune stuff. um And i'm I'm always just interested about how does this change what I do in the clinic?
Speaker: Yeah, totally. And I'm not sure how much it it will, to be honest, but I have been also watching from the sidelines as as this debate sort of goes on. And um yeah, I mean, I guess it is it's it's interesting and maybe, know, there's Maybe we're blinded to the way that it might change our clinical practice. um But, yeah, it doesn't doesn't appear to be that way. I read something on twitter on your Twitter, well, now X, where you said a shift, we need to shift from joint health to person health when it comes to knee osteoarthritis.
Speaker: can i I guess a lot of people listening, um like, yeah, there's ah there's a clinicians that listen, but there's also people with with pain that are listening on. and And they're probably thinking, you know, like pain, I mean, as they've listened, they've probably realised that pain is at least more than what's going on at the the painful site. um But I think there's a big shift in this research, too,
Speaker: away from the the joint itself into like all the factors that might be contributing to it. Do you want to just expand on on that? Yeah. So I suppose in many ways, our healthcare systems are often so are quite reactive to pain.
Speaker: um And by that, I mean, you know, someone comes in with established knee osteoarthritis or hip osteoarthritis. So The the intervention then is focused on the joint, isn't it? So we we give them exercises to strengthen the joint. and And even our explanations around physical activity would be, you know, this is healthy for your joint. This is healthy for your knee. This is healthy to get your knee moving. It's still very much the knee focus. um and and i and And again, it's not that I don't think these things are helpful or relevant, but but I think it's how they're communicated to people.
Speaker: the patients like we, as as you've alluded to, there's an emerging body research around the upstream influences or causes of joint pain. And that will include everything from um your metabolic health, you know, your, you know, and and and some of the broader psychosocial stuff that that influences pain, regardless of whether we're talking about knee away or our chronic back pain.
Speaker: um And within that, there's probably subgroups. So, you know, there is some body research around subgroups of people with osteoarthritis, more mechanical subgroups versus more metabolic subgroups and all of that kind of stuff. But again, i try not to box patients into these nice neat categories in the clinic. it it doesn't It doesn't tell me what to do. It's about saying, like, what are the modifiable and non-modifiable factors that we can change here, right?
Speaker: to address your problem um and that very well may include a strengthening program around that sore joint i'm i'm not saying that's irrelevant but i will also have the discussion with them around these broader stuff that we we talk about with with just about anyone um but it's how i frame it that might be a little bit different you know i i won't i won't specifically talk about the joint very much i'll talk about the benefits if you're getting more active your things like your sleep is going to improve and if your sleep improves that has an effect on things like low-grade inflammation that has an effect on your pain levels so we we can treat your knee by not just treating your knee and all of these other factors have the potential to influence your your overall health as well and and it's a point i try to get across to patients a lot that the healthier you are in general, the the better your overall wellbeing, the less chance that you're going to have a disabling pain problem. And and I think that I'd be quite confident that that holds true based on the on the research that that that that we see. So even in so-called well-defined nociceptive pain conditions like osteoarthritis, that's not to say there aren't nociplastic pain components, but I suppose people see it as a mechanical pain condition.
Speaker: that all of these other broader psychosocial influences are always still relevant. How how much they're relevant and from person to person may vary. But again, this is a very hard thing to quantify. So I don't go down the road of saying this is 70% nociceptive and 30% nociplastic because like, how do i how do I stand over that reliably? Or you know what's the validity of my take on that? I go back to what can I change?
Speaker: change that and see the effects. But just think a little bit more broadly that, you know, we might need to look at improving their sleep, their physical activity, you know, other life stresses that may be going on, you know,
Speaker: Weight gain is often an issue around in in certain scenarios, but that weight gain may be driven by other life stresses and other changes in, you know, in in their roles as well. So it's never a simple case of just exercise and lose weight for for osteoarthritis, as is often possible.
Speaker: kind of the recommended first line intervention we've got to think about what what what are the things that underpin that weight gain how do i you can't just tell somebody to lose weight and and expect this to happen you know it's bringing them on a journey and looking at all of the factors that have led them to to that so that's what i mean about treating the person and not just the joint yeah Yeah, no, it's awesome. we We definitely align a lot. So this just been great for my my biases, Derek. but When we talk about the modifiable, um well, you talk about non-modifiable and modifiable factors. If we can, yeah you've mentioned them time and time again, and they are, you know, they're the big factors that we all know, sleep, exercise or movement, social connection, psychological wellbeing, nutrition.
Speaker: What are, ah are those the big ones and, and, um, Could we dive into, i know you like physiology and I'm like, I want to learn a little bit more. So how does how does it, and I know patients don't necessarily need to know how it affects downstream, but like if we talk about sleep, for instance, how does that influence sleep?
Speaker: I guess these neuro immune things that are going on. So I suppose before we get to that stage, ah when when I think of modifiable factors, I think, I think i'll quite broadly. So a lot of the times I see people and, and I suppose their, their story is defined by uncertainty. They're very, very uncertain of their situation.
Speaker: Um, uncertain at many different levels. they They may have had a belief that they've been told that it's all in their head. They may be worried that there's something not diagnosed that needs to be diagnosed. And before before we ever get to the intricacies of things like, you know, sleep and life stress, I suppose that initial assessment of it.
Speaker: our interaction with the patient is, is is crucial. So I'm very open with them in, in what we do understand and what we don't understand. So, and, and that, that even comes down to what I call it, the diagnosis. So if I see somebody and they have a diagnosis of fibromyalgia, I will have an open discussion with them about the benefits of calling it something and, and, and, and what might be some of the drawbacks, but, but ultimately,
Speaker: I want them leaving thinking, okay, like the treatment is based on you and and your story and the things that we can change. It's not based on the label. and and And that's crucially important. And it's about acknowledging the uncertainties. It's about saying, well, yeah, look, you've you've had all of these scans.
Speaker: It does so show all of these changes. I'm not in any way saying that they're not relevant, but they they're not the entire picture. You you can still change your situation,
Speaker: without that scan changing, rather than coming down hard on them and saying that scan is irrelevant, those changes are just normal for your age. You know, we can be very flippant with our explanation. So it's it's saying, look, this is a real jigsaw puzzle.
Speaker: There are some pieces that are more important to that picture than other pieces, but really the jigsaw is only complete with all the pieces. So when, when we're, when we're intervening, when, when, when someone is getting more active, yes, we're having an effect on the tissue capacity and structure as well. So, so we're making those tissues healthier. So if there is ongoing nociception from those tissues that I can't measure directly,
Speaker: then we're still addressing them. so we're not we're not ignoring them or we're not saying, you know, it's one versus the other. So that that bit is fundamental because if you if you miss that, regardless of your other explanations, you're you're going to lose that patient. They're going to leave thinking,
Speaker: You know, i I haven't had a good assessment. They don't know what's wrong with me. you know, clinicians are often very uncomfortable with uncertainty. You know, I don't think you can you can be a good clinician and be uncomfortable with it. You have to have an open discussion from day one. And then we may talk about, you know, things like, well, what can I change? And that might be sleep or it might be physical activity. And you don't you don't need to go after them all altogether. So.
Speaker: For example, if we can look at getting somebody a little bit more active, that that can often have a knock-on effect on improving their sleep. So I don't think we need a separate intervention to change all the variables that we need to we need to change.
Speaker: And then I suppose the question as to why does this help? lots Lots of reasons. so you know, if someone is sleeping better, there's there's probably lots of things that are happening that are that are quite positive. So...
Speaker: You know, even at a very broad level, people's mood is better. They have more energy to do things so they they can become more active. um their their Their mindset may be better. They may be a bit more motivated to become more active. um At a more neuroimmune level, there's reduction in things like pro-inflammatory mediators. So that may reduce the sensitization that we discussed of the peripheral and the central neuroimmune system.
Speaker: and and maybe a less pain so we we know from studies in non-pain populations that even 24 hours of sleep deprivation is associated with a hyperalgesic response um you know and i'll talk to patients about this that we have studies that that that um tell us that your pressure pain thresholds change even without any tissue damage. or Or I might allude to things like you know the pain that they have or experienced when they've had the flu or when they've had an infection.
Speaker: And that's that's driven by this neuroimmune cascade rather than by peripheral tissue injury. And you know sometimes then that that brings them on board that this isn't this isn't in my head. Like i can have I can have terrible pains and aches with the flu and I'm not damaged from a tissue perspective.
Speaker: And that's not different than maybe the scenario that I'm that i'm stuck in now. um So yeah, sleep sleep can have its effects via a reduction in these inflammatory mediators, um changes in cognition and and and psychological functioning, getting people more active because they have more energy, they they're they're more refreshed to to do things. So it's it it it it just opens up other opportunities that that that may not be present for somebody that's not getting very good um sleep. So it's, again, a very complex area. And, you know, I'm i'm clear on my on my role. I'm not an expert on on on on that side of things, but, you know, at a very broad level, it's probably a good anti-inflammatory. um
Speaker: Good sleep is probably good anti-inflammatory. And I will talk with patients in this regard. It probably helps things like, descending inhibition. So i will regularly talk with people around, you know, the so-called runner's high or when somebody goes out for a run and they feel better or they might say, oh, the sore spot warms up. And that's partly because,
Speaker: when we exercise, the you know, we get this huge release of endogenous opioids. I know Dave Butler talks a lot about this, the pharmacy and the brain kind of scenario um and how this system isn't so good when we have persistent pain, but it it it's modifiable. It can be changed by...
Speaker: looking at things like improving your sleep. So you can start to get these benefits of activity and exercise that you may not be getting now. So again, there's this real complex neuroimmune reason why sleep helps your pain. But then there's this more superficial explanation that's really going to get the patient on board as to why I'm i'm trying to change their sleep.
Speaker: you may have noticed a recurring theme. Sleep, stress, exercise or physical activity are mentioned a combined 62 times because these are some of the biggest levers that we have with someone with chronic pain.
Speaker: Pain Coach helps turn complex chronic pain into simple habit targets by running correlations between these important factors and the individual's personalized pain experience.
Speaker: Yeah, awesome. You're very humble, but I can see that you're... you're a great clinician and a great communicator in the way that you go about it. When, when we're talking about this stuff, I think a lot of people will be, well, some people listening might be scratching their head going like, this does not sound like traditional physiotherapy. um And I work at, um I'm a part owner at Pace Health, which is a telehealth clinic, multidisciplinary clinic for, for chronic pain. And we, we do telehealth ah physiotherapy sessions and, you know, a lot of people come and they're like, well,
Speaker: well, they don't come. Before they come, they're like, how how are you going to help me via telehealth? Like you can't put put my hands your hands on me. what do you howd do How do you see the role of like hands-on treatment and how do you kind of um explain this to to patients that are that are seeing you?
Speaker: Yeah, so look, again, that's that's an ongoing debate, isn't it um I suppose by the time that often by the time patients get to see me or come to see me, they've often tried a whole host of other interventions. um And they they they are at a point in their journey where they're quite open to other explanations or other ways um around their scenario. So,
Speaker: from it from a hands-on perspective, from a treatment perspective, I suppose it's not something that I that i that i would need to do or do a whole pile of simply because of that kind of cohort that ah that that I would see. but But I think when we think of hands-on, it's not just in it it's not just an intervention. you know when When I'm assessing patients, it's very important to do a proper assessment. and And part of that is going to be hands-on approach, um whether whether you're looking at you know, things like your your basic stuff is still important. Your range of motion, your you know, your your palpation, particularly from a rheumatology perspective, looking for things like enthesitis or synovitis and that kind of stuff. So it's it's really showing them that, yeah, like I am interested, i am doing a thorough explanation, um but it doesn't always have to be seen as an intervention. Now, I suppose a good assessment is may may be seen as an intervention in itself. um So we need to move away from hands-on as necessarily it treatment and it it it also is a huge part of um part of how we assess patients. So, you know, they they feel like they've been assessed properly, that you haven't just spoken to them. But but as you alluded to in a telehealth setting, that's probably, obviously that's not that's not possible. and and And I don't think the evidence tells us that the outcomes are any inferior um for telehealth versus in-person care. So if if the argument is that this hands-on approach is
Speaker: and additive to their outcome or or improves their outcome, then why don't we see that reflected in the in in the evidence base from ah of the telehealth versus as inpatient care? um so so So I'm not convinced um about that. I think fundamentally it's about feeling valued, that they've been listened to, that they've been assessed, that there There has been this idea that we've swung away from the hands-on stuff to a more biopsychosocial approach and that this the pendulum has swung too far.
Speaker: You know, again, I don't believe that's the case. I think we we all probably live in a little bit of an echo chamber on social media that, you know, we think everybody is getting this, you know, biopsychosocial approach, and that's probably not the case.
Speaker: We still have scenarios where things like psoriatic arthritis goes under the radar for nine or 10 years. So if we've moved so far away from, you know, like, what what why why are these things happening? If if our, you know,
Speaker: if our reasoning is so solid and so good. So I think we have a long way to to go to, for for the pendulum to swing so far that it's gone that it's gone too far. it's it's it's It's about nuances and that it's not one or the other. um Again, it's about treat the person and listen to the person in front of you rather than having this kind of preconceived notion that we have to we have to be hands-on or this is automatically going to improve someone's outcome i probably i don't i don't disagree that you know a hands-on approach can have some changes in pain but lots of things can change pain you know i don't think there's any anything that's unique to
Speaker: manual therapy per se, any mechanism that's specific to manual therapy that doesn't that that that can't be achieved in in in in other ways. um So while I'm not disagreeing that short-term relief of pain is important or necessary, or i don't think we have evidence that that it's the only way.
Speaker: Or that short-term change in pain somehow sets somebody up for better outcomes in the in the longer term. I think the broader stuff, the broader behavioral change stuff is much more difficult to to get on top of, but probably more potent in the in the for longer-term outcomes.
Speaker: I think notoriously, clint well, the general public and some clinicians, sadly, overvalue the hands-on short-term relief and undervalue some of these other things that we've been speaking about so much. And um yeah, I feel like that shift needs to to come. And I think it starts with with us as clinicians or but researchers, clinicians, and and and the general public as well. We'll start to to see the difference there.
Speaker: Absolutely. If someone's listening to this and they're in pain, what would be your advice to them? Yeah, so I suppose. without Without knowing any specifics around something like that, it it it is important to consult healthcare care professional with with with experience of helping people with pain because.
Speaker: you know, we we we should never forget that there there is a small group of people where they may have they may have a red flag condition. They may have ah another a very clearly diagnosable problem that needs prompt treatment. So i'm i'm I'm very much aware that when I see people, regardless of how long they've had pain, it doesn't mean that, excuse me, that they don't have a very specific condition that needs a very specific type of intervention. um So they should consult with somebody that that that can do a good, that can listen to their story, that can can assess them and that can can identify scenarios yeah where they may need something and additionally from a medical perspective.
Speaker: And if not, then having the assessment that we've spoken about throughout this conversation around, well, you know, what, what, what, listen to their story, help them to make sense of their story.
Speaker: And then when, when, when they have that understanding, then look at how you might go about changing that story. Um, so definitely seek somebody that's willing to listen to you. That's willing to, you know, um,
Speaker: I suppose, empathize with you on the journey that you've been on. And that's just a good communicator. So we we fundamentally underappreciate the importance of that communication, but it's it's so incredibly important. um both for the clinician to get the patient on board, but then ultimately for improving um patient patientent outcomes. you know so So link up with somebody local or now with telehealth, we have we have great opportunities to link up with clinicians not in your local area that that that may have the expertise needed to to to bring you on on that journey. so
Speaker: And look, the internet's a great resource as well. There's lots like you know, I know you do great work um from a podcast perspective and just sharing these stories. There's a lot of great resources out there. The danger is that without patients being signposted to the appropriate ones, then that they're they're often fed information that's not so helpful. So from a patient perspective, sifting through the good versus bad information is the most challenging part. But, you know, with podcasts now and everything, it's're we're in a great area to, you know,
Speaker: ah to to improve how we educate people and how we improve people's understanding of of of pain. So, yeah, i suppose that's a very superficial answer to a very, what could be a very complex question.
Speaker: and No, it's ah it's a great answer and you clearly are a great communicator um and i've had a pro I've been privileged to be able to speak with you and thank you. I feel like art there'll be plenty of people that it will help. So thanks for coming on.
Speaker: I know. And look, and again, thanks for all your own work. Again, as I said, these resources are very useful for us clinicians, but also for um patients. So I appreciate your work very much.
Speaker: Thanks, Derek. Cheers. Thanks for having on me. Cheers.
