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FC2O Episode 9 - Phil Austin
16 Plays5 years ago
Join me chatting with Sydney-based osteopath Phil Austin. Phil is not only a clinician, but is an authority on working with those experiencing persistent pain. Listen to Phil's top tips and profound insights into effectively helping those experiencing pain.
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Transcript
Recognizing Spiritual Distress in Terminally Ill Patients
00:00:00
Speaker
There's been quite a lot of work done in the palliative care world from that perspective. So in relation to things like spiritual distress in internally ill or dying patients. And that's another part of my research area is we've developed a questionnaire, for example, to see if not just clinicians, but
00:00:22
Speaker
and auxiliary staff who are on the wards, do they recognize spiritual distress in patients who are dying? And the answer is they recognize the definitions, but they don't recognize the behaviors.
Holistic Approaches to Chronic Pain with Phil Austin
00:00:35
Speaker
Welcome to FC2O. Today we have Phil Austin with us, an osteopath, researcher and author of the book, Chronic Pain, a resource for effective manual therapy. In this episode, Phil and I delve into the importance of an holistic and integrated view of working with people experiencing persistent pain or ongoing health challenges.
00:00:53
Speaker
So settle in with a cup of tea and dive deep with us into topics as diverse as irritable bowel syndrome, the Virgin Mary, psilocybin mushrooms, and virtual reality. Enjoy the show. Here we go.
00:01:19
Speaker
So welcome to another edition of FC2.0 with me, Matt Walden, and my guest today, Phil Austin. Welcome, Phil. Hey, good to be here. Thanks for asking. Yeah, no, that's a pleasure. It's a pleasure. So Phil, obviously I know your background is as an osteopath from the UK. So you've got a lot of common ground there. So where did you train for your osteopathic training?
Phil's Journey: From Europe to New Zealand and Beyond
00:01:45
Speaker
I trained at the European School of Osteopathy. Oh, okay. And between which years? 93 and 97. Exactly the same. So we got a mirror image there. I was at BCNO as it was then. And of course, it's BCom now. So we could have ended up in the same class. What was it? I wanted to go to BCNO, but I couldn't get a grant. I couldn't get a grant for ESO. But don't tell anyone.
00:02:10
Speaker
Okay. Yeah, it was interesting. I wanted to go to, to BSO because that was mainly because that was the one I was familiar with. And then obviously went to the other colleges to take a look and I actually preferred the other two. I love the idea of being in the countryside with the ESO but the BCNO somehow
00:02:31
Speaker
captured my imagination more and so I ended up going there. But yeah, so you did that training and then what do you do post-graduation? I got a job in the west of Auckland in New Zealand and I moved out there about a month after I graduated. Wow, so I did almost exactly the same. So I was in Rotorua, so I was a couple of hours south of you.
00:02:57
Speaker
and probably a little bit smellier as well. How was it in your part of the country there? Did you have much volcanic activity? I was near the beach, so I worked in a practice run by a girl called at the time, Helena Bromley, which is now Helena Towner, and she's still there. It was a really sort of busy village practice on the outskirts of Auckland. Fantastic, fantastic. Excellent. And how long did you stay in New Zealand?
00:03:25
Speaker
I was there for a couple of years. Yeah. Yeah. Okay. And then did you come back to the UK or did you, cause you're in Australia now, aren't you? Yeah, I came back to the UK and I was there for from 99 to 2006.
Academic Pursuits: From Master's to PhD in Pain Management
00:03:41
Speaker
And then I moved to Sweden, did a few years in Sweden and then I came here to Australia. Okay. Cause I knew there was a connection with Sweden. Cause at one time when we were trying to set this up, you were saying that you were in Sweden. Were you teaching or were you just visiting? No, I was just visiting friends.
00:03:55
Speaker
Okay, excellent. I wondered what the connection was there. I also go to Sweden from time to time. That's mainly with my Czech teaching, but I tend to go to the south to Malmo or to try to think of where Aleko are based.
00:04:13
Speaker
Helm Studs. Where about do you tend to go to? I was in Stockholm. I did a bit of work in Gothenburg at their college quite often. So when did you do your PhD?
00:04:29
Speaker
So I did, well, I'll start from a bit further back. I started a master's Edinburgh University in pain management in about 2007.
00:04:47
Speaker
And on the back of that, I did a research study for the master's program. And that sort of naturally led on to the question that was being asked to us then, then became the PhD. Okay. And I started that in 2010, and finished in 2015. Right, right. Okay, fantastic. And so what was the sort of theme of the PhD? What was the what was that question?
00:05:12
Speaker
Well, the question at the beginning was for the master's program was looking at multidimensional diagnostic algorithms, if you like, for chronic visceral pain. And I think like all osteopaths, we're all a bit frustrated with chronic visceral pain. It's very hard to treat because there's so many different comorbid factors, as it were. And it turned out at the time there was no
00:05:40
Speaker
multidimensional or multi-axial diagnostic criteria for any of the functional GI disorders really. So my PhD was quite a large Delphi study targeting worldwide experts in functional gastrointestinal disorders.
Rome Foundation: Resources for GI Disorders
00:05:57
Speaker
And I put out quite a few questions to them and on the back of that
00:06:04
Speaker
That led to the development of their, what's called the Rome Foundation's Rome Four criteria, which then became a multi-dimensional diagnostic criteria for things like irritable bowel syndrome, functional dyspepsia, chronic pain syndromes as well. Right, right. So I guess IBS is probably the best known of the functional GI disorders. It's by far the most common for sure, yeah. Yeah, yeah. And what was the dyspepsia one?
00:06:34
Speaker
functional dyspepsia, that's a sort of functional reflux. Yeah. Yeah. Yeah. Okay. Okay. And so, you know, where, where did that research end up leading you? So it was, it was the visceral side of it, really the,
00:06:47
Speaker
got taken out of my hands really because once my PhD had finished and I'd published the articles on the back of that, that was then swallowed up by the Rome Foundation who then took on, who were taking on that project anyway. And it's a project for
00:07:04
Speaker
over 100 people in reality. So I thought I left it at that really. And then I moved to Sydney and I took on a research role there, initially looking at digital paper, then moving on to other stuff. Right, right, right. Okay, okay. And so
00:07:20
Speaker
this Rome Foundation that they are still sort of continuing the work they did and so what have they created that's useful from a clinical standpoint for us in practice? Is there something that you would say you need to go to this resource for questionnaires or for learning or whatever?
00:07:41
Speaker
Well, it's exactly that. It's a source of questionnaires and it's a source of learning. They published not only journal articles, but books. I mean, it's not a free service. You have to pay per questionnaire or for the whole lot of questionnaires. I mean, there's over 60 different types of functional GI disorders. So there's quite a lot of information there. But if you go to Google and put in the Rome Foundation, all the information is on the website.
00:08:11
Speaker
Yeah, yeah. And presumably that's spelt as in the city. Yeah. Yeah. Yeah. Yeah. Yeah. Good. And so, you know, I guess if we've got clinicians listening to this or people working with anyone that may have functional GI disorders or even members of the public who think they may have something going on with their digestive system and it hasn't been diagnosed
00:08:34
Speaker
What is the, I guess, what's the practical sort of application of this Rome Foundation? Could they go online and find the right questionnaires for their patients? Yes, they could go online and order. Or there might be some free stuff. If you go on to sort of Google images, you get the occasional questionnaire on there as well.
00:09:00
Speaker
I mean, it's really symptom based because there are no gold standard diagnostic tests, as it were. And because there's so many different sort of confounding factors, or comorbid factors, this is the whole point of these, well, it's not just chronic visceral pain, but any chronic pain disorder, it's the net result of many different inputs, most of them being negative.
00:09:29
Speaker
yeah yeah yeah sure sure and so then you know if we're trying to explain what that what that does to someone let's say we've got a patient come in they've got these digestive symptoms maybe they've even you know found a questionnaire that's that's diagnosed or sort of um
00:09:48
Speaker
Well, that's actually quite an interesting point. Are the other questioners able to just facilitate a diagnosis or are they quite diagnostic in themselves? Like how accurate? Well, there'll be there'll be diagnostic in themselves for a set of symptoms. Right. So it's a bit similar to the fibromyalgia diagnoses where you well, the old ones where if you have 11 or more points of out
Collaborative Approaches in Chronic Pain Management
00:10:11
Speaker
of 18. Yeah.
00:10:12
Speaker
painful points, then that is a symptomatic diagnosis of fibromyalgia. I mean, that's a bit old fashioned. But for example, if you have all of these symptoms, let's say it's for the purposes of today's discussion, irritable bowel syndrome, you have your abdominal bloating, distension, sensation of fullness, flagellants, constipation, diarrhea, and you've had all of your medical tests and everything is negative,
00:10:40
Speaker
It'd be quite easy to go to an osteopath or any form of therapist and they can work biomechanically but because the inputs are very rarely biomechanical, this is where the confounding factors and the co-morbid disorders come into play.
00:10:58
Speaker
yeah okay okay and so then let's stay just staying with that um let's say it is an osteopath or someone who's working with more mechanical approaches um what would you encourage those practitioners to to then do do they need to team up with someone who is a nutritionist or a psychologist or psychologist or absolutely yeah yeah yeah
00:11:18
Speaker
Okay. And so, you know, what would be it? Have you got any case examples or could we create that kind of hypothetical example of someone's they've come in, perhaps, perhaps they're testing as having it will bow syndrome on one of these questionnaires.
00:11:33
Speaker
And like you say, there may be a small mechanical input, perhaps, I don't know if you still subscribe to that, but probably there's a lot more biochemical, emotional, you know, lifestyle factors that are driving it. Absolutely. So how might you deal with someone like that? Well, I mean, sometimes it's in your control and sometimes it's out of your control. So the most common example
00:12:00
Speaker
would be, I mean, if anyone who works in the center of London or any capital city in a finance area or an area of law, they're under the pump for the majority of their younger working lives, usually unable to get deadlines and they become quite stressed and they don't sleep properly and a whole load of other sort of issues as well. And because of that, their diet tends to go down the pan
00:12:29
Speaker
And the net result of that is, are these irritable bowel symptoms? Now, it's very easy for you to change your job or change your lifestyle. But in reality, it's what they've spent years going to college for. And it's the job that they're signed up for. And it's very difficult for them to challenge the deadlines that are given to them, if you say what I mean. So it's very difficult for you to have an influence on those types of people.
00:12:54
Speaker
And they're more your sort of maintenance type people. So you work on the factors that you can affect things like sleep, things like diet. You can obviously work on sort of more musculoskeletal, spinal
00:13:11
Speaker
factors that you think might be influencing these irritable bowel symptoms as well. How effective you are with that is probably impossible to sort of find really, it'll be temporary at least.
00:13:25
Speaker
Yeah, yeah. You see, one of the things that sort of reminds me, when I did my master's degree in 1980-2000, we had a section in our master's degree taught by Caroline Stone, who I love. Oh yeah. A brilliant teacher. You know her very well. Yeah, of course.
00:13:42
Speaker
you know, it's very much, you know, the visceral specialist, one of the key visceral specialists in the world of osteopathy. And she, at that point, so I don't know if she's changed her mind now, and she may well have done, but at that point, I remember saying to her something along the lines of, you know, do you ever work with nutrition with your clients? Because of course, she's, you know, teaching a lot about, let's say, bowel dysfunction or whatever. And she said, Oh, no, no, I like to see what osteopathy can do on its own. I don't want to kind of cloud it by using other modalities.
00:14:12
Speaker
And in a way that disappointed me because that's, you know, I've been trained obviously at BCNO, so we were very much taught about nutrition and about psychology and the impact of those sorts of things in addition to the mechanics. And obviously what you're saying there is that really,
00:14:29
Speaker
you know, for something like IBS, as much as there may be some benefit from a mechanical approach, there's so many other factors that have to be addressed. And do you think, well, I don't want to sort of cast any expressions. Do you think that's that's the way that, you know, most people should be beginning to think now and perhaps Caroline is thinking that way as well by now. I think most people I think most people are now thinking that way more people are
00:14:56
Speaker
Even if they're just thinking about it, I have a sort of now more related to the concept of a biopsychosocial approach to most chronic painful disorders or conditions, whatever you want to call them. And whether that's if you take on all of those hats.
00:15:14
Speaker
Then then that's fine as long as you're prepared to sort of see it through if you like. Yeah myself I prefer to I've always worked in multidisciplinary clinics. So I work with psychologists. I work with nutritionists I work with Thank You Pinterest. Yeah. Yeah, so we we tend to cross refer quite a lot good. Does that work quite well? Depending on on what's going on it can be I've experienced
00:15:38
Speaker
sort of multi-disciplinary clinics in the past and some of them work better and some of them don't work so well. It's almost like it's a series of individuals that provide a breadth of treatment, but they don't necessarily inter-refer. That's exactly right. That's a difference, a multi-disciplinary clinic, they may not ever talk to each other, so I would rephrase that and say inter-disciplinary.
00:15:58
Speaker
Yes, exactly. Yeah. Yeah. Yeah. Now I was talking with a colleague of mine who runs an interdisciplinary clinic in London and he corrected me on that point as well. So yeah, that is good. And it's very easy to think that you are following a biopsychosocial model as a monotherapist, if you like. But whether you actually implement your thoughts into practice, I mean, one of the things that I've been
00:16:24
Speaker
doing in the research is I do a handout a lot of questionnaires to participants, so cognitive stuff like catastrophizing and hypervigilance and the likes, but also emotional based questionnaires, moods, stress, depression, anxiety. And even to the point where we ask about people's meaning and purpose in life and relationships and faith, not necessarily in a higher being, but in their GP, for example.
00:16:50
Speaker
And you can really see in some of the papers we've published, we can see what the predictors are for people who get better and people who don't get better. So for example, people who catastrophise a lot, i.e. the pain is never going to end, they ruminate constantly about what's happening. They're the most difficult cohort of patients really to get better because they never stop thinking about it, they never switch off. At the same time, people who have no meaning and purpose in life, they have no reason to get up in the morning,
00:17:20
Speaker
they're actually more predictive in not getting better. Really? So what we do on our pain program, and then a sort of research on with that pain program, if you like is, is we've developed a meaning and purpose and inner strength resilience type approach to these to these courses. Yeah. So when we finished with them, after six weeks, they've got tools to go off and, and manage themselves, if you like,
00:17:45
Speaker
Yeah, fantastic. Fantastic. And can you... It is. It's really amazing. Can you elaborate on that at all in terms of, you know, is there a defined process or is it quite, you know, variable depending on the individual?
Resilience in Pain Management Programs
00:18:00
Speaker
Well, these are group classes. It's normally of a group of about 10. Yeah. This is just unique to our clinic and we have three Penn specialist consultants. We have a psychologist, a physiotherapist,
00:18:15
Speaker
and I'm the guy who tortures them to get data basically. And one of the main strengths is are people meeting other like-minded or other people in the same situation as them, where they are not lost. And they develop friendships over time of the course and they remain friends. And one of the things that we found quite strange was that
00:18:40
Speaker
we were part of a service that covers the whole of Australia and New Zealand and all of the data that we get from the PAIN program goes into a big data bank at Wollongong University and they publish every year how everyone is doing and we did really well
00:18:58
Speaker
because of the uniqueness of our course about the meaning and purpose and the sort of existential side of it, as well as all of the sort of physical and psychological side of things. A couple of years ago, we had the distinction of having the best results of getting people off opioids, long term, heavy duty opioids. Oh, wow. That's fantastic.
00:19:19
Speaker
Yeah, over 50% had over 50% reduction in OPI use. Wow. Wow. So that's fantastic. And so is that your your methods being sort of expanded out to other other groups? Is it something that? Yeah. So I mean, I'm not in this particular study, but my boss, who's Professor Philip Siddle, who was pretty big in the International Association of Study Pain World, he
00:19:49
Speaker
And the physio have got a $2 million grant to develop a program that specializes in inner core strength, not being Pilates, but more resilient. And this has been our problem. What do we call a course? Every time we call it Inness Core Strength, people think of Pilates. Yes, exactly. And we can't find a better name, unfortunately. We've tried hours and hours. We've done all sorts of face-to-face meetings and we're stuck with inner core strength.
00:20:18
Speaker
right right fair enough fair enough but it seems to be the way forward yeah yeah for sure isn't it i mean isn't absolutely fascinating how powerful the the mind is because all of those things you've just mentioned you know talking about catastrophizing purpose meaning faith you know various cognitive assessments and emotions and so on um obviously that's a reflection of of uh the individual's mind and mental state i guess uh which is obviously
00:20:43
Speaker
is then a reflection of their life experiences and the society within and so on. These questionnaires are all freely available on the internet. And so what I do with patients who are particularly difficult, I'll give them three or four questionnaires after the first initial consultation, they'll go away and do them themselves. And then when they come back to the clinic, we'll see where they spike, where the high scores are.
00:21:10
Speaker
And then we'll work on those together. So if they think that every time they do any exercise or every time they get pain, it's a sign of tissue damage, and they've been imaged to the max and there's nothing there, then once you tell them that it's actually not a sign of tissue damage, it's more of a, and you give them a basic pain education course on central sensitization, they go away and they can really crack on and help themselves.
00:21:34
Speaker
I think, you know, you touched on something there also that I guess historically there's been and probably absolutely still today, there's a risk that when you start talking in those terms, that the patient thinks that you're saying it's all in their heads, which I know is a big thing that we need to be really careful with. So how would you how would you convey
00:21:52
Speaker
Well, I'll start with the dorsal horn. So I'll just talk about things that didn't used to be painful and now are painful. And that is because inputs from the periphery haven't changed so much. It's the activity, the signups in the dorsal horn that's changed.
00:22:10
Speaker
Yes, exactly. And that sends abhorrence or increased nociceptive or pain information into the brain and it's perceived as being worse than it actually is. Sure, sure. So very simple. But it's quite difficult to get to get the phraseology right. I mean, basic pain education is quite difficult to develop to keep it in a sort of low speak if you. Yes. If you know what I mean. Yeah, absolutely. Absolutely. Yeah.
Innovative Pain Assessment Tools
00:22:31
Speaker
And so what's your feelings on things like explain pain as a resource? Do you use that at all? I think it's fantastic. Yeah.
00:22:39
Speaker
And that's, uh, what's his name, isn't it? Lorimer Moseley and the like. Yes, exactly. Exactly. Yeah. Yeah. I mean, they're more of a brain only that nearly everything they talk about is from the brain. Okay. Yeah. But we, we.
00:22:52
Speaker
Our lab tend to think that there still is some form of a peripheral input that can kick everything off or can maintain. So we work on both sides, if you like. Excellent. Yeah, that's great. So we've developed a questionnaire that's just been submitted after about four years of work. And we're trying to elicit in this questionnaire whether pain is being driven from the spinal cord or the periphery or
00:23:22
Speaker
or the brain down. And that will really sort of siphon management of that person a lot more quickly. Right, right. And so is that, you know, about to be published in a paper or how does development work? It's quite a contentious area. Yeah, because we're using everything is hypothetical. Yes, of course, of course. Because what central sensitization is, it's a description of
00:23:45
Speaker
a series of altered morphological changes in the dorsal horn in animals, in animal studies. And we are hypothetically linking it to humans, who display similar symptoms that have been found in animal studies. And that's the problem we have. So we've had a few problems in that we're basing all of our
00:24:12
Speaker
questionnaire items on hypotheses, basically. Yeah, of course. And journal reviewers have their own opinions, of course, on lots of different things. And even the tests that we do. So we're using something called Condition Pain Modulation, which is a pain inhibits pain paradigm. So if you have a test stimulus, for example, where you have pressure on your foot,
00:24:40
Speaker
When you get to four out of 10, you tell them to come off and you record the pressure pressed for that four out of 10. Yeah. And someone with no pain, if you then stick their hand in a bucket of cold water at about 10 degrees for a minute, and then you redo that pressure test, they will be able to stand more pressure for that four out of 10. Yes. Okay. That is essentially conditioned pain modulation. Now on people with chronic pain, it's usually reversed where their
00:25:10
Speaker
tolerance for the pressure will go down, so a four out of 10 will come a lot quicker. There's a lot of argument about the actual test, but that's one of the things we've hung our hat on. Could that in some ways explain some of the perceived benefits of hydrotherapy or not? Not necessarily, because it could be any secondary stimulus.
00:25:33
Speaker
Yeah, okay. It's just a conditioning pain stimulus. It just so happens that the cold water is the most reliable. Right, right. That's interesting, isn't it? Is that because pain and temperature are, you know, sort of perceived by the... Yeah. But you can also give an electric shock. That's another way of doing it. Or heat. Okay, yeah.
00:25:59
Speaker
Yeah, interesting. So you mentioned a number of questionnaires and obviously, you know, we've just most recently talked about the one you're in development with at the moment. Is the idea with that, will it ultimately be available to clinicians or is it something that they have to pay for access to it? No, no, no, it'll be available. It'll be freely available. Right. But we have to get it first. Yeah, yeah. Okay. Okay.
00:26:24
Speaker
And otherwise it won't be valid. Yes, exactly. And fair enough. And the other question is, you mentioned that you give a raft of questions, which I'm a huge fan of actually in terms of working with clients in that way. I think the traditional way of
00:26:41
Speaker
sort of meet and greet and making the assessment on the spot I guess that can work to some degree for more acute conditions but when you're dealing with people with more persistent health issues and pain issues and I think the questionnaires provide so much insight that it's invaluable really to get started or I should say before you get started have those questionnaires
00:27:08
Speaker
What's your process? Do you, if someone calls you up and says, look, I've had X number of surgeries on my back or my knee or whatever it is. And, you know, I've been in pain for, for 10 years or so on. Would you just say, okay, great. You know, come in and see me and then provide questions or do you send them out to the questionnaires in advance? No, I would, I would, I would speak to them first. Yeah. Yeah. Okay. Well, there would happen. Okay. Okay.
00:27:34
Speaker
And then if it turns out that they were going through a difficult time with their business, or their marriage, or they would have agreements around, that seem to mix in with the whole sort of etiological matrix, if you like, what would your thought processes be? Would you think, ah, this questionnaire is the right one, or we need to give them x number? So can you elaborate on that a bit?
00:28:02
Speaker
I mean, you're really looking for cues. So the, yeah, if we start with something like mood, if someone describes their ping, well, if I go back even further, if someone but describes their pens, their pen is being intense, it's really sort of sharp.
00:28:21
Speaker
And it's a sort of seven or eight out of 10. That that's a sort of sensory cortex, character location. And there's no other sort of factors that influence that that's your basic pain response. Right, right. But if and that's, that's an acute pain response. Yeah. Yeah. But if someone says that their pain feels really awful or unpleasant,
00:28:42
Speaker
The script is emotionally based. If someone starts using those definitions of pain, then there's a good chance that there will be an emotional component to their presentation. So that's the mood part of it. And those are the basic cues. If someone talks about
00:29:04
Speaker
tissue damage and their vigilance and then they notice every single change in pain intensity and character. Then we're talking about hypervigilance. If they start talking about the pain will never end and they can't see any hope, then that tends to be more the catastrophizing sort of areas. So unfortunately, you have to do, there's quite a lot of
00:29:27
Speaker
knowledge involved that you have to return yourself as a practitioner to acknowledge what those cues actually mean. Yeah, absolutely. Okay. And that basically means you need to know what the questionnaires mean. Yes. And you need to know every single item basically. Yeah, yeah, yeah. Okay. Thank you. Is there training for this? Is there, you know, are there papers that you recommend or books?
00:29:45
Speaker
Well, I mean, every single questionnaire will have had a validatory process where papers have been published and how the items have been developed, whether they use item response theory or whether they use factor analysis, which is all quite theoretical and quite difficult to understand, I find. I see. I mean, we've got someone, thank God, who's a statistician who's a bit of a whiz with factor analysis.
00:30:14
Speaker
Right. And all I do is crunch the numbers. But it's, you just have to be aware of what catastrophise, what altered cognition means in regards to pain, what altered mood means in regards to pain. And, you know, you can go from the sort of mood, cognitive stuff. And you've got to be careful, you're not crossing over into sort of more DSM, yeah, sort of personality stuff as well, because that's another problem.
Cultural Influences on Pain Perception
00:30:40
Speaker
Yeah, yeah. So I know what you mean when you say that, but to clarify, essentially, you're kind of saying that you don't sort of step outside your own area of expertise. And DSN is the dynamic statistical manual for psychological issues, isn't it? And so I guess that is difficult to know where that line is, because it's probably quite a fuzzy line, isn't it? Well, again, there's
00:31:10
Speaker
people who again these are very generalized so please don't hang your hat on these but it helps me if people who come in are anxious and distressed about their pain and they try hard to get better and they don't blame you and probably blame themselves I didn't have a good night's sleep or I've got deadlines at work or the kids were playing up
00:31:35
Speaker
That is sort of safe country, if you like, where people who have these mood disorders, if you like. But people who start to blame you as a practitioner and never blame themselves for themselves not getting better, then you've got to start thinking, oh, this is probably out of my hands a bit. Yeah, right. It's more the personality stuff that's more apparent. Well, I think that's... Again, it's a generalized switch, but it tends to work for me. Yeah.
00:32:03
Speaker
Yeah, yeah, for sure. I think that's a really fascinating area because, you know, for me personally, I think that links back in very well, very beautifully to the biopsychosocial model from the perspective that, and, you know, I've written about this a little bit in my editorials for the Journal of Body Work and Movement Therapies. Oh, yeah, I saw that. Oh, did you? Okay. But the idea that, you know, from a
00:32:28
Speaker
From a social perspective, of course, we're growing up in societies that have, well, I say we, I should say that I, but I imagine a lot of people, let's say from the UK originally, are growing up in a society that has a traditional religious belief of Christianity.
00:32:50
Speaker
And, you know, of course, I want to be as inclusive as I can. So, you know, whichever society you're from, there's typically, there are no real societies without some kind of religious backdrop to them. We know that from the anthropological research.
00:33:07
Speaker
so but but the interesting thing is if when you look at the history of religion um religion has gone from being sort of more animistic where you see spirit in everything from rocks to rivers to animals to trees etc um to being more polytheistic so you know a god of war and a god of rain and a god of this and a god of that to um monotheistic where you've got this kind of god in the sky um and and it strikes me that what that does is it puts
00:33:34
Speaker
the idea of power, the locus of power outside of the individual from a social context. It doesn't. Yeah. I mean, that's something that we work on again on the program. It's another factor. Yes. Yes.
00:33:52
Speaker
I suppose where I'm really interested in your expertise on this is that one of the things that we were trying to convey in the original Ghost in the Machine paper that we wrote was that a lot of these beliefs are below the level of conscious awareness. So they're not the sort of thing that are easily identifiable
00:34:10
Speaker
through a questionnaire. So have you got any thoughts on that? Do you know if there's any work being done on that?
00:34:23
Speaker
I mean, there's been quite a lot of work done in the palliative care world. Yes. Yeah. From that perspective. So in relation to things like spiritual distress, right? Right. In internally ill patient or dying patients. And that's another part of my research area is we've developed a questionnaire, for example, to see if not just clinicians, but
00:34:48
Speaker
in auxiliary stuff who are on the wards, do they recognize spiritual distress in patients who are dying? And the answer is they recognize the definitions, but they don't recognize the behaviors. Yeah, right. Well, that's fascinating, isn't it?
00:35:00
Speaker
Yeah, it's fascinating. And then a knock on from there was if you're looking at something like death anxiety, and there are actually quite a few questionnaires that measure levels of death anxiety, people who are high and a study we did in New Zealand that people who are highly religious have massively high levels of death anxiety, compared to people who are spiritual who don't follow a set of rules.
00:35:27
Speaker
who may be, their existentialism is related more to sort of nature or whatever. They have the least amount of death anxiety. Wow, that's really interesting. The more rules you have to follow, the more stressful it is to keep adhering to them. Right, right. I remember listening to a guy, I don't know if you've heard of him, called James Hollis, and he's a kind of, do you know his work or not?
00:35:55
Speaker
I know the name, but I might be familiar with his work. Yeah, well, he's more of a Jungian psychologist, I'd say. Certainly he's got a strong Jungian influence. But one of the things that he says is that, what is it? Religion is for people who don't want to go to hell, and spirituality is for people who have been there.
00:36:17
Speaker
I've never heard that, but that's quite interesting. I was just thinking, in the context of what you were saying, it's like there's this fear of death, which I guess for some people is their sense of hell. But the idea that
00:36:33
Speaker
Spirituality is something very distinct from that and it's a means of coping without existential anxieties and perhaps people have been bereaved or have had very traumatic situations and they have to try and make sense. It's like a sense making mechanism of the world.
00:36:51
Speaker
and so you can see how that could reduce stress but you know kind of back to the the blame side of it if you've got the idea that the locus of power is outside of you and it's in a god that's in the sky or whatever and yet he or she or whoever you perceive god to be is not helping you with your pain and you can understand that this blame culture
00:37:14
Speaker
or sort of psychology starts to ramp up in you. So yeah, it's very, very fascinating. Like I say,
00:37:22
Speaker
you know, it strikes me it's not just a psychological thing, but it's a social thing. And there's this kind of almost, this is why we called it the ghost in the machine is that, you know, we were talking about the ghosts from the perspective that it's unconscious, or you're unaware of it, but also the fact that it's kind of almost seems to transcend generations. And it's a, you know, almost like a hidden factor in our behaviors is the fact that we have come from certain cultures that have certain beliefs. And, you know, one of the studies we talked about,
00:37:51
Speaker
Let me just finish this moment and then I'll come back to you and your point. But one of the studies that we talked about was a study which was looking at it was called Foxhole atheism. And it's the idea that when you are
00:38:09
Speaker
You take two groups of people and you've got one group that are, via questionnaire again, they're assessed as being atheists and another group that are assessed as being non-atheists, not necessarily religious, but non-atheists, they believe in a higher power.
00:38:26
Speaker
Then when you ask them consciously in a questionnaire about their spirituality and their belief in a supernatural or a higher power of some sort, then of course you get exactly the response you'd expect. But when you prime them implicitly to think about death,
00:38:49
Speaker
and then retest them and only give them a very short period to respond. What you find is that the atheists all switch to becoming much more believers in some kind of spiritual afterlife or so on. So, you know, I just found that, they were saying, you know, there's no such thing as an atheist in a foxhole, which is, you know, a fairly sort of well-known comment relating to the idea that if your back's against the wall and you're facing death, then most people actually do innately have some kind of
00:39:19
Speaker
uh deep spiritual uh longing or or uh feeling etc so um what's that sorry
00:39:29
Speaker
or a protector. Well, yes, exactly. Exactly. Yeah. So I know you were going to jump in at one point there. Did I throw you off your absolutely not. There's I mean, if you want, there's actually been there was quite an interesting study done in Oxford by a woman called Irene Tracy. Right. He's quite famous in the neuroscience world, especially regarding sort of pain mechanisms and pain pathways. Yeah. And she did a study with Catholics.
00:39:59
Speaker
where she showed them as the test the image of the Virgin Mary and then as a control the image of a woman who looked very similar but was not the Virgin Mary and at the same time they did a lot of functional imaging MRI imaging
00:40:18
Speaker
of brain responses, and at the same time that they showed them the images, they also gave them a painful stimuli, which was an electric, I can't remember what it was, but it was a nociceptive input anyway that was painful. And when the Catholics looked at
00:40:38
Speaker
the Virgin Mary, the pain responses were a lot lower than when they showed them the picture of the equally nice looking woman. But even though the pain stimulus was of this intensity. And when they did the functional imaging, they found that an area of the prefrontal cortex, which is the area which is where you sort of process all the other information that's sort of been thrown into the brain, as it were,
00:41:05
Speaker
There was a specific part of that prefrontal cortex that lit up when they were shown that the Virgin Mary, but not it didn't light up when the other image was shown, which is quite interesting. So it is, it is almost innate. Yeah. Yeah. Yeah. That is some module in the brain. Yeah.
00:41:22
Speaker
if one could find a new and manipulate it. And would that relate to, see one of the people I've been interested in reading around his work is a guy called Philip Zimbardo. His whole sort of latter part of his career has been based around time perspective and looking at people's, there's essentially six different time perspectives. So there's, as he's defined it and he's, you know, tested his various, he calls it a time perspective inventory.
00:41:52
Speaker
Basically, there's past positive and past negative, so this is how you view the past and what recollections you have of it. Then you've got present hedonistic or hedonistic and present fatalistic. Then you've got future, just a general future time perspective, and then you've got transcendental future time perspective.
00:42:14
Speaker
And it strikes me that what you're saying there about the functional magnetic resonance imaging of people looking at the Virgin Mary, it's almost like they probably have a very strong transcendental future time perspective. They're looking to this kind of post
00:42:33
Speaker
death figure that is there for them in the afterlife or whatever and that somehow that's providing some kind of sense of security to them in the present. Yeah, absolutely. Yeah, yeah.
00:42:47
Speaker
Because one of the things that Zimbardo talks about is that it's very important to get the balance right between each of these different perspectives. And obviously if you focus too much on negativity in the past, then that's going to potentially hold you back and make you keep ruminating on those past life events that didn't serve you well. And of course, if you focus too much on the future,
00:43:13
Speaker
then you're not pregnant in the now. So I guess it'd be really interesting and I know that he's done a lot of research with different religions as well and religious groups, but it'd be very interesting to understand more about the time perspective profile and how that affects people in pain.
Impact of Early Life Stress on Chronic Pain
00:43:34
Speaker
Well, I mean, epidemiologically, there are answers to those sorts of questions. Right, right. So, for example, you talk about people looking negatively in the past. Yes. And most people with chronic pain have had some form of negativity or adverse event or events in their childhood or in their teens. And so, for example,
00:43:57
Speaker
I think the study was done in the mid 2000s, but people who had three or four early life adversities, i.e. during neuro endocrine development, they were more or less guaranteed of an adult onset chronic disease. So what happens there is that if you give a child who is developing
00:44:24
Speaker
a consistent or a set of highly anxious situations. And it doesn't have to be anything dramatic like the worst forms of abuse, but it could be maternal-paternal separation, for example. That will have quite profound effects on the sort of hypothalamic-pituitary-adrenal axis. They'll set up
00:44:49
Speaker
a higher state of inflammatory product release generally on a permanent basis and because of that you are more susceptible
00:44:59
Speaker
to painful situations because you're already producing a larger amount of inflammatory product than you would be normally. And that's because of its heightened hypothalamic, pituitary, adrenal axis. Right, right. Yeah, and I guess an example that I've heard before is it's like turning up the game in a kind of speaker system so that
00:45:23
Speaker
you know, when you strike that guitar string, you know, suddenly everything goes blam. And that's the kind of example of someone who's experienced, like you say, a significant life stressor early in life, whereas for somebody who hasn't, then you hit that guitar string and it's set at the right level. And it just, yeah, it might be uncomfortable, but it's not going to go into kind of sensitized mode. Is that fair?
00:45:48
Speaker
But the other unfortunate thing with all this is that the feedback mechanisms, because of this release of inflammatory neurotransmitters and other sort of hormones released from the adrenal glands and the pituitary gland, they have negative effects on neurotransmitters in the brain, which are essential for development, for example, in children. But this is why the kids have developmental problems as well. And it's not because of
00:46:15
Speaker
the way they were born, but the feedback mechanisms that have occurred as a result of repetitive, stressful events, I feel like. Yeah, yeah, of course, of course. Have you ever seen much of Bruce Lipton's work and his sort of description of, I guess, epigenetic expression? Well, that's exactly what that is. Yeah, yeah, yeah.
00:46:37
Speaker
It's because you are changing, you are developing a new phenotype with these events. So once you have this cranking up of the volume, if you like, it might go down, but it will never go down to what it should be. Because you have morphologically changed
00:47:00
Speaker
synaptic strength in some areas where you basically increase synaptic strength in facilitatory areas and decrease synaptic strength in inhibitory regions or pathways. That can relate to the dorsal horn, inputs coming in from skin or muscle. There's a new type of supercharged receptor
00:47:24
Speaker
in the synapse that reacts more easily to sort of insignificant input delay. And those are new phenotypically produced receptors that won't go away. Really, really great concentrations of these receptors are produced than before as well. So you get a larger concentration which it makes
00:47:42
Speaker
it more able to produce stronger inputs going up to the brain. So that's just that's just the dorsal horn. Yeah, well, then you've got all the areas of the brain as well, which are involved on the descending inhibitory pathways, which are involved in the condition pain modulation I was talking about earlier. Yeah, yeah. So essentially, so epigenetics is a big part of
00:48:05
Speaker
Sorry, I think it was slight delay there. I was just going to say that for people that are unfamiliar with what we're talking about here, I guess the simple way to say it is that your pain threshold has decreased and your pain perception has increased. They're the kind of two arms of the same process, I suppose, which ultimately increases pain perception overall.
00:48:33
Speaker
And also people with chronic pain, they have thickened areas of grey matter that are related to pain facilitation and atrophied areas of brain matter that are associated with brain pain inhibition. Yeah, that's amazing. So going in as an osteopath thinking that you're going to do wonders with biomechanical input ain't gonna do it justice really.
00:48:54
Speaker
There needs to be, there needs to be other inputs. Yeah, yeah. Sure, sure. And so one of the things I know that Bruce Lipson talks about is the fact that, you know, we're talking about the individual and them having potentially, you know, a major life stressor early in their lives during development. He was talking even, you know, when we were saying developmental, he was talking even with the child in the womb, when the mother is very stressed, then the release of cortisol into her system,
00:49:20
Speaker
crosses the placental barrier, gets into the fetus, and redirects blood from the forebrain to the hindbrain. So you end up with a child who has a lot more of a reflexive kind of capacity as opposed to a responsive capacity. So they're more likely to get, let's say,
00:49:42
Speaker
they may struggle more with ADHD type symptoms or just be more reactive and get into more trouble with their peers and so on. I know that sounds like a huge generalisation. I'm sure it is a generalisation. There's been a large amount of recent work done in Cork.
00:50:01
Speaker
Okay. Looking at the effect of stress on on on animals who are pregnant, and how that affects the fetus. Yeah. And then one of the biggest causes of this reef hyper reflexia, if you like, is down to alterations in gut bacteria. Really? And bacteria can infiltrate the blood brain barrier.
00:50:28
Speaker
especially at that age, then facilitate everything that we've been talking about over the last 50 minutes. Wow, that's incredible, isn't it? Who'd have thought that these little bacteria could have such an effect? Suddenly, we begin to realise the importance of these little guys. Well, it's looking like they're important in personality disorders, they're important in hypersensitivity, they're important in a whole host of different things.
00:50:54
Speaker
dysbiotic microbiota, if you like, would be the correct term, I would say. Yeah, yeah, okay, okay, yeah, yeah, very interesting. You know, so sort of taking this a step further, you know, Mark Wolin is a guy who I was reading, reading his book recently, his whole thing is looking at the core languages that we use. And essentially,
00:51:16
Speaker
I guess his hypothesis is that we inherit a certain way of talking about the world and communicating about the world through our family and through our tribe, if you like, people that we're exposed to. And so he's very interested in that. But part of his research was looking into epigenetic effects.
00:51:38
Speaker
And he was quoting other people's research, particularly there was a lot of research on Holocaust survivors showing markers of all kinds of HPA access dysfunction, blood sugar dysregulation. And this seems to be true up to three to four generations beyond the Holocaust survivors. Now, is that anything that you've
00:52:02
Speaker
read into or have any background awareness of? I don't have any background, I'm afraid. No, no, no. But I can totally, it does make sense. Because once you change your phenotype, or parts of your system phenotypically,
00:52:21
Speaker
that will be passed on to the next generation. So it makes sense from a genetic perspective of course. Yeah, very interesting. So looping back round to the visceral pain where we started off.
00:52:39
Speaker
When people, let's reframe that to visceral, I don't know whether dysfunction is a good term, or visceral symptoms, because many people out there that would have, for example, it's bloating, or they might have a bit of diarrhea, but they wouldn't particularly say that they're in pain, and they might
00:52:56
Speaker
you know not really it doesn't really affect their lives particularly so something like that where you've got something fairly low grades and then maybe you know a history of an old knee injury so the knee injury is you know from time to time flares up and gives you a kind of pain input into the obviously into the lumbar spine sort of l34 level you've got your colon
00:53:22
Speaker
let's say sending some afferent drives because it's a bit irritable into level L1, L2. Would those two things together potentially be enough to make you somewhat sensitized and more prone to, let's say, a persistent low back pain? Or is that not enough? Do we need more than that?
00:53:45
Speaker
No, again, it depends what the person has come in with. It depends what's there before, really, would be the answer to that. I mean, the other thing is that, you know, the segmental innovation thing that we've all followed with, you know, the stomach T6 to 10 liver T6 to 10. I mean, that's sort of old-fashioned old news, really. I mean,
00:54:10
Speaker
Most of the most visceral organs are so multi segmental that they're indistinguishable from each other. So for example, the stomach, or just just the lower just the esophagus can be as being recorded in animals as being going from T2 to L4, for example. Wow, that's a big range. So there's no there's no real differentiation between levels.
00:54:36
Speaker
Right, right. And that's one of the reasons why visceral pain and visceral symptoms are really quite diffuse, really poorly localized. Yeah. And that's because once it goes into the spinal cord, it just goes crazy. It just goes all over the place. It doesn't just go up and down many segments. Yeah. I mean, if you compare it to a single, single somatic afferent neuron that comes into the outer part of the
00:55:02
Speaker
the spinal cord, the dorsal horn, and it synapses in one laminae. And it has one connection and it goes to the brain. Hence, we can measure with dermatomal testing, if you like.
The Complex Role of Gut Bacteria
00:55:13
Speaker
If you do a comparative single visceral afferent neuron coming in, it branches like crazy over many, many different laminae. And it also crosses over contralaterally or to the other side of the
00:55:27
Speaker
of the spinal cord as well. And additionally goes into the dorsal horn as well. So we always think of the dorsal horn as being sort of like touch and proprioception and what have you. But there's a strong visceral pain component
00:55:39
Speaker
or pathway in the dorsal hole in the dorsal columns as well. So it's a bit of a different beast. And there's also the influence as we're finding out now that has been driven mainly by altered composition of gut bacteria. Yeah, it's not not that I'm preaching the newfound fame of gut bacteria, but it's looking like phenomenally, I would say that that gut bacteria are responsible for
00:56:06
Speaker
much more than we ever considered. And it's not simply corrected with a bit of kimchi or whatever, it's quite a difficult thing to approach. Yes, yes, exactly. Well, interesting enough, I went to Mexico for my brother's wedding a couple of months back and I picked up some kind of
00:56:26
Speaker
Mexican gut rot. I was in trouble for a couple of weeks after that just to stay hydrated so I won't give you any more detail than that.
00:56:42
Speaker
But, you know, I, you know, I thought, OK, I've taken some probiotics and, you know, I was taking some, I forget, like some garlic and so on. After a few days, you think, you know, this is just ridiculous. This stuff is so impotent compared to what's going on in my gut at the moment. And it's almost like you just have to ride it out. And not to say I don't recommend those things or I wouldn't do those things, but it makes you realize the potency of these, you know, just little infections. Yeah, absolutely.
00:57:10
Speaker
And, you know, how limited, like you say, a bit of kimchi is not going to solve that problem. Well, you know, the results from studies are so varied. Some people like they'll have a fatal transplant and they're a changed person. Oh, really? But other people will have the same thing and it doesn't even touch them. Yeah. So the consensus now really is that the gut bacteria you come out of your developmental years with is the one you're going to keep.
00:57:37
Speaker
right yeah yeah and i've read also that it relates very closely to of course the the company you keep so your family your tribe the people that you hang out with
00:57:49
Speaker
Which is, which is kind of interesting as well. Um, that it's, it's again, it's almost a biopsychosocial, um, biome, if you like. Yeah. Yes. Yes. Absolutely. Yeah. Funny that, isn't it? Funny how these, uh, these terms overlap. I always, you know, I remember the moment when I realized that the term, the colon.
00:58:13
Speaker
It's called the colon because it has a colony of bacteria. It's like these little linguistic things that drop into your head. You're like, ah, that's why it's called that. And that's how we make sense of these things. OK, so one thing that you may or may not be aware of, but it's something that has been a kind of pet topic of mine. And I've worked with it a fair bit clinically and seems to add up to me. But I'd be interested in your take on it, is the idea that visceral,
00:58:43
Speaker
visceral pain or viscerosomatic reflexes can affect motor control potentially in the regions, let's say, I know you just said that we can't really talk about topographical regions so much, but let's say if someone had a colon issue or had any kind of digestive issue really, that that may affect the functioning of the musculature
00:59:11
Speaker
in the core um and this is something that you know i don't know anything about me to be honest but it sounds interesting okay well yeah so you know i i found research um and i don't know the the exactly the the quality of it but um you know i've found uh obviously you know back in the day at college frank willard was talking about this kind of thing a lot but um i've subsequently looked into various other research papers which i've written about in my editorials um
00:59:38
Speaker
which seem to suggest that when you get, let's say, aberrant, afferent or sensory drives into the cord and you get this sensitization starting to be set up, that it seems that there can be an inhibitory effect on the tonic motor neurons. Just like with pain, you know, when you get pain, we know that the tonic motor neurons seem to become inhibited to some degree by pain. And so,
01:00:06
Speaker
It strikes me that when you look at the whole field of motor control, I haven't seen any studies so far, although I haven't looked in the last couple of years, but I haven't seen any studies that talk about visceral drives and whether or not they may be impacting essentially significant confounding variables.
01:00:27
Speaker
on motor control, because as we've just talked about, a lot of people in pain have a whole raft of other things. So let's say a population of persistent low back pain patients, then a whole raft. And if you hit on that, an important point there actually, in that that one of the things that are really good for chronic functional GI disorders
01:00:53
Speaker
is exercise. It's shown to be far more beneficial than anything else. What reflexes and what pathways they affect?
01:01:08
Speaker
We're not quite sure. We know that by doing exercise, you are being anti-inflammatory, you produce a whole lot of transmitters that reduce inflammatory mediation. You also produce a whole load of endorphins and you produce endogenous opioids and what have you. But there may be other things that are in the mix as well that also can have inhibitory effects on visceral pain as well.
01:01:30
Speaker
Yeah, for sure. It just strikes me, I was looking at your chapter in your book on visceral pain and on the first page, you're talking about the epidemiology of visceral pain.
Integrating Spirituality in Clinical Practice
01:01:42
Speaker
I haven't looked at the book for about two years, just saying that. That's right, I'll read it out to you so it jogs your memory. But you had the visceral pain rates in adults, 25% for intermittent abdominal pain, 20% for chest pain.
01:01:57
Speaker
and 16 to 25% for pelvic pain in women. So it just shows you, this is essentially around a fifth or quarter of the population have active pain in the visceral system and A potentially lowers their
01:02:14
Speaker
possibly lowers their motor control. That's that's my sort of hypothesis that I threw in there. But but it certainly is, it could well be lowering their threshold for pain. So they perceive pain that bit earlier. And the same, sorry, the pain persists that bit longer, because of that underlying visceral issue. Yeah. And is that does that make sense to your way of thinking? I mean, I think there'll be a few more factors involved. Yes, yes. Which may be numerous, but I would say essentially, yeah, yes.
01:02:43
Speaker
Yeah, yeah, yeah, fantastic. So, you know, back to talking about the sort of more spiritual factors, research that you got involved in, because you've got a few papers on those that you've either written as the lead author or as a secondary author.
01:02:59
Speaker
What would you say you've taken from that research to your clinical work? I often when I'm presenting, I do explain that I see myself as working with patients using a physical, emotional, mental and spiritual model.
01:03:16
Speaker
And I know that's going to raise the eyebrows of some people in the audience always, because you're talking to a heterogeneous group, of course, with the whole array of beliefs and understandings. But the way I temper it a little bit for everyone is I say, the important thing is that it really doesn't matter what you believe is the clinician.
01:03:39
Speaker
but it really does matter what the patient believes. And that's why you've got to have, that I believe you've got to look at an individual from a physical, emotional, mental and spiritual perspective. You've got to acknowledge what they believe. Right, yes, yes, exactly. I think you can do no more than that, really.
01:03:59
Speaker
And so what would your approach be from, you know, if you had someone coming in who was, let's say, you know, a terminal cancer patient, and they were looking for, you know, maybe they heard that they might get some pain relief from working with you. And so they've come in to see you.
01:04:23
Speaker
And you sort of thinking, okay, this person is clearly going to have some existential or not clearly, but likely going to have some existential anxiety going on here. Have you got any specific tools you would go to in terms of assessment or in terms of something called the facet extended spiritual questionnaire, which you can, which you can get on.
01:04:46
Speaker
It's F-A-C-I-T. They do a whole range of different questionnaires for chronic diseases. And the extended spirit goal is a 23-item questionnaire that the first eight items are related to peace and mean.
01:05:03
Speaker
The second four related to faith and the last lot are related to relationships. And I tend to, I mean, I don't see terminally ill patients in the rule. I've questioned them in research studies, but I've never, which I find quite difficult, I have to say. So, you know, once you work out where their spirituality lies or their emotion lies, you work
01:05:33
Speaker
on a sort of meaning based concept, if you like, and you find out what they want, where they want to go. Even in like we use virtual reality, you can just stick a Google, Google Earth immersive VR headset on the reds. And a lot of them, there was a study that came out recently, most people who are dying, they don't want to go back to where they live, they want to go to a place they've never been before. So
01:05:58
Speaker
You sort of open the door for them, if you like, and you give them the hint and they can take it from there. Right. And then you empower them by doing that. Yeah, yeah, yeah. So the thoughts are about empowering, we haven't really talked about that tonight, but empowering patients. It's no good you're starting off as the clinician saying, do this, do that, but you have to empower them enough to get them to do it. Absolutely, absolutely. Yeah, and I think that's so-
01:06:28
Speaker
my I'm about in patient empowerment. If that was my end goal, that's what it would be. Yeah. Yeah. Okay. Okay. Brilliant. So you know that that that's a questionnaire that you mentioned. What does that give you as a clinician? It tells me
01:06:49
Speaker
depends which part of the questionnaire I'm looking at. I normally just look at the first two parts, to be honest. Yeah. But I mean, in a nutshell, if they've got no reason to get up in the morning, you've got to give them a reason to get up in the morning. Yeah, yeah, for sure. Sure. And if they don't have faith, and from a faith perspective, if they don't have faith in their GP, then you know, you can advise to get a second opinion, something as simple as that. Yeah, yeah. Or, you know, you've got to work on them having faith in you as well, of course.
01:07:17
Speaker
yes yes absolutely absolutely yeah but the meaning the meaning the main part of this whole thing is is i would for me is the most important yeah okay okay it's you have to give people have to have meaning in what they do yeah and why they do it yeah yeah for sure whether they've got whether they've got three days to live or 30 years to live yes yes well that that leads into you know a couple of papers i've read recently um because uh
01:07:43
Speaker
I guess for both my editorials, but also for some of the teaching that I do, we talk a lot in the check system about a process that we use called the 1234 approach. And so the idea is that with any patient or any client, let's say, because a lot of the people that a tech professional would work with are not necessarily in pain, but they just have a performance goal, let's say. But even then, sometimes the performance goal may not be
01:08:11
Speaker
relevant for them given their physiological status or you know it may be that they've perhaps developed a goal based on again a kind of social or cultural norm and when they really dig down into why they want to achieve that goal it may be actually that that's not what they want to achieve with their life and so what
01:08:33
Speaker
what we do is we have a kind of coaching system where we identify, help them to identify what their purpose is or what we call their one love. So that's the one dream or the one legacy that they're going to leave behind. So it's the big purpose for their life.
01:08:49
Speaker
And then the next phase, so the number two, is looking at the balance of catabolic to anabolic stresses. So essentially the yin and the yang of life. And to take a using the questionnaire system that we have, we look to see are they
01:09:05
Speaker
extremely stressed, are they, is their digestion good, how is their sleep, etc, etc, you know, are they hydrated or dehydrated? And so we use this whole sort of approach to say, well, of course, for most patients, people are in pain, they tend to be a bit too young, they're in a state of inflammation times, they're in a state of, you know, not sleeping enough, they're too stressed. So these are all kind of young qualities as opposed to being rested and relaxed and, you know, well fed and all this kind of thing.
01:09:34
Speaker
So it's just, you know, again, you can coach them on that and say, well, where do you think your life is out of balance here? Are you too young or too young to catabolic to anabolic? And well, I guess we do that in practice really anywhere, don't we? If we're taking a biopsychosocial approach anyway.
01:09:50
Speaker
Yes, yes, absolutely. But I suppose where I was going to go with that was that the papers I found, one of them was saying that it was looking at longevity in the over 60s. It was saying that people who have purpose have greater longevity by a very strong statistical margin. Absolutely. Absolutely.
01:10:12
Speaker
Not that surprising. You could say it's common sense. And it's also, I guess, a common observation, isn't it, that when people retire, there's a real period in the first, I think, year or two after retirement, that the mortality rate really shoots up. And when you get through a certain period in post-retirement,
01:10:29
Speaker
then you tend to last a bit longer if you can develop that sense of purpose again. But the other thing that struck me, which ties back in with a lot of your work, is that I had another paper that I referenced, which looks at purpose as a predictor of allostatic load. And for me, again, what it was showing was that if you have
01:10:55
Speaker
life purpose and they measure you for allostatic load at the moment the trial started. They then reassessed 10 years later and 10 years down the line what they found was that the people with purpose had a much lower allostatic load.
01:11:12
Speaker
So how did they measure allostatic load in that case then? They measured it. There was a whole raft of tests, a lot of things like assessing HbA1c, measuring, so that's for blood sugar, measuring cholesterol, measuring HbA axis function. So it was a whole lot of biochemical screenings as opposed to questionnaires. What they found was that
01:11:35
Speaker
10 years later, the group that had life purpose had a much lower allostatic load than the group that had no definable or defined purpose, let's say. Yeah, go on.
01:11:52
Speaker
Well, I was going to say that to me what that suggests is that the allostatic load is what to me is likely to lead into all of the symptoms that we've been talking about that perhaps are either clinical symptoms or subclinical symptoms that can cause central sensitization in the longer term.
01:12:09
Speaker
Yeah, so I mean, so it's so it's a sort of facilitatory loading is another way of looking. I mean, other statics, quite broad, a lot of people use elastic loading quite wantonly, I think. Yeah, yeah. But for me, it's, it's, it's an over facilitation.
01:12:27
Speaker
of emotion and cognition or altered cognition and dysbiotic microbiota and central sensitization relating to pain. It's a whole body facilitatory response. Yeah. And more facilitatory is I want to keep coming back to the lesson hit in the less the inhibit inhibition pathways can have an effect. And the more they become, for want of a better term atrophied,
01:12:52
Speaker
Yes, yes, right. Yeah, for sure. Sure. Or disused. Disused. Yeah. Yeah, yeah. Yeah. So everything's trainable, isn't it? I think Dan Siegel is one of the guys that I like to listen to and read his books a bit. And he was saying that the brain is quite an extraordinary organ because
01:13:09
Speaker
it can grow itself by thinking, essentially. By the way you use the brain, it will grow itself. But it's very much like a muscle, obviously. But I guess in the way we see the brain, we see it as our tool of thinking and our tool of mind. But what Dan and his group do is they've spent years and years, and so this is like a think tank of
01:13:34
Speaker
psychiatrists, psychologists, sociologists, anthropologists, and so on, trying to understand what mind actually is. And, you know, because he was already, as an author and a speaker, he had already been traveling the world speaking to large audiences. And he would always do a test to ask, you know, because of course, these audiences were largely from the psychological sector or counseling sector.
01:14:03
Speaker
And so he would say, you know, you've all been through professional training about the minds. How many of you actually given a definition of what mind is? And he said, he said, you know, across sort of 10, 15 years of doing this, less than 5% of people worldwide, and this was over 100,000 psychology professionals that he had asked, less than 5% of them were actually ever given a definition of mind. And so, you know, what he
01:14:32
Speaker
came up with, with this group of, like I say, interdisciplinary group, they said that mind is the embodied and relational flow of energy and information. And I think the kind of field that we're entering into in manual therapy is an understanding pain. That definition fits very beautifully with a lot of what we're seeing that, you know, mind isn't in the head. It's not something that is like a hard drive in a computer, but it's the embodied.
01:15:02
Speaker
and relational flow of energy and information. And so, you know, that suggests to us up and down. Yes, exactly. Exactly. That it can be held, we can hold tensions in the body as a result of experiences that we've had, emotions that we're holding and so on. Well, patience if you don't relax is a good example. Yes, exactly. Exactly. Yeah, yeah.
Psilocybin's Potential in Treating Anxiety and Depression
01:15:26
Speaker
So I forgot what it was that triggered me to talk about
01:15:30
Speaker
Dan Siegel, but anyway, maybe I'll come back to that if it comes back to me. Sorry, I'll interrupt you too many times. No, that's fine, that's fine. So one of the things that I've been aware of and it's partly through listening to Jordan Peterson online,
01:15:51
Speaker
is that one of the things that can provide a lot of relief from anxieties, especially the kind of existential angst that we were talking about, is psilocybin doses, which is, of course, the sort of magic mushroom, you know, as it's known eloquially, which is technically described as hallucinogen. But I think more
01:16:20
Speaker
Well, in sort of shamanic and neo-shamanism type circles, it's often termed an entheogen, which means that it's a God-evoking, I guess, in inverted commas, loosely speaking, a God-evoking substance.
01:16:39
Speaker
The experience that many people will report on, and again, this is not too left of field because these are clinical studies that have, I mean, they're fairly recent, the last 20 years or so, because I think it was a very taboo field since the kind of swinging 60s.
01:16:58
Speaker
these kind of more hallucinogenic compounds became listed as class A drugs. So there was a block of maybe 30 years or so where there was very, very little medical research. But as of the late 90s, there was a real sort of re-blooming, if you like, of the research interest in psychedelics.
01:17:27
Speaker
So psilocybin being obviously a naturally occurring one has been studied by a number of different people. But what Jordan Pearson was saying about it was that it reduces the depression and anxiety associated with being in a terminal state. You know, many, many statistical points more than any other. Yeah, I've seen some evidence of that, actually, but not myself, in research.
01:17:55
Speaker
Yeah, yeah. And have you have you got any thoughts around that where that could come from? Because of course, we would I think the standard narrative would be that, you know, hallucinogen is just it's kind of like dreaming, you just make up stuff in your head. And it's, you know,
01:18:12
Speaker
You would think then if that were the case, if you're facing death, you would think that actually you could have what might be termed a bad trip, right? A really bad trip because it's altering your mind state and you're in a very anxious state already. Yeah, let me just read this off to you. So this was an initial study that a guy, let me see if I can find his name, Roland Griffiths did. He's a clinical pharmacologist.
01:18:38
Speaker
He said, 80% of patients with life-threatening cancer were given a laboratory to synthesize psilocybin in the carefully monitored setting in conjunction with limited psychological counseling. More than three-quarters reported significant relief from depression and anxiety, improvements that remained during a follow-up survey conducted six months after taking the compounds. And he says, this is simply unprecedented in psychiatry, that a single dose of the medicine produces these kinds of dramatic and enduring results.
01:19:08
Speaker
Yeah, I've seen a similar thing. I think it was on a... I think the results were shown on... Mike Moseley did something about that. I think it was Mike Moseley. But the study stopped.
01:19:24
Speaker
and you weren't allowed to give any more so the depression came back in a lot of these people months later and they're not allowed to go back on the medication again. But it did have profound effect, you're right. But that's about as much as I know.
01:19:42
Speaker
what mechanisms it works on is as good. I wouldn't even hazard a guess. Yeah, yeah, yeah, certainly. Yeah. Well, one of the things that I've seen written about psilocybin specifically, but also some of the other hallucinogens is that when
01:19:58
Speaker
These things are assessed using a functional magnetic resonance imaging approach. What you find is that quite contrary to what you'd expect, again, you'd expect to see the whole sort of visual cortex light up. You'd think that if you're having all of these hallucinations, that you would be seeing all kinds of imagery and the whole thing would light up.
01:20:23
Speaker
But what it seems to do, it actually seems to inhibit brain function. So you get much less activity during hallucinogenic experiences. Well, now I support them as dreamlike, then your brainwave patterns would be far less intense. Yeah, yeah, maybe, maybe. You know, one of the theories that I had put out around that was that maybe if we were to
01:20:48
Speaker
invert the way we look at these things, which is the idea that the hallucinogen is generating imagery. If we were to invert it and say, well, the imagery is there, but normally we're inhibiting it through our normal brain function. So when the brain is activated, it inhibits
01:21:07
Speaker
an aspect of reality that we can see when we inhibit the brain using something like hallucinogen, then suddenly we're exposed to other parts of reality. And this is why people, of course, it's very controversial. So I'm not saying this is what's going on. I'm just saying this is one theory on it.
01:21:26
Speaker
It's a very interesting theory because, of course, what most of these people found that had been through these psilocybin experiences, even though they had less than six months to live, was that they're existential anxiety reduced, but they're also comforting all of their own relatives to say it's all fine, it's going to be okay, it's not a problem.
01:21:48
Speaker
So it's probably because they found peace. Yeah, yeah, it could well be, could well be. Yeah, and I did see something else about how the one mechanism of actually, I think it was LSD, which has a similar effect. It seems to almost inhibit the parts of the brain that are associated with ego formation.
Virtual and Augmented Reality in Pain Management
01:22:12
Speaker
or not ego formation, but a sense of self I suppose is a more technical term. So if you lose your sense of self then your conscious experience is that you're actually a part of everything as opposed to being an individuated component. So I think that way will be outward looking. Fascinating stuff.
01:22:37
Speaker
So yeah, I think just to round off, we've touched on some of your PhD work and we've explored around that field a little bit. I know more recently you've done a bit of work with virtual reality and you did touch on that, but is there anything specific from that recent work you've done that you'd like to share or would be interesting? Well, we're still finishing the research. At the moment we're looking at
01:23:03
Speaker
Because it's still very much in its infancy, of course. But we're just looking at simple distraction. And we're using spinal cord injury patients with pain at and below level of the lesion. So essentially phantom pain in a limb that shouldn't have any sensation. So what we're doing is we're doing an immersive virtual reality application. And they have the same application as a control on a laptop screen.
01:23:31
Speaker
And although I can't talk too much about the results, what we can say is that the immersive, the pain relief with the immersive headset is quite profound.
01:23:42
Speaker
Right. Wow. Wow. And to the point now where we've got to grant the next day, I'm going to do the same with with cancer pain. Right. Right. And does this relate to the rubber hand type type experiments? It's just it's more immersive than having a rubber hand. So they're completely surrounded by a 360 degree scene that they can wander around with a hand control.
01:24:07
Speaker
So all of the spinal cord injury guys, they're all they're all see six, seven and below because they've got to be able to manipulate the Yeah, right. Right. Of course, of course. Yeah. But but but really, but and then at the same time, they've got an EEG cap and we're measuring brainwaves and what parts of the brain where the brainwaves change in frequency are related to the pain relief, etc. Yeah.
01:24:32
Speaker
I don't know yet because we have another person, a researcher who's the EEG genius and they're doing all of the analysis. Right, right, right. Well, fantastic. So we nearly finished that study. That study should be, we've got about two or three more participants to get through and then we'll be, well we've already started writing up the the Arctic. Fantastic.
01:24:56
Speaker
but it's still very much in its infancy. And the other thing that's coming on from that is augmented reality.
Navigating Clinical Information and Mentorship
01:25:02
Speaker
So you talk about hallucinations. You could actually manufacture these hallucinations in augmented reality glasses, which is the next step. So they can go around their normal day with these glasses on and see a brighter life, if you like. It's a bit scary in a way, isn't it? But kind of cool.
01:25:25
Speaker
Well, augmented reality is used now in surgical training where they put these glasses on and they open up a person and the glasses differentiate different tissues into different colors, for example. Wow, that's awesome. Really amazing.
01:25:41
Speaker
It is fun, yeah. It's so awesome you can square it. Yeah, yeah, yeah. So let's just sort of finish off by going into, as you're aware, the podcast is called From Chaos to Order. And I think we've talked about, I guess the title is a little bit tongue in cheek. I'm not saying that there's complete chaos out there, but there is so much kind of information for us as clinicians and people working with your clients.
01:26:13
Speaker
How have you made sense of that kind of chaos or confusion in your own clinical practice? You mentioned you work with other professionals, I guess that's one way too.
01:26:29
Speaker
I know it's quite demoralizing to say it, but it's been a hell of a long journey from step in foot in that master's degree and working with and studying with a whole host of different sort of medical doctors and psychologists, psychiatrists. And I've become immersed since 2007 and it's been a really long
01:26:51
Speaker
often frustrating, but quite a fruitful and rewarding journey. And it's only now, after all that, that I'm able to talk like I am to you with some confidence. It's hard work to get on top of what we've just been talking about, I think. It's not rocket science, but it's just a lot of information and how you process it.
01:27:19
Speaker
as a practitioner and how you simplify it for yourself and then simplify it further for the patient. For example, writing that book, the most difficult bit was dumbing it down from really technical neuroscientific speak to manual therapy speak. Right, yes, yes, exactly. That was the hard part about that book was condensing it all. Yeah.
01:27:46
Speaker
Yeah. So that's what I, yeah, I mean, I would say you've got, you've got to be, you as a clinician have to be immersed in, in the devil of the detail, if you like. Yes, yes, exactly. Okay. And so I mean, what would you say to someone who, you know, if you were talking to someone who's just about to graduate, and
01:28:06
Speaker
You know, they were asking you for career advice. Would you say, follow the same kind of path I've done? You know, get- Well, for everyone, people, you know, I would never dreamed in a million years I'd be doing research. I was quite happy sitting in my clinic. I would say, you know, the first thing I would say it would be find a mentor. Yeah. Yeah. Great advice. And find a mentor that you relate to. So it may not be research. It may be, it may be biodynamic or whatever, you know, but something that's gone to,
01:28:36
Speaker
you know, improve you as a person and as a practitioner. And as a listener, I would say.
01:28:44
Speaker
Yeah, excellent. Excellent. Well, I think we've covered most of the areas that we wanted to cover.
Tools and Resources for Chronic Pain Assessment
01:28:52
Speaker
Is there anything else you wanted to throw in, any particular gems or snippets of things that you found really useful working with clients with persistent pain or just run of the mill clients?
01:29:07
Speaker
Yeah, funny enough, I still enjoy the run of the mill clients, most of all, you know, the club acute, low back pain, neck pain, they're the ones you get the best success with. And they're the ones that give you the most joy. But from a from a intellectual perspective, definitely the chronic pain patients, the really puzzling patients, the ones you've really got to do your you've really got to go to the to the databases and study
01:29:33
Speaker
the presentation, if you like, and the co-morbidities that go along with the presentations. I find them equally as rewarding, but I think you can't leave any stone unturned and get yourself a set of four or five good, validated, strong questionnaires that you can use with the patients. So no more than four or five, because you don't want to exhaust the patients. They'll just switch off when you give them too many questionnaires. You have to give them something that's really succinct.
01:30:02
Speaker
and something that opens their eyes as well. Right, right. Yeah, yeah, for sure. And have you got any specific resources that you would point to there? You know, is there a specific site or do you got? Well, so I would download I would get ahold of the pain catastrophizing scale. Yeah, the pain self efficacy scale. So that measures your ability or your confidence in your ability to do stuff while you're in pain. That's another cognitive
01:30:28
Speaker
A pain-related question. The DAS21 is what we use here. That's a stress-anxiety depression question. That's only 21 items, of course, and that's useful. What else do we use? The facet I talked about, if you want to get a bit more existential. I think that would cover it, to be honest.
01:30:51
Speaker
as a basic set of, as a basic set of questionnaires. Yeah. Perfect. Perfect. And how about, so you're developing a questionnaire for central sensitization, which is, which is the big challenge at the minute. Is there anything on that front? I know we've had a couple of
01:31:09
Speaker
Posters at the National Association for the Study Pain, we had a poster there and we actually won best poster prize at the Australian New Zealand Pain Society scientific meeting last year. So the interest for the questionnaire is there. We've just got to get past the bureaucracy, if you like. Yeah, yeah. No, fair enough. And when it published, hopefully it will be called the pain modulation index. Okay. Okay. So one to look out for.
01:31:36
Speaker
Yes. Fingers crossed. Yeah, yeah, yeah. Excellent. Good stuff.
01:31:41
Speaker
Well, that's brilliant. Thanks so much for your time today and for doing the work you're doing. It's really fascinating. And I think, you know, really important for us as, you know, as manual therapists, as health care practitioners, even fitness professionals to understand these kinds of things. If people wanted to get hold of your work, I know I've got your book here. So that's chronic pain, a resource for effective manual therapy.
01:32:09
Speaker
great book actually I've not read it obviously cover to cover yet but it's not a cover to cover book it's a book you go to when you have a question you need to answer sure it's a reference book yeah and do you have I know you've got a number of papers available online but do you have other resources or courses that you run anything like that?
01:32:36
Speaker
The trouble is with paying is, is I'm often the purveyor of the inconvenient truth. Yes. Where I don't give them the $64,000 technique that's going to make them a lot of money. Yeah, yeah. And because of that, I've decided that I'm not I don't set myself up as a paying cost person. Yeah, fair enough.
01:32:58
Speaker
only because I've seen lots of other people try and fail. So what I do, I more speak at manual therapy osteopathic conferences and I talk about the same thing I've been talking with you and it's a better way of putting it across.
01:33:16
Speaker
Yeah, excellent. Excellent. And do you accept, do you accept patience as well? If someone's got a patient, they happen to be nearby to you and, or not even if they are nearby, maybe people fly in to see you, but is that something that you're actively? Yeah, people, I mean, people do, yeah. I mean, they might only be in town for a day or so and they come in, yeah. I mean, it doesn't happen very often, but it does happen, you know, a few times every six months, I would say.
Episode Conclusion and Upcoming Events
01:33:41
Speaker
Brilliant. How can they find you?
01:33:43
Speaker
uh address wise yeah well i guess you know to look you up they they just uh look up philosophy on google oh well sent luke's clinic in uh in sydney excellent okay okay perfect all right well what i do is i'll put uh any relevant links uh into the show notes and um then hopefully you can
01:34:03
Speaker
can track you down if they need you or want to learn more. But thanks so much again for today, Phil. No, no, it's been a pleasure. It's been interesting to talk to you. Yeah, likewise. Yeah, hopefully our paths will cross at some point. I'm out in, hopefully, fingers crossed, out in Australia in March next year. So I don't know if you're going to be around, but if you are, hopefully we can grab a coffee or something. Yeah. Aren't you in contact with Jonathan Pern? That's right. Yeah. Yeah.
01:34:30
Speaker
And so, yeah. So he told me, yeah, that's right. Yeah. Perfect. Yeah. Hopefully in March then. Yeah. That'd be awesome. All right. We'll take care to them and, um, all right. Thanks again. Yeah. Wonderful. I'm looking forward. Bye-bye. Thanks again. Bye-bye.
01:34:47
Speaker
Thank you for listening to this episode with osteopath and post doctorate researcher Phil Austin here on FC2O. If you enjoyed that and found it useful, please feel free to share it with your friends, colleagues and loved ones. To learn more about Phil's work, please head over to osteopathy-chronicpain.com. That's osteopathy-chronicpain.com.
01:35:11
Speaker
And for those of you in Australia and New Zealand, I'll be heading out your way next March, 2020, to put on a two-day presentation and workshop, one in Auckland and one in Sydney, called 2020 Vision, putting persistent pain behind us in the next decade. Details are available on mattewaldon.com. Finally, ensure you catch our future episodes by subscribing to Apple podcasts or following us on Spotify or Stitcher. Looking forward to having you join us on the next show.