Transcript

Speaker: Are you telling me it's all in my head? Made to feel that it was all in her head and that if she just watched you know a funny movie she'd be fine. And i I just found that was so... those encounters are are very invalidating. When Tasha speaks about pain everyone should listen.

Speaker: It's as though we have a system that's working too well.

Speaker: This podcast is not personalized medical advice. Consult a health professional before acting on anything discussed. 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 one who is, thank you for being a loyal listener.

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Speaker: Tasha, you have ah an amazing reputation when it comes to pain science. um Merv Travis, a previous travers a previous guest of mine, said when I asked him the question, who should I get on? He said, undoubtedly, Tasha.

Speaker: um And he said, when Tasha speaks about pain, everyone should listen. yeah. so you you come with a very big reputation, but what I want you to unpack is what led you down this journey of pain science.

Speaker: ah First, thank you. That's so kind. um I'll have to give ah Merv a big snuggle next time I see him. um But yeah, it's it's always interesting, isn't it? When we think about how we got to where we are, I think um truthfully, it probably all started when i was working as a physio. And so I worked in, um,

Speaker: a workers' compensation tertiary care centre that was kind of seeing lot of people that had so-called failed, which oh I hate that word right away, but who whose previous care had not gone to how they had hoped it would.

Speaker: And um I think I just felt so out of my depth. I did not know what to do. I didn't even, I didn't feel as though I had a framework with which to um to treat or to help. And um I think that just really, it made the job hard, very humbling for sure. But I think it also, i think just helped me start on a journey of what is important to me.

Speaker: Like, what do i what do I really get excited about? What sort of things um are You know, making me feel upset with the system because I often find the things that we get angry or upset about are often the exact things that really mean a lot to us. um So i I guess I really struggled with how much emphasis was placed on people's you know scan findings and if they didn't have any scan findings. They were in a world of of hurt, literally often. um So I just think that, yeah, those early experiences as a physio really shaped me into realizing the limits of my knowledge and really asking questions and really trying to uncover, you know, what we don't know. And then thankfully, now that I i guess i've I've been able to go into a career science, I've been able to explore those what we don't knows. So, yeah, it's...

Speaker: um I think it also is very helpful when you can um find people that you find exciting, inspiring, and that you think are doing excellent work. And I think that definitely pulled me into an area um of of pain science.

Speaker: Who are some of those people? Yeah, so there's quite a few, i would argue. um i mean, I think probably the most influential um and when I really started um my pain science journey was Laura Mermosley. So I did my postdoc with him and then continued to collaborate with him. But I mean, at the time, i i joke about this, but if you would have told like, baby physio Tasha that, you know, one day you're going to get to work with Lorimer. I just would have been, that can't be right. So it's, that's been amazing. um

Speaker: Certainly Dave Butler um in has shaped a lot of the work, especially as I've gone more into, um you know, kind of the education part of pain science.

Speaker: um And I think some of the the people that I had um in my training. So Jane Latimer, she's a physiotherapist out of Sydney who kind of does a smattering of amazing work across numerous areas. um At the time was was most noted for her back pain work. And she was just a wonderful role model. um And Greg Kochuk, who who worked at University of of Alberta, where I just did my master's. He was just this amazing communicator and just brought energy, like all of these people that just, I think, really shape you and make you excited about what you do.

Speaker: Yeah, for sure. For sure. Do you have any personal experience experiences, whether it be yourself or like family members that shaped your career trajectory or or your understanding about pain?

Speaker: Yeah, well, I think probably the the biggest one would be my mom. So she um was diagnosed with um fibromyalgia after of years and years and years of experiencing a lot of chronic pain and just like really weird symptoms that were hard to explain. It also made, the you know, being a physio as a daughter quite hard because I'm like, I don't know what's going on, mom. I'm sorry. um But, and I think what really probably spurred me definitely into the pain science area was just the fact of how many times she was just really poorly treated um by health practitioners. So, you know,

Speaker: kind of really being made to feel that it was all in her head. And that if she just watched, you know, a funny movie, she'd be fine. And I, I just found that was so, those encounters are are very invalidating. And they just, when someone's really struggling, they're there's really tough things to go through. So I kind of, I think, felt in my head, I i really don't want that to be happening to people. And I would really like any and all of the work that I do to be actively working against that, whether that be, you know, working in with clinicians and in how to um apply pain science education to what they do and how to communicate and how to talk, but also in the science that we do. So we do a lot of um a lot of work with co-design um where we're working really directly and deeply with people who have lived experience of pain as as well as continuing to work with clinicians. But

Speaker: Really doing that to understand the heart of the problems and together work on solutions toward it. Because I think sometimes as scientists, we tend to presume we know the problem.

Speaker: And I think we might know adjacent to the real problem. But I think when we really delve deeply with um people with lived experience as partners, we really you know just get a whole new look at everything.

Speaker: Mm-hmm. I am personally someone with lived experience and I've i've become more and more um outspoken and it's about that. um Yeah.

Speaker: Outspoken is probably not the right word, but i was I was very, it took a while for me to kind of want to like share that. Yeah. It kind of plays at the stigma that it can bring. And especially with someone like myself, it's like a I have this, I guess I was a,

Speaker: an athletic young man who, you know, didn't quite make it where he wanted to make it in the basketball world. But, you know, and then like to develop persistent pain and still have that like athles athletic spirit and that sporting, I guess, the spirit that comes with that. it it was it was complicated in my own mind. um And, yeah,

Speaker: I think that's exactly why I want to share because like I think sometimes we have this like idea of like this is what chronic pain is. This is the kind of person or what it looks like and um and I think that that's they're very we're a very diverse group of people um and then there's also that wrestle of like well how how how public should I be with that anyway? I'm a geotherapist that works in this space. And anyway, it's been a journey, but yeah, I appreciate that you think highly of the importance of lived experience. And and if you have any questions of me, feel free to ask. But yeah,

Speaker: I find it interesting because one of the biggest pushbacks, at least with pain science done poorly at least, um but even i so I would argue done well, but misinterpreted is this idea of like, are you telling me it's all in my head?

Speaker: Yeah. um So what is pain, chronic pain um and how does it how does it work? Isn't that the million dollar question? um Look, i think I think you're exactly right that there can be, I think, um a tendency, depending on how something's framed, for it for it to go wrong, for it to come away with the exact thing that you don't want someone to think. um Look, I guess from um how I guess I would view it is um that it's chronic pain, well, pain in general is just this

Speaker: incredibly complex emergent phenomenon that comes from having, um you know, a body, a brain, all of these different things, our neuroimmune system, neuroendocrine, like,

Speaker: it's It's so many complicating things working together. But ultimately, i guess how I view it is um from a survival evolutionary perspective is is ah a really key way to protect us, a really key way to grab our attention and you know make us change what we do. um And that when we are in situations where it's persisting, um that we're um we in some ways it's, it's as though we have a system that's working too well, um but not in a way that is, is continuing to potentially be adaptive. And I think there's been really interesting um increases in our understanding of, you know, the changes in, for example, the sensitivity um of our um nervous system, of um all the interactions that we're starting to understand occur with the immune system as well, that mean that, That signaling is so much more complex than we thought. But I guess I i tend to view chronic pain not necessarily as a static, um like unchangeable thing, entity.

Speaker: I see it as a dynamic, changeable process, which means that I guess what it opens up then is that there is possibility for change, for improvement in what we might call bioplasticity or the ability of our our body tissues or body systems to adapt and change. um But that was certainly very different than I think how I viewed it when I started. And and I hope it's one that um

Speaker: like understanding that difficult can like things that are that have multiple contributor contributors is a really hard thing for us because like as humans, we like X equals Y. So if I do, X, Y will happen and that's exactly you know what will occur. And in fact, Q, R, S, T, A, B, C, all of these other things are all intermingling. And so I think understanding, first of all, I think that it is a complex thing, weirdly can sometimes be feel helpful um in that if there's multiple contributors, there's also multiple things that we might be able to target.

Speaker: Yeah, for sure. It can bring hope to someone that hasn't been able to find that single contributor. What what I find fascinating when I speak to people that are clearly lot smarter and wiser than me in the pain field is that...

Speaker: yeah there's this humility of like, man, there's so much we don't know. and you as someone that has, I think, probably some very robust answers at the moment, and yet there's probably more questions than you have answers, um is quite it's quite fascinating. And and it it kind of wars against some of the the clickbait nonsense that you can see out there. um So, yeah, I appreciate the humility in that.

Speaker: um ah It's... The relationship you have about with complexity is an interesting one and one that I wanted to touch on because I think Pain is complex is so, so true.

Speaker: Yet at the coalface clinically and also personally, you kind of want simple, actionable things that you can yeah do. And I think we'll delve into that later um because I think some of the solutions, despite the complexity, are fairly simple. And when I say solutions, I use that in, you know, It might not be absolute or, you know, but there are things you can do to modify it and change it.

Speaker: um And I still hope that absolute. But let's let's delve into some complexity a little bit. um So what are your what were your thoughts that you previously had about pain that you now go, hmm, wasn't quite right that you've changed your mind on? Because I think that's yeah it's an awesome thing to do.

Speaker: Yeah, look, I think there certainly has been a shift from in in my own, um i think, approach to it is I think there was a really big push at the start in trying to shift the idea that it's not just the body, that the brain is also involved. But I think giving soul...

Speaker: um focus on that also isn't correct. um I would argue that um with all of the other things that we think might be contributing, i'm I think it's less accurate to even and And I've certainly said this in past talks, but almost like the brain decides because that almost feels like there's a little you know woman or man sitting on your shoulder that's like, yes, no, yes, no. And and that's not how we we think that it works.

Speaker: um It's an interesting, I think it brings up a really interesting discussion for the field of how the The aim to be as accurate as we can, I think, with communication of science around anything, but certainly around pain. But then acknowledging that, yeah, sometimes that that knowledge shifts and you don't quite get it right. And I feel like I'm very comfortable in knowing deep down in my gut that many of the things that I say, at some point, I hope that

Speaker: they become incorrect because then that means that we've actually moved forward. So I think that's actually a really positive thing that's occurring. i do think it is it is challenging when you have um someone potentially that has quite black and white thinking and that they have only ever been um attributed or or or attributed pain to the kind of a pathoanatomical cause. and And it's a biomedical framing um and model that they work off of.

Speaker: It is interesting because i wonder from an educational perspective, whether you might have to go in steps with that, maybe introducing the brain as a contributor is a nice little step to then start to, um,

Speaker: understand and move to that that level of, I think, appreciating just how complex things are. But um yeah, it is it's an it's an interesting um dynamic, that's for sure.

Speaker: I've definitely moved with the language that I use in clinic um because I work in a ah specialty persistent pain clinic with pain specialists and psychologists and and physios and dieticians. it's ah It's actually a really cool environment and very collaborative um but i've moved away from the language of brain altogether because it i think when when they hear brain they don't hear what i'm actually trying to say because they hear also it's all my fault it's all in my head i'm like fabricating it or making up which is all like very invalidating not what we're trying to say because people think of the brain as just you know

Speaker: the the stuff that you're awareness you're you're aware of, but actually there's more depth to it than that, obviously. um so I've moved away from that. And and then I started saying sort of like nervous system, um using that language more. um And more and more I'm kind of moving towards like just dysregulated systems in general throughout the body. um what What is...

Speaker: There's so many ways I could go with this conversation. um What is a like what is it a really helpful model or understanding that for a clinician listening that's working with patients or a patient themselves? what's ah what's What do you think is the most ah accurate model to our current understanding of pain that that can produce meaningful ah insights and direction?

Speaker: Yeah, i look, I certainly resonate with you're what the the clinical move that you've you've just discussed there. um I think, I guess I would, I don't know that I have the perfect answer for that, but i if I think about how I might frame this, I think it would be um discussing discussing this aspect of, I think what we're seeing here is um ah a variety of systems that are trying to protect you.

Speaker: And um what we think often can occur when um pain lasts is that um sometimes they become too sensitive. So they respond really quickly and to stuff that normally happens.

Speaker: before this happened wouldn't have been painful. And and oftentimes this can be things like allodynia, so pain with touch or or thing, you know, that that sort of aspect that can be like a nice way to um to to illustrate it. um So there, you know, it's it's beginning to maybe respond quicker and earlier, but we also know that like we're, what we basically do is, um we're always trying to predict what's going to happen next for ourselves.

Speaker: um So, and that's how we kind of, you know, we learn in our world, we we learn that some things are bad, you don't eat this type of thing, you you do eat this, maybe that's fine. um But that when we think that sometimes when people have pain that lasts, it's um as though the system, and this when I say system, I'm talking broad, I'm talking all the different things, um is really kind of in that predicting that things are not okay.

Speaker: And a great way when we're we're not sure that things are okay um is to produce pain because it makes us change our behavior. So what we're trying to do, I guess, is to understand what sort of things might be increasing, um things being more sensitive, but also explore the different things that might be um creating that prediction.

Speaker: So that that idea that actually things are not okay, the best answer is to produce pain. um And I think that um depending on, i think that always has to be really like titrated to that person in front of you. I think probably it's many more um times less about maybe the exact explanation and more about linking and understanding who they are and the symptoms that they have. And then being able to use, I think, some of their experiences and bring that into the explanation. Like if, for example, like pain is becoming, you know, more widespread or it's, you know, affecting other body parts, that's usually a ah pretty, um,

Speaker: good example of things starting to become a bit more sensitive or like the example, if I said allodynia, I guess some it it does it is challenging because I think it's trying to convey the fact that it isn't one thing. It's not an entity. It's not that if let's say there's back pain.

Speaker: Yes, of course the back is important. Of course, but that's not the only area we're looking because there's all of these other things that are going to um contribute in addition to what's going on, what might be happening in the back. But if we only think about the back, we change none of these other things. um And I guess some of the work that we've done in knee osteoarthritis have really explored this idea of um like body-wide um kind of heightened inflammation, so systemic inflammation, and the role that that plays actually both in the as a disease process, so it can can have affect changes in the joint itself, but also as what that does to the the milieu of the rest of the body, how it increases sensitivity to things. Meaning that often what you're feeling isn't necessarily an accurate picture of exactly what's going on in, let's say, a sore knee. um But that's also then why it can be okay um to to push things a little bit because we're almost helping to, um I know this is a very controversial terminology, but kind of relearn things.

Speaker: that things are okay with some, with certain activities, let's say. So yeah, that kind of went down 10 pathways. Yeah, no, that's, that's great. That's great. I want to double click on a few of those. So some things you mentioned, um, one of the, uh, I have a knee surgeon here on the Gold Coast that kind of, he does refer to us a bit and, um,

Speaker: he he He uses the words to me, he said, the carpentry looks good. You know, he might have gone in and done a knee replacement and the person's still in pain well beyond the normal timeframes that they would expect. and um and and And he uses that terminology as like the carpentry looks good, um so there must be something else going on and that's when, you know, I get him i can get involved.

Speaker: Yeah. What is, what else and that illustrates your point that, you know, it's not just the back or it's not just the knee that we need to think about. um What's going on there? What are the other factors that could be contributing to it? um I know that's a very broad answer again, but it depends.

Speaker: Try not to say it depends, Tash.

Speaker: I guess of the things that we're kind we're interested in um that my group is doing at the moment is exploring um in people who have pain after they've had a knee replacement surgery, um whether there might be something going on with kind of sensory motor processing i'm regarding that body part. So um some of the work that we've done has shown that um people who, after they've had a knee replacement surgery, if their knee doesn't kind of feel right to them, it like, you really have to pay attention to get it to move the way you'd like.

Speaker: might feel like it's really swollen, but it isn't, like kind of body perceptual impairment kind of territory. um People that then have higher levels of kind of this body impaired body perception, they um were the ones that were more likely to go on to develop um chronic ah persistent post-surgical pain.

Speaker: um And then some of the work that we've done with colleagues in Japan have then showed if you um target this, so you're doing things like um touch discrimination, as well as like more traditional proprioceptive retraining, but also aspects of things like graded motor imagery, that that can be helpful um to the pain that they feel. And I guess one of our hypotheses is in the other work that we've done, we've it suggested that when um there's kind of impaired body perception around the knee,

Speaker: people that with knee osteoarthritis are less likely or to respond to traditional aerobic and strengthening exercise. And so our hypothesis for this, and actually we just got some funding to test this in a big trial, is um that it's almost like for some people, they don't after they have the surgery, they don't take on the new knee as their own.

Speaker: So they might have had impaired body perception before, but for people that don't develop this pain, that seems to reverse so soon um shortly after they have their surgery. And so we're hypothesizing that um then they might, if they haven't taken on the knee as their as their own, and we know that impaired body perception influences your response to exercise, they might not be responding to traditional rehabilitation. And we might need to kind of get them to take that neon as their own first before we do that. So um yeah, we're testing that in a bigger trial. So that's one area that is is is quite specific. um I do suspect um in

Speaker: Others, um there are likely numerous contributing factors. I mean, we did um a scoping review, a qualitative medicine business in this area, and there was often a lack of um information and understanding in people. And they were quite worried about almost doing too much and potentially wrecking their prosthesis. There was, you know, people that reported that they actually didn't really do much at all because they were waiting for their follow-up appointment. And then,

Speaker: kind of got in a situation where they've hardly moved it. They haven't pushed, they haven't, you know, required anything to sort of adapt. So I do think that um it really um involves looking closely at the person in front of you and exploring what might be contributing. But yeah, impaired body perception or potentially sensory motor processing is one thing that we're really interested in looking in.

Speaker: Yeah, that's really cool. that's That's interesting. Do you have like, do you get any pushback from um some knee surgeons around some of your work? Like, or is there, are they on board? i don't think that they have the answers and I think that they kind of do admit that. um Yeah, yeah. I think these are...

Speaker: Particularly in this area of I guess, trying to either like prevent post-surgical pain or reduce its impact. I think they're really on board because that those are really challenging cases for them that they're, I mean, I've had really candid conversations with with numerous surgeons and they're like,

Speaker: oh man, like your your heart just sinks because you don't really know what to do. And they said, often this gets this pathway where we're trying to do more, you might do a revision surgery, but like the the response rates are um are not great.

Speaker: I think there is probably, I would say a little bit of pushback in thinking about knee osteoarthritis as a process rather than an entity, because I mean, oftentimes they're removing the entity, they're giving, they're resurfacing the knee. And so I think um there is sometimes a tendency um to not necessarily appreciate some of some of that other work that we're potentially suggesting. But I think it often is, um,

Speaker: it's It's not, I think, outright, like not wanting to be involved or or being upset or anything, because i if we're getting people moving more fit, more healthy before they undergo surgery, that's better outcomes for everyone, including that surgeon. So I think it's probably just in the way that we we frame it.

Speaker: Yeah, no, it's interesting. um And it just emphasizes your point that it's more than the body part. I think, you know, obviously in some cases, knee surgery is a fantastic yeah ah surgery and has great outcomes. And then there's some that not so much. um Are we any wiser at being able to predict that?

Speaker: No, um we're very, I mean, I think the the best predictive factors are, it's still a little bit over chance. um I think what's challenging about that is that there are not only potentially factors that can be occurring who from that person as an individual in the environment, embedded within a society, but you also then like you are undergoing a surgery. So there are then unique factors that can be an occurring there. All of those things interact. It is really tough.

Speaker: um And we do. um So I think it's part of the reason why it's really important that we catch it early when things seem to not be going quite right and trying to intervene there before um kind of pain, post-surgical pain gets established. Cause I do think that, that that is, is quite a challenging thing if it's been there for, for quite some time.

Speaker: Yeah. Interesting. I, um, just in some of the more practical things that we do in clinic, I just want to bring out one story. I had this guy with, you know thoracic pain, um long long standing and his two point discrimination on the left compared to the right is like outrageously different.

Speaker: Like, yeah um and I don't quote me on the numbers, but because I don't remember, but on one side it was like, you know, 14 centimeters. And on the other side it was four centimeters. And I don't think, i don't think um like physios that work in just general private practice, they probably don't see many of these kinds of cases. Um,

Speaker: but like they they really do happen. And what what is the, dive into a little bit more of the treatment options for someone that scenario. that scenario m Yeah, sure. So, I mean, first of all, I think if you're assessing that and seeing that it is a really nice way to bring in the fact that there's more things involved than we might think. It's just immediately relevant to that situation. um In terms of...

Speaker: yeah Sorry, before you go on, he it was the aha moment because he'd he'd been through the pain science stuff like previously. um And the penny dropped when you when he goes, oh, my goodness, like, what's going on there? And then was like, okay, let's let's talk about it. So, yeah, and I just emphasize your point. Sorry to cut you off. No, no, not at all. um But I think that you're you're exactly right, is that often it's, again, we like tangible things. We don't like abstract things generally. To be convinced, we often need evidence of this in me.

Speaker: um But um yeah, so one of the um strategies that is used is tactile discrimination training, where basically you're nothing Nothing too groundbreaking, but drawing you know a grid of numbers on the affected area. And basically, we often just take a picture with their mobile phone They look at the picture of that grid that's drawn on, let's say, they're the thoracic spine in this case. And then what we're doing is we just touch, we teach them where the different numbers are located, and then we um touch and get them to tell us what number we've we've touched.

Speaker: um You can make it harder by you know making the numbers closer together, by getting them to discriminate the type of stimuli that you're touching with, maybe sharp or blunt. um You can do things like graphesthesia, where you're basically drawing patterns on the skin. It might be numbers, letters, or shapes, and that's really requiring them basically to attend and use spatial sensory discrimination to be able to map what's what's happening. um And I think like i what I kind of love about that is it typically responds quite quickly. So within a few weeks of of doing this type of training, and I think it also then can be a really um powerful reminder.

Speaker: that things can change and they can improve. Because I think oftentimes it might be people that um have not experienced necessarily that change or improvement in other things. um And I think giving a tangible and appropriate glimmer of hope is so important.

Speaker: have we Have we seen an improvement of that is correlated with actually a ah pain outcome? Or is it just an improvement of the sensory... Yeah, it's a good question. In some populations, yes.

Speaker: um So I believe in CRPS, Complex Regional Pain Syndrome, there was an association between the improvement in tactile discrimination and pain. I'm not sure if we've seen the same thing in back pain. I'm thinking about the resolve trial that James McCauley and um Matt Begg led out of Sydney. um i think, I mean, from a theoretical perspective, I guess what we're we're sort of,

Speaker: Also considering is that non-noxious information from things like touch that also provides us with important safety cues and it gives us the capacity to trust almost what's coming from that body part. Because if we're getting really ambiguous, not very accurate information, we tend to learn that. And then it also then potentially means that, you know, learning that movement is safe is really hard because actually the information that you're getting, you're not quite sure how you're moving. You're not quite sure where you're being touched. You're like all of these different things, I think, influence our capacity um to um to, you know, change and um and learn.

Speaker: The first time I kind of learnt about this stuff, I was actually doing some work with Daniel Harvey, who you yeah I'm assuming you'd know, up here when he was on the Gold Coast at Griffith University. It was a very, very brief period because he actually then shifted midway through, um but I was a research assistant for him. um And I wondered whether we've actually developed these devices yet to to like he had one that he'd kind of like makeshift made. um But ah or are we still just drawing numbers on on the person's back and, you know, like because he his device, you probably know.

Speaker: Yeah, it it it was like joint to an app and, you know, you could strap it on and then you could, you know, play the games basically. we, has anyone done that? Has, has Daniel gone and produced that? Cause he should.

Speaker: yeah that oncesing me Yeah. I mean, I did get to use his, um yeah his device. I think it was a couple of years ago now and it is very cool. um Look, not that I'm aware of. And I think some of the um ah probably limitations with it are technological things.

Speaker: in general. So as you know, like tactors and sensors get smaller and easier to connect to things like Bluetooth, we don't have to have, you know, like 1000 wires everywhere. um But I think it's a really um relevant thing to look into. I guess oftentimes, what we found is, it ended up being easier for us to do it just because anatomy of people differs so much. And so anytime that you have something that you're placing on an area, Oh, this one's not, you know, touching the skin very well. And all of those things that I think with, with a product development, you'd be fine. But I i think sometimes it sounds easier.

Speaker: that yeah totally. Totally. I think there's, there's a market there though. if someone produced it and especially if the research, you know, grew in the evidence base. Like I think, you know, you mentioned there's a few trials in CRPS, but whether that actually changes outcomes in or just the awareness in other bodies. We're assuming, and I'm very hopeful that it,

Speaker: you know, actually changes something that's important to a patient. Yeah. yeah Because I think that, yeah, at the moment, I don't think we have great evidence to suggest that is, you know, the key thing. um But it, I think it probably at minimum, it's, it holds that value in being able to, um explore and start those conversations about. Yeah, definitely.

Speaker: Definitely. I don't think that there probably won't be the thing, hey, because as's it's multifactorial, which is, I mean, maybe it is the thing that ah to your, and I shouldn't say this without context, but the bilby, you know, the bilby hasn't jumped into the bath yet to overflow it. um You know, you could pull that thing out and maybe that's an enough, but yeah.

Speaker: I think in the the resolve trial where they use that in back pain, Um, it's hard because I think they had different people measuring two point discrimination, which always means your reliability is a little bit, um, not as great, but I think, um, it was change in back beliefs were still the, and knowledge were the largest mediator of the effect of the education and graded sensory motor training and back pain. So, uh, I think, I don't know if I'm thinking of two point discrimination came out. I don't think it did. um but yeah, it's, I think it's, they're really interesting questions to look at.

Speaker: Yeah, for sure. For sure. I, I once did a pain science talk at, ah um at Crumman Clinic, which is a mental health hospital I was working at. And it was with psychiatrists that I was explaining pain. And one of them had a really good question. And I'd love to ask you the question. It was,

Speaker: because i you know you talk about how pain is protective and how fear can sort of drive that and you know how that fits into psychology, et cetera. And he asked a question, which was really good, and he said, so why doesn't everybody with PTSD have pain?

Speaker: um Because he obviously sees patients with like post post-traumatic stress disorder that don't develop like this embodied physical pain in a limb, um and I thought it was a great question do you have any thoughts on that um I will absolutely start this with the caveat that I'm not an expert in PTSD um but I guess I mean it from a wider perspective we would think about a lot of different things that occur as of everyone having a variety of protective responses like you can have a muscular response, you can have, you might have an experience of pain, you might have an experience of, you know, feeling dizzy, of panic.

Speaker: Emotions can be, you know, elicited in in protective ways. um Yeah, so I i i wonder whether, i guess we wouldn't,

Speaker: why why don't then all people with pain have PTSD? you know like yeah You would suspect there would probably be other contributors. And I i would suspect that in many people, therere probably there I would largely suspect that there would be a nociceptive signal coming.

Speaker: I would still suspect that there would be that occurring. And maybe we're not we're not seeing that driver and that increased sensitivity of the systems that do, we know, play an active role in contributing to the experience of pain in some people that have PTSD. um It is, I think, interesting to look. um I do remember looking at some of the literature that the co-occurrence of chronic pain and PTSD is quite high. um So that certainly would speak to the point that having a higher protective capacity in one area might make it a little bit more likely that you also experience it in another. um

Speaker: But yeah, that actually would have been a very interesting environment to give give that talk andrea I wish you were there um to answer that question because you did a better job than I did I can tell you how much but I just yeah I just acknowledge he he already fully acknowledges the fact we had a good you know working relationship and he was already acknowledging the fact that you know that correlation between PTSD and pain does exist and there's a higher higher proportion of people with PTSD do have chronic pain but he just kind of was like well why doesn't it always like And I guess that's just the complexity of the world that we live in to some degree. um

Speaker: i there's I think there's this idea that like if you have if you don't have a patho-anatomical cause that you can see through like some of these imaging modalities, that there's nothing going on in the body. And I i think that's that's not true. like there is like If we could zoom up, if we had the the vision to be able to see some of these systems,

Speaker: you know ah like the nervous system, for instance, if we could zoom up in there, where we could see some neurochemical changes within the... the nerve synapses that they're communicating etc um so i think regardless of whether you can see it on a scan there's something going on in your body what is going on in the body in regards maybe we just talk about like inflammation and chronic pain because you mentioned it when you're talking about knee arthritis yeah well i think As soon as we have a situation where um you have higher inflammation, it means that everything's more sensitive. So um all the way from nociceptors in the periphery, they will be more likely to activate with a, if we're thinking about the knee, maybe if we think of a mechanical stimulus, a lesser mechanical mechanical stimulus will be sufficient to activate nociceptors. So they activate

Speaker: quicker and also you get a greater population um activating. So they bring in friends. um You get the same at the dorsal horn of the spinal cord. You can get ah you know silent nociceptors in the periphery that are activating. So they normally wouldn't activate, now they do. You also can get um you know increased sensitivity at the dorsal horn where you can now start to get non-mechanical stimulus or sorry, non-noxious stimulus, such as mechanical input, able to activate um that pathway. um So I think right away, it's almost like it just puts turns up the gain of the system so that there I would anticipate if we could stick a needle in someone, there would be a larger nociceptive um input going up, which then I think you also use that to learn, to make associations with different things. So it then drives a

Speaker: numerous other processes that would be occurring when you're engaging in everyday life. um But then i guess we would then um a hypothesize that using, well, and the data suggests this as well, that when we can use things like lifestyle behaviors that are daily things that we're doing all the time, things like physical activity, that can help reduce that. body-wide type inflammation in particular, um eating well, gut health, all these these different things um can make a really big um impact on that. And I think that's also why it because i I've always struggled with this aspect of it's very counterintuitive to tell someone who's been told that their joints are worn out, that they should use them more.

Speaker: And that's going to be the key thing to make them better. And yet, because it's it's a process and it's you know higher levels information, all these other things going on, that's actually the exact things because it's targeting all these you know wider systemic things that are um certainly contributing.

Speaker: And this is what this is what I meant when I spoke about it earlier. Like, yes, there's complexity here, no doubt, in terms of understanding. But the solutions are actually sometimes when you like boil them down practically, it's like get a good night's sleep. go for like and And this sounds invalidating and it shouldn't and I don't want it to feel that way because like I'm obviously doing all these, well, trying to do all these things. But get a night's good night's sleep.

Speaker: You know, be active, have good social environments where you feel connected, belonging, et cetera. Look after your mental wellbeing. Like all of these are quite broad and practical and we know just intuitively that we should do those things since we were nine years old. Yeah.

Speaker: And I think that's where it's, it is, it's tricky because it's like then as clinically it becomes like a habit change problem, really. um Like it's easy to know something, but then to actually change the habit is, is one of the tricky, tricky bits. Is there a way, sorry, you were about to say something, you've got some thoughts. um Yeah, I guess I was just going to say that I think, I mean, we can see the those things generally. But I think when we have a person in front of us, we are really looking to their unique situation. And also, you know, applying principles like the sweet zone where we're trying to figure out kind of the point at which they probably have their greatest bioplastic potential. So when it's they're not pushing too hard, they're not pushing too little, but they're kind of right at that cusp yeah of pushing body tissues and systems.

Speaker: But but then that is that requiring them to adapt and update. And that is, I think, a really useful thing to work together with because it especially when things are maybe there's, you know, increased sensitivity, um that can be really hard to find and it can switch day to day. And like, so I think it it becomes then a really targeted exploration within that person.

Speaker: and What are the things for you? um We had a really interesting case. um uh, scenario with a a patient who, um, had neostriacinitis and was getting, um a lot of, um, pain and particularly swelling when he was trying to get past a certain amount of walking. So I think it was about 30 minutes and, and he was also trying to get so that he could walk on the sand again. And every time he did it, um,

Speaker: that it would just, you know, swell. And it was really interesting because we did kind of explored all these different aspects and kind of tried to to figure out what are the the unique things that are contributing to you. And one of the biggest things that ended up shifting, which I suspect was paired with body tissues and other systems adapting at the exact right time, but it was in the way that he talked about his knee.

Speaker: So it used to be like the bad knee or this is the the bum one or, you know, all these kind of words like that and literally switched the way that he was thinking about the capacity and what he would say about it.

Speaker: And all of these things kind of fall together. And yeah, he did really well. Like it kind of was the the, it was the good Bilby in the bath. Yeah. Yeah, yeah, totally, totally. I love that you say that because, you know, like on a population level, we know like directionally these things like, you know, so improving mental health will help. But does that mean it will help for everyone? Maybe not.

Speaker: and And, you know, we could list off those some of those lifestyle factors and they're not necessarily going to change. Every individual. I've built this tool called Pain Coach. um it's ah It's a clinical tool that basically looks at correlations between the lifestyle factors that we've discussed and that individual's pain. And obviously, it's you know it's not a perfect tool and I can point out some of the flaws in it. um But it gives like...

Speaker: a habit that we can target from some of this complexity is go, okay, well, it seems like this relationship exists for you. And it's also for me, like a way for us to like, just lead with curiosity, rather than telling them, like, yeah after one session, we've met them for an hour, and then we know everything about them. It's like, it's a bit, um,

Speaker: Yeah, I just don't think that's the reality. And so it's like just more a curious, like let's just see what factors seem to be related to your symptoms and then target them. yeah But yeah, it's so true because as a clinician, it's like yeah there's all these things, but like what what's the important thing for this person in front of me?

Speaker: Yeah, yeah. and I think you'd be really interested in, um so my postdoc, um Dr. Erin McIntyre, she's leading some work in um the balance of activities over a 24-hour period because we often tell people to move more, but we only have 24 hours in the day. So at expense of what?

Speaker: um Is it at the expense of sleep? Is it at the expense of, you know, rest? if Like what what is being switched out when we get people to move more and what is the optimal balance for that person? um So she's doing some yeah really cool work in that area because I think that what we don't often think about as much is we often think about getting to people to move more, but but what is the optimal balance between rest and and that movement? And I think that that actually is a really fruitful area to look into.

Speaker: Totally. Because it's that that the person is an interesting, um just recently, I had a guy who has um developed pain post-surgically in his ankle and You know, I was actually thinking, man, I think actually you're probably just over pushing it a little bit. Like, because, you know, sometimes the flip side of someone buying into this concept is that they go like, oh, there's nothing wrong with my ankle. I'll just like push it very hard.

Speaker: um And I was trying to like pair it back with just like some objective data, which we we just were using step count, right? Yeah. um But the reality is, is like when I decided, when I said, well, maybe we just pair that back. He's like, well, I've got two kids and like yeah all of these like things that really were important to him were going to be affected by that.

Speaker: What is a question that I should have asked that I haven't asked? um there There might be some things, things that you kind of, what are some questions that you're asking? Yeah. Um,

Speaker: take That is a good and hard question. um I guess one of the things that I've been really interested in is um how sometimes we can take these increases in knowledge that we have um from a theoretical perspective and take them clinically. um And because I think that sometimes and I don't want to speak on behalf of clinicians because it's been such a long time since I've worked there, but I can certainly recall that there would be new information that came out, but I was like, I don't know how to apply this. I don't know how to necessarily use this in a way, and I can make a guess.

Speaker: um But some of the, I guess we've been interested in thinking about how we can apply some of the learnings from perceptual theories like active inference and predictive processing, where um as ah as a brief thing, the the premise of this is that we um hold a generative model about our body, about the things that we can do, and that it informs our predictions and that generative model is built by our expectations, our life experiences, all these things that we've learned over over time, as well as our cognitions, what we think about things. um and But the idea with this is that sensory information is so noisy and ambiguous that in the past we thought it was just, you know, any all ah all of that information was was coming up and kind of being indiscriminately prone processed. And the argument has been made that just it's almost impossible. Like we would be immobilized if we were actually processing all that data and we wouldn't be able to respond quickly. So we think that instead what's happening is when things aren't what we expect, then we sample that prediction error.

Speaker: and it updates our generative model as needed. um And I guess we've been exploring this context in, um or this this theory in the context of um exercise and um using technology like virtual reality.

Speaker: um Because I mean, obviously, as physio, with my physio hat on, I'm like, oh, yeah, no, I just want to get people like moving more and actually getting the exercise stimulus enough to really foster adaptation and change and um improvement in many areas. And so we've been yeah using this to basically um create what we term a prediction error. We have no physical measure of the ability to to say that a prediction error is going up, but that's our theory. um By um basically getting people on at the virtual reality, they're on a bike, they're wearing a headset and in the headset they can see the virtual environment go by. And um what we do is we speed that up a little bit so that the environment is moving by quicker than your true physical effort.

Speaker: um And if we get that right, so we don't do it too much, too little, the sweet zone of our of our visual game, um if we will. ah then what we see is that it actually makes people feel really good and feel like they're they're giving less effort, even though many times they're actually, actually we have evidence showing that they're they're working harder. So we're getting this situation where they're feeling better despite working harder. um And we think that this shift in in kind of how you feel is because we've created this prediction error, because you know how fast you should be going. You're going faster. And even if you pedal faster, you can't catch it like you can't you can't fix it, so to speak. So it kind of generates this good feeling. um And we've tested this now in a feasibility um randomized control trial showing really, really um positive effects of using this versus more traditional um cycling. And so, yeah, things like that, I i think that always intrigues me because it it considers um ways in which we might actually be able to apply that theory.

Speaker: Yeah. Oh, that's epic. I really like, is that, um is that like a reality health or Ben Sheets kind of work or is there? No, this is, um we, I can't remember what we called it, maybe VR cycle. We have one paper, two paper, I think now that have been published. One that is just about to come out, I think in physical therapy and then one that's published in a psychology of exercise and sport, I think. um But yeah, it's, it's this idea that like,

Speaker: we i I think sometimes virtual reality gets put into this like bucket of like, oh, it's a bit of a fad and it this, you know, whatever, this is what we use it for. i guess we're really trying to use theory driven approaches to it. So really have a ah backing in why we're doing this exact thing that we're doing. But yeah, um Ben Sheets, the reality health is very cool. Have have you had a chance to try that?

Speaker: I haven't actually, no. You have to catch them one of the days. They've got a great one where you're standing on, like you're reaching out and touching different things and all of a sudden everything drops away and you're on the edge of a cliff. And like, you know, of course it's not there, but your whole demeanor changes and you can like video people while they're doing this and just show them how, you know, as soon as your environment changes, your protection changes like your, yeah. yeah It's very cool. it's good difficult do um So that ah RCT is already out.

Speaker: The one with this just the. It's just about to be published in physical therapy. Okay, cool. Oh, awesome. I'd love to love to say that when it comes through. Um, If someone's in pain listening to this, um, what would you say to them?

Speaker: Um, that's a good question. think I would say, first of all, I'm sorry, that really sucks. Um, and you're certainly not alone in that experience of it. We are trying to do our jobs to make it less common, but, um, you, you aren't alone.

Speaker: Um, But I think I would say that the fact that you're listening, that you're thinking about stuff like this, that's already on the right track.

Speaker: That's on exploring different options, different possibilities in understanding what's going on for you to the the best of our capacity and you're you're already on that track.

Speaker: um I would say finding people, um whether that's family or friends or clinicians that have your back and that they're going to be um your people um through this journey, I think is probably one of the most important things that you can do.

Speaker: um But then I would argue that The available evidence that we have um when I speak generally about about persistent pain is that I think we have um much, much more evidence ah of hope rather than inevitability, that nothing can change, nothing will go on. I think there's we're always changing in some way and everything that you choose to to do and engage in and to to push yourself that's already shaping the way that you're changing right down you know from your the synapses all the little uh communication areas in your nerves um to the way that that signals are going up to your to your ah your spinal cord to your brain to the way that your body responds your way your immune system responds to things all of those things are adaptable and and and can change and so um

Speaker: it's It sometimes doesn't happen as quickly as we'd like, which can be really, really frustrating, um but um it changes possible. That's such a cool answer, Tash. Thanks for that. um We'll provide a lot of hope for people and a very thoughtful response. So where can people find more about what the work that you're doing in this field, where can they kind of find you if they want to ask you any questions? Yeah, sure. um So probably the best place to find different resources is just to to do a Google of Tasha Stanton and it will bring up a... um

Speaker: at the kind of the university page. So I work at Adelaide University and it will kind of list different things. We're in the process um of trying to get together um a separate website that has some of the different resources that we're starting to create and link specifically to different projects.

Speaker: um i Because I think um one of the the things that we're really quite passionate about is that the things that we're creating is is we're not, you know, we're trying to make things as open-minded And available for people. um For clinicians, um I would say we've got some cool things that are that are kind of coming up. um One of again, ah another postdoc of mine, Dr. Monique Wilson, who's just nearly um come ah formally completed her PhD, but she has done some work in something called pain plans. which is basically it's and a system that allows you as a clinician to navigate different pain science education resources. And its aim is to help you be able to provide this um quickly to your patients. So it creates, um you can, we've, you know, done a lot of work to find ah a bunch of different resources and you can then select the topic that you're looking for. So for example, maybe,

Speaker: um Pain, persistent pain is overprotective or something like that. And then what it does is you can select the format that you want, whether you want a podcast, a short video, long video. infographic. um And then what you can do is it will um then allow you to generate an action plan where you can place QR codes for each of those different things onto a a personalized calendar for your patient, which they can then take home and it can guide their, what they do in between appointments. So yeah, lots of cool stuff that definitely reach out. We love getting emails. We can pass it on to the appropriate person that that would be the best person for you to talk to if you're interested in being involved in stuff like that.

Speaker: Yeah, awesome. Thank you so much, Tasha. I appreciate you coming on. And um yeah I think it's been a very insightful discussion that will be very helpful for many people. So thank you so much. Oh, absolute pleasure.

Speaker: Thank you.