Narration

Did you know that how you think about pain can change the way it feels and the amount of pain you experience doesn't accurately measure tissue health or necessarily equate to damage? Pain however, is a mechanism produced by our bodies for protection. This episode of Talking Physio brings together pain scientist Professor Lorimer Mosley, and Chair of the APA Pain Group, Dianne Wilson, for a robust conversation on all things pain. The duo discuss pain research over the past 50 years and the predictions for physiotherapy and pain science in the 20 years to come. But before we dive in, I'd like to give a shout out to our show sponsor Flexeze, who are not only proud sponsors of this episode but also remain the exclusive partners of the Australian Physiotherapy Research Foundation, which work to support the profession by promoting, encouraging and supporting research. So thank you and let's get into it.

Dianne

So Hi Los.

Lorimer

G'day Di.

Dianne

Great to be able to have a chat. So I'd like to have a chat to you about looking back over the last 20 years. Do you think acceptance of pain research has changed dramatically over that time?

Lorimer

It's a great question, but what I'm really interested in Di, is why you've changed the question? Why did you change it from 'pain research has changed' to 'the acceptance of pain research has changed'?

Dianne

Because I actually think pain research has been there for a long time, but it's been a long time before we've actually accepted it and seen it.

Lorimer

Yeah, sure. Do you mean particular discoveries or our, I guess, pain research has being there since Socrates, hasn't it? But it feels like our understanding of pain has changed a lot in actually, realistically 50 years, don't you think? Maybe not. I mean 20 years it has changed as well, but Gate Control was '65?

Dianne

Yes.

Lorimer

And Clifford Woolf's very famous central sensitisation paper was 1983, same year that Australia won the America's Cup.

Dianne

Yes.

Lorimer

A long time ago. So I agree, yeah the research has been around for a long time, but the acceptance has changed. So if I try and respond to your question now that I've jibber jabbered, and was it about why has it changed?

Dianne

I think I'm probably coming from the point of view as a physio. We've actually seen those changes in the last 20 years whereas the research has been there, but we've become more accepting gradually of them and integrating them more into our practice over the last 20 years. Is that what, probably where I'm coming from?

Lorimer

Yeah, but if there was a why in there Di, a big chunk of that I'm looking straight at, at it, right? Because you think, actually you think that these things don't change without champions and with people pushing it and it's no fluke that you were just made an honoured member of the APA.

Dianne

This isn't about me!

Lorimer

I know it's not necessarily about you, but I reckon that's a big chunk. The 2003 World Congress on Physical Therapy found the couple of abstracts that were suggesting that physiotherapy would, sooner or later, move towards a model that embraced far beyond the joints and the muscles and into the spinal cord and outrageously, even beyond. And I think there's 2 or 3 abstracts, and they weren't very well received, and that was 16 years ago. And now physio is leading the clinical translation of contemporary pain science into care. I think it's really exciting and clearly you do, because otherwise you wouldn't have campaigned and moved towards this specialisation in pain.

Dianne

Exactly, and I think that, you know, we've been a long time and we're not the only profession. I mean, there's degrees professions in all of the health sectors that have not seen the research that's been there. So acceptance and integration, I suppose, is what I'm really looking at and how that's changed over 20 years. So perhaps we could get back to the original question, and has the research itself actually changed over 20 years?

Lorimer

I think they've had discoveries. Yeah, in the last 20 years, for sure. I mean, from a neuro physiological perspective I think that the spinal cord related discoveries that Clifford Wolff drove in the 1980s showing this up regulation of the second order nociceptor or the spinal nociceptor, which really has had a massive influence; so much so, that you know, I hear people saying it's central sensitisation pain. I don't really know what that means, but that's the language that was triggered by those studies and now I think our understanding of the nociceptor system has left that behind. So much so, that Clifford Wolff again wrote a paper, I think, 4 or 5 years ago, really well described by Tory Madden in a blog post that she wrote on, "What do we call this sensitivity to everything?” Remember that?

Dianne

Yes. Yes. Yes.

Lorimer

And really, I found that paper simultaneously true, you know, because it was true to this, how the science has changed. And now we'd think, well, this is not all about this spinal nociceptor, but I also found it a little bit frustrating because I think what we what we do? I mean, what do you do clinically, when you conclude that someone's pain system is being overprotective? What do you do?

Dianne

It's a good point. We actually have lots of indicators that it may be overprotective. We have a few objective signs that we can pick up and demonstrate that,"Hey your system has become really, really sensitive," and it's often then when you can actually show them. Look, you know, they are feeling light touch is pain on one leg, but not on the other and hey yeah, there's something going on here, and it's not in the tissues, Where else can it be happening? And so then you can start the conversation about the system becoming a bit up regulated, and your alarm system is over protecting you. And how do we look at decreasing that over protectiveness? And we, as physios, have got some great strategies that we can use. Psychologically informed physios have got even more to be able to help to down regulate that. But I think you have to be able to, well it helps if you can demonstrate that they are one of these people with an over regulated system, or an up regulated system, so that then you can incorporate that into their management and they can see some change. Talking about it is great. I know a lot of people will pick up on the conversation and pick up on that knowledge. And it's not hard for people to understand that they've got a spinal cord and a brain involved in this production of pain, output of the brain. But how that relates to their particular presentation? There can be a separation between those bits of knowledge and how does it apply to me? So it's great if you can find something clinically that's you can say,"Hey this is your system being overprotective and look what it's doing to your responses." So then I find that that's the way to be able to make it meaningful for them.

Lorimer

So if I was to play, the perhaps the naive interviewer in this scenario, what I hear you saying is the musculoskeletal physio should have an understanding of pain science. But the impression that I get from the rest of what you said is that it's a very complex thing and it's a human thing. It penetrates all aspects of physio. I imagine that there will be some people confused; that what, isn't this just the progression of musculoskeletal? And why do we need a pain specialisation? What would you say to that?

Dianne

[Laughs] Yes, well, I think this is science that needs to be integrated across the board. It's not just musculoskeletal. You're talking to the pelvic pain people tomorrow. You had paediatric pain here. Pain. Most of our work is done because people present in pain. The majority of presentations especially in primary contact are because people want some relief from their pain, that their pain is affecting certain aspects of their life. And so whether that's in pelvic pain, whether it's in musculoskeletal pain. We're now moving into cancer pain. It's post surgical pain. All of those areas are areas where physiotherapists can be working, and so to have a knowledge of how pain is produced as an output of the brain no matter what the trigger is, if there's nociception to start with, whether there's no nociception, whether they're learning that response, it crosses all areas of physiotherapy. And so it's probably the one thing that helps to break down silos in physiotherapy. We need to use this as an overarching umbrella that, yeah, it's the brain is involved. The brain is all powerful in all areas of physiotherapy.

Lorimer

You know one thing that if, go back to the idea of what's changed in the last 20 years, and another thing that's changed from my perspective as a pain scientist, is that interaction between the immune system and the nervous system. I think that clinically liberating finding of the up regulation of parts of the pain system in the presence of immune threats and even molecular patterns associated with particular cognitions, or behaviours or all sorts of cues - opioids - I mean Mark Hutchinson's work is amazing on that. But for mine that tells me, this is, pain really is not actually a brain thing or a nervous system thing, almost like we've moved from pain being a musculoskeletal thing to pain being a nervous system thing, and now I think the next development is actually pain is the unified human. Pain sweeps across, is one protective output of this incredibly complex. Glory! I mean you know how much I love the wonderfully and fearfully complex nature of the unified human. But that's where I think pain science is sufficiently intuitive for us to be able to integrate it into everything we do and sufficiently complex that we need to learn a lot about it and the human, how the human works, and to be able to work with an organism that's producing pain and has been producing pain for 20 years. To be able to work with that organism - the human - towards recovery, there's no doubt in my mind that it needs a higher skill set, and I love that physios are at the leading edge of recognising that higher skill set. Anyway, something you said made me excited about that and the reality that we have the capacity to communicate with; coach, persuade, inform, counsel in an appropriate fashion, people, and we can still touch them. And we've got great credibility for safety of the body. I mean what an opportunity, anyway.

Dianne

And having that understanding, actually sort of pervades all aspects of physiotherapy because we're after healthy system. So now that we know how much the neuroimmune system is involved in pain, we don't know where that's going to take us next. But we do know that some of the strategies that we as physios have got to upskill or to upgrade that neuro-immune system such as exercise and then certainly as we become more psychologically informed, we're actually able to integrate some of those psychological strategies into our management. Just strategies of using language appropriately; we're not claiming to be psychologists and fixing psychopathology. But the more we understand the way that we talk and interact with our patients, the effect that that can have on their neuro-immune system and hence their pain and then their wellbeing. You know, we have got some far reaching effects there that we can tap into and continue to make us a really, really viable profession in the health field generally. We don't have to be too localised and specific. We need to be able to recognise that this science actually crosses across all of our areas of interaction with people.

Lorimer

Yeah, I wonder, too, that if in 20 years whoever is going to be having these conversations, it won't be you and I, if their topic will be, you know, I wonder if it will be the next development of a pain specialisation, and maybe it's 30 years whatever; a pain specialisation is just applying all of that that we're learning in the pain sphere to all the chronic diseases that we're trying to deal with. And as you know, many people with persistent pain have a range of comorbidities.

Dianne

Absolutely.

Lorimer

And I wonder if that's the next thing for physios, that a physio's journey, to become pain or maybe a disorder of hyper-protection physio through cardiac rehab, or through diabetes care, or through post stroke recovery, respiratory.

Dianne

Respiratory, look what's happening in breathlessness and the perception. So we're changing perception of inputs into the body and how that can affect outputs.

Lorimer

Yeah, that's a cool idea. That's a cool potential, that, yeah, that's consistent across all those. And I love the breathlessness example, stuff that Marie Williams is doing - almost explained breathlessness. I think I think she might talk on that at this conference. Does raise that possibility that the skill set that someone with high level and expertise in pain, will be an easy jump that way and vice versa.

Dianne

And I think it's that mindset that, you know, we have an endless possibility here that we don't have a confined set of science yet. We're evolving. We are discovering new things all the time that can keep our options open for inclusion in our profession. I think it's not a set of techniques or a set of skill set at the moment. It's ever expanding because the body of science is expanding.

Lorimer

We're so off track with our suggested talking points.

Dianne

I'm sorry we've really moved right off.

Lorimer

What's the next one?

Dianne

Maybe we should think about the next one, which some of our audience might be interested in learning your views about. About what are some of the misconceptions or myths about pain and treatment, and I'd be hoping that anybody listening to this might have already picked up that we've actually talked about some of the myths and addressed some of the myths. But probably for clarity, some of the myths that we've tried to dispel with the pain science as its basis, we bring that out a bit more clearly from your perspective.

Lorimer

I often find myself in conversations on this sort of broad topic. You know, I should give it more thought before I talk about it, because I imagine I probably wish I'd said something different all the time. But if I was to think about, what is the common understanding of pain that the people I've dealt with have? And I guess the last few years of my explained pains sort of experiences have been very much in public facing outreach events, rooms of people, maybe patients, but maybe not, maybe just interested punters. And in those conversations that you have as part of that and afterwards over a cup of tea, probably the most consistent surprise that people have is this idea that pain is not a marker of the extent of damage, but is a mechanism for protection and that there are no exceptions in my understanding to that rule. And that's the real big kahuna, I reckon. And you have these conversations after you have a public event. It's 45 minutes. It's a performance and a few jokes and hopefully you've planted something. But then you have the conversation afterwards where someone might say,"I was really surprised by that graph you put up, that figure you put up where to get a pain free injury it has to be catastrophic." And I think, ‘Fantastic! Let's talk about that’. And I say,"Yeah in all of my understanding of pain and my experience of it myself (you know, in science and treating people), there's no exception to the rule that pain is measuring tissue damage." And often people say,"Yeah, but if you do a bad injury, it hurts more than a small injury." I said,"Yeah, that's cool. But why would it hurt more in a bad injury?" And hopefully the answer will be, or I'll coach it,"Because you need to protect the bad injury more so it will heal." So, yes, so it fits the principal. And it's almost like this problem of association versus causation that we see. We feel minor injuries hurt less than major injuries, so we presume that the size of the injury causes the amount of pain. But actually what the science is telling us is different to that. Because actually, some of the worst pain you can have is before injury. And I just did a podcast two days ago with a different conference, and I had this example, so I apologise if we're doubling up. But if you were - I don't recommend anyone does this - but if you were pushing a drawing pin into your thumb, slowly pushing it in, it will really hurt just before you penetrate. Just before the injury will be the worst pain. And once you penetrate, the pain doesn't get worse. So, actually, the relationship between injury and tissue damage there is a non-existent relationship because pain is changing and tissue damage doesn't exist yet. So you can't plot that. And when you have these sort of conversations, I feel like that grabs maybe the most powerful reconceptualisation. If I could shift that question with consumers and with clinicians, I think that was also there with clinicians, is to flip your whole understanding, to process all of what we think about when we think about pain from a protection model rather than from a damage and pathology model. It doesn't rule damage pathology out, right. I mean we completely recognise that. I reckon that's the biggest.... And then obviously there's the example of the slipped disc, which I love to hate. What about you? What in your experience, what are the conceptions that people come to that you think are most, are the most significant barriers to recovery?

Dianne

I think sometimes I feel as though I've done a reasonable job at explaining the complexity of pain. And then, you know, they might say,"Well yeah but I still hurt. It's still bothering me." And as I try and help them to reconceptualise that this is your system protecting you, and it depends on the context completely, is how they actually take on board that language and that conversation quite often. But I think also what I've come to realise more often and more recently is that, this is a complex message for patients, and I really have to break it down into small bite size pieces and in the language that's appropriate for that particular person. Because we lose sight of the fact, I lose sight of the fact, that I've bean talking and thinking this way for a while and that it makes perfect sense to me. But it's a huge leap for that person in front of me who is actually complaining of pain and suffering from some disability, either physical or emotional, that's hindering their life at the moment. And so to break it down into bite size pieces so that they can take on board one message at a time. And for a lot of people, it's a slow reconceptualisation. They might need to be able to break it down even more so that they can just go home with one piece of information at a time and then slowly integrate that into their response themselves, so that they can bring about some change themselves. So I think that my working with people has really come - I think I used too complex a language at times. And I think it's also something that people develop an intuition, or physios develop an intuition, as to what the right level is to intervene. And I think for young physios, inexperienced physios, that's either intuitive or it's got to be learned. And so for some people, it takes a long time to learn that. And that's not something that's easily taught. But to be able to get to the level for that person in front of you so that we make it very person centred. And then to be able to ascertain that my message that I wanted to get across is actually being perceived in its right form rather than what I think I've said. That is that perception again of what, you know, I think I've put across really well. But [indiscernible] message. And we find this quite often that people come back and say,"Oh it's something to do with my brain."

Lorimer

Yeah, yeah, I was chatting with a woman not that long ago who was terrified and totally disabled by her new understanding of her problem, which was that the pain had got into her spinal cord and now had reached her brain. And it was a disease and degenerative condition of her brain. And you know, when I heard that, I thought I can recognise the message that the clinician tried to deliver, and I'm recognising myself as being one of the proponents of delivering that. So almost feeling slightly responsible for this misconception that really was way more damaging to this woman than her pain had been for 20 years. I mean, potentially that's quite confronting for someone like me who's been part of that trying to push, ’Come on, let's give people the understanding’. And I really enjoyed actually what Adrian Traeger was saying this morning on the basis of the Prevent Explain Pain trial that I was very involved with and when one of the things he took away was, is the whole idea of - this is me reinterpreting what Adrian said. He didn't say this - but what it made me think was: by trying to give people understanding of stuff, are we over treating and bringing in new problems and wasting resources?

Dianne

Yes.

Lorimer

What do you think? Do you think that's possible?

Dianne

Well, I think for some people, yes. I think it might need to be an integrated approach. For some people, the message, if you could get across the message that pain is there to protect you, but that is to allow your body to heal and your body has got inherent healing capacity. And so….

Lorimer

The irresistible drive of healing, Di.

Dianne

Yes. And so for some people that might be a really positive take home message. They might go home and think about. ‘Well how is that working?’ And then you can expand a little bit more into some of the science. But for some people that might be all they need or want to hear. I think we do fall into the trap of trying to give too much information, at times. I'm talking about somebody with an acute injury or sub acute injury who hasn't been through a whole complex system of doctors and investigations and hasn't got trapped into the world that we really need to untangle. So I think for somebody in the early stages we can explain pain as a protective mechanism. It may well be that you have to say, "Look, it's not always even in an acute stage, reflective of the degree of tissue damage," because we know that some people, even after acute injury, would feel the same level of pain as a different intensity and some of those factors have been investigated and it's often the degree of other life traumas that are going on for that person at the time, rather than the actual incident. And so, you know, this sort of research was some years and years ago, by one of my colleagues, when I did my Masters and it was long before the pain science was really out there and so…

Lorimer

You're not that old Di.

Dianne

I am. [Laughs] That was in 1990 I think. Anyway.

Lorimer

I was still a student.

Dianne

Yeah, I know you probably weren't even born. [Laughing]

Lorimer

Thank you so much. Isn't that generous!

Dianne

Yeah so, you know, so I think we've been able to see that difference or that discrepancy sometimes in terms of how different people responded. Now we've got reasons for why. But that's off the question. I forget where we started there.

Lorimer

But what I thought of, yeah, we're completely off topic. But that idea and the scientific evidence that context is important and pre-loading of the protective system is important, is one thing that I love about the protectometer concept. You know, the idea of, let's pile everything into a internal protection machine. And my understanding of biology is that that's our highest priority as organisms.

Dianne

Yes.

Lorimer

Protect ourselves.

Dianne

Protecting ourselves. Yes.

Lorimer

And then seek reward.

Lorimer

In that order.

Dianne

Yes. So, you know, that's a nice message that we can start with for a lot of people, and that might be a good starting point for somebody who's come in with an acute injury. And we want to put that into the context of what we know, or how we know that this pain is working in our favour.

Lorimer

But I don’t reckon having, I don't think that having persistent pain puts you into a basket where you need a lot of complex explanation.

Dianne

No.

Lorimer

I remember a patient that I saw, I spent three hours with her. Explain everything. Thought, 'Oh yeah, I've nailed this.' She came back a week - and she was in a wheelchair with 20 year history of back pain - and she left and came back a week later, walked in, looked 10 years younger. I said, "How are you?" And she said,"Great. Haven't had any pain for 5 days. Everything's good. I'm making plans." And I presumed, 'How good is that?' You know, like, I've just explained it, she's understood it. That's been enough. And I said to her,"So why do you think that is?" waiting for her to sing my praises. And she said,"Well, after I left you, I really didn't get any of that, but I left you and went to my sister's clairvoyant.” And at the end of that interaction, the clairvoyant said to her. I'll call her Deidre (wasn't her name). "Oh and Deidre you don't need to be in the wheelchair because your back has healed. And I woke up the next day and I felt great." And we followed her for 13 months, over a year. And she was right. So I… and then people who were very kind to me, saying to me, "Oh yeah but you probably laid the foundations.”

Dianne

Set the scene

Lorimer

But she said to me, “I've got no idea what you were saying, I wasn't paying any attention.” But it was like this fundamental shift and that experience for me makes me think, imagine if we could get at that. Imagine if we could make that happen. Or imagine if we could make happen what happens in sadomasochists, where a noxious stimulus is pleasurable. Imagine if we could do something that would flick that switch. And I reckon there are these miraculous outcomes, and a lot of clinicians have these, and they might associate it, like I did, with a great pain science education interaction. But they might associate with a particular manual therapy manoeuvre or a particular dry needle or exercise, and we all allocated to that intervention and maybe it wasn't. It was just that necessary click.

Dianne

And maybe it was being listened to for three hours.

Lorimer

Maybe. I'm back on the table as a contributor to her recovery, thanks Di.

Dianne

Yes, I think so. Well, you can't take away from the human interaction effect. I think that's going to be always there. And that alliance that you can form with somebody and they may not not take much from the detail, but the fact that you were interested in them and that you listened to them and you validated. I think validating their pain is a really important component of our interactions. And so I think that can be, if we introduce the complexities of pain science too early, it may be interpreted as invalidating their pain. And so I think that we have to be astute there. So there's a lot of skills I think that aren't necessarily taught for physios to be able to actually deliver this appropriately and to know how to make it a person-centred approach.

Lorimer

What about, Di, what about the X factor? Like, you know, I've seen you engage with people and I've watched Pete O'Sullivan and people like Dave Butler, Jenny McConnell, and a host of other top notch clinicians, who all seem to have the X factor. Can you teach that?

Dianne

I think there's a personality behind that, which you can't necessarily create. But I do think with confidence and passion you can develop it.

Lorimer

Right. Oh, can we nail that quote everyone: 'With confidence and passion, you can develop it.' That's a cracker, man. That's so much wisdom in that. So how should we change the training for physiotherapists or professional development for physiotherapists to give them the confidence and passion to make that happen?

Dianne

I think they have to do in a non threatening situation and that is away from a patient in front of you. You know, I think we have to have more interviewing, communication type of environments and practices and have that simulated environment, really. Because it's not until you've actually been through the tricky stuff and found yourself slipping over the wrong words or slipping out the wrong words at the wrong time, then you think, 'Oh why did I say that? I know that she's interpreted that completely differently to what I intended.' And so that sort of experience primes the practitioner a bit for being a little bit more astute, not using their default words. If we go back, yesterday's keynote speaker talked about us transforming our approach and not using our default position all the time. I think often in a clinical situation you'll fall back to a default word and we'll talk about something like your pain pathway, and then it sort of really reinforcing the wrong message, because that's been the default. And so we might have to think about okay, that was wrong, but I'd like to be able to do that in a non-threatening situation where I'm not conveying the wrong message to the patient. And we also need to learn some more skills about, well how do we actually institute some behavioural change in this patient? What are the strategies about it? And so there was a nice, I've been to a nice paper this morning, that talked about behavioural change and what's needed for behavioural change. And so you know, it is things like confidence and motivation. So we need behavioural change ourselves as practitioners, and we need to be able to know what those criteria are for behavioural change to try and help our patients make that change as well. So I think we've got a lot of work to do in that communication behavioural change setting, to be able to integrate our knowledge of pain science in an effective way across.

Lorimer

Do you reckon, then, that instead of doing these professional development courses that people run where the expert shows them how to do stuff, we should have the ‘expert’. You come to the course and you get to be the clinician, while the ‘expert’ pretends they're the patient. That would be interesting, wouldn't it?

Dianne

Yeah, well, we're just talking about delivering the Pain Level Two course, developing it, and we're thinking about making this an actual practical series of modules like, you know, you'll learn a skill, some part of motivational interviewing, and there are some basic skills that can be taught, or you can pick up quite easily and go and practice. And so we'll have modules of skills in communication and behavioural change strategies that you can actually teach the theory behind. But okay for your homework before we do the next module, we want you to practice this with a peer and record yourself.

Lorimer

Yeah right.

Dianne

And have that feedback so that, you know, we actually establish those skills and see if that helps us with delivering the knowledge so that we can help with that change that we're after.

Lorimer

That's the sort of model that we're using in Pain Revolution.

Dianne

It is. So that leads us on to Pain Revolution. Can you tell us a little bit about the Pain Revolution and where we're going with that?

Lorimer

Sure. Pleased you asked. Well, Pain Revolution, as you well know, because you are a core player in it, it's really a movement. Inter-disciplinary, inter-organisational inter-professional, highly collaborative movement, with a very bold, but not outrageous, vision that - and here comes the spiel - that all Australians will have the knowledge and the skills and access to local resources to prevent and overcome, persistent pain. But I think what's different about Pain Revolution from other excellent implementation and practice change initiatives, is that we are focusing on consumer expectations as part of it. I guess if we had a three pronged attack: one prong is consumer expectations; another prong is capacity, clinician skills and knowledge to deliver it; and then policy and trying to get changes there and different funding models. But at the consumer expectations level, I get turned on by the possibility, and I mentioned this possibility this morning, that just imagine a world where the contemporary thinking physiotherapist, or some other clinician, GP, had a patient in front of them and they didn't have as the first massive challenge, teaching this person or persuading this person or opening this person's perspectives into the possibility that low value care was not the best thing for them. Imagine if that was our first. We could get rid of that barrier. So someone comes in and the patient comes and says."I've hurt my back." I say, "That's not good. What are your expectations of me?" "Well, I expect that you'll be able to reassure me that nothing's seriously wrong, that you'll be able to teach me what I can do while this recovers, and I'm happy to think of active skills or any psychological techniques, or how can I self manage my journey to recovery?" Imagine if they said that to you and they didn't say, "Well what I want is the same sort of treatment that the professional footballers get. I want an MRI, and then I want to see the best surgeon in town," or whatever. You know, people come with these expectations, and I'm blowing up that, I know it's seldom actually that full on. But that's the vision of Pain Revolution. So that if we can start rurally and regionally and have resources in place, so the local pain educated program, the idea of that is a long game, capacity building strategy. And, as you know, these health professionals opt in to, it's a proper training program, takes a year of university, part time study, mentored planning and delivery of events. But I think that the feedback that we're getting from those local pain educators in how it's improving their own clinical practice, as well as developing the networks in their communities that they're locked into. That's another thing that I think is really powerful, that the people who are jumping in to take on this massive challenge, and it's a massive burden as well, are doing it because they're so committed to their community. You know it's not the blow-in model, which we've done a million times. We're still doing in some jurisdictions and it's very expensive, and it's a low, low impact intervention. So Pain Revolution really is a multiple strategy hit on regions, trying to change consumer expectations, and trying to implant in communities people with a higher level understanding of pain and pain education and high value care. They're the three things.

Dianne

So really, we're shifting, I guess the power play aren't we? We're moving it away from the traditional primary contact person, which is, you know, especially in regional areas, it's generally been the GP and we're giving it to the patient, with some education, through education.

Lorimer

Yeah I really think we are. I think that's the objective that we're giving power to the people in a way and resourcing them. It's the same approach we're having to lots of health conditions. Well it's the same objective, not the same approach. But it really strikes me that the top down pressures to influence the system to avoid low value treatment and diagnostic things and promote high value interventions they're not enough, they're clearly not enough. And in rural and regional areas, the low value care is skyrocketing and the high value care hasn't been changing. So we need another lever. And what Pain Revolution is trying to do is to get in there inexpensive health professionals, people we can afford to pay as a community and change consumer expectations. And if we can marry those things, if we got physios in there. I mean wouldn't be great if every town had a pain specialist physio? That's probably unrealistic. But if every town can have a health professional who's got sufficient understanding of how pain works and how to coach someone and steer them towards high value care, which is low cost. It's high value and low cost. I reckon we can have a population level difference.

Dianne

And so you're thinking not just for people who are in persistent pain and stuck in the system.

Lorimer

No.

Dianne

You're thinking of an overall education program so that people don't expect to go and get the X-ray the first time around or the medication. They don't need to go straight onto opioids and high pain relievers. They have that expectation that that is not what they need, right from the word go.

Lorimer

Yeah, yeah. I mean, I guess there are other really nice initiatives that are targeting that which are fantastic. I think the thing that we're trying to get at, is trying to find health professionals and implant health professionals, embed them in communities that understand pain really well. So when that complex person arrives and they might be a complex acute pain patient, then they're still not going to panic and send them towards low value care. I really enjoyed another aspect of Adrian Traeger's talk today, looking at how you can do this nudge behaviour to change. He was talking about what GPs do. But wouldn't it be great too if a GP had high on the list, someone comes in with distressing musculoskeletal pain or any pain, and the GP first thing they thought is, ‘Oh I'll get you to have a chat with the local pain educator’. Not, I'm going to give you this drug, this scan.

Dianne

So yeah, that's amazing. That leads us to one of our final points is that, and I think this is a system level issue now that we've got to. We’ve sort of come through from the patient, clinician, the wider community. And so you know, what changes would you like to see in the Australian health care system in reference to pain and to this more empowering approach?

Lorimer

Yeah, I want to throw that back at you Di, because you're actually way more engaged in that side of things and what you've done with APA, but also engaging with a range of stakeholders. What would you like to see change?

Dianne

Well, I see from my position as a private practitioner, I see one of the biggest barriers is cost for the individual.

Lorimer

Do you mean the person in pain or the clinician?

Dianne

The person in pain and probably the clinician, because business models don't encourage or don't really allow for the type of consultation with people. I'm talking about complex pain now, not initial acute pain. I think that every clinician has the absolute responsibility to ensure that acute pain is handled appropriately so that it doesn't have the capacity, or we decrease the capacity, for it to become chronic. I think that is a basic, absolute importance for any any practitioner who's working with patients. And we can make or break that situation in the very early stages of an interaction. But for people who are in chronic pain, we know that they're not going to fit well into a private practices business model. A lot of private practices work at a 20 minute consultation point to be able to make money. We're not appropriately remunerated in terms of money for time. I know that if somebody has got a complex problem, the biggest thing I can do, or the first thing I can do that's going to help them is to listen to their story. And I can get the details of the complexity of their story and factors that might be impacting on it and where I might start my education about them, because not everybody with chronic pain has a fear avoidant pattern. They might be the overachievers. And so if I just throw the whole lot at them, it's not going to be useful. So I need time to hear their story, to find out the context of their pain and that can take an hour, an hour and a half. And so that is a big barrier for integrating my preferred method of management, which I know is evidence based and which is in keeping with the science. And so we have put in some submissions for recognition of this, with the latest MBS submission through the APA. And even if we were compensated through Medicare for an initial consult at a length of one hour so that we could develop a plan for people then to be managed within the Medicare system, in a group setting even, or for shorter one on one consults, I think that would, it's not ideal, but I think it's a step in the right direction so that we could make ideal pain management more accessible for people who are stuck with persistent pain. And I think that there's a two pronged attack. We must all tackle that initial early acute pain and use the right language, communication styles, appropriate intervention and not intervene when it's not appropriate. All of those things that are good management for acute situations, but then when the situation has become more problematic and early identification of risk factors so that we can try and stem those from becoming [chronic]. But once we have these people in chronic pain and we know that we've got a lot of them, we've got 20% of our population, they need to be offered a better financially remunerated position so that we can actually treat them and help them properly. And this is so that we can actually relieve some of the pressure on the tertiary pain clinics. A lot of people don't need to get to that tertiary pain clinic stage if we could treat them in primary care and still be appropriately remunerated for it.

Lorimer

So you're engaged at a federal level. What about at a state level? Tertiary care is normally state funded right?

Dianne

Well, the Medicare system is federal. So with looking at trying to get some scheduled items through Medicare but certainly the tertiary levels pain management units in the hospitals are state funded. But I actually think we need to try and keep people out of them.

Lorimer

Yeah, but I just wonder whether actually it's in the state, it’s in the interest of the state budget, to keep people in the primary care, right? So I know there are a range of organisations sort of umbrellaed with Pain Australia that are sort of lobbying state and federal levels for this.

Dianne

Yeah.

Lorimer

And the other thing that I thought that you might touch on was that, whether this is feasible or not, but using funding levers as disincentives for low value care. I don't know that's something that's on the radar or not. I know there's been a furore in Victoria, and particularly in the UK, where the decision makers have said you're not getting paid to do that intervention and entire professional groups are out of a job, or more to the point, have to change what they're doing. But do you think that's on our horizon?

Dianne

Well, I think that's probably part of what came through with the review of alternative and complementary practices. And so a lot of our physios were affected by that when Pilates was considered under that umbrella, and the APA has lobbied to have that reconsidered and I think, yeah, it may be appropriate. But then you know, on the other hand, some of those practices have a role in the management of chronic pain people, if those practitioners were appropriately skilled as well.

Lorimer

Yeah. Yeah.

Dianne

So I think it is quite complex in that sense, but there are certainly, I think, in terms of passive therapies, we should be really, okay there isn't a place for this, but that's a can of worms.

Lorimer

Oh so is. Okay time's up Di.

Dianne

Yes.

Lorimer

It's a pleasure to chat with you in a way that everyone else can listen in. And remember, honoured member, what a great day it is and happy birthday!

Dianne

Thank you very much Los and thank you, as always, for your great input and insight into the way you're thinking about pain management into the future.

Lorimer

No worries Di.

Dianne

Thanks Los.

Narration

That was Professor Lorimer Mosley and Dianne Wilson and you've been listening to another episode of Talking Physio. One final thank you to Flexeze, Australia's number one heat wrap for helping us to produce this podcast. Thank you Flexeze and thank you all for listening. I hope it's been both informative and interesting, and we can't wait to bring you another episode very soon. Thank you.