Forward thinking leads the way in pain
As the body of knowledge of pain science grew and evolved, so too did a group of passionate physiotherapists seeking recognition for peers and colleagues working in the field of pain management. Lois Tonkin, Tim Austin and Dianne Wilson explore the journey towards the formation of the APA Pain group.
1. Focus on pain knowledge
In the early 1990s, pain management programs were being developed in the large teaching hospitals in Sydney. Programs were modelled on those being run in the US, using cognitive-behavioural principles as described by clinical psychologists such as William Fordyce. This work was based on behavioural principles—responding positively to healthy behaviours and ignoring pain behaviours.
The models then moved on to recognising the role of beliefs, based on programs such as that developed at the University of Washington, Seattle. These programs were conducted by clinical psychologists, incorporating physical upgrading programs run by physiotherapists under the umbrella of the psychologists.
In Sydney in the early 1990s, a group of physiotherapists working in pain management programs in the teaching hospitals came together to support each other in this emerging field of practice. A journal club was run for some time, attracting both private practitioners and public hospital therapists. It was seen as important to help ensure an equal professional balance between physiotherapists and clinical psychologists conducting these programs.
2. Great minds come together
At the International Association for the Study of Pain (IASP) scientific meeting in Vancouver in 2001, Judy Chen, from the Prince of Wales Hospital, and Lois Tonkin, from Royal North Shore Hospital, put an invitation on the conference notice board for any physiotherapists present to attend a lunchtime meeting. From this meeting, the successful pain and movement special interest group of the IASP began—a great advocate for the role of physiotherapists in pain management.
From this, physiotherapists from around Australia had the opportunity to attend a workshop in Brisbane with Professor Patrick Wall, who, along with Dr Ronald Melzac, had developed the Gate Theory of Pain, which arguably is the basis of current thinking on pain neurobiology. An approach was made at that time to the NSW branch of the APA to begin a pain management special interest group. Unfortunately, this was not successful, as introducing current knowledge on pain neurobiology into the prevailing manual therapy framework at the time appeared to be a bridge too far. However, through the consistent and dedicated work of many physiotherapists, pain management physiotherapy became an accepted specialty area of practice and is now strongly supported by the APA and its members.
3. Building the foundations
Since its beginnings in the 1980s, the Australian Pain Society (APS), through its annual scientific meetings, has provided the most consistent opportunity for education and networking of physiotherapists with a particular interest in pain.
These meetings have been important not only for pain management physiotherapists to connect with each other, but also with the many different professions that treat pain. At the 2012 APS meeting in Melbourne, through informal discussions, physiotherapists began to re-explore the possibility of developing a pain special interest group, particularly with the idea of developing a pathway to recognise the specialist skills associated with the pain discipline.
The following year, at the APS meeting in Canberra, a pre-conference physiotherapy workshop was convened. There was robust discussion at this meeting as to whether a special interest group should be formed through the APA or the Faculty of Pain Medicine, and it was agreed the group should be run through the APA. This led to a presentation by the now-APA Pain Physiotherapist, APA Musculoskeletal Physiotherapist and APA Pain group chair, Dianne Wilson, and past APA NSW branch president, Dr Damien Finniss, to the APA National Advisory Council (NAC) in August 2013. The NAC agreed with the proposal, and the APA Pain group was formed on 1 April, 2014. Since this time, in a strong sign of interdisciplinary connection, the APA has sponsored the pre-conference workshops at the APS meetings.
4. Looking to the future
As well as promoting professional development in each state, the Pain group has a national professional development agenda with the recently developed Pain Level 1 course, conducted by APA Pain Physiotherapists Duncan Sanders and Tim Austin in Sydney in May and in Melbourne last month. Following review of the content, the course will be rolled out nationally. To complete this year of firsts, the Pain group will conduct its first scientific conference as part of the TRANSFORM 2019 physiotherapy conference in October in Adelaide. Professor Julia Hush, APAM, is chairing the scientific committee, and planning for a workshop and the full program is underway.
Such a lot has happened in a short space of time. We thank APA CEO Cris Massis and the NAC for their foresight in 2013 in recognising that the body of science which exists in pain needed to be integrated into physiotherapy. Our thanks also go to James Fitzpatrick, as he has encouraged us to work towards our aspirations for specialisation, and to the APA for becoming a leader in the pain field among allied health professions.
5. Growing in numbers
APA Pain Physiotherapist Lester Jones was the inaugural chair of the APA Pain group, and under his most dedicated and thoughtful guidance, the network grew rapidly—with more than 300 members in its first year, and state committees formed across the country. The staple continuing education offerings in the early years were lecture evenings, ever expanding in topic areas. These and other events also offered opportunities for members to network, professionally and socially.
As its membership grew, the APA Pain group was afforded administration and support relative to its status. As recognition of the body of pain science increased across all disciplines within the profession, its integration into undergraduate and postgraduate programs began. Contemporary pain science, promoting the understanding of pain perception and pain management in a biopsychosocial context, is gradually being accepted as fundamental to modern physiotherapy. With this emergence, the goal of developing a pathway to titling and specialisation in pain has become a guiding beacon for the direction of the national and state committees. With the assistance of the APA professional development committee and the direction of APA General Manager Education James Fitzpatrick, titling in pain was approved in late 2017, with the first successful applicants in April 2018. To date, there are 62 titled Pain Physiotherapists recognised by the Australian College of Physiotherapists.
6. Career pathway moves forward
The national committee of the Pain group viewed the recognition of titling as a step in the process towards specialisation. Although a good understanding of pain and pain management is necessary for all physiotherapists, the training, assessment and recognition of those with expert qualifications in this knowledge and clinical application was seen as essential. This was not only to improve the management of complex patients, but also to enable advocating for better funding of chronic pain at government levels and to demonstrate successful credentialing to our interdisciplinary colleagues. During the second half of 2018, several planning meetings took place to determine an appropriate pathway towards specialisation, with in-principle approval given by the Australian College of Physiotherapists in December 2018.
In February this year, meetings took place with the College to consolidate plans for an inaugural training program, and a proposal was put to the College Council in March. Modifications to the proposal were approved and an intensive and compressed training program will commence this month. The aim of this one-year program is to train and assess specialists who will become facilitators and examiners for future two-year training programs. The Pain group will now also have representatives on College committees.
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