New approaches bite into pain management

 

The annual Australian Pain Society (APS) scientific meeting was moved to an online format this year in the light of COVID-19 challenges across the country and around the world. Here, InMotion speaks with some of the presenters to address this year’s event in its first digital iteration.

Gaining from pain

Dr Samuel Robinson was named as the winner of the Australian Pain Society’s 2020 Rising Star Award at the conference in April. Here, Samuel, from the University of Queensland’s Institute for Molecular Bioscience, explains how venomous animals are providing us with insights into pain pathways that may lead to new treatments.

Our bodies are equipped with an ingenious system for detecting and responding appropriately to all manner of external stimuli—our sensory nervous system.

Think cold, heat, touch, acidity and more. We can even distinguish between different grades of each stimulus.

And when we encounter something that is potentially damaging to us, our sensory nerves detect it, interpret it as unpleasant, initiate a signal to withdraw and imprint that unpleasant feeling in our memory.

This, of course, is what we call pain. Pain is good for us. It teaches us to avoid dangerous things. Without it we can’t survive.

But, like any system in our body, pain can also go bad. Different diseases, chemical or mechanical injuries can result in unwanted pathological pain—sometimes short- term and sometimes long-term.

One in five Australians will suffer from chronic pain at some point in their lives. Not only can this be debilitating to the individual, but it represents a huge economic burden to the nation (an estimated annual cost of $73.2 billion).

Our strategies to treat pathological pain are many and varied. The most common pharmacological interventions are paracetamol, the non-steroidal anti-inflammatory drugs (eg, ibuprofen) and the opioids (eg, morphine or codeine).

However, the former two are not effective for many pain pathologies, while the latter are fraught with the danger of addiction when used long-term.

In short, many types of pathological pain remain poorly treated and there is worldwide demand for new and creative pain treatment strategies.

Dr Samuel Robinson

I am an expert on plants and animals that sting, and the biology, chemistry, pharmacology and pathophysiology underlying those stings.

Now I know what some of you may be thinking: what does this have to do with developing new pain treatments? Let me explain how understanding the chemistry behind different stings can lead to better pain treatments.

My research program is based on several simple observations: that most venomous animals use their venoms defensively, most defensive stings or bites cause intense pain (think of the last time you were stung by a bee, a wasp or an ant), and not all stings are equal.

For example, the sting from a bee feels different from that of a scorpion. (If you’re curious about the differences between different stings, check out my social media accounts on Twitter @StingScience or Instagram @stingscience.) Importantly, what these observations tell us is that venoms represent a pharmacologically diverse source of pain-causing toxins.

Toxins from venoms have been instrumental as tools in shaping our understanding of the cardiovascular system and the neuromuscular junction.

My goal is to identify the pain- causing toxins from different venoms and determine how they work—that is, what they target in our sensory nervous system to cause pain.

In doing this, I’m hoping to discover toxins that reveal new components of our pain-signalling pathways.

For example, this might be an ion channel or receptor that we don’t yet know is involved in pain signalling. The toxins can then be used as tools to study the role of these components in pain signalling and validate them as potential targets for new classes of pain therapeutics.

So far, I’ve identified new pain-causing toxins from the venom of bull ants (Robinson et al 2018), stinging trees (Gilding et al 2020), spitting cobras (Kazandjian et al 2021), stinging caterpillars (Walker et al 2021) and many more.

Already, several of the pain-causing toxins identified in these studies have revealed previously uncharacterised components of our pain-signalling pathways.

Characterising these components is now a major focus of my research program and it’s my hope that these will represent new therapeutic targets for the treatment of pain pathologies. Watch this space.

Dr Samuel Robinson is a research fellow at the University of Queensland's Institute for Molecular Bioscience. Samuel is a biologist at heart and has been since he can remember. After training in pharmacology and neuroscience at university, he has found a way to combine his love of biology with his training in biomedical science and has ended up becoming an expert on things that sting.

References

Gain not pain

1.            Robinson SD, Mueller A, Clayton D, Starobova H, Hamilton BR, Payne RJ, et al. A comprehensive portrait of the venom of the giant red bull ant, Myrmecia gulosa, reveals a hyperdiverse hymenopteran toxin gene family. Sci Adv. 2018;4(9):eaau4640.

2.            Gilding EK, Jami S, Deuis JR, Israel MR, Harvey PJ, Poth AG, et al. Neurotoxic peptides from the venom of the giant Australian stinging tree. Sci Adv. 2020;6(38):eabb8828.

3.            Kazandjian TD, Petras D, Robinson SD, van Thiel J, Greene HW, Arbuckle K, et al. Convergent evolution of pain-inducing defensive venom components in spitting cobras. Science. 2021;371(6527):386.

4.            Walker AA, Robinson SD, Paluzzi JV, Merritt DJ, Nixon SA, Schroeder CI, et al. Production, composition, and mode of action of the painful defensive venom produced by a limacodid caterpillar, Doratifera vulnerans. Proc Natl Acad Sci U S A. 2021;118(18).

 

Virtual meeting addresses key pain issues

Professor Lorimer Moseley is a physiotherapist, author and educator who thrives on audience interaction.

So when it came to delivering the International Association for the Study of Pain global year about pain lecture at the 2021 APS 41st Annual Scientific Meeting, Lorimer found the online format a little challenging.

‘I think I rely a lot on feeling the crowd, of reading the room and seeing the responses of things that land and don’t land—and you just can’t do that virtually. You have no feedback whatsoever,’ Lorimer says. ‘Give me real life any day.’

Regardless of the platform, Lorimer relishes any opportunity to speak about topics that inspire him and feed his passion for driving change in the understanding of back pain as a treatment strategy.

And knowing that physiotherapists are at the cutting edge of developing better treatments for—and shifting the understanding of—back pain makes him proud to be part of the profession.

His lecture, entitled ‘Learning and back pain: Challenges, opportunities and groovy little tricks’, encompassed research findings into back pain and the implications for today’s clinicians.

Empowering practitioners to trust in their abilities is what excites Lorimer about this area of treatment.

He leads Innovation in Implementation and Clinical Translation in Health at the University of South Australia, is a Fellow of the Australian Academy of Health and Medical Sciences, is an Honorary Fellow of the Faculty of Pain Medicine and an APA Honoured Member.

Professor Lorimer Moseley

Lorimer has also been recognised by awards from government or society organisations in 13 countries, including being made an Officer of the Order of Australia in 2020.

‘I think that physiotherapists are very well represented in the people who are on the cutting edge of developing better treatments for, and more understanding of, back pain.

'That said, there’s a pretty big range within our physiotherapy community of how we understand back pain and the challenges with back pain, in particular, are extraordinarily complex,’ Lorimer says.

In his lecture, Lorimer began by speaking about learning within the nervous system and how that increases the sensitivity of the body’s pain system over time.

This included exploring the potential role of learning history in the development of chronic problems, the social determinants of health related to educational attainment and the funding models that feed into that thinking.

‘The growing body of literature about learning about back pain shows us quite clearly that the models people have in their minds about what causes back pain, which are based, to a large extent, on what healthcare professionals have told them, really do emphasise the fragility of your back, which really couldn’t be further from the truth,’

Lorimer says. ‘It’s a remarkably strong and robust part of our body that has evolved over time to take loads day after day, with big, strong muscles working around it.

‘I think we’ve all been part of the problem. We have to shift our understanding as the new scientific data emerges, which has been happening particularly quickly over the last 30 or 40 years,’ Lorimer says.

‘Another challenge is that our patients turn up expecting low-value care from physios. They turn up to a physio and say, “I just want you to put your hands on me”.

'The challenge for a physio is to say, “Yes, I’ve got great skills in my hands, but I’m going to use them as part of the process for you to be able to exploit your own system to recover”.'

Lorimer says there are huge opportunities for physiotherapists, not just in chronic back pain, but in musculoskeletal pain in general.

‘Historically we have dug a hole for ourselves in pitching ourselves as pain relievers.

'Our true value, I think, is in coaching people towards recovery and emphasising the physiotherapist’s very high ability in communicating understanding of anatomy and loads on the body, in how the nervous system and brain works and the full depth and breadth of our complex biology.

'We have the immense privilege of being able to touch people and give them confidence that we understand the body. And we, usually, understand the idea of “the unified human”.

‘I don’t think physios should be psychologists. We should be working with psychologists when they’re needed, but we really have to change our own mindset to “I’m your coach who will do everything I can to help you master your situation and exploit your glorious, beautiful bioplasticity”.

‘Physios are leading the charge for better consumer outcomes and there are so many excellent physios doing excellent work.

'When you see the transformation of the role of physiotherapy in pain care over the last 30 years, physios have gone really from [being] the assistants to being in the driver’s seat. And it’s great to be part of that.’

Driving change for pain after road crash

Although a first-time presenter at the APS scientific meeting, Professor Ian Cameron is no stranger to making presentations on a variety of platforms, be it face-to-face or to an online audience.

Delivering the opening plenary session on the second day of the APS conference, Professor Cameron discussed ‘Chronic pain after motor vehicle crash injury: assisting recovery’—a topic keenly followed by health practitioners, people working in public and private health, and those working in the insurance industry.

Professor Ian Cameron is a clinician researcher who has the Chair in Rehabilitation Medicine and is head of the John Walsh Centre for Rehabilitation Research at the University of Sydney in New South Wales.

He has research and clinical interests in chronic pain and was recently an National Health and Medical Research Council Practitioner Fellow conducting and translating research on injury-related disability.

Ian divides his time equally between clinical work and research and education. He works as a rehabilitation physician in public and private practice in New South Wales.

One of Ian’s research streams is recovery after injury and he says pain is an issue for recovery. Ian has an interest in compensation health, particularly in recovery from motor vehicle crashes.

However, he says similar principles apply to work injuries andto illnesses that may cause disability.

During his presentation at the pain conference, Ian spoke broadly about identifying the early predictors of delayed recovery after a motor vehicle crash, about approaches and solutions to help injured people understand and manage chronic pain, and about assisting recovery after injury using a biopsychosocial approach.

‘Recovery in terms of pain, but also other things, is predictable, through an appropriate assessment.

'I was suggesting that clinicians and others should be using an assessment that stratifies people into risk of recovery or non-recovery, and then tailor their interventions to the risk of non-recovery, but obviously embrace a biopsychosocial approach.

'And then apply usual clinical techniques [of an] evidence-informed approach [and an] objective assessment to show improvement,’ Ian says.

‘I was arguing that you’d try and engage with the person in terms of appropriate pain management, if you can; therefore you provide appropriate treatment. But if you can’t, you stop after assessing the person—if they’re not going to engage.’

Professor Ian Cameron 

Ian took the audience through the Clinical Framework for the Delivery of Health Services and discussed key principles including measuring and demonstrating the effectiveness of treatment, empowering the injured person to manage their injury and implementing goals that focus on optimising function, participation and return to work.

Citing the contrasting experiences of two workers three months after injury—Mary, a cleaner with a shoulder injury, and Bruce, 35, a technical assistant with a traumatic brain injury—Ian discussed the importance of identifying predictors of delayed recovery, which can include barriers such as complicated return-to-work processes and the ability or inability of employers to modify work for employees recovering from injury.

During the presentation Ian argued that chronic pain caused by a motor vehicle accident should be approached in the same way as chronic pain from any source.

‘That’s the approach we’re taking in research projects generally, that because the psychosocial predictors are similar in all types of pain your general model is the same no matter what part of the body is painful,’ Ian says.

‘For example, if talking about chronic non-cancer pain, for example…the approach we’re applying is the same for neck pain from whiplash associated disorder as for low back pain, osteoarthritic pain from the knee and so on.’

On the topic of acute whiplash associated disorder, Ian pointed to a recent study (Sterling et al 2019) that showed that for people with acute whiplash associated disorder who are at risk of poor recovery, physiotherapist-delivered stress inoculation training, integrated with guideline-based exercise, results in clinically relevant improvements in pain and other outcomes compared to guideline-based physiotherapy exercise alone.

‘We’re looking at trying to influence clinician practice with reference to helping people recover from musculoskeletal conditions. So we’re trialling approaches based on a risk-stratified approach,’ Ian says.

‘We’ve got several ongoing cohort studies looking at recovery over time, to try and understand how different factors contribute to recovery.’

Accidental relationship to pain inspires learning

Pain management is a growing area of healthcare and a legitimate space for physiotherapists to be developing and learning in, says Tim Austin, who has become the first APA Specialist Pain Physiotherapist (as awarded by the Australian College of Physiotherapists in 2021) in Australia.

Tim Austin found his way into pain by accident. When he and his business partner took on Camperdown Physiotherapy, they inherited the physiotherapy services in the associated multidisciplinary private pain clinic, Camperdown Pain Management, which was one of the earliest private pain centres in Australia.

That was over 27 years ago, and Tim has learned a great deal about pain and its treatment since then.

‘I was very green with regards to pain management, thrown into it with no experience whatsoever as a very young physio. But, I learnt from an excellent team—a medical specialist, psychiatrist and clinical psychologist’, Tim says.

‘Before that I had worked at Royal Prince Alfred Hospital for a couple of years; I really liked hospital work and could easily have stayed there and specialised in something.

'But this opportunity came up in the practice, and so my partner and I took it on. I suppose it was a “jumping in the deep end” experience.’

Tim was driven to learn more about pain to help his clients and so embarked on studying a Master of Pain through The University of Sydney before going on to become a teacher/tutor in that degree program—a position he has held for the past 13 years.

Many of the teaching staff on the online degree program have been and are associated with the world-renowned Royal North Shore Hospital pain clinic.

Tim’s involvement in teaching saw him move further into the pain management space through joining a committee of the Australian Pain Society (APS).

Former APS president Amal Helou ‘volunteered’ Tim for a position on the Relationships Committee, made up of representatives of all of the professional groups, including the APA.

Tim says this enabled him to understand more of the interdisciplinary pain landscape as it related to those professions.

‘One of my big passions is interdisciplinary care. It’s one of the things that we talk about it in the physiotherapy profession but it’s really not done often or well.

'We need to be aware of the other professions that we work with, learn from them and assist them with what we know about pain. I started to understand what the field of pain meant for the specialist pain doctors and what they were dealing with, with the clinical psychologists, the nurses and so on.

'I spent five years on that committee, which spanned the time before and just after the APA Pain Group was formed,’ Tim says.

Tim’s position on the Relationships Committee grew organically and he joined the APS Board of Directors, eventually taking on the post of Treasurer. He was also part of a small group of physiotherapists to advocate for the creation of the APA Pain Group, which came about in 2014.

Tim Austin

Tim has continued to forge ties between the APA and the APS, facilitating an annual Physiotherapy in Pain pre-conference workshop at the APS conference.

In that pre-conference workshop at the 2021 Australian Pain Society scientific meeting in April, the topic was appropriately about ‘psychologically informed practice’.

The natural progression of the Pain Group of the APA was to develop a Specialisation program through the Australian College of Physiotherapists.

After much sweat and tears by many passionate people, that training program commenced in August 2019. A cohort of six titled pain physiotherapists from across the country worked tirelessly to progress through the program.

In March this year, Tim was notified that he had passed the exam to become the first APA Specialist Pain Physiotherapist. He sincerely hopes his five fellow registrars join him in this success in November this year.

‘It is exciting being the first Pain Specialist, but it doesn’t sit comfortably with me because I feel like I’m up on this pedestal as being the “biggest, brightest and best” but I just happened to have the opportunity first.

'There are some truly excellent pain management physiotherapists across the country and I don’t see myself as being better than them,’ Tim says.

‘It was a rigorous but incredibly rewarding training program. It provided challenges because everyone had to work out how to fit round pegs into square holes, tailoring quite a different discipline into an already established process at the College.

‘The College process, I would say, refines you—and that’s a big positive. I know I’m a better clinician than two years ago, having had a very strong touch-up in clinical reasoning, which is very important in pain management.

'Pain is always a biopsychosocial experience, so developing an understanding of all that contributes to pain is very important.’

Following his exams, Tim took up the role as Chair of the National Committee of the APA Pain Group.

‘It is such a wonderful group of passionate people and one of the committee’s goals is to see more titled pain physiotherapists progress through the Specialisation training scheme in the next few years.

‘If you are thinking of applying for specialisation in pain, be prepared for the fact that it is a rigorous program. You need to reflect on your own strengths and weaknesses and to challenge yourself, but you will do it with the support of the pain management community.

'That is, not only pain physiotherapists, but the whole interdisciplinary pain community.’

Click here to find out more about the APA Career Pathway and Specialisation through the Australian College of Physiotherapists.

 

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