The 2019 Australian Pain Society’s 39th annual scientific meeting on the Gold Coast was held in April to coincide with the International Association for the Study of Pain (IASP) Global Year Against Pain in the Most Vulnerable. Here, selected presenters detail their work in various pain-related fields that have implications for clinicians working in pain as well as communities affected by it.
Trudy Rebbeck, Darren Beales and Kerrie Evans discuss their presearch investigating ‘Innovative solutions and clinical pathways to improve management of common musculoskeletal disorders’.
Musculoskeletal (MSK) pain disorders such as low back pain, neck pain, whiplash and osteoarthritis are Australia’s highest disease burden. Possible reasons for this include clinical guidelines being poorly implemented in primary healthcare, increasing burden on the healthcare system (eg, overloading GP/primary care system) or the difficulty of identifying patients at medium-high risk of poor recovery.
For example, in Australia, many people with whiplash receive treatments not supported by clinical guidelines and more than 50 per cent of people receive unnecessary imaging. Appropriate advice on strategies to manage low back pain is provided in only 21 per cent of GP consultations. Despite the unanimous recommendation for active therapies such as exercise, only 13 per cent of patients with knee osteoarthritis receive such advice. The burden of musculoskeletal pain requires innovative solutions.
Our proposed solution is to implement an efficient health service delivery model with a strong physiotherapy focus. Our wider team has developed validated tools (eg, the Short Form Örebro Musculoskeletal Pain Screening Questionnaire and the Keele STarT MSK Tool) that can help determine who will recover well and who have a poorer prognosis.
Patients with a good prognosis (low risk) should recover well with minimal care, guideline-based advice and exercise provided by physiotherapists and other primary healthcare practitioners (HCP). To assist management, our team is developing My Pain Hub, a website where primary care clinicians can access up-to-date information and evidence-informed resources regarding low back pain, neck pain/whiplash and knee osteoarthritis in a one-stop portal. Importantly, emphasis is on avoiding ‘medicalising’ the person’s experience, which can result in negative iatrogenic effects that may actually prolong recovery for these individuals.
In contrast, patients at risk of not recovering well will be referred to a specialist physiotherapist who will undertake further examination of domains that may be related to delayed recovery or higher levels of impairment. The specialist then liaises with the HCP on further care that is targeted and patient-centered.
On occasions where the patient has a more complex presentation, the specialist may manage the patient for a few sessions before referring the patient back to the primary HCP. Alternatively, the specialist may refer the patient for an opinion from another health or medical practitioner if appropriate (eg, psychology, pain physician, orthopedic or neurosurgeon, rheumatologist). While similar pathways utilising physiotherapists in secondary referral roles have worked well in hospital settings, these pathways have yet to be formally tested in primary care settings.
The pathway will be implemented in an Australian-wide NHMRC-funded trial, involving research and clinical experts across low back pain, neck pain, whiplash and knee osteoarthritis. More than 1000 patients with musculoskeletal disorders will be recruited. There will be a strong involvement of APA physiotherapists as the primary HCPs, with assistance of specialist physiotherapists Australia wide.
The research and clinical team involved in the PACE MSK trial include: Emeritus Professor Gwendolen Jull; Professors Kim Bennell, Ian Cameron, Luke Connelly, Nadine Foster, Paul Hodges, Michael Nicholas, Kathryn Refshauge, Tim Shaw, Michele Sterling, Lyndal Trevena, Ian Harris, David Hunter, John Orchard, and Raoul Pope; Associate Professors Paulo and Manuela Ferreira and Drs Darren Beales, Kerrie Evans, Rana Hinman, Carrie Ritchie, Milena Simic and Julia Treleaven. The trial is led by Dr Trudy Rebbeck.
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1. Why is the My Pain Hub model of health service delivery important for physiotherapists?
Trudy: As a profession, we have a responsibility to deliver healthcare efficiently and effectively. We are the ideal profession to do this for people with musculoskeletal disorders. However, to do so, we need to reduce care when not necessary, instill patients with confidence to self-manage, particularly for those patients who are likely to recover well. Equally, musculoskeletal clinicians are committed to providing a vaulable service to primary health physiotherapists by assiting with the management of high risk– complex patients.
2. What does this pathway offer for people with musculoskeletal disorders?
Darren: When a person with a musculoskeletal problem is not responding, or has a complicated presentation, their care pathway often leads from the primary healthcare practitioner to a surgeon. However, the vast majority of musculoskeletal complaints do not require surgery. The care pathway we are implementing facilitates access to expert non-surgical care with specialist musculoskeletal practitioners.
3. How do people with musculoskeletal disorders feel about this pathway?
Darren: We are only touching the tip of the iceberg in the potential of intra-professional referral in physiotherapy. Patients, however, are very accustomed to receiving additional input from expert and specialist clinicians. Our experience is that people with complex musculoskeletal disorders are very engaged in the process. They are very happy to receive additional input.
4. What is the benefit of this model for physiotherapists?
Kerrie: Physiotherapists enjoy working with one another to do the best they can for their patients. Referring a patient with a more complicated presentation to another physiotherapist with recognised expertise in that area or condition, offers the referring physiotherapist a second opinion, or a ‘sounding board. From a specialist physiotherapist’s perspective, having the opportunity to help patients with more complex presentations, and collaborate with the person’s primary treating physiotherapist, can really bring about a sense of professional satisfaction.
5. What resources are you developing?
Kerrie: We are developing a website, mypainhub.com, that will explain the pathway to patients and clinicians, and will house videos, information and links to other evidence-informed resources about low back pain, whiplash, neck pain and knee osteoarthritis. These resources have been developed by the team of research and clinical experts involved in this trial, in consultation with patients and key industry stakeholders. The website will go live in August.
6. What is the take-home message for APA physiotherapists?
Trudy: I am incredibly proud of our profession and have seen our roles expand over the 30 years I have been involved in it. We embrace change as a profession, and the team in this study believes this new model of delivering healthcare is the right way forward. We would love APA physios to become involved and be part of owning and shaping the future. Together we can cement our profession as the leaders in managing musculoskeletal disorders.
Nicole Haynes co-presented with APA Musculoskeletal Physiotherapist Richard Newsham-West on ‘The science and art of patient communication’. Here, Nicole discusses the importance, and delivery, of communication with young patients.
Persistent pain is a significant problem in paediatric populations, with varying incidences reported from 11 to 54 per cent (King et al 2011, Swain et al 2014). The most common presentations include headaches, and abdominal and musculoskeletal pain. Persistent pain in children results in significant functional impairments, the point at which help is often sought rather than at the early education and management stages.
In paediatric pain presentations, there is an added layer of complexity of the family dynamic, which must be considered. Understanding family relationships, the hidden contributors to pain and the far-reaching impacts which lie beneath the surface is paramount to good outcomes. Parents of children with pain often feel helpless, unsure of what is going on and how best to manage their child’s symptoms.
Unfortunately parenting doesn’t come with a handbook and most parents do not understand pain and its complexity, so parenting persistent pain is a massive challenge—and the ideal management is counterintuitive to parents. Families often keep children home from school, withdraw them from sport, hobbies and leisure activities while also reducing the child’s and the family’s social engagements. The negative impact of this is great, and it certainly is not the path to managing persistent pain.
The focus of a paediatric pain program is not dissimilar to adult populations. Our aims are to build knowledge of pain, promote return-to-functional activities and develop independence with pain management. The difference lies in the way we deliver the content in an attempt to make it engaging and productive.
During our workshop, Richard presented some great material on communication techniques focusing on motivational interviewing—a useful tool when working with children. I certainly adopt many of the techniques when working with children and families. The rest of this article provides a summary of the main concepts I presented at the workshop.
Talking to the child patient may include the position you adopt when greeting the child, conducting an interview as well as when performing an assessment. The tone and language adopted can communicate comfort, empathy, understanding and a sense of safety, which is critical to building a strong therapeutic alliance to work together towards positive outcomes.
Talking with the child promotes discussion and engages them in conversation. Asking open-ended questions and allowing time to hear a young person’s story provides validation and helps the practitioner understand their beliefs and experiences. You have to be extremely patient when working with children to give them sufficient time to express their thoughts and feelings.
Talking for the child is about communicating at a developmentally appropriate level and it is important to consider their level of health literacy to ensure they are developing the knowledge and understanding necessary for them to apply in everyday life. We may also need to talk for the child as an advocate to family, friends, teachers or coaches—they need to know we’re in their corner.
Communication is not a one-way or two-way street; I like to think of it as a complex network of transportation. There are so many options as far as modes of transport, pathways to take and interactions that occur along the journey. It is important to take note of who is talking during the assessment and treatment consultations between yourself, the patient and the family dynamic. Take note of how well the child is engaged with the conversation. Do they:
- leave the communication to the parents?
- allow parents hijack the conversation and not give them a chance to communicate thoughts and beliefs?
- talk and advocate for themselves?
- experience conflict between their and the caregivers’ perceptions?
- need you to be the moderator within the family dynamic?
The communication dynamic is always a nice comparative as a young person progresses through their treatment program, often developing a sense of control and independence.
Children want variety in so many aspects of their life—and pain education should be no different. Employing a variety of mediums when educating and promoting function may include using visual tools and representations, auditory learning tools such as podcasts, tactile experiences, electronic versus face-to-face delivery, artistic communication, music therapy, physical-based learning, self-directed learning at home or peer-to-peer learning. Sessions will also be a mixture of different interfaces including families and clinicians, children and clinicians or parents and clinicians.
Interactive, experiential and integrated learning approaches improve retention, promote engagement and are much more fun for the educator and the learner. Teaching may be explicit, inferential or incidental while undertaking other functional activities such as cooking, playing games, being artistic or being active. We get down on the floor and do lots of visual and creative learning sessions.
I’ll teach while being physically active; we might be playing ball games, doing some exercises or just going for a walk while we talk about the benefits of physical activity, distraction tools or pacing. Children will write and draw on the whiteboard, on work sheets or on butchers paper. We do visualisation sessions, relaxation scripts and mindfulness activities.
Empowering young people and families to become coaches for themselves, and perhaps peers, teachers and extended family members, can assist with families solving many of their challenges. This means the solutions make more sense and are meaningful to the patient. They are less likely to challenge their own solutions and more likely to result in the desired behavioural change than if I tell them what they should do.
Reflection and repetition are critical for patient learning. Within a session we will reflect on our last session, reflect immediately upon a learning and reflect at the end of a session—that’s a whole lot of reflection and repetition.
Discussing how and when the young patient may have been able to implement strategies from a previous session as well as reflecting on their functional achievements between sessions is valuable. Asking a child to recap a session to their caregiver is a great learning tool, as is asking them how they might explain a concept to a friend or family member. Completing workbooks, home activities and listening to online learning resources are all ways to increase the repetition of key concepts within your curriculum.
Graded exposure to functional activities that are meaningful to the patient are more likely to lead to gradual improvements. Ideally, we want to create intrinsic motivation through competence, autonomy and relatedness so we need to consider what their perceived capacity is, what they can do for themselves and what their interests are. This gives you a starting point to create a safe and positive functional program, which gradually builds physical confidence, reduces activity-related fear and can then be built upon in a graded way. It is empowering for the child to lead or assist with the selection and progression of activities.
Facilitating and creating opportunities for families, carers or role models to connect and engage through physical activities can have benefits far beyond the physical domain. Something as simple as going for a walk together or throwing a ball together and can do wonders for the parent/child relationship.
Paediatric pain is a significant issue that impacts individual, families, communities and the healthcare system. When working in paediatric pain there are some population-specific considerations and complexities; however, the underlying content is the same as an adult program—a comprehensive program that builds knowledge, promotes function and increases independence and control.
Nicole Haynes, APAM, is the chair of the APA Paediatric group and the clinical director of Q Paediatrics, the paediatric department of Allsports Physiotherapy. She has worked exclusively with children since 2007. Her private work has included delivery of services within the clinic, community, educational settings and multidisciplinary community-based clinics.
Dr Bernadette Brady discussed important considerations for the design, implementation and evaluation of culturally adapted pain management.
Managing chronic pain in multicultural societies, such as Australia, requires attention to the unique ways culture and the migration experience shape the pain experience. As a subjective experience, pain is known to be framed by social and cultural constructions. For example, culturally based beliefs, values and attitudes mediate emotional responses to pain and underpin strategies adopted to manage pain. Similarly, migration between societies with fundamental differences in values can dramatically influence health-seeking behaviour and interactions with healthcare providers. As such, healthcare providers need to be able to recognise and incorporate the views, values and contexts underpinning their culturally and linguistically diverse (CALD) patients’ pain experience.
Cultural adaptation is one potential strategy for responding to the challenges that exist in delivering pain management for CALD communities. Defined as ‘the systematic modification of an evidence- based treatment to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values’ (Bernal et al 2009), cultural adaptations represent a merging of the core elements of evidence-based interventions with content that is grounded in the values and beliefs of specific ethnocultural communities. This workshop session used examples from research conducted with three CALD communities living in south-west Sydney.
Explanatory frameworks for pain
An explanatory framework or illness model is essentially ‘notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process’ (Kleinman 1980). Patients and healthcare providers carry their own explanatory framework, and these are focused on their own experiences, frustrations, sources of knowledge and resources at hand. Importantly, patients and healthcare providers can have discordant explanatory frameworks for pain and this influences the therapeutic relationship, subsequent management decisions and, ultimately, the patient’s outcome.
To explore the evidence for different explanatory frameworks for pain, we conducted a series of focus groups with adults from three CALD communities: Assyrian, Mandaean and Vietnamese (Brady et al 2016). Broadly, each community communicated a different explanatory model for conceptualising pain, with biomedical, biopsychosocial, and traditional Eastern models underpinned by principles of Âm Dúóng harmony.
Subsequently, pain management content and delivery approaches were modified to align with this explanatory framework, and key concepts and messages were positioned in ethnoculturally acceptable ways. For example, recognising that some exercises are classified as Âm and others Dúóng can facilitate patient engagement in exercises that specifically target imbalances in their Âm Dúóng harmony.
Eliciting and incorporating ethnocultural values
Eliciting the personal, social and cultural narrative of pain is fundamental for arriving at shared understandings of pain, and for guiding management. A culturally-informed pain assessment, guided using the Pictorial Representation of Illness and Self Measure (PRISM), a pictorial assessment tool of pain-related suffering (Brady et al 2019), facilitated identification of different cultural values to be incorporated in treatment. They are hierarchical social order, collectivism-individualism, gendered roles and spiritual identity.
A value of hierarchy manifested in the roles adopted in patient– healthcare provider relationships informed the use of educative techniques such as Socratic dialogues. Similarly, values of collectivism framed treatment strategies and priorities such as promotion of strategies that aligned with engaging community and/or family and facilitating role fulfilment. Spiritual identity underpinned coping strategies (active or passive spiritual coping) and could either magnify or attenuate a person’s sense of responsibility for their pain management. Awareness of spiritual identity could facilitate engagement with self-management principles such as spiritual rituals as a means of relaxation or the use of proverbs to facilitate motivation and self-empowerment.
Health literacy and health system considerations
CALD patients may have greater threats to health literacy than Australian- born communities, and this can be magnified for those without English- language proficiency. Using the Health Literacy Questionnaire, we identified that CALD communities had poorer health literacy than Australian-born patients with chronic pain across four of the eight dimensions including ability to actively engage healthcare providers, navigate the health system, find good health information and understand health information well enough to know what to do with it. This is consistent with other research.
Similarly, cross-cultural research indicates that healthcare providers behave and communicate differently with CALD patients, including evidence of implicit and explicit biases, less positive affect and less quality and collaborative care. Awareness of one’s own personal and professional biases and directing resources, time and attention to addressing access barriers and improving cultural acceptability of pain management materials are potential strategies.
Use a structured approach to cultural adaptation
Finally, successful adaptations are more often achieved when a deliberate and structured model of cultural adaptation is adopted. Evidence from health promotion, mental health and chronic disease literature highlights that adaptation strategies based on deep-level understanding of ethnocultural beliefs, values and challenges to healthcare have a greater effect than those adopting singular or superficial strategies such as language adaptations.
In our research, we delivered a cultural adaptation of a physiotherapy-led pain management intervention based on a structured adaptation model (eg, the ecological validity model), and observed higher rates of program completion, attendance and adherence across three distinct ethnocultural communities compared to usual care (Brady et al 2018).
In summary, to meet the needs of multicultural populations, interventions should be tailored to the individual, social, and ethnocultural factors that influence health. Physiotherapists can play a key role in ensuring their assessments and interventions are delivered with culture in mind, thereby optimising their engagement and partnership with the communities they serve.
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APA Musculoskeletal Physiotherapist Dr Bernadette Brady has clinical expertise in musculoskeletal and chronic pain physiotherapy. Dr Brady works clinically in the Department of Pain Medicine at Liverpool Hospital and was awarded her PhD in 2019 and received a RPF Seeding Grant in 2016. She continues research affiliations with Western Sydney University and The University of Sydney.
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