Soph
Today we're joined by Jessica Fishburn. Jess is an experienced physio who works primarily in pelvic health and with patients experiencing persistent pain. As an advocate for women's health literacy, Jess has a fierce passion for population-wide education and thoroughly enjoys her presenting roles at events, forums, conferences and universities. Jess is committed to improving the health and wellbeing experience for rural women. Alongside her business partners, she's a director of Gen Health Hamilton and Profeet Footwear, Hamilton, a specialist podiatry shoe store.

Outside of work, Jess wears many hats. Mum, wife, volunteer, retired board chair, hiker, veggie gardener, ocean swimmer and novice aerial hoop artist. You keep yourself very, very busy, Jess, thank you so much for joining us. Welcome to Physios on the Mic.

Jess
Thank you so much for having me. And that bio, it does often spark lots of conversations, in terms of business and randomness of my hobbies, too.

Matt
Do you mind telling us a little about your physio story, your physio journey, and why you wanted to do physio in the first place? Because you have many other hobbies and skills.

Jess
Sure. So my journey actually goes back quite a long way in that when I was a little girl, I actually wanted to be a plumber. And my dad's a plumber. And my mum very wrongfully, reflecting back now, sort of sat me down and said, most little girls don't want to be plumbers. Maybe think about something else. And at the time I was a dancer. So I thought, well, that's it, I’m going to join the Australian Ballet, I'm going to be a professional dancer. And I probably got to maybe 13 or 14 and realised that I was never going to even make the front row at a ballet performance, let alone the Australian Ballet. But I was always at the physio, so I thought, well, I'll join them that way, and I'll become a physio with the Australian Ballet.

So I worked really hard, was fortunate to get straight into uni directly doing a Bachelor of Health Science, Masters of Physio Practice at La Trobe. And then in my very first year I was really fortunate to do an observation placement at the Mercy Hospital in Melbourne and the rest is history, in terms of, I just went straight down the path of pelvic health. Back then, it was deemed women's health. We weren't as inclusive as we are now. And that really started my really fierce passion for women's health.

So I graduated in 2013, and I had a job lined up back here in Hamilton, in southwest Victoria, where I'd grown up. Recruitment is a very big challenge in rural settings. And so, my boss at the time had offered me a bursary to come back. He was my local physio growing up. And so I moved back. And while the job wasn't, you know, it was the classic, don’t go straight into private practice, you're not going to have support. It wasn't a really great start to my physio career. It wasn't about the healthcare, it was about the numbers. So I actually left that job, after 18 months and together with my housemate and her boss and one of my work colleagues, we started a business called Gen Health. So I was only 18 months out of uni, which is absolutely wild. I don't think I told anyone that I was involved in the business for the first three years, to be perfectly honest. The person that I was going to for all my support was my colleague Mel. So she was going into this and I was like, well, if she's, you know, she's doing all my mentoring, she's doing all my supervision. I'll join forces.

So we started Gen Health and we've just turned ten, which is wild. I'm very proud of that. And so we started as two physios and two podiatrists. it’s wild to say this now, but we were the first and the only combined allied health clinic in our region because everyone else was just working in, you know, there was a physio clinic, but the physios were working in silos, no one was referring to each other. There was a chiro clinic. The chiros were working in silos. No one was referring to each other. There was a podiatry clinic and that was it. And then there was the local hospital. And so we were like, this is ridiculous. We need to be, you know, what happened to the MDT, or the multidisciplinary team, you know, that was the way that we'd studied at uni, and my housemate was a podiatrist so I would come home from work and have a patient with hip pain, like, I don't know what I'm doing or the patient's not getting better. And my housemate Steph would say, well, have you looked at the foot posture? And I'd say, I don't know. So I send, you know, refer down. So it just sort of came organically. And so yeah, we started with two podiatrists and two physios, but we now have a team of six physios, four podiatrists and an exercise physiologist. And two OTs. Sorry, exercise scientist. Hopefully in the near future we'll have another exercise physiologist and two OTs.

So yeah, we've grown and but in that time, I then also went and did my pelvic floor pelvic health training. So right from the get-go that were really very much, I did the Women's Health Training Associates pathway back then. It was before the APA pathway. But that's what's now moved into the APA pathway. And it was, you know, you really needed to have two years’ clinical experience before you could go down this path. And I was banging on the door, I'm like, I want to do it. Let me do it. I had done my final placement at the Royal Women's, and I was very fortunate to have a couple of people that gave me some very kind references to actually jump in and do my women's health training, sooner than the two years. So I started my first year out, whilst I was still, you know, working in a musculoskeletal private practice with pretty minimal support. So it was sink or swim, unfortunately.

Soph
Absolutely. And it's so amazing, Jess, to hear, like, obviously you had such a passion for women's health so early on and you just, like, you know, ran headfirst into that, which is just awesome to hear about. And congratulations on your ten-year anniversary, too, that’s some very impressive and massive milestone. It sounds like, you know, women's health in particular has really been where you've, sort of, focused on pretty much from the get-go. If we reflect, maybe, on your current caseload and the, sort of, people that you're seeing on a day to day, what does that look like for you? And like, what sort of, I guess, presentations or patients are you generally working with?

Jess
So at the moment, I do two and a half days clinical, and then two days non-clinical, whether that be teaching or business stuff. And it's pretty well so I only see women's health or pelvic health patients now mixed in with complex pain, complex and persistent pain. So, I would say my breakdown is about 50% of that is complex pelvic pain. So I do get referrals, because of my interest area in pain that then developed, you know, two or three years into the pelvic health journey I get quite a few referrals from our local gynies and the local doctors.

Unfortunately, we’re, being rural, we are still quite slow with the referrals into pelvic health. So what happens is the patients will often be referred to the gynaecologist because the doctor thinks that they need to refer up. And they get to the gynie and like, we can't do anything until you've done pelvic floor physio. So I get most of my referrals from the gynaecologist, which is fantastic, and I work really closely with them. So it's like 50% is, persistent pelvic pain, I'd say. Then another, maybe 20% is persistent musculoskeletal pain, which might be, you know, complex back pain, complex WorkCover presentations that have then really gone into that nociplastic pain.

I get a few referrals from orthopaedic surgeons after, you know, they've done a few surgeries and the patient is still experiencing pain and they, unfortunately, wipe their hands and say, oh, my job's done now you need to see the pain physio. Which is not, you know, unfortunately, then it's a really complex position for the patients to be arriving in because they've had a lot of intervention. Usually at least one or two surgeries and we know that their nervous system is very, very hyperaroused.

So I said it's about 20%. And then the other 30% would be general pelvic health. So, a mix of antenatal, postnatal, prolapse, constipation, that sort of thing.

Soph
Sounds like you've got a really good mix of things going on enough to keep you firing on a few different, you know, give you the variety that you might, break it up a bit, I guess. So, like, give you different things to think about. Quite challenging.

Jess
Yes, I really do. And I can literally go from, like, looking at my day tomorrow. I've got my first patient is a perianal fissure that hasn't recovered. And then my next patient after that is a complex, persistent pain. WorkCover, who I'm assisting one of the other physios in the clinic with managing their nociplastic pain. And then I've got, you know, an antenatal pilates class, which is just great. And I'm holding onto babies and, you know, exercising women. It's just, it's really fun.

Matt
You do so much and you see so much in your clinic. Can you describe your approach? Let's say someone's complaining of persistent pain in the pelvis. What's your approach and management for that person? What does that look like?

Jess
Great question. I think, generally speaking, so, for a bit of context of where I am as a clinician, we’re in a rural setting so, Hamilton, where the clinic is, is an hour north of Warrnambool and about four hours west of Melbourne. So, I like to refer to it as the mighty southwest of Victoria, in the Western District. And a lot of the time when I'm seeing patients, it's taken them a really long journey to get to see me. So they might have seen you know, they might have seen, like I said, a doctor, they may have been dismissed with their pain. Or they're very likely to have been dismissed with the pain, especially if it's complex pelvic pain. And they've been living with, you know, period pain for five, ten, 12, 15 years. And then it's getting to the point where it's impacting on their quality of life. It's impacting on their ability to be intimate with their partner or to reproduce, or it's impacting on their ability to work or, you know, do the sports or things like that that they like. And number one, most of the time is actually just really getting a timeline of their story.

And right from the get-go and at every single point, validating it. So, you know, really reaffirming that I can see that you're in pain. I can see that this has had a really big impact on your quality of life. You know, number one, your pain is real. So that's the biggest thing that I'm doing. And you just see this, it breaks my heart because they've got to me, they've had this really long journey and most of the time they've either been told that their pain is in their head and that, you know, they've got conscious control over it, or that, you know, the pain is not real. Oh, we've done all these tests and therefore we can't see anything. Therefore, what you're experiencing isn't real. And when someone's, you know, not able to go to work or not able to go to school or not able to be intimate with their partner, you know, that's huge.

So usually my approach is explaining who I am as a pelvic floor physio and as a pain physio, and saying the things that they've done in the past contribute to their story and understanding their pain story and, you know, identifying the musculoskeletal factors that are contributing, but then also layering it with the pain education of the neuroimmune response or that nervous system upregulation and identifying that we need to work on the two of them together. We can't do them separately. And that, you know, working on those things together that we can help manage or we can help treat and recover from their persistent pain. Language is so important, you know, as you both will be aware of, language, the narrative, the context in which they come in is just so important.

So that's how it sort of starts. And then from there, you know, it's obviously a tentacle of number of different treatment options. You know, if they haven't had any form of rehab or if they haven't had, strength training, you know, I'm getting them moving, but I'm also then teaching them why they hurt, teaching them about, you know, the factors that may be contributing to their upregulation of the nervous system. So identifying stresses, identifying beliefs around pain, identifying poor habits with sleep and diet and, you know, social isolation and things like that. And then really addressing the ones that are causing the most impact or addressing the ones that are going to have the biggest impact straight away so that you can get that buy-in and then, you know, taking the patient along the journey with you.

The reason why I just loved pelvic health straight away was because of the impacts that you could have on someone's quality of life. No offence to elite dancers, if you're listening. You know they're already functioning at 99%, but seeing these women that, you know weren't able to just function and you could have a positive impact on their life, like, it's very cup-filling. And the same thing with pain, you know, if someone comes in and, it's a running joke, like, I've got a box of tissues sitting here, I go through a box of tissues a day in the clinic. Because I seem to make all my patients cry. But I think it's them getting that chance to actually, you know, be heard and, have a path forward that I'm not having much responsibility in, but I'm taking them on that journey to recovery.

Matt
Yeah. So it sounds like you're kind of identifying, you know, what they've gone through and explain their context and really encouraging them that there is hope. There is hope for, you know, restoring quality of life. And they have quite an active role in their own restoration.

Jess
Yeah, that’s actually a really good point, Matt, because it's something that I say to every single patient on their first visit, particularly if it's a pain patient. Have hope because I believe that hope stands for Hold On, Pain Ends. That's my mantra. And, you know, I get them to say, let me know when you're losing hope. Because if you're losing hope, there's something that we're needing to change. And I think that's really powerful.

Soph
Absolutely. Jess, I'm really interested because I know that you have this really fascinating sort of, like, mixed caseload. And I know that you have a very strong backing, I guess, in the more traditional sort of musculoskeletal, chronic pain space. And then obviously you have started to take it into the women's health space as well. I'm really interested to know, based on your experiences and what you've seen when working with patients, particularly in the women's health space, can you think of any particular sort of challenges or maybe difficulties, when it comes to the translation of some of the pain management or pain science in that group, or maybe some of the unique things that you find you have to sort of adapt or do differently, that maybe is different to just the traditional sort of musculoskeletal pain.

Jess
Such a good question. It's such a nuanced position and, you know, I'll sit at pain conferences and hear pain science, you know, and being like, this is gospel. And then I'll sit at women's health or public health conferences and, like, pelvic pain conference and it's like, this is gospel. And that doesn't really apply because, you know, this is end organ, you know, particularly when we're thinking about, adenomyosis and endometriosis and things like that. I honestly straddle the middle. I see that there's, you know, both aspects contribute. I don't think that we can completely disregard pain science. I do think that there is some very much nuance when it comes to endo and adeno, and I would say that more so with adeno than endo.

But, you know, clinically, what I see is that if we are treating the whole person, if we're treating the musculoskeletal response, so if we're looking at a patient that's got really debilitating pelvic pain because of endometriosis or because of, you know, a number of contributing factors, it can start regardless of whether it's endo or not. It can start that visceral, visceral or visceral convergence cascade that we see. And then we see upregulation of the nervous system. We see pelvic floor muscle spasm. And then, you know, if we can treat that pelvic floor muscle spasm but try and lessen the impact of that end-organ contributing factor, whether it be endo or adeno or polycystic ovarian syndrome or, you know, whatever it may be. Yeah, if we can couple them together, I think it works really nicely. You know, we're treating the musculoskeletal response while suppressing the end-organ impact, I think that both can be, you know, true at once. And I clinically see that, you know, I can see women that have had debilitating endo and that have had, you know, five or six laparoscopies, they've been told that the only thing that's going to improve their endometriosis is a hysterectomy. And they're 22 and they're like, but what about children? And, you know, the fact that that's still happening when we don't have any evidence for that, is really debilitating. I mean, again, adenomyosis is not a new player on the field. But we've got a lot more research coming out about, adenomyosis and the treatments are different. And yeah, so I think both can be true. And anecdotally I see it working really well. When you treat the musculoskeletal response and you're treating that upregulation of the nervous system or that nociplastic pain, but really identifying the two of them together.

Soph
I think what you're describing there, this idea that it's not necessarily ‘either/or’ it can be ‘and’, you know, it's ‘this and this’ and it's about giving the person the best opportunity for recovery by bringing lots of these things together. I'm going to ask you, because I know that this is an area of particular interest for you, and you're far more of an expert than either Matt or I. But, you know, I guess endo has obviously been very topical recently, and there's been a lot of discussion about, you know, treatment of endometriosis and funding and research. It has traditionally been viewed very much through that sort of medical lens of, you know, we need to go in and do surgery or we need to just treat it hormonally. And not to say that those two things don't necessarily have any value. But I know I've certainly, sort of, come across sort of some growing areas and sort of recognition that maybe that broader sort of management can be useful. Could you maybe comment on that side of things a bit more?

Jess
Yeah, absolutely. I think, you know, even removing the context of endo, if you look at what we as individuals are doing and what our patients are doing on a day-to-day basis in terms of wellbeing now compared to what they were doing 20 to 25 years ago, we're eating differently, we're moving differently, we're sleeping differently, you know, we're so wired all the time, that actually relaxing and switching off is such a foreign concept for anyone. Slight anecdotal side note. Last night I do this hoop class and one of the girls fits the bill of, she's got dysautonomia. I think that there may be some sort of Ehlers-Danlos-type, Mast Cell Activation-type presentation with her. And, you know, she'd been given so many different medications to try and was like, has anyone actually suggested doing diaphragmatic breathing or taught you how to do diaphragmatic breathing? She was, like, what is that? And then we lay down on the floor and did some diaphragmatic breathing. And it was so incredibly challenging for her. But I can see the biggest impact that that's going to have on her thoracic spine her tightness, her pain, is actually just mobilising it and relaxing that diaphragm.

Some days I get to the end of the day and I'm a little bit, like, have I had the same conversation five times today? And this is why we like the population health impact side of things. Like, I go and talk about flow states with women that are in, you know, perimenopausal, no one is exercising, no one is doing any form of strength training. Everyone is stressed out in their minds because of, you know, societal expectations of, you know, they need to be doing this, they need to be doing that, they need to be seen to be doing this. Like, we need to just strip it back to, we need to eat well and regular food, good quality, you know, not hyper processed food. We need to move our bodies and move our bodies in multiple ways and functional ways. Like, we don't have to just be doing, you know, high weights at the gym and walking. We just need to, you know, have play therapy.

And so a lot of what I'm actually doing with people is bringing it right back to just those absolute basics. If we can do the basics, and we can also manage the end organ with either suppressing periods or, you know, removing active endometriosis once, just once, it doesn't need to be done and redone and redone again, And we're still having issues, that's where we need to intervene further. But if we're not doing the basics, we can't just look at these bandaid approaches. And there's some amazing things in the pelvic pain sphere, in terms of treatments like pelvic wans and TENS machines and, dilator therapy, you know, they have a place, they absolutely have a place. But a lot of the time, it's not that I'm prescribing that because I'm prescribing diaphragmatic breathing. And people come back and they're like, oh my God, like, it drove me mad. But it was the best thing that I've done and I'm sleeping better because of it.

So I really do feel like we need to strip it right back to basics, as well as then adding these adjuncts and, you know, it's not trendy, that's not Instagramable, that's not, you know, no one's paying $1 million for it as a new treatment, but we just need to bring it back to that, if that makes sense. That's my opinion anyway, and I see it working.

Matt
I think we're quick to, you know, try and throw in more fancy treatments or fancy stuff just because if it looks fancy, it's probably gonna work well. But, you know, we're designed to move, we’re designed to do the basic stuff that you're talking about. And if we don't do that, it seems like it has a cascade in your whole body. Like, your whole body is just really upset.

Jess
Back when Soph and I did the professional certificate in pain science through UniSA, I just sort of noticed this pattern that I was describing to patients all the time. And my team mates here have dubbed it my pain flower, because when I draw the diagram, it looks like a flower because it's got five, you know, domains. But basically something that I explain to all patients is that pain is in the middle and pain impacts on the way that we move. And so if we've got really bad pain, the way that we move is hindered. You know, a lot of the time with pelvic pain we’re, you know, wanting to be in the foetal position and not wanting to move. And we've been sold this scenario that if you've got period pain, you need to have a hot water bottle, take the day off and lie on the couch and watch daytime TV. That's the last thing we need to be doing. We need to be engaged with community. We need to be connected. We need to be moving our body in a safe and, you know, gentle way.

And so, you know, a lot of the time in that sort of second part of the first petal is that, I recognise that this is a podcast and no one can see my hands, But figuratively, if you're listening and you're thinking about how I'm talking about this, that first petal of the pain flower is the way that we move. If we're not moving, it makes a pain worse. And then pain impacts on our thoughts and feelings. And we know that if we're not addressing our thoughts and feelings around pain and our thoughts and feelings, you know, we've got the statistics and the correlation between depression and persistent pain and persistent pain and depression. If we're not actively addressing that, and that's not always in our scope of practice as physios to be addressing, but referring out and referring to the appropriate people that have got that backing and they've got a solid understanding of pain, you know, if we're not addressing that, that makes our pain worse. So that's coming down and linking that second petal of the pain flower.

You know, pain makes us eat poorly, if we're in pain, the last thing we feel like doing is going getting fresh produce, standing and preparing it, or eating wholesome food. And we go for the quick fixes, you know, we go for the prepackaged veggies, we go for the prepackaged, frozen meals or, you know, even worse, takeaway. And then that makes our pain worse because we're not getting that really good, nutritious, regular consumption of food. We don't see that we're eating good protein, you know, we're not having that nice balanced diet.

And so, you know, that links that next pedal of the pain flower just making everything worse. Same thing happens with sleep. You know, pain impacts on the way that we sleep. It impacts on the way that we can fall asleep. It impacts on our quality of sleep, it impacts on staying asleep. And so if we're not addressing sleep, our pain actually gets worse as well.

And then the final, you know, the fifth petal is sort of that linking the social and the work aspects. Or, you know, the other occupations that we have outside of our identity of our role and our jobs. But, you know, the way that we rock up in community. The way that we participate with our family, the way that we participate with friends and social networks. If we're in pain, that's the last thing that we feel like doing. And if we're in pain, we don't do it, which makes our pain worse. So it just ends up being this, you know, spiraling, self-fulfilling prophecy that pain's impacting on all aspects of our lives. And so we'll explain that to a patient. And I sit with them with that. And I'll say, you know, I can see that this is impacting on every aspect of your life. That's really hard. But it comes back to that concept that there's many factors that impact our pain, which means that there's many factors that we can positively influence to decrease them.

And so, you know, while we can't have all five of those, you know, being championed at all times, I personally do believe, and I see it clinically, that if we can have three out of five of those pretty good, you know, you can manage your pain quite well. And in someone that's got a condition that does have an ongoing narrative around pain, something like a fibromyalgia or an endometriosis or, you know, a rheumatoid or an Ehlers-Danlos or that, you know, pain is sort of netted into the identity and the diagnosis. My response is that we just need to have three out of five going well and three out of five that we can work on and have active influence on. So, you know, sometimes diet does, you know, go out the window, or, you know, it's the middle of winter and you live in Hamilton and it rains and it's so cold and it's dark and you’re not exercising. But if we, you know, I still want people exercising, but if we can prioritise the other three, I tend to see better outcomes. And again, it's just an analogy that sort of came and has been developed, and for my own personal scenarios with patients, but it gets that little bit of buy-in, too, because, you know, it's not just someone saying, oh, have you tried exercising or have you tried improving your sleep? Because a lot of the time someone said that to them, but they're like, but how do I do it? So yeah, I'll spend time finessing that.

Soph
I think, yeah, you've touched on that, like all of these things, I would agree are really important. And I think, the point you made about, you know, we can say these things and it doesn't necessarily always mean it's an easy fix or that we can do all of these things all at once, is really important. But, you know, even just knowing how much of a biological effect that has, I think is, is really valuable too. And we know, you know, for anyone who wants to go on a deep dive, you know, the relationships between these different factors and how that impacts on the nervous system and the immune system and the endocrine system. It's such a fascinating thing. And we can really kind of biologically see why these things have an impact. But to hear you articulate it that way, I think is just a really lovely example, Jess, thank you for sharing that.

I'm interested in your reflections on your women's health journey and pelvic health journey. And with everything that you've learned and your interest in pain and hearing how it it's so valuable to your practice and the ways in which you use it. And it really sounds like it's just an essential piece of what you do with people on a day-to-day basis. Do you feel that currently that sort of bringing in of the pain side of things is something that happens, you know, pretty well across the women's health space generally? Or do you feel like it's still something that maybe needs a little bit more work or integration?

Jess
It's hard to say, because in the circles that I'm in and, for example, being, you know, at the pelvic pain conferences and things like that, I do think it is. The people that are interested and are subscribing to educating themselves and furthering their education, I think it is. From a pelvic floor scenario, I think it's definitely improved greatly in the last five years. Personally, I see that. I think the big gap where it's still an ‘us and them’, like, or, you know, a pain and a women's health and it's really segregated is not necessarily in the physio realm. It's more in the medical, gynaecological realm. And so, I'm so fortunate the gynies that I work with, they just, you know, it's any pain patient, anyone that's coming to them for pelvic pain. But, you know, they've including a pelvic floor physio in the journey.

Unfortunately, being rural and me being private, I’m not accessible to everyone, that does have a really big barrier. I also am booked out for about three and a half months. And you know, there's not a heap of us around the area. There are a couple of incredible pelvic floor physios in Warrnambool, which is amazing. But again, they're in the private setting. We've got quite a shortage in the public health setting. It doesn't help that everyone keeps lollypopping in and out of maternity leave because that's a scenario that happens.

You know, we've got challenges. I don't say this lightly. We've got challenges in rural health where, you know, it takes six to eight weeks to see a GP and the GP that you see may have never trained in any pelvic health, you know, they might not have any interest in it. They might have just on their base-level training, which could have been 20 to 35 years ago. If that's a patient's first experience of the medical system and the you know, what help’s available, that can be, you know, incredibly damaging, and you set them back, you know, five years to seek help.

At the moment, I've currently got a patient who had been splinting the back wall of her vagina with a bi-manual splint. So inserting two fingers into her vagina to splint the back wall of her vagina to empty her bowels for the last 25 years. She was told that that's normal, since she's had children. She, on two occasions, she'd asked a doctor about it, and they had both had said, oh, no, you've had a child that you know that fits within the realm of normal. And it was only that she was actually at a pharmahealth information night that I was, you know, talking. And she said, is there anything you can do? And I was like, absolutely. You know, there's so much that we can do.

So I wouldn't say that it's so much in the physio realm anymore. I feel like that there's some really good big players that are championing the conversations at a really international level, and, you know, the Pelvic Pain Foundation of Australia just do such phenomenal stuff that they are really bringing that on board. It's more the medical pain side of things that then is, you know, really looking hormonal. Let's remove organs, that kind of stuff.

Matt
Do you see some of your capacity is educating, like, your local GPs or things like that?

Jess
I do and it is a really nuanced, challenging thing. It's a really, really challenging thing, like, to be perfectly honest and going on a podcast and saying this, being a younger female in a rural area where some of the doctors in the clinic were here when I was born and I'm 35, they do not want to hear from me.

With the pain professional certificate in pain science and pain education that I did through UniSA, Soph and I were really lucky to get scholarships to do that through Pain Revolution. And one of the commitments of that was actually, you know, taking this latest pain education and pain science to our rural communities and translating that into practice. You know, I've had great uptake with allied health professionals. I've had great uptake with community. And I know the EQUiPP program is now rolling out through our area of actually taking that pain education to community because, you know, these doctors, and it's not necessarily just sitting on the doctors, but they have to be generalists. They have to, you know, they've got anything coming through the door. So they have to know exactly what they're doing with the latest updates with, you know, diabetes right through to, you know, random cysts. And so if it's not an interest area for them, we see hormonal presentation and particularly perimenopause, menopause and anything that's hormonal.

You know, we've got two female GPs in the region. I'm sorry, two and a half. You know, in a in a regional town of 10,000 that serves a bigger population, they're then getting, you know, anything that's hormonal. And, but that's not necessarily their interest area either. And so not only are they completely at capacity, they're not wanting and they're not necessarily wanting to engage with a physio who is, I hate to say it, but the biomedical model of health care and the hierarchical health care really exists in rural Australia. And I think it's going to be a long time to break down those barriers. And I'm trying, but there definitely is days that I feel really disheartened.

I've really pivoted and shifted in. I'm really lucky I get asked to do all these education sessions for, you know, right from schools, right through to, you know, parents of school kids, right through to, you know, local health, bush nursing centres, footy clubs, like, I'm often speaking at the ladies day at football clubs. And if they give me a mic, you bet me, I'm yelling things like, talking about where the clitoris and when the clitoris was found and, just challenging gender norms and gender stereotypes in a rural setting and yeah, really, really challenging that. But I'm having a better and a bigger impact at a population level than I am in a GP level.

And I think I feel a bit nervous saying that on a podcast. So hopefully no one come fight me. But if someone, if someone locally is hearing that and they finding that to be offensive, that's where I'm like, let's have the conversation. I'm not trying to, you know, I'm not trying to tell you what you're doing is incorrect. I'm just trying to actually say, hey, you know, can we think about adding pain science education to the way that we're talking and changing the language. You know, I don't know how many times I have patients come in and they tell me that they've got bad knees or, you know, someone's told them that they've seen their x-ray and they're absolutely stuffed or, you know, farmers use a lot stronger words than that.

Soph
What you've really articulated, and what jumps out at me is just what an important role women's health physio can have. And where, you know, we can really make a big difference for a lot of people. Before we finish up and maybe as like a closing point, if you want to, anyone who's listening to take away just like one key insight or maybe one bit of advice, what would you want them to walk away with today?

Jess
Don't be afraid of persistent pain. Don't be afraid of working with these patients with persistent pain. There's some amazing short courses that you can do to get you, you know, to get you firstly versed in it, and then I do encourage people to, explore further options of pain, persistent pain. You know, it's not as trendy as sports. It's not as trendy as women's health or pelvic health or neuro or, you know, other things. But I think that it is such a rewarding aspect. And, you know, the main reason people seek out a physio is usually because of pain.

And at the end of the day, like, they are coming in because of pain. And if we are well versed, it's something that I do with our whole physio team here. You know, every acute injury, we are needing to be thinking about, you know, I don't like the term yellow flags, but we need to be thinking about some of those contextual things that have happened around the time of injury, to pick up if that is going to develop into a persistent pain presentation, as opposed to, you know, nutting it in the head straight away and treating it as an acute injury, but coupling it with some of that pain education right from the get-go. We could be preventing ridiculous surgeries that probably don't need to be happening. Don't get me wrong, there's some surgeries that do need to happen, but, I think that that would be my biggest thing, that if you've got an interest area or if you starting to see it, you know, lean into it, it's really rewarding.

I mean, it does come with its challenges. We haven't touched on trauma as a pelvic-floor physio working in pain. My caseload is incredibly high of intimate partner violence, sexual trauma, childhood sexual assault. And that is very confronting. And you need to make sure you're well supported to be able to see those patients, to be trauma informed and to have the practices and processes in place to look after your own physical and mental health. So that is something that is very important. And, I don't say lightly and I don't think that we can ever take lightly because, I get a lot of first disclosures of trauma from, you know, 20 years ago because they're in an environment where they feel safe.

But I would say, sorry, on a lighter note, in summary, just lean into it, get the right training and, you know, lean into finding those pathways, whatever that may be. Join the pain groups in your APA networks and states, but lean into those pathways.

Matt
Yeah. Awesome. You did the advertising for us, I think.

Soph
Yeah, this is great.

Jess
Didn't intentionally mean to but I think, you know, the pain groups have such a good role to play. And get to conferences. You know, conferences is where cool people hang out and awesome, you know, awesome conversations happen.

Matt
Well, thanks so much, Jess. It's been awesome and very encouraging to hear how you practise, how you approach pain and just your passion for helping people with chronic, persistent pain and pelvic health as well, amongst many other things that you do. And we want to thank all our listeners for joining us today. We've had a great time chatting, and exploring many things that has to do with pain and really appreciate you taking your time to share your experiences and insights.

And for the listeners out there as well, we've got additional episodes. Please tune in to those. Many thanks for tuning in. And, we'll catch you next time on Pain in Practice.

Soph
Thank you so much.