A few months ago I was contacted by Diarmuid Denneny MCSP on behalf of the UK’s Physiotherapy Pain Association to see if I would speak at their annual study day, which was held in London on Friday 27th January 2018. Having only been in touch via email it was great to meet Diarmuid in the flesh in October 2017 at the stakeholders meeting for the new persistent pain guidelines being developed by NICE (the UK’s National institute of Clinical Excellence), to which we had both been invited to attend.
At this same meeting I also had the chance to meet up again with The Vice-President of the British Pain Society, Dr Martin Johnson, who the following week was due to attend our conference at the Royal Society of Medicine. Dr Johnson was already aware of our work, but attending the conference with our International speakers allowed him to really gain a good understanding of how and why our approach should become more widely integrated into the current pain management approaches. You can read the testimonial Dr Johnson wrote after attending our conference HERE.
I am aware of just how much the understanding of chronic pain has evolved over the past 10 years, helped by the growing fMRI studies and thankfully more and more health care professionals are considering psychosocial factors more seriously. I was, however, looking forward to attending the PPA Study day to get more of a feel for where the leading edge of chronic pain physiotherapy stands in relation to the biopsychosocial, or even psychosocial, model now.
Generally the tendency is for the focus to be on the impact current stress has on pain, so I decided to present the evidence demonstrating the main factors linked to pain onset and it becoming persistent, which includes; current psychosocial factors/stress, past traumas (including adverse childhood experiences), personality, negative beliefs about pain and depression. I believe that being aware of these factors will allow healthcare professionals to consider them when considering a treatment approach.
During the day it was interesting to see how elements of each speaker’s talk related to our own work within SIRPA. It was also encouraging to know that there was a general acceptance of;
- How chronic pain treatments should be person-centred
- How important the therapeutic alliance is
- The importance to educating the patient and helping them become empowered
- The importance of understanding an individual’s beliefs about their condition before deciding how to progress
Clinical Psychologist, Dr Amanda C de C Williams, started off the day talking about the evolutionary perspective on pain-related behaviours and the persistence of pain. One interesting point she made was that chronic pain has not been documented in wild animals, but it does occur in humans, pets, zoo animals and farm animals. One paper she cited by Williams in 2016 questioned whether domesticity fosters chronic pain! She also mentioned studies we include in our SIRPA training about what happens when an animal is injured, how it behaves and how many of these ‘behaviours’/symptoms persist in chronic pain in humans, perpetuated by our ability to analyse, ruminate, worry and catastrophise.
The next speaker was Prof Mick Thacker, a well-respected Physiotherapist and lecturer in chronic pain. He spoke about his current work which is the focus of his PhD in philosophy, the Predictive Model to explain pain. This explains how each level of the ascending and descending neural pathways between the brain and the site of pain/sensation is affected by previous experiences and unconscious responses. This is an interesting concept and certainly something relevant to the work we do. For example, by using an emotional awareness and expression approach to address past, or even recent, unresolved traumas related to an individual’s pain, this helps break the unconscious learned reactions to sensations and activities that would have previously triggered or exacerbated the pain.
Ben Cormack is a musculoskeletal therapist who specialises in a movement and exercise-based approach. He emphasised the importance of education, using a person-centred approach and the therapist being the coach, rather than determining what an individual ‘should’ do. He presented some interesting papers about the benefits of exercise, yet suggested there was no real evidence as to whether it was the actual exercise or activity itself that created the benefits, or for example whether it was a response to socialising, being in nature etc. Ben also talked about beliefs and how important it is to understand what our patients beliefs are in relation to their pain so we can begin to help them gain a more rational/healthy understanding of their condition and physical state/ability.
The next speaker was Clinical Psychologist, Rebecca Chasey, who spoke about compassion-focused therapy, which definitely plays a part in the SIRPA approach. She explained how helpful compassion-focused strategies can be when used with people for example who;
- might have known little care as a child
- are overly self-critical or harsh on themselves
- are ‘strivers’ who are very driven, and
- those who understand that pain doesn’t mean damage, but it still hurts.
Evidence shows that fear, anxiety, ruminating and expectation of pain will exacerbate pain, so teaching our patients how to address these and self-soothe, can only be helpful.
Professor Roger Kerry is a physiotherapist who is well published and is currently undertaking research in philosophy of science, investigating the nature of causation in the health sciences. Most relevant to SIRPA’s work was his explanation of the Dispositional Vector Model. This is a model which demonstrates the factors that tend toward symptoms manifesting (i.e. Stress, fear, sleep, anxiety, beliefs, low mood/depression, lack of social support and self-sufficiency, plus previous experiences) and those that tend against manifestation of symptoms, such as exercise and activities. When practitioners are aware of this, it gives them the chance to explore them with each individual and address any that are relevant.
I presented next with a talk which focused mainly on the evidence related to what are often unrecognised causes of pain, such as adverse childhood experiences and other psychosocial factors shown to be linked with chronic pain.
Dave Baker MCSP, who is an extended scope practitioner and a supplementary subscriber, talked about being an independent prescriber of medications for pain and the evidence base behind the use of opioids etc in the management of chronic pain. With the media focusing on the over-subscribing of opioids at the moment, it was a very relevant talk.
Finishing the day was Physiotherapist, Dr. Clair Hebron, who spoke about the use of social media within Physiotherapy. She focused on the benefits of using social media, for example to;
- keep up with new evidence
- nurture relationships with peers
- learn about what others in your field are doing, even if it doesn’t fit within your own model of understanding.
All in all it was an interesting day and I left feeling inspired and motivated to continue with my own work, knowing that there is a definite shift in the understanding and approach to chronic pain. With the growing evidence showing the impact psychosocial factors play in not just the perpetuation of, but the triggering of, chronic pain these must be considered and addressed in order for our patients to have hope of recovery, rather than just ‘management’ of their pain.
It is also reassuring to see that many of the leaders in this field are becoming so much more aware of the need to have a more person-centred, educational and self-empowering approach to chronic pain, which in our experience allows an individual to have hope in their recovery.
Georgie Oldfield MCSP
Physiotherapist & Founder of SIRPA
Information about the first level of SIRPA’s new online training can be found here.
Purchase my book, ‘Chronic Pain: Your Key to recovery’ here. (available as hard copy, e-book & audio)