It never hurts to discuss pain

Last updated: 07-03-2020

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 It never hurts to discuss pain

Although the 2020 Australian Pain Society’s 40th annual scientific meeting was postponed due to COVID-19, InMotion provides a platform for some of the physiotherapists who were lined up to present at the conference in April to share their research, insights and pain management strategies. We present a mix of contributors and interviews. 

In his book Future Shock published in 1970, futurist Alvin Toffler wrote ‘the illiterate of the 21st century will not be those who can’t read and write but those who can’t learn and unlearn and relearn’. It is a sentiment to which physiotherapist and author APA Musculoskeletal Physiotherapist David Butler wholeheartedly prescribes, and one he often quotes in his many presentations nationally and internationally about pain and pain education. David is also fond of sharing his own quote, ‘learning is the most renewable energy of all on the planet’, at the end of his presentations.

Both concepts go to the core of what David, a pain communication expert and learning enthusiast, had planned to speak about at the Australian Pain Society (APS) conference, and that is what it means to learn, specifically discussing whether patients might be victims of clinicians’ learning experiences and what can be done to change that. Under the umbrella topic of ‘Thinking outside of the box’ and alongside fellow pain researchers Dr Tasha Stanton, Dr Fiona Kerr and Dr Hannah Brown, David had planned to engage his audience in thinking about andragogy—the education of adults.

The co-author of Explain Pain, an educational tome for clinicians, people in pain and their loved ones that he co-wrote with Lorimer Moseley in 2003, says when groups of university-educated people are asked whether anybody has ever taught them how to learn, the vast majority, upon reflection, will say no. And, he argues, if people have never really been taught how to learn, they might have passed on their faulty learning strategies to their patients, to their friends, family and on and on.

‘In terms of learning for physios, if they see a client just twice a week for half an hour, that’s only 0.6 per cent of the week. So what happens in the rest of the week?’ David says. ‘So this why we’re looking at this “learning to learn” thing in some detail.

‘Lorimer and I wrote Explain Pain a while ago and we have been reflecting on elements of that. So we were actually teaching in what was called “one-way transmission education”, this is education from us to the patient. That’s typical in medicine and health, that education goes one way. It’s as though you’ve opened the patient’s brain and poured in a bit of knowledge and put a few drugs in and shut their brain and they should get better. But when you really look at educational psychology, that’s really not the best way to do it. So this “learning to learn” thinking has been out there in education—but never really in pain education or in health,’ he says.

Educators, David argues, have a responsibility to get better at educating and build up the learner’s ability to learn, particularly when it comes to complex matter such as new pain science. One of the key educational systems that seems to fit health, which David says is still not really used, is self-regulated learning. Modelled on the work of educational psychologist Barry Zimmerman and the self- efficacy model of Albert Bandura, self-regulated learning involves staged learning, guided by metacognitive, cognitive and motivational strategies.

‘When I teach people about this, I always tell them to go and watch the movie Dead Poets Society. t’s 30 years old now but that’s where the wonderful Robin Williams … gave a great demonstration of self-regulated learning as the teacher in it. He said things like “it’s not what another thinks, it’s what you think” and “when you think you know something, look at it in a different way”—all this great stuff,’ David says. ‘So we also link this self-regulated learning into growth mindsets. Fixed and growth mindsets as researched by Carol Dweck. With pain, we’re trying to link into and enhance the growth mindset.

‘So then my talk was going to be about some of the skills and strategies that people use to drive this self-regulated learning. And so I have a list of about, from the science, 12 examples of strategies that people can use to drive it. And it’s the learning to learn which has effects on your own learning, your child’s learning and your patient’s learning. This has become a key part of a lot of the new methodologies that we’re using in some of the randomised controlled trials going on now. We’re making sure, where possible, that participants in trials have the best skills to learn. Clinicians and their patients will be the ultimate beneficiaries.’

Every patient we see has a pelvis. Given that in Australia around one in five women (Pitts et al 2008) and one in 14 men (Pitts et al 2008) have pelvic pain, a large proportion of our patients likely experience pelvic pain, whether they disclose it or not.

The aim of our topical session was to equip the everyday clinician with the tools that they need to start addressing pelvic pain. The session would have focused on intertwining science and practice, highlighting new areas of research and integrating that with tips learned from the clinic to help the non-pelvic clinician start to tackle patients with pelvic pain.

Not surprisingly, many patients don’t disclose pelvic pain patients to their clinicians because they’re embarrassed. What is surprising, however, is that around one in five patients don’t disclose their pelvic pain because they feel their clinician will lack empathy and may not have the knowledge needed to help (Mann et al 2013). This is something we can address clinically, simply by starting a conversation around pelvic pain, asking questions and demonstrating empathetic listening.

You can ask about pelvic pain directly but some patients might need more explanation about what the pelvis is comprised of— the organs, genitals and perineum.

Many types of pelvic pain are functional related, so asking about pain during these functions can also spark discussion. Some useful questions could be:

If you have started the conversation and your patient has disclosed their pelvic pain, you should follow it up with an assessment. Don’t fear—the assessment of a pelvic pain patient can be quite similar to any other chronic pain patient, and many valuable assessments can be undertaken through a ‘pants-on’ approach.

Like other pain presentations, the biopsychosocial model can help to guide our assessment of patients to understand their experience and contributing factors to their pain. Some pelvic pain presentations are associated with biological factors (adenomyosis and bacterial prostatitis as two examples), but many are not (vulvodynia and abacterial prostatitis as two examples). This can make a diagnosis difficult to achieve, but understanding the nature, pattern, and aggravators for a patient’s pain is a good place to start.

Cyclical pain in women may suggest a link to hormonal fluctuations such as dysmenorrhoea (period pain). Pain that is aggravated by different functions might give insight into possible biological contributing factors—for example, pain on defecation may be associated with endometrial lesions involving the bowel in women with endometriosis (Fauconnier et al 2002).

Psychosocial factors can play a role in the onset and/or maintenance of pelvic pain for some people (Nickel et al 2008, Stones et al 2000). Some research that I have been involved in has looked at how we can assess these psychosocial factors, and how pelvic pain might also influence a person’s psychosocial status.

For female patients, the Pelvic Pain Impact Questionnaire (PPIQ) can be a starting point for understanding how pelvic pain may impact a patient’s life (Chalmers et al 2017). A male PPIQ has just been developed but isn’t yet published. Similarly, a soon-to-be-published tool, the Pelvic Pain Psychological Screening Questionnaire (3PSQ), screens for comorbid psychological factors in pelvic pain patients and may assist in determining the need for on-referral for psychological interventions.

It is also important to gather similar information that you would with any other chronic pain patient, to get an understanding of the types of interventions you could use. How much does your patient understand about pain and/or their condition? What other factors could be contributing to their experience of pain? What is their overall health like?

Given that many patients fear that their clinician will lack empathy, validating the patient’s experience as real is the first essential step. No two patients will be the same, so a one-size-fits-all approach won’t work with pelvic pain.

There are, however, some general management strategies that seem to help many patients. Many of these strategies are borrowed and adapted from research undertaken in other chronic pain populations, as research into pelvic pain is sparse.

Many pelvic pain patients will relate their pelvic pain symptoms to times of higher stress, so implementing strategies to reduce stress can be helpful. Stress can cause reflexive tightening of the pelvic floor, so many pelvic pain patients will also present with pelvic floor hypertonicity. The Pelvic Pain Foundation of Australia has some good resources for pelvic floor relaxation techniques.

There is mounting evidence to support the role of pain neuroscience education (PNE) in treating chronic pain conditions; however, evidence specifically in pelvic pain patients is limited. Recent Australian research by James et al (2019) supports the use of PNE in female pelvic pain patients. This education should include basic PNE principles such as those outlined in Explain Pain (Butler & Moseley 2013) but, as suggested by James et al, should also include education specific to the pelvis such as organ cross-talk, overcoming taboos, and consider the impact of pain on sexual function and partner relationships.

At the core of the intervention, the learning outcomes we hope our patients achieve from PNE will be similar for all patients, regardless of whether they experience pelvic pain or some other kind of chronic pain.

A final tip for clinicians is to not embark on this journey alone. As physiotherapists, we cannot expect to have all the tools necessary to treat all complex pelvic pain patients.

Having a network of multidisciplinary practitioners you can refer to will help you to provide holistic management to pelvic pain patients. Pelvic physiotherapists, gynaecologists, urologists, psychologists, and GPs with an interest in pelvic pain are all good players to have on your team.

The APA’s online Facebook group for Women’s, Men’s, and Pelvic Health Physiotherapy is also a fantastic resource where you can reach out for help, ask questions, and start discussions with fellow clinicians.  

It was during a lunchbreak at Sydney’s Westmead Hospital that Joshua Pate, APAM, senior physiotherapist at the hospital’s pain clinic, had something of a lightbulb moment. Joshua had been thinking how the same educational message about pain—that pain doesn’t necessarily mean tissue damage—was being told to his patients over and over, and wouldn’t it be cool and efficient to have a professional animation video created to help patients visualise the concept?

Having watched many TED Talks and YouTube videos in his spare time, Joshua decided there and then to turn his idea into a reality. What started out as a ‘bit of a side project’ for Joshua has become an animation that has been viewed millions of times across YouTube and Facebook. And it is this novel approach to large-scale pain-related education, by working with TED-Ed and YouTube to disseminate educational animations about pain science, that Joshua had planned to discuss at the APS conference in April.

At the now-postponed conference, Joshua, one of his PhD supervisors Professor Julia Hush, APAM, and Dr Hazel Jenkins had each planned to share their unique perspectives on ways to engage different populations in pain-related education. For Joshua, the dissemination of public health information has occurred via the medium of online animated videos, which he says are useful based on the responses and positive feedback from patients.

‘We’ve had really good feedback—I get emails all the time from people saying things like “I’ve never seen inside the nervous system before.” Often patients are afraid of textbooks, but if there’s a really engaging story, and a clever animation, they’re more than happy to watch that,’ Joshua says.

‘That’s what much of the data I was planning on sharing at the conference is about; how far these videos have reached, what are the limitations of this approach, and what are the future directions for the field. If you have an idea, how do you distribute it, and is it a good idea to distribute it everywhere or do you need to test the ideas first, before disseminating?’

Joshua, who was awarded the Best Student Research Paper in the pain stream at the 2019 APA TRANSFORM Conference Awards (supported by the Physiotherapy Research Foundation), has produced two animation videos with Ted-Ed; the first is the ‘Mysterious science of pain’ ( and the second is ‘The fascinating science of phantom limbs’ (tinyurl. com/yaasl5e3). Both of these videos have reached an audience in the millions on YouTube, and a third animation is currently in production, Joshua says.

In his research paper ‘Creating online animated videos to reach and engage youth: Lessons learned from pain science education and a call to action’ ( ycx2759t), Joshua collaborated with another leader in the pain field, Professor Lorimer Moseley, to compare the approach Lorimer used for the Tame the Beast animated video, ‘It’s time to rethink persistent pain’ ( y9yj4ndo). In the paper, Joshua and Lorimer explore the differences in cost, ownership, number of hours provided by the content expert, time from idea to publishing and other factors between using Ted-Ed and Tame the Beast.

‘With TED-Ed, you don’t have to pay any money but you won’t make any money, and you have less control and ownership; whereas with the private Tame the Beast approach, you have to have tens of thousands of dollars up front to be able to do it, but then you have much more control. In terms of reach and target audience, TED-Ed have 11 million subscribers, whereas working privately you have to make sure you know how to reach your audience,’ Joshua says.

‘So we wanted to call people to action: We, as physios, have important knowledge and public health messages to disseminate, and now we have access to platforms where we can educate the masses using really compelling animations.’

Joshua, who completed his PhD in paediatric pain education and who now lectures in musculoskeletal and paediatric physiotherapy at the University of Technology Sydney (UTS), says engaging and collaborating with TED- Ed in such a way would allow physiotherapy clinicians and researchers to be context experts and allow creative experts to concentrate on creating the animation.

‘You get to be a context expert. You have a meeting with the producers, you explain the idea and then they run with it. For me, a big misconception about pain is that people think that the amount of damage someone has in their body correlates well with the amount of pain they will have, but the literature doesn’t support that idea. To be able to give scientific illustrations and stories to back that argument up has been really interesting,’ Joshua says.

‘There’s been quite a bit of media coverage and we’re starting to get a bit of traction—people appear to be changing the way they think about the complexity of pain. That’s what my PhD has focused on, how people think about pain, so this project followed on really nicely to my thesis.

‘Rather than settling for a slideshow presentation, we have access to skilful people who are effective at communicating creatively. I think for me, the take home is: why don’t we engage more with other industries?

Everyone involved can benefit from these collaborations. For example, with TED-Ed, the animator’s incredible work can get picked up by big companies like Pixar and such, which I think is why they’re involved in the animation process for free,’ Joshua says. ‘It’s not just the animators who can benefit, but the narrators, audio engineers, producers and directors too—so why don’t we give it a go? It really isn’t a huge time commitment for the content expert if you know your message and audience: it was a few hours’ work over the course of a few months.’  

The way we talk about a health condition shapes the way we think and respond to a health condition. Our group of researchers from the University of Melbourne and La Trobe University has been looking at how people talk about knee osteoarthritis to help us better understand how people make treatment choices.

The group is myself, Nicholas Taylor, Penny O’Brien, Peter Choong, Jason Wallis, Michelle Dowsey and Nora Shields. This topic is important because while clinical guidelines recommend evidence-based, non- surgical interventions such as physiotherapy, exercise and weight loss as first line interventions for knee osteoarthritis, the evidence suggests these interventions are under-used.

At the APS scientific conference, I was to speak on how the language used by clinicians can perpetuate negative beliefs and behaviours among patients, and I was planning to present a series of interactive videos modelling helpful and unhelpful messages in the clinical setting. Instead I can detail an aspect of my presentation here.

To explore how people talk about knee osteoarthritis, we conducted a systematic search of the literature, gathering together qualitative studies exploring knee osteoarthritis from the perspective of people experiencing knee osteoarthritis, their carers and clinicians. The majority of 56 studies we found were conducted in the UK, Australia, the US and Canada, and therefore mostly represented a Western view of health.

Using a technique called discourse analysis, we identified two main ways of talking about knee osteoarthritis: an impairment discourse and a participatory discourse. In the impairment discourse, the body was typically referred to as a machine and knee osteoarthritis was a broken part of the body machinery, which stopped people from doing what they wanted to do. Just like using an unoiled engine, using the ‘broken’ knee was believed to be dangerous.

The only way to ‘fix’ the broken part was for a ‘mechanic’ to pull it out and replace it with a new park. Like with any machine, body parts had a ‘manufacturer’s used-by date’. The ‘inevitable’ decline of the knee joint was perceived to be a normal part of ageing. As part of ‘normal’ ageing there was no need to provide psychological support for this ‘failing machine part’. Instead one had to learn to ‘put up with’ knee osteoarthritis until it had ‘worn enough’ to warrant a knee joint replacement.

In the participatory discourse, ‘busy bodies’ were healthy bodies regardless of age, and a healthy knee enabled the body to remain busy. Rather than trying to ‘fix’ knee osteoarthritis, the focus was on maintaining knee health for the busy body. The knee was perceived to be a structure cocooned in muscles. Unlike joint cartilage and bones which degenerated through invisible processes over time, muscles were visible and under voluntary control. By building up muscles, knees could become stronger and ‘healthier’.

People with knee osteoarthritis were positioned in the driver’s seat, steering the way to knee health. The role of clinicians as ‘custodians of knowledge’ was to empower people with knee osteoarthritis to seize the wheel, help ‘map the route’, and ensure the person had the resources and capacity they needed to navigate the journey.

Once en route, knee health became a life journey rather than a destination.

While our study was limited to knee osteoarthritis, the impairment and participatory discourses we identified likely have relevance to other musculoskeletal pain conditions. Despite evidence pain experiences are poorly correlated with patho-anatomical changes, the belief that musculoskeletal pain signals a damaged body part which needs to be investigated, healed or fixed is widespread. People who endorse this belief are more likely to avoid activity and seek surgical rather non-surgical care.

It is critical that people with musculoskeletal pain have access to a discourse that encourages active participation in healthy behaviours. Physiotherapists play an important role in shaping discourses and are ideally placed to provide people who are seeking care with an alternative way of communicating about musculoskeletal pain.

The analogy of the ‘body as a machine’ can perpetuate unhelpful beliefs about using the ‘damaged body’, relying on others to ‘fix’ the body, and can de-legitimise suffering. Instead, the notion of maintaining the ‘busy-body’ focuses on engagement in life activities and equipping people experiencing pain with the knowledge, skills and resources they need to drive their own healthy life journey. 

Neuropathic pain, central sensitisation, non-specific pain, widespread pain—these are terms that are often used interchangeably to describe persistent pain. And having inconsistent use of language to describe pain is something Tim Mitchell says can lead to confusion for practitioners, patients and students.

‘Someone could go to three different practitioners—for example their GP, their physio and maybe a medical specialist—and have three different terms used, although they’re all broadly talking about the same thing. And that’s one of those classics that creates confusion for people,’ Tim says.

‘Another challenge is that because pain knowledge is still emerging, there are new terms being thrown around that are perhaps not being used in the right context. The language around pain is extremely important both for communicating between practitioners but also, more importantly, communicating with the patient,’ Tim says.

Tim is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2007) and a co-author of the Musculoskeletal Clinical Translation Framework(MCTF). At the Australian Pain Society’s 40th annual scientific meeting in April in Hobart, Tim was to have presented a pre-conference workshop on the MCTF—a framework that was designed to help clarify the use of pain terminology and better enable healthcare practitioners to examine, interpret and implement targeted management for people with musculoskeletal pain disorders based on contemporary evidence and using a common clinical language.

As a lecturer at Curtin University in Perth, Western Australia, Tim says one of the strategies he employs is to practice what he preaches and embed consistent language in the teaching programs, while encouraging other teaching staff to do the same. Other universities have also started incorporating the MCTF into their teaching and there have been a number of other national and international programs that have taken it on outside of the physiotherapy profession, Tim says.

Nursing, medical, chiropractic and osteopathic practitioners as well as kinesiology courses have started using the framework in their teaching, and the MCTF e-books are about to be translated into five languages.

‘We set up the framework by using contemporary language that is broadly accepted and not just “physio speak”, and that’s across different health professions as well. So that language is consistent,’ Tim says. ‘The musculoskeletal framework that we developed was initially to assist teaching students about musculoskeletal pain. And it was about trying to create a fairly simple but comprehensive framework that encompassed all the different domains that do impact on people with musculoskeletal pain.’

Tim says the MCTF has application beyond musculoskeletal pain; the different factors within the framework have application in a whole range of pain complaints and look at factors such as pain features, psychosocial considerations, work considerations, whole-person considerations and functional behaviours.

‘For example, we talk about lifestyle factors and whole-person considerations such as comorbidities and psychosocial factors, and those are across any health condition, those domains still apply,’ Tim says. ‘We’ve specifically tailored the framework around the musculoskeletal pain but you can have people with a cardiorespiratory or a neurological problem and these different factors will still be relevant to consider in their presentation. But there might be specific cardiorespiratory system or neurological system considerations with their diagnoses as well, obviously, but how we approach this is not different.’

Tim will conduct a live online lecture on Tuesday, 28 July at 7.30pm about the different domains of the MCTF. The lecture is for APA members and Australian Pain Society members who were going to attend the APS conference in Hobart in April. The lecture is appropriate for any clinician who deals with any pain condition, not only musculoskeletal pain.

It will incorporate training in the use of the framework, and will be immediately useful in clinical practice. The online event ( is being coordinated by the APA South Australia branch in conjunction with the Australian Pain Society. Participants must register by noon on 28 July to be able to view the lecture. 

APA Honoured Member Dr David Butler is an educator, author, clinician and researcher. He is a Director of the Neuro Orthopaedic Institute and an Associate Professor at the University of South Australia. 

Dr Jane Chalmers is a senior lecturer in pain sciences at the University of South Australia. Her research is focused on understanding pelvic pain, ranging from the lived experience of people with pelvic pain through to the physiotherapy assessment and treatment of pelvic pain. 

Dr Joshua Pate is a lecturer in physiotherapy at the University of Technology Sydney (UTS) and he has worked as a senior physiotherapist in multidisciplinary hospital pain clinics. Joshua’s PhD publications focused on how children think about the science of pain, and how that influences their pain and movement. He has also authored several TED-Ed online animations about pain science. 

Dr Samantha Bunzli, APAM, is a post-doctoral researcher at The University of Melbourne, Department of Surgery, within the Centre for Research Excellence in Total Joint Replacement. She has methodological expertise in qualitative research and content expertise in health behaviour models. In her research, she uses qualitative methods to explore the beliefs, coping responses and treatment of people with musculoskeletal pain and their clinicians. 

Tim Mitchell is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2007) who works clinically managing and providing second opinions for more complicated and persistent musculoskeletal pain problems. Tim has taught on postgraduate musculoskeletal physiotherapy programs and also reviews Australian physiotherapy curricula. His research and teaching interest is in translating musculoskeletal pain knowledge into logical clinical practice.

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