A Member's reflection on the recent 'Back to the future' PPA study Day.

The PPA recently ran a study day entitled Back to the Future: The past, present and future of physiotherapy pain management. I was asked to write a blog about my day and so in line with embracing the digital age, the title of the final lecture by Dr Clair Hebron, I obliged. It is impossible to do justice to everything that was covered in a short blog but this is a little taster. As it says in my twitter bio – all views are my own!

I arrived as most people do at study days, happy because I’m not at work, looking around and waving enthusiastically at people I know. Most of whom I’d seen the day before, but acting like I’d not seen them for years! ‘Fancy seeing you here!’ The wooden lecture theatre, uncomfortable seats and people staring at their phones reminded me of being back at university. But unlike university I wasn’t hungover and at no point throughout the day did I feel myself nod-off! This was because the line-up for the day proved a proper back to the future style rollercoaster of speakers, covering topics from pain theories and management approaches to empathy in ants and tricky brains. All rounded off with a call to embrace social media and get tweeting #PPA2018.  And very much like the rollercoaster-style content, my emotions and responses to the talks also did a few loop-the-loops.

Looking around you could tell it was a room full of physiotherapists. Most people were seated bang on half 9, backpacks and water bottles everywhere, and pens at the ready! With the words of Prof Mick Thacker ringing in my ears; “don’t believe anything, keep asking questions” I prepared to listen, learn and be challenged.

First up was Dr Amanda C de C Williams, Reader in Psychology and Consultant Clinical Psychologist. An incredibly interesting and thought-provoking talk proposing an evolutionary model of pain. Studying differences in pain behaviours in humans and other animals provides clues about the function of pain and the development of chronic pain conditions. Simply put, animals demonstrate far fewer, if any pain behaviours, and chronic pain does not appear to affect wild animals. However, as well as humans, chronic pain behaviours have been observed in farmed, domestic and zoo animals. Which raises the question; ‘what is it about humans, human influence or our environment that affects pain?’ Anxiety was put forward as a driver for pain behaviour and again something assumed unique to humans, and raises the bigger questions about the role of social factors in the maintenance of pain.

As a physiotherapist, it was great to hear that, from studying animals that have survived nasty injuries and have had to move for survival that movement appears to play a significant role in recovery.Cue the sob-story of squids having tentacles cut off and having to survive being eaten! Amanda therefore posed the question ‘does rest prolong pain and movement desensitise the nervous system?’

Prof Mick Thacker, Associate Professor was up next and is a dab hand at delivering an edge-of-your seat challenging lecture, partly in turn because it is very much at the cutting edge of pain science but also because you’re never quite sure what he is going to say next! Mick started by deftly challenging “braincentric” and peripheral focus theories and then proposed an addendum to the IASP definition of pain and questioned whether we have actually been studying pain at all! His theory of predictive processing is about a dynamic, bidirectional interaction between higher centres and the periphery. My understanding is that we are constantly subconsciously predicting the input we get from our bodies, environment and experience. And if there is an “error” in what we have predicted, then we notice, respond, adapt. Putting this into real life, it can explain why we can take knocks when walking through London, and why someone can be hit in the face and not necessarily experience pain if they see it coming! Two things struck me in particular about Mick’s talk; firstly, that he is placing the individual in the centre of the pain experience, meaning the person/patient does not get lost when it comes to nociceptive mechanism and science. And secondly, and especially important for someone like me who doesn’t quite have the same encyclopedic knowledge as Mick, his theory takes into account our previous understanding of pain science. And it’s fair to say, albeit some slight tweaking to the pain narrative with patients, this is something that could be worked into our existing models.

After a quick break Ben Cormack, Director and educator of Cor-Kinetic took on the task of discussing the role of exercise! For me, a physio also working within an MSK environment, there were couple of really strong points I took from Ben’s talk. Exercise is not THE answer! Thank you, yes agreed, and importantly for some people getting rid of pain isn’t always possible. Pain physios reading this will know this of course, but these messages are really key for the wider physio world and helping to educate the use of exercise and movement for people with persistent pain. Getting rid of VAS, yes agreed, focus on value-based goals, yes agreed, exercise doesn’t have to be lifting weights or going to the gym, yes agreed!

Clinical Psychologist Dr Chasey, took the slot before lunch to talk about Compassion-focused therapy (CFT)– and what a great talk! Just like the topic name, compassion seemed to ooze from here every pore! Again, similarly to Mick’s talk, she promoted CFT as an integrated approach and championed for building compassion in people. The model of threat and drive really resonated in my experience with patients (and self) and how the role of compassion would be so helpful. I really liked her message of no blame or fault but there is responsibility and choice.

After an all veggie-lunch and brisk walk, it was time for some more hard-core thinking and philosophising with a lecture by Prof Roger Kerry, Associate Professor and “social media celeb”. His concept of N=1 is trying to take into account the human factor in research and evidence based medicine (EBM). This questions what “it works” actually means and whether EBM and clinical practice marry up with regards to this. It certainly made a lot of sense to me clinically as to why there is not a “one size fits all approach” – and in fact, if I’ve got it right, the more we understand about role of the human factor in research the stronger this argument will be. What Roger was not promoting however was to throw away all research, but to accept a fairly high level of ambiguity and that each person we see in clinic is different and will present with different causal factors. It’s these causal factors that he and others want to think more about – click on the link for a better explanation! https://causehealthblog.wordpress.com/2017/06/22/what-does-causehealth-mean-by-n1/

Georgie Oldfield, Physiotherapist and founder of SIRPA (Stress Illness Recovery Practitioner’s Association) was up next. This was probably the most challenging talk of the day for me, as it shook some of my fundamental understandings of persistent pain. Like Georgie, I have found it useful analysing my own pain experience to gain further understanding, and have certainly recognised stress and psychological factors as being part of my experience, but not in isolation. Challenging the biomedical model was a good place to start for the lecture and something we can all understand theoretically and clinically. I suppose what struck me was the apparent replacement of an old linear model with another, rather than bio being the guilty party it was now the psycho part. It makes me feel slightly uncomfortable when I hear the word “cure” and persistent pain in the same sentence, or in fact the idea of simplifying treatment or management of what is a complex thing – persistent pain. Certainly thought-provoking and, hey, nothing wrong with being challenged.

The second to last talk was by ESP Physiotherapist and Clinical Director, Complete Physio, David Baker. It was really pertinent given the recent increased awareness and media coverage of prescribed medication and the opioid epidemic. He started off by highlighting some of the dangers associated with seemingly harmless drugs, for example >2200 deaths caused by Nurofen every year in the UK (more than asthma and cervical cancer combined!)You may then ask why do we want more physio prescribers? David argues that physios have a unique and important role in the management of medication. Firstly, we have the time to properly discuss and educate people about the medications they take. Secondly, he very much sees physios’ role as de-prescribers – surely a suggestion that benefits everyone involved!

So to conclude, a really fascinating and thought-provoking day – high-five PPA! We like a good reflection, we physios, but genuinely this was a day that required reflection in abundance. A couple of key points have stuck with me. Firstly, I’m not sure I will ever eat squid again – thanks Amanda. Secondly, the role of physiotherapy is essential and here to stay, phew! Movement is key in pain management. But like we always encourage our patients to do, we need to remain flexible in our approach and be open to adding on extra skills such as CFT and social media and updating knowledge such as pain science, as we go on. But just as a caveat to that, understanding our professional boundaries and the power of the MDT.

Secondly, putting the person at the centre and understanding the human factor is essential. I felt this was a common theme throughout the lectures; from human pain behaviour to valued exercise and movement. As Mick put it nicely, ‘you are not studying pain if you’re stuck looking at Na⁺ Channels.’

Finally, I think having a selection of speakers from different professions and working backgrounds was really good. I sometimes feel pain physiotherapists are seen as a slightly stranger breed of physio to our more traditional inpatient or outpatient colleagues. This may be true…. but I generally think we are on to a good thing when it comes to how we treat each other and patients and think we have a role to play inviting others into our world and keeping the door very much open.

Alice Morgan
@painspeaking