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Managing occupational-related musculoskeletal pain

Managing occupational-related musculoskeletal pain

Synopsis

Interesting review paper co-authored by Le Pub guest Morten Høgh, exploring education in the workplace to help occupational-related pain.

Education appears useful although exactly what this should look like is not clear. Even the attention given to the individual in pain has an influence on their improvement!
 
Check this open access paper out here
 
Find ways to support people to remain in the workforce! Another super interesting read as introduction on work-related musculoskeletal disorders/pain. Staying in paid work is associated with better physical and emotional HRQOL (health-related quality of life). Plus, it’s associated with less pain and tiredness in this cohort of people with Rheumatoid Arthritis!
Paid work…”gives them a sense of normality and purpose in life and they feel that they make a difference in society.” You can read the full paper here
 
This resonates with messages from a brilliant Le Pub with the fantastic Bronnie Lennox Thompson in July.

Key Points

There is a gap in knowledge regarding the best content and delivery of education of material in the workplace. Although beneficial outcomes were reported, more RCT studies are required to determine the effects of education material as compared with other interventions, such as exercise or behavioural therapy.

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Relive: What can we learn from childhood experiences of pain?

whereDoOurChildhoodExperincesFitIn
whereDoOurChildhoodExperincesFitIn

What can we learn from childhood experiences of pain?

A/Professor Melanie Noel, kicked off our winter Le Pub Home Brew program by exploring the role of childhood experiences of pain in adult pain.

Melanie has contributed hugely to the scientific base on pain in children and has been recognised widely for her outstanding research, receiving early career awards from the International Association for the Study of Pain (IASP), the Canadian Pain Society, the American Pain Society, the Canadian Psychological Association, and the Society of Pediatric Psychology. 

She is particularly fascinated by the role of parents and family in children’s mental and physical health and in-particular to the development of self-regulation around the pain experience.  She is an absolutely awesome researcher and speaker, bringing her energy and passion to the subject.  

“I’m really excited to do this, I hope there are lots of questions! I’m not really bringing much powerpoint material, I just really want to share what really gets me going, why this topic is so interesting and what I’m working on right now.  I love that this is a live and open space where I can really just share my ideas with you all.”

 

From the first days of birth, infants can form memories of pain. Once formed, these memories play a powerful role in shaping future pain and health care experiences. As children acquire language and their explicit memory system develops, these memories become constructed and reconstructed in their interactions with others, and particularly for young children, in their interactions with parents. Memory is not like a tape recorder. You can’t play back an experience and have it recounted exactly as it happened. Rather these memories are highly susceptible to distortion. Children who develop negative biases in memory (i.e., they recall more pain than they initially experienced) are at risk for developing fears and avoidance of pain and heath care, and are also at risk for pain transitioning from an acute to chronic state. Moreover, emerging research suggests that brain regions associated with memory are implicated in the chronic pain state in youth. Once pain become chronic in adolescence, more pathological forms of remembering (e.g., in Post-Traumatic Stress Disorder) develop which further exacerbates pain and decreases quality of life. Dr. Noel will describe a program of research that is establishing factors implicated in the development of children’s memories for pain, the role of pain memories in future pain experiences, and the development of a parent-led intervention to reframe children’s pain memories to buffer against the development of memory biases and lead to better pain outcomes in the future. She will also discussed work to understand the neurobiological, cognitive-behavioural, and interpersonal factors that lead to the development and maintenance of chronic pain and PTSD in youth to improve how to tailor treatments for the most vulnerable children.

Key Points

Key messages from the Le Pub for clinicians:

  • Only 40 years ago it was widely believed that babies couldn’t feel pain. The things we experience the first few days of our life can affect how we experience pain throughout our entire life.
  • 1 in 5 kids has chronic pain. Only in the last 7 or 8 years have we learned that, if untreated, these kids become adults with chronic pain.
  • Memories matter – Pain and pain learning starts in childhood. How parents talk to their kids about painful experiences has a profound effect on pain memories and has a HUGE influence on a how a child experiences pain into adulthood
  • Pain is not just a sensation…parents can create a positive or negative ‘experience’ around it. Correct exaggeration, help a child to see they have some control over the experience and offer distraction…e.g. take a deep breath, we’ll go for pizza afterwards
  • There is hope! Even if you feel like you’ve messed up as a parent responding to your children’s pain experiences, just a couple of positive experiences can change your child’s pain trajectory

Key messages from Le Pub for Patients

  • What happens to us, what happened to our parents, even to our grandparents, can set the stage for whether we have pain as adults. Pain and pain learning starts in childhood
  • What can parents do to help raise kids with good pain coping skills? Talk about the pain experience. Highlight anything positive that happened. Remember pain is not just a sensation, but an entire experience. Help them see they have some control over the experience
  • Pain is stigmatized, it’s disbelieved, it’s repressed… and because we don’t talk about it, we learn many of the things we (think we) know about pain from popular media. Stop and pay attention to what you (and your kids) are watching and how it portrays pain.
  • Validation is fundamental. People  experiencing pain need to feel heard

Research papers

It seems outrageous that some people believed that infants didn’t experience pain.  Check out this fantastic paper to find out how early painful experiences can influence us.

If you are a parent with ongoing pain can this influence your child’s experiences of pain? And if so, in what way? Check out this fascinating (free access) paper exploring the intergenerational connections between chronic pain and PTSD.

One of Melanie’s most cited papers exploring the fear/avoidance model relating to pain. Not only does this paper explore the link between fear and anxiety for the child’s experience of pain. But also touches upon the role of the parent and the impact upon the parent.

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Relive: Key Messages about work-related pain

stopLifting

We are delighted to have had the brilliant Morten Hogh on Le Pub. Morten took us on a journey through the ins and outs of pain in the workplace, looking at the real reasons why people of working age are the most affected by musculoskeletal pain and if our traditional approaches to addressing the problem do more harm than good.

It has previously been thought that pain caused at work was a result of poor working practices and inadequate equipment and that the solution was to adjust the way we work. New research suggests that this may not be case and that the most effective approach is to continue to work, despite the pain, and that in some instances the traditional solutions may actually cause more harm than good.

This talk discussed the arising paradigms in the management of work-related pain.

Key Points

Key messages about work-related pain from the perspective of a person in pain:

  1. “Work” is about meaningful occupation, not just remuneration, and by changing the way we view (and reward) work, we can include more people in the workforce. 
  2. The most important question to ask (from John Loeser): “What does the pain prevent you from doing that you need or want to do?”
  3. The decision to RTW (return to work) should be made by the patient, because (and when) it’s the right thing to do for that person, and not under duress.
  4. “Work is therapy!” – working can offer huge benefits to health and well-being. How can we make work more therapeutic?
  5. We too often centre the economic costs of absenteeism. What would happen if we instead centred the person, and their needs/wants/goals?

Key messages about work-related pain from the perspective of a healthcare professional:

  1. Every person who has pain is either employed or unemployed. Therefore, work-related pain is relevant for everyone.
  2. Should we use the term work-related pain? Most people with chronic pain experience pain in all areas of their lives, not just when they’re at work.
  3. Getting a professional athlete back to their respective sport is work-related. Can we change the perspective of clinicians and employers to realise the importance of facilitating a return to work for all people in pain?
  4. It’s better to work painfree but if this is not possible (which may be true for many people) it is better to work with pain than not work at all.
  5. The cost of not working is huge for the person in pain (not just the employer). Find ways to make this happen that fit the individual. Be creative, make adaptations, create flexibility and above all open a constant dialogue between person in pain and employer (and clinician if appropriate).

After hours discussion

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The value of uncertainty

Brilliant essay on uncertainty – co-authored by a previous Le Pub panellist Mark Miller.

Quick summary:

– We can deal with a bit of uncertainty in our lives, in fact it is healthy

– However, uncertainty takes many forms and when our worlds are turned upside down (with no predictable end) this can be unhealthy

– Engaging in activities that question or tease our expectations may be helpful, particularly when they’ve become entrenched (predictable). For the inner geek relating to chronic pain and volatility:”Sustained exposure to such volatile situations and environments [i.e. ongoing pain]

– where the outcomes of actions appear inherently unpredictable

– leads to an inevitable decrease in confidence in one’s ability to bring about the outcomes they expect. At that point, our predictive brains begin to infer an inability to exert successful control, and this then forms a damaging part of the model that guides our future actions.”

– perhaps leading to a state of learned helplessness?!

Check it out – read and re-read – there’s an incredible depth of insight and knowledge.

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Relive: Tasha Stanton

I. Am. Stanton
I. Am. Stanton

Tasha Stanton – I Am Stanton! Adventures in Pain, Perception and Science

Tasha Stanton

When Lorimer Moseley recommends someone by saying they are quite simply ‘an excellent person, great communicator and fantastic research leader’ as he did when he introduced us to Tasha Stanton, we knew we were in for quite a night!

 

A/Prof Tasha Stanton’s life and work in science has truly been an adventure, we don’t use that word without good reason! Tasha’s award-winning research is focussed on understanding the deep complexity of why people hurt and why, sometimes, pain doesn’t go away. In order to do this Tasha’s work has taken her to the frontiers of perception, using technology such as virtual and mediated reality to fundamentally alter peoples’ perception of their body and their experience of pain.

Key Points

  • A lot of our senses have homeostatic functions, their role is to try to keep balance within us and promote us to undertake different behaviours to help us retore balance. If you feel cold, the feeling of cold has this homeostatic function to make us seek warmth
  • Sensory information; sound, vision, touch influence our perception and our bodily feelings like pain and stiffness.
  • Stiffness protects us from movement that might be damaging or that we believe might be damaging.
  • Sensory cues can change pain. When we manipulate sensory input, there can be a significant reduction in pain and stiffness. The sound of a creaky gate can increase stiffness. The more it is repeated the larger the effect. We also see the opposite, when the noise decreases the pain and stiffness reduces.
  • If bodily feelings aren’t just a ‘read out’ of the peripheral information that’s coming in then we need to rethink what those bodily functions (stiffness, pain) are for.
  • We have innate processes between vision and pain. Using illusion to change the size of body parts, you can manipulate pain and swelling.
  • Not only are our bodily experiences shaped by sensory cues, but we are actually altering physiological regulation of the body.
  • We have a dynamic system that adapts and updates based upon the available information, for that person, in that environment, in that society.
  • Clinicians- are we adding safety or danger to our sessions? Many of our treatments are targeting fear.

And there are some keypoints for patients too:

  • The assumption that bodily functions like pain and stiffness solely reflect the biological state of the tissues doesn’t hold up. Many people have enormous amounts of pain and no damage or people have scans which show a great deal of damage but virtually no pain.
  • We have unique experiences of the world.
  • Your beliefs shape what you see.
  • Its key to approach each clinical encounter with the primary aim of listening…ask questions without assumptions. Do not make quick judgements.
  • Many people underestimate how challenging it is to have pain that doesn’t go away.
  • Visual cues in general can have large influence on what people experience. Scary scan pictures.
  • We have a need for experimental lab research because we need to better understand how our treatments work or don’t work.
  • We can use perceptual alterations to promote discussion about biological process that underlie our bodily feelings like pain
  • New theories are needed to underlie and underpin new treatments. To make progress we have to do the background work to understand how treatment mechanisms work .

Research papers

“Does feeling back stiffness actually reflect having a stiff back?”

This (free to access) paper by Tasha Stanton demonstrates what a superstar of the pain world she is.

Feeling stiffness in the back: a protective perceptual inference in chronic back pain

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Meet A/ Prof Tasha Stanton

If you’re interested in pain, you probably know Tasha’s work. If you weren’t living under a rock last year you’ll have seen that Tasha went viral with the ultimate take down after a man suggested that she “read Stanton’s work on the subject”. This gave rise to her legendary response “I. Am. Stanton.”

Tasha has joined us for a very special online and live Le Pub Home Brew session on 1 August 2020.  She took us through her adventures in pain, perception and science, explaining how the findings from carefully constructed research in the laboratory can inform and inspire studies that aim to relieve suffering and improve treatment for people living with persistent pain.

Tasha’s award winning research is focussed on understanding the deep complexity of why people hurt and why, sometimes, pain doesn’t go away. In order to do this, Tasha’s work has taken her to the frontiers of perception, using technology such as virtual and mediated reality to fundamentally alter peoples’ perception of their body and their experience of pain.

In this live and interactive online event, Tasha took us through some of her outstanding and novel findings, including how the sound of a rusty gate can influence someone’s perception of how stiff their back is and how a video illusion of a person’s knee being squashed or elongated can alter their experience of pain.


Tasha has definitely accomplished A LOT in her career so far. A brief professional introduction:

I am a physiotherapist and a clinical scientist. I began my physiotherapy career at a rehabilitation centre for injured workers in Canada. This sparked an interest in chronic pain; I then completed a Master’s in Rehabilitation Science studying the spinal mechanics of common stabilisation exercises. I gained a highly competitive International Recruitment Scholarship to complete my PhD at the University of Sydney under Profs Chris Maher and Jane Latimer, world leaders in low back pain and epidemiology. I have since received two highly competitive postdoctoral fellowships (10% and 15% success rates) and moved into a world- leading clinical pain neuroscience group at UniSA, under the mentorship of Prof Lorimer Moseley. I now lead my own research group (1 post-doctoral fellow, 1 PhD, 1 Masters, 2 Honours students) evaluating perception, multisensory integration, cortical body representation, and pain.

Summary of Key Research Achievements:

I have received >$2.2m in competitive research funding and I have authored 53 peer-reviewed papers in high-quality pain and imaging journals. I have been first author or senior author on 40% of these papers (past 5 years). I have an h-index of 20 and my papers, the majority published since 2011, have >1400 citations. I have given Plenary or Keynote lectures, all costs covered, at >40 major international/national meetings. I have presented my research at 21 international and 34 national conferences in 14 countries. I have presented my research in specialised topical workshops at 10 conferences in 6 countries, chairing 3 of these. I have delivered 35 extramural lectures at the invitation of 12 universities and 9 hospitals in 4 countries. I am a Commissioning Editor for the BodyinMind Research Blog that has >65,000 visitors from 120 countries.

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Pain Education – A future perspective

Since David Butler joined us in le Pub Scientifique Home Brew (May 2020), he set the scene for a new wave in his professional life. A wave that reflect on the previous revolutions in healthcare including education. He made his point clear. Education has been underestimated widely and needs reconsideration on how its been used as a therapeutic tool. We have collected some highlights from Dave’s talk about the missing bit – the educational science and future possibilities in the paineducation field.

Carol Dweck

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Explain Pain – The Final wave

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Relive: David Butler

Learning how to learn before we learn.

Has anyone taught you how to learn?

If you agree you, your family, clients are likely to have been victims of a learning experience. And you may have passed on your limited or faulty learning strategies to children, friends and patients. We have probably had learning errors for our lifespan. Is learning increasingly becoming a survival tool in the world of today? E.g. Medical knowledge doubles every around 73 days and half life if knowledge is shrinking. Think of virus research today! (Densen er al. 2011).

Our error with Explain Pain – I told them all how to put the lifejacket on, but did they learned it?

Dr. David Butler

If you see a client twice a week for half an hout that is 0.59% of the week. Sport coach with athletes are estimated at around 1-5%. What happens in the rest of the time? And in the chronic pain clientele, the processes constructing pain and inflammation, and long term medications are likely to affect learning. Educational psychology is one of those areas that rarely been intergrated in healthsciences. There is som much to learn. Start build a frame work or toolbox.

Educational science has broadly two areas. The learning and instruction area is definitely the biggest but a second area, the science of conceptual change is less common but probably most valuable in health. The most fundamental difference is that the conceptual change field focusses on the nature of existing knowledge (Vosniadou, 2017). This is also known as ‘androgogy’ – which refers to methods and principles used in adult education. Pedagogy on the contrary is obviously the better known big brother. Patients will bring their existing knowledge to the clinic too. And especially on health, patients bring a huge amount of experiences, beliefs en knowledge along with them. You can’t blame them. Healthcare providers have shown to be a big resource for common misconceptions too.

What is the ideal learning strategy or technique for adult learners in pain and for their deliverers? We need to address this question if we want to improve it. A philosophy that fits the context is the concept of constructivism which comes from the wider scope of learning theories. The learner is nog a passive recipient of knowledge, that knowledge is constructed by the learner. Therefore Self Regulated Learning seems to provide the ideal framework for paineducation. The Self stand for – you ultimately do it to yourself, its not done to you. The regulation parts are regulations of movements, exercises, cognitions, emotions, time, contexts, etc. Resources before, during and after the learning experience. This is getting seriously the next wave in the paineducation world. More will come soon!

Written by Bart van Buchem

The learner is not a passive recipient of knowledge, that knowledge is constructed by the learner.
David Butler
Educationalist
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The Rollercoaster of Professional Life – still evolving

By David Butler,  November 22, 2016

I wrote the first version of this over 3 years ago and I still get contacted by health professionals who want to discuss their similar rollercoaster journeys. Here’s an update on my ever-evolving roller coaster.

web-rollercoaster

The first wave

When I emerged proudly with my degree in the late 70s, all packed with Maitland style manual therapy, I was convinced I could fix all and sundry and I often opened a clinical conversation with “what can I fix today?” (I feel ill saying it now!) Anyway, it all worked well for a few years but then I noticed that “it” was not delivering the goods so well. Unbelievably some patients dared not get better. Things were feeling professionally grim, career changes were pondered, but then, proud and erect, fresh from New Zealand, Robin McKenzie rode into town, maybe even on a white horse!

The second wave 

Wow – this was it! How silly was I to miss the disc and the novel notion of actually getting people to treat themselves and to give your thumbs a good rest. People started getting better again, my practice was full of lumbar rolls, the “Treat your Own” books and models of discs and I was on a roll too. This McKenzie approach worked wonders for a few years, but then the outcomes began to taper off, some patients wouldn’t improve, some wanted the old fashioned hands on that I had almost given away and a now familiar professional grimness emerged again. What next?

The third wave

I heard about a year-long Maitland post graduate course in South Australia and I reasoned that there must be more to it than I’d first thought, so I signed up for the year. I made it through a bit wounded, but the old “I can fix anything” returned and I went into the outer suburbs of Adelaide to ply my trade, wriggling and cracking joints and doing the new teasing nerves stuff. People got better and complex problems seemed to dissolve. But would you believe it – it happened again – the clinical outcomes tailed off with what I now recognise as centrally sensitised states, overuse syndrome and complex regional pain syndrome. I pondered a career change. Perhaps professional surfing?

The fourth wave

By now (late 80s, early 90s) I was becoming a bit older and wiser and trying to think more deeply about things – so I thought –“stuff the others – I’ll try and work it out myself”. And so I went off on the “neural tension” bandwagon – the idea of the physical health of the nervous system and mobilising nerves. I did some reading, had a few thoughts, stood on the shoulders of a few others and even wrote a couple of books. This was it I thought! Life will be easy from now on as we wriggled and glided and teased nerves from head to toe. Patients flocked in … but the old diminishing outcomes emerged again, even for something I had helped to invent. Grim days – coffee was coming into fashion I pondered becoming a barista and investigated what it would take to become a marriage celebrant.

The fifth mini-wave

I was getting very wary now – the early work of Vladamir Janda was being updated and researched, particularly at the University of Queensland and once obscure bits of anatomy such as transversus abdominis, obturator internus and short neck flexors were now the new targets and the “with it” practitioners had ultrasound machine to view muscles. I went to the courses and gave it a go but my heart wasn’t in it. Waves can be exhausting, and the outcomes were eluding me again, just like my transversus abdominis. I tried the taping stuff too, but like a focus on a single muscle, it just didn’t make enough sense.

I drifted off into the world of pain and neuroscience and am still happily here. No magic, just a lot of hard work using neuroscience to fuel educational and imagery therapy and the good parts of the historic waves I’ve ridden. I thought I may have reached nirvana with the brain, but now I realise that neurones are only 10% of the brain and as the rest is immune cells, so there is long way to go.

I am still on this fifth mini-wave – trying to keep up with the world of brain plasticity, neuroimmunological balances and recent research and concepts of DAMPS (danger associated molecular patterns) and BAMPS (behaviour associated molecular patterns) and even CAMPS (cognitive associate molecular patterns) among others, all identified by Toll Like Receptors which can ratchet up their behaviour and keep enhances immune responses bubbling. It’s infectious science.  But …

Uh oh – a sixth mini-wave beckons

I never thought this would happen, but I peering back at the tissues where I started all those years ago. The brain is so trendy that the scientific and some of the clinical world seemed to forget the rest of the body. I have been trimming my nails in anticipation of a return to the flesh! Not giving up the neuroimmunology of course but things like how can we dance with the different receptors in tissues, deal with the immunocompetence of the meninges, or indeed most tissues, and the simple and undervalued licence to touch is sacrosanct – even if just touching a hand while sharing knowledge. I notice and try and understand the trend towards predictive processing and Bayesian thinking, and find it fascinating but I am a wary old bugger. After all – all the talk was about phenomenology a year or so back but it seems to have gone out of favour. Are some of our colleagues onto their next mini waves

Three thoughts

1. I look around now at the course advertisements in the back of the journals and it seems the new roller coaster is still driven by dry needling, loading joints and lifting weights, someone called Pilates, and now mindfulness has become trendy – even yoga is on the up. No doubt some people are flying with it, and good on them, but not me – I am too war weary to get on the roller coaster again but I am sure there is something in it like there is in everything and if your professional paradigms are wide enough and trending towards biopsychosocial then there is a rational place for everything. The waves are not a loss if you can absorb them.

2. What bugs me is that it took so long to realise that it was I myself who was probably the main variable in outcomes – not the techniques. I am not saying that massaging patients with a wet salmon will help. However the interactional power needs better analysis and understanding and as Pat Wall would say “in the end, if the majority of the outcomes are based on placebo, do not fear, but work out what it was in the placebo which gave the outcome”.

3. But what saddens me is that I now see a rapid and enforced rollercoaster in young therapists just out of college – youngsters with that precious, must be captured mindset of wanting to change the world. Yet increasingly employment is all about the dollar, the speed, the getting patients back and thus treatment processes inevitably based on singular biomedial paradigms. There is no time to work out for themselves what this professional rollercoaster of life is all about. We all need to work it out ourselves in some way. If not – we face professional burnout. I am looking forward to wave 7 soon!

– David Butler

Original post is published on NOIJAM.COM