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Pain Revolution – a community-based approach to pain education
Pain Revolution is supporting local health professionals to become pain experts to promote pain education in rural and regional communities in Australia through its Local Pain Educator (LPE) program. In this article, osteopaths and recent graduates of the program share their experience and discuss how they are using what they learned in their communities.
PAIN REVOLUTION’S LOCAL PAIN EDUCATOR PROGRAM Pain Revolution’s Local Pain Educator (LPE) Program is a long-term strategy to build capacity in rural and regional communities by embedding knowledge and skills around best practice pain care. Pain Revolution trains and supports LPEs. In turn, LPEs serve their community by providing public outreach and training, with a focus on evidence-based active, psychological and self-management strategies. Some LPEs go on to create collectives in their local community. Local Pain Collectives (LPCs) are communitybased interdisciplinary networks of rural and regional health professionals who meet regularly to build their skills in contemporary pain education and care.
The program highlights the importance of using a biopsychosocial framework for chronic pain management and its implications for rural and regional areas, and the role osteopathy can play in educating communities about pain.
THE PATIENT THAT HAS YOU STUMPED Many practitioners can probably relate to that case where a client has shared their complex pain story and you’ve sat back and thought ‘Where do I even start? What is the best approach to their management? What does the evidence suggest? How do I meet their expectations?’. As a practitioner, there can be real pressure to be the ‘fixer’ but it is often helpful to take a balanced approach to management to achieve the best outcomes for patients.
A bird’s eye view Polarising viewpoints online can leave you feeling confused or that you need to ‘take sides’. No doubt many practitioners have questioned the place of both traditional and new tools in osteopathy at some point in their careers. Regardless of a practitioner’s personal opinions, the reality is that the scope of osteopathy has evolved.
Some may question the place of handson therapies or newer additions, such as exercise or pain neuroscience education (PNE). Is it old versus new? Or is it more nuanced? Can we find a middle ground? Can we start integrating both evidencebased practice and traditional osteopathy in our own unique way? Of course!
Consider the perspective of a bird (youtu.be/bG2y8dG2QIM). Some birds
KATE JOHNSON works in private practice in Albury-Wodonga and has been actively involved in Pain Revolution and the Murray Local Pain Collective for twoand-a-half years. She recently completed the Professional Certificate in Pain Sciences.
TEANO NGUYENVERDENET is based in WA. He has a keen interest in evidence-based medicine to ensure patients get personalised solutions that combine osteopathy, nutrition and lifestyle advice, physical exercises, manual therapy, and tailored pain strategies and management plans.
CHARLOTTE BYRNES practises in Anglesea and is passionate about educating everyone in the community on best practice care for people living with persistent pain. She completed the Professional Certificate in Pain Science and Education as part of her Pain Revolution scholarship.
MADELEINE GOODMAN graduated from RMIT University in 2014 before moving to Perth to embrace her career as an osteopath. She recently completed the Professional Certificate in Pain Science.
MADDY THORPE is an osteopath with an interest in pain, neurological conditions, and innovative care. She is the Education and Communications Coordinator for Pain Revolution.
KEVIN JAMES is an Osteopathy Australia Advanced Sports Osteopath. He is passionate about education and is a clinical supervisor and teacher at RMIT University. At Pain Revolution, he is working to evaluate the impact of Pain Revolution’s programs.
Human versus bird vision Constituent elements of evidence-based practice (EBP)
that just look black to humans appear as iridescent rainbow-coloured to other birds. A snake is a better well-known example, as they can see the infrared associated with heat. The point here being that using a different lens allows you to see a different world, and the more lenses you have, the more points of view you can challenge. So how does this approach relate to clinical practice?
Evidence-based practice Evidence-based practice comprises: Best scientific evidence; Patient values; Clinical experience.
If we view osteopathy as a gigantic, ‘all-encompassing telescope’, through which we filter many smaller lenses, we can evaluate what tool to use by looking through different lenses and weighting them accordingly.
Some examples might be: The biomechanical lens; The pathological lens; The education lens; The exercise lens The hands-on lens The market lens (yes, this is a thing!); The referral and multimodal lens; The mentor lens; Infinite more lenses.
Based on the combination of the three elements of evidence-based practice, some lenses are given more weight than others, which in clinical practice translates to your ever-changing treatment plan.
Putting theory into practice – an example of an individualised approach
Applying a biopsychosocial approach does not mean that osteos take on the role of psychologists. Rather, it is about understanding that many factors influence pain. We need to be very mindful that our interaction, words and presence can tip the scale either way.
Take the example of a patient who presents with a 15-year history of chronic low back pain. Over this time, he may see many therapists without success. During his first consultation, he discusses how he had received many different diagnoses over the years. Some of the ‘causes’ for his low back pain included:
His back and/or pelvis were ‘out of place’ or alignment;
He had poor glute activation;
He had no core stability;
He had a twisted sacrum that was creating tension within his fascia;
His paravertebral muscles needed to switch off.
The list goes on. In his initial consultation with an osteo, when asked what he thought about his body, he replied “My back is broken. I don’t know how to fix it. My pain took everything away from me.”
It was clear that his current knowledge and beliefs about his back were going to be fundamental to his recovery. This patient was worried and fearful of movement due to his pain. It had caused him to lose his job. It had also affected his relationships. The pain had completely overtaken his life.
After a thorough assessment and examination that ruled out red flags and pathology, the working diagnosis was chronic low back pain. Management involved providing this patient with an evidence-based and accurate understanding of his back pain and manual therapy.
During lumbar and passive range of motion assessment, time was taken to create a new narrative to match the information elicited during the physical examination:
“Yes, your back muscles are really stiff but I don’t feel that your spine is actually out of place. A spine is robust and strong as there are a lot of ligaments and muscles around it.”
“Your pelvis seems to move quite well too in these positions, and you don’t have any sharp pain or jolting sensation when I move your pelvis in anterior and posterior positions.”
“It looks like you are guarding a lot and bracing yourself because of the pain.”
Osteopathic treatment was guided by assessment and consisted of muscle energy techniques, counterstrain and mobilisation. During each step, the patient and osteo were reflecting on his ability to move better and feel better. Throughout the consultation, the use of phrases such as “motion is lotion” and “if you don’t use it, you lose it” provided further patient education.
Management of this patient also included movement rehabilitation, which aimed to provide him with increased confidence in his spine, reduce his hypervigilance and fear avoidance behaviours.
After four sessions, this patient had a significant reduction in his back pain and felt much more confident in selfmanaging his condition. He had a much more accurate understanding of chronic back pain and understood the psychosocial factors that may influence his pain experience. He also decided to get mental health support to address his anxiety, depression and stress.
This case is an opportunity to reflect on which of the many lenses have been applied and how these interconnect with a biopsychosocial approach. By understanding how biopsychosocial elements are linked and how a patient experiences and overcomes pain, osteopaths can adjust our professional practice to find an approach that suits each individual patient.
Practitioner experiences of the Pain Revolution program
Teano Nguyen-Verdenet
The Local Pain Educator program gave me the tools I need to understand how pain works, including tissue biology, exercise, psychosocial factors affecting pain and more. I was already aware of the research relating to pain science, which can create some disparity between osteopathic knowledge and skills. However, the more I learned about pain through the course, the more I realised that osteopathy can have a unique place within the healthcare landscape by integrating pain science and a biopsychosocial model of care within clinical practice.
The course allowed me to gain a better understanding and clarity of pain and it helped me to answer many questions around the subject.
Charlotte Byrnes
The Local Pain Educator program is multi-faceted, comprising a University of South Australia Professional Certificate in Pain Science and Education, the Explain Pain course, and the ‘Revolutionary Immersion Weekend’.
While COVID meant content was delivered online, the sense of support was strong. The scholarship includes a year of one-on-one mentoring, which has been invaluable to my growth as an educator as I established and continue to facilitate the Local Pain Collective in the Surf Coast region, while still practising clinically. I feel privileged to be part of the national pain network. We meet quarterly for ‘cab sav’ sessions to discuss recent research and current projects, and it always leads to a great discussion.
Kate Johnson
Completing the Professional Certificate in Pain Science and Education has allowed me to engage with a diverse mix of health professionals within my community and across Australia. First as a member of my Local Pain Collective, and now as a Local Pain Collective Facilitator, I have been able to build and establish relationships, and referral networks, as well as access quality up-to-date professional development locally which not only benefits my growth professionally but also client outcomes.
Find out more about Pain Revolution and the University of South Australia Professional Certificate in Pain Science and Education at www.painrevolution. org, or contact Maddy Thorpe via email maddy@painrevolution.org
Meeting patient expectations Some patients expect manual therapy. Many osteopaths will have had the experience of blasting people with exercise and education, only to never see them again. This is where you may need to consider the market lens.
The market is generally a pretty good indicator of what services you need to be providing and the market demands hands-on therapy. There are so many people that get value from hands-on treatment, so the market indicates that it is of value to people. Regardless of whatever way it becomes a value, whether it is only perception as is commonly discussed, perception is reality at the end of the day.
You might slowly start to introduce a concept or two, plant a few seeds. And the opportunity to apply a new lens may present itself.
Measuring the effectiveness of patient management Should we focus on better outcomes such as, for example, pain reduction? This can be a very reductionist approach and for many patients it may lead them on the path of searching for the ‘quick fix’, which may not be realistic in some cases. As clinicians, this focus can also lead to a dismissal or misunderstanding of the patient’s actual goals and expectations.
Providing care which is patient focused, empathetic and structured on sound clinical reasoning, with predetermined objectives, is important to ensure we are engaging in optimal care. Self-reflection is integral to review our effectiveness as well as continued growth as practitioners. This requires us to routinely step back and critically evaluate our listening, reasoning and interactions to ensure we are meeting our patients needs as best we can.
