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Transcript — Programme 111: Physiotherapy, Mind, Body and the Social Component

Anx­i­ety and expec­ta­tions, how fear cir­cuit­ryaffects self-man­age­ment, and the impor­tance of social prescribing

To lis­ten to this pro­gramme, please click here.

This edi­tion has been fund­ed by friends of Pain Concern.

Direc­tor of CSPC Phys­io­ther­a­py in Leeds, Ali­son Rose, spe­cialis­es in work­ing with high-lev­el ath­letes, par­tic­u­lar­ly those with com­plex injury his­to­ries. Rose speaks to Paul about her expe­ri­ence with chron­ic pain as being sub­jec­tive for both ath­letes and non-ath­letes, explain­ing it as a unique puz­zle that needs to be put togeth­er to find the core mech­a­nisms that cause pain. We also hear about the many unex­pect­ed phys­i­cal rela­tion­ships with­in our bod­ies that cause pain, as well as the impor­tance of social networks.

We then hear from Cardiff Uni­ver­si­ty Pro­fes­sor of Med­ical Edu­ca­tion Ann Tay­lor. Pro­fes­sor Tay­lor speaks about her work explor­ing how those with chron­ic pain per­ceive non-pain relat­ed infor­ma­tion, and how this infor­ma­tion is processed through fear cir­cuit­ry which can have detri­men­tal effects on self-man­age­ment. Pro­fes­sor Tay­lor pro­motes more focus on the ‘social’ aspect of the biopsy­choso­cial mod­el and the ben­e­fit of con­struc­tive con­ver­sa­tions between patients and their health­care pro­fes­sion­als, some­thing which Pain Concern’s Nav­i­ga­tor Tool aims to do. We hear again from Pro­fes­sor Mark John­son of Leeds Beck­ett Uni­ver­si­ty, con­trib­u­tor to Air­ing Pain 110, about the impor­tance of deliv­er­ing health­care with a social emphasis.

Issues cov­ered in this pro­gramme include: Anx­i­ety, com­ple­men­tary ther­a­pies, con­fi­dence, cul­ture, depres­sion, edu­cat­ing health­care pro­fes­sion­als, emo­tion­al sup­port, fibromyal­gia, flare-up, GP, hyper­sen­si­tiv­i­ty, men­tal health, Nav­i­ga­tor Tool, phys­io­ther­a­py, pol­i­cy, psy­chol­o­gy, social care, sports injury, sup­port groups and time banking.

Paul Evans: This is Air­ing Pain, a pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain and for health care pro­fes­sion­als. I’m Paul Evans, and this edi­tion has been sup­port­ed by Friends of Pain Concern.

Ali­son Rose: Anx­i­ety of ath­letes com­ing up to an event they will quite often have some­thing that comes out of the blue and you either see it every sin­gle time there’s a big race com­ing up, that they will present in the physio room with an injury, which, when you look at it, there isn’t real­ly any­thing there.

Ann Tay­lor: If Mr. Jones, with chron­ic pain, is sit­ting in front of the tele­vi­sion watch­ing the Olympics, what’s hap­pen­ing in their brain when they’re pro­cess­ing infor­ma­tion about peo­ple run­ning around?

Evans: From couch pota­to to Olympic ath­letes, we all have brains and we all have bod­ies, but they don’t always talk nice­ly to each other.

Ali­son Rose is a phys­io­ther­a­pist who works at CSPC Ther­a­py Clin­ic in Leeds, whose patient list cov­ers the whole gamut of abil­i­ty from elite ath­letes, includ­ing gold medal Olympians Kel­ly Holmes, Jes­si­ca Ennis and the Brown­lee broth­ers, through to the week­end war­riors and yes, couch potatoes.

Rose: For me, no one should live with pain and I think it comes out of the fact that we’ve got one body for life and I think these prob­lems are intrigu­ing because they usu­al­ly have got a real­ly com­plex nature to them.  Obvi­ous­ly the effect on the per­son is real­ly great and for me, physio is about fit­ting togeth­er a puz­zle. I think quite often pain man­i­fests in a cer­tain way but it actu­al­ly poten­tial­ly might be the accu­mu­la­tion of any of the lit­tle injuries we’ve had since the day we were born, right up until the point where the body just says ‘actu­al­ly, no, I can’t do this any­more’.  For me, it’s find­ing the keys to unlock that and to help the per­son have a more func­tion­al life.

Evans: So how do you unrav­el all those lit­tle things…well, they may be lit­tle things…that are going on?

Rose: Get­ting a real­ly good sub­jec­tive his­to­ry is super impor­tant, so find­ing out what the pain means for the per­son, what effect it is hav­ing on their life.  Some­times it’s that thing between ‘oh I’ve got a bad back’, but actu­al­ly it means ‘I can’t play with my chil­dren’.  So there’s a real­ly impor­tant rea­son to get rid of the rea­son why they have back pain, so they can play with their children.

Like I said, it’s tak­ing a real­ly good sub­jec­tive his­to­ry, so going right back to the point where ‘have you had falls off a bike and head injuries and even hav­ing teeth pulled out’ can make a dif­fer­ence to how mus­cles sit around your neck.

I do a full body assess­ment and just tie in symp­toms with func­tion and how the per­son moves. Some­times, you can get a prob­lem in a cer­tain area but it can be because there’s a very large dys­func­tion some­where else.  For exam­ple, you might have back pain because your hip and your foot on one side doesn’t work very well, there­fore it affects the way you move, there­fore you get back pain because that’s the area that takes the strain.

Anx­i­ety of ath­letes com­ing up to an event, they will quite often have some­thing that comes out of the blue and you either see it every sin­gle time there’s a big race com­ing up that they will present in the physio room with an injury which, when you look at it, there isn’t real­ly any­thing there.  Then, when you get to know the ath­lete, you real­ize that this is the pat­tern that they have, that they will present for physio just before a big event.

I think some­times it’s the anx­i­ety around an event that just they are just more sen­si­tive to things and will report things and I think some­times, it’s just that they want to come in and speak to some­body that they trust and just get lit­tle bit of, I guess, con­fi­dence from that.

Evans: But that doesn’t mean that the prob­lem doesn’t exist?

Rose: It obvi­ous­ly exists for that per­son. You wouldn’t belit­tle the fact that they feel that, because who’s to say that one per­son feels some­thing and some­body else doesn’t? Obvi­ous­ly I’m not feel­ing that person’s pain, so it might be some­thing that I can see and some­times it just takes time for the per­son to real­ize that actu­al­ly, this is what they do every sin­gle time there’s a big race com­ing up, that they will present as something.

Evans: So you have to address the psy­cho­log­i­cal side of things as well?

Rose: Yeah, it real­ly does come into it because pain is some­thing that is… it can pre­vent you from doing things that you want to do.  It can affect how you see your­self and it can affect your per­cep­tion, it can affect your social life, it can affect how you inter­act with oth­er peo­ple and all of those things will tie in with how this pain affects you.

Evans: That’s work­ing with elite ath­letes, but what about oth­er peo­ple with chron­ic pain con­di­tions who come and see you?

Rose: Obvi­ous­ly those with chron­ic pain, their end-stage rehab won’t be as high a lev­el but I would look at them in exact­ly the same way. I would exam­ine them in exact­ly the same way, the same thing with their sub­jec­tive his­to­ry. It is find­ing out what that pain means for them, but if their aim to per­form is to be able to get up and down the stairs and be able to take the chil­dren to school or go about their busi­ness, for me, it’s total­ly the same and I wouldn’t change the way I treat those people.

I might be more gen­tle on those with chron­ic pain than I would be on an ath­lete in my treat­ment, but still I would be look­ing to get to the bot­tom of that or get to the point where actu­al­ly, ‘you’re mov­ing real­ly well now, I know you’re still a lit­tle bit sore but actu­al­ly it’s fine and you will not hurt your­self mov­ing for­ward’, so, just kind of get on and go about your busi­ness. It is real­ly the same puz­zle that I’m putting together.

Evans: What sort of con­di­tions do you see?

Rose: I guess one of the best exam­ples I’ve got was a lady who’d had headaches for 40 years and she was on a lot of strong med­ica­tion. Actu­al­ly the rea­son that she had that pain was because the bot­tom of her back wasn’t mov­ing very well and she’d fall­en on her coc­cyx. There’s a con­nec­tion, obvi­ous­ly, through your spine from the bot­tom of your spine right up to your head and your neck, so in get­ting the low­er back to move bet­ter, that allowed us to set­tle down every­thing all the way up.  So we man­aged to get rid of the headaches that she’d had for 40 years on a dai­ly basis and man­aged to get her down from the car­ri­er bag full of painkillers that she was hav­ing to take — she might take one every so often, but it’s [once] in a blue moon now.

Prob­a­bly the most dif­fi­cult areas to treat are pelvic pain, headaches, head pains, neck pains, neur­al type of symp­toms and then quite often we will see peo­ple, if they’ve had surgery for exam­ple, [they] may end up…because obvi­ous­ly the scar tis­sue tight­ens and there are changes that hap­pen because of a surgery which has been necessary.

Quite often just releas­ing the soft tis­sue around there enables the per­son to move bet­ter, which takes the stress off the area.  There usu­al­ly is a weak area that is under strain because of some­thing which, if you can change that, it just allows every­thing to set­tle and life becomes more manageable.

Evans: Do you deal with peo­ple with fibromyalgia?

Rose: Yes.  So again, I think quite often those have… your ner­vous sys­tem can get high­ly sen­si­tized and I think you can real­ly tie in with that. But quite often, those types of peo­ple have got a high­ly sen­si­tised ner­vous sys­tem because they might have had either head injuries or teeth pulled out, or they’ve had big trau­mas, car crash­es and if you think about the things that we lay­er on through life from when you’re small, to the falls out of trees and the falls off a bike, right the way through to car crash­es or slips down the stairs. All of these things, they all sit in your sys­tem and I think your brain isn’t real­ly good at dif­fer­en­ti­at­ing between prob­lems, then some­times it is just unpick­ing those.

Evans: So what you’re say­ing is that somebody’s body, my body, is the prod­uct of, say, 62 years’ worth of trau­ma, how­ev­er light that might be?

Rose: You know, our bod­ies are amaz­ing at adapt­ing. They will adapt and will adapt because we have to get around in life.

Obvi­ous­ly years ago, you had to be able to move to sur­vive and we will find a way to move in a pain-free way. Some­times, even falling over will jan­gle your ner­vous sys­tem around and just upset it and if you do one or two of those too many, things do add up. I think bod­ies are incred­i­ble things and they will adapt and adapt and adapt and I think there does come a day where, whether it’s an emo­tion­al stres­sor that comes in or anoth­er phys­i­cal stres­sor or you become ill and your sys­tems get over­loaded, but actu­al­ly your body just goes “whoa this is enough” I need to actu­al­ly find some­one that can help me sort this out. I think that is where we would come in.  Some­times, it’s just unpick­ing the lay­ers and lay­ers that peo­ple have added on through their lives.

Evans: We are the house that Jack built, the exten­sion on the exten­sion on the exten­sion on the extension…

Rose: Exact­ly. I tell peo­ple that they’re like onions and some­times you are undo­ing all of those lay­ers and just help­ing them to move and func­tion bet­ter. Every­thing, whether it’s just tis­sue that you’re rolling through, you are stress­ing those if you’re not mov­ing very well and your body will cope to a cer­tain point, but then will start to complain.

Evans: Now what I hadn’t con­sid­ered as suit­able for manip­u­la­tion were the bones in the head. Ali­son Rose again…

Rose: I think there’s a myth that the bones in your skull will get fused as you grow up and that your head is like a sol­id bowl­ing ball.  Actu­al­ly it’s not fused, it’s a sys­tem of flat bones that fit togeth­er a bit like dou­ble-sided tongue-and-groove and they can, with var­i­ous knocks, end up being slight­ly twisted.

If you had a sol­id bowl­ing ball as a head, if you did fall over and hit your head, it poten­tial­ly could crack, so this sys­tem is in place so that you get mobil­i­ty there, but it is pos­si­ble to treat those bones. If you think about your head not sit­ting quite straight on the top of your neck, your body will have to adjust so that your eyes are actu­al­ly straight in the space because your body wants to have your eyes straight so you can see prop­er­ly, but oth­er things under­neath that might have to adapt.

But I’ve had peo­ple in who pre­sent­ed with dou­ble-sided shoul­der pain six months after they’ve had var­i­ous teeth pulled and braces and blocks put in, and actu­al­ly that’s been because every­thing around the head has been pulled out, so it’s put a lot of stress on the nerves com­ing down into the shoul­ders. But hav­ing treat­ed those areas, it’s got rid of the shoul­der pain that they’ve had. Some­times, the bits that have been missed are actu­al­ly [to do with] the fact that your vis­cera is the thing that isn’t mov­ing and we see that so often.

Again, I think with chron­ic pain some­times obvi­ous­ly if you’re tak­ing lots of pain med­ica­tion it will obvi­ous­ly over­load your liv­er and it can there­fore then make your liv­er not move very well, which can then make your rib cage not move very well, but the neur­al inter­con­nec­tions again will hyper-sen­si­tize your sys­tem, that’s where a lot of the chron­ic things come in.  If you’ve had a car crash or fall on your bum or, I don’t know, you’ve had a cae­sare­an or surg­eries or some­times it is the oth­er effects, your organs should move on the inside. They have some­thing called motil­i­ty which is how they move when they func­tion, but also they do need to move inside you.  For exam­ple, your liv­er needs to be able to rotate with­in your ribcage and it needs to be able to flex for­ward and bend back­wards to give you those move­ments that obvi­ous­ly can be on the outside.

We do see a lot of peo­ple who poten­tial­ly might have had, again it’s usu­al­ly relat­ed to a trau­ma, but some­times if they’ve had a lot of med­ica­tion because they’ve been ill, that things do get over­loaded, or they stop mov­ing very well. So, if you can pic­ture a tin of beans which you shake up, obvi­ous­ly the tin of beans on the out­side will still look the same, but the inside will be shak­en up. So if your organs aren’t mov­ing very well on the inside, that will have an effect on the out­side and how your body will be able to move, which can then have a knock-on effect on chron­ic pain.

Evans: I don’t under­stand. I mean I would have thought my inter­nal organs are in the place where they should be and that is that? So how do they move?

Rose: OK so, organs can become less mobile with­in your sys­tem in a vari­ety of dif­fer­ent ways. If, for exam­ple, you fall over onto your bot­tom or you’re in car crash, your body will move but with­in you, your organs will move back and forth with­in your skeleton.

The oth­er thing is that because obvi­ous­ly your organs are inner­vat­ed by nerves, if your whole ner­vous sys­tem, in par­tic­u­lar your upper back (which is relat­ed to your sym­pa­thet­ic ner­vous sys­tem and your fight-or-flight) that can have an effect on the blood sup­ply to your organs, in the same way it would if you go into fight or flight because you’re feel­ing anx­ious or you’re being chased by somebody.

So if that’s hap­pen­ing in the long term, it can be a mix­ture of poten­tial­ly trau­mas, it can be med­ica­tion over­load­ing organs which again just stops it func­tion­ing very well, or like I said if your whole ner­vous sys­tem is real­ly dri­ven and it’s real­ly on over­drive, it can in itself have an effect on caus­ing these organs to just not move as well and go into what we would call vis­cer­al spasm.

Evans: So as a phys­io­ther­a­pist, what you do to work on that?

Rose: You learn how to assess how an organ feels.  There are dif­fer­ent ways of being able to mobi­lize and they’re real­ly, real­ly gen­tle tech­niques but they do help the organs to move bet­ter with­in your sys­tem, which will then allow you to move bet­ter as an enti­ty or it will allow the organs to func­tion bet­ter, which again can have a big effect, it just helps to get rid of toxins.

Again I’ve had patients in who just feel that they’re tox­ic and when you start get­ting their whole sys­tem mov­ing and obvi­ous­ly your liv­er not mov­ing very well, for exam­ple, will have an effect on your diaphragm, which will have an effect on your breath­ing, which then will have an effect on your tho­rax and anx­i­ety. So every­thing again, to me, it’s all tied in, you can treat one area of the body and it will have a marked effect on another.

Evans: For some­body with the long term pain con­di­tion, what advice would you give about seek­ing out a phys­io­ther­a­pist or any oth­er practitioner?

Rose: I think in any pro­fes­sion, there are peo­ple that are good at what they do. I think it’s real­ly impor­tant to not just go to one per­son and think ‘well, actu­al­ly, physio didn’t work for me’. Maybe that wasn’t the right physio for you. You should be start­ing to see a dif­fer­ence with­in the first two or three ses­sions and start­ing to feel that things are chang­ing. I think it’s real­ly impor­tant to have a physio that will actu­al­ly check every­thing and actu­al­ly not just look at the bit that’s sore, because like I said, quite often, the bit that’s sore, where the pain is com­ing from may be because of a dys­func­tion some­where else and it’s sec­ondary to the oth­er dys­func­tion. So I think it is real­ly impor­tant that some­body is look­ing at you real­ly, real­ly holistically.

Some­times it does take two or three times to find the right per­son. One of the things I treat is chron­ic groin and pelvis pain and peo­ple will trav­el from all over the UK because actu­al­ly, I think we do look at that in real­ly holis­tic way. We do get peo­ple bet­ter from that but these again are peo­ple who’ve seen many oth­er phys­ios and maybe it just hasn’t been the right approach for them.

Evans: So, for some­body who’s been in con­sul­ta­tions with Dr Google, Dr Yahoo, or who­ev­er, is there some­thing they should look out for as a stamp of approval, if you like, for a physiotherapist?

Rose: You need some­body who is real­ly expe­ri­enced and has a real­ly wide skill base and also some­body who rec­og­nizes that ‘actu­al­ly, this is where my lim­its are and actu­al­ly, I do need task for help from poten­tial­ly a doc­tor, the pain clin­ic [or] anoth­er prac­ti­tion­er’. We obvi­ous­ly don’t have all the answers all the time but actu­al­ly hav­ing a real­ly good net­work of peo­ple around you, that if you do need to refer on because there are cer­tain things that we can’t do or we real­ize that actu­al­ly this isn’t with­in my skill set. I think it is real­ly impor­tant to have that net­work as well.

Evans: Phys­io­ther­a­pist Ali­son Rose.

I just need to remind you that whilst we in Pain Con­cern believe infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound based on the best judg­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well-being. He or she is the only per­son who knows you and your cir­cum­stances and there­fore the appro­pri­ate action to take on your behalf.

Now, Ali­son Rose talked about the anx­i­ety ath­letes might feel com­ing up to an impor­tant event and how they might present with an injury which, on exam­i­na­tion, is just not there. Of course, pain linked with anx­i­ety or oth­er emo­tions is not unique to elite athletes.

Ann Tay­lor is Pro­fes­sor in Med­ical Edu­ca­tion at Cardiff University’s School of Med­i­cine. In her doc­tor­al research, she looked at the way peo­ple with chron­ic pain per­ceived non-pain relat­ed information.

Ann Tay­lor: So we put them in the scan­ner, showed them a series of pain words and also showed them pic­tures of activ­i­ties of dai­ly liv­ing and com­pared with healthy con­trols that were matched, it showed that they actu­al­ly use their fear cir­cuit­ry to process that infor­ma­tion.  So despite using a self-assessed ques­tion­naire, [where] they said they were not fear­ful of move­ment, in fact when it came to look­ing at how their brain func­tioned, when they saw these words or saw these pic­tures, they were actu­al­ly fear con­di­tioned. So they sub­con­scious­ly pos­si­bly felt, processed, those pain words and those activ­i­ties of dai­ly liv­ing very much using fear circuitry.

So these peo­ple were very com­plex peo­ple liv­ing with chron­ic pain, they were on high opi­oid use, they had lots of mood and phys­i­cal func­tion­ing prob­lems [and] they scored very high­ly on their pain despite large dos­es of opioid.

I was very inter­est­ed in, if Mr. Jones with chron­ic pain is sit­ting in front of the tele­vi­sion watch­ing the Olympics, what is hap­pen­ing sub­con­scious­ly? Or what’s hap­pen­ing in their brain when they’re pro­cess­ing infor­ma­tion about peo­ple run­ning around?  So it kind of sug­gests that any move­ment or any pain words that you show peo­ple with chron­ic pain, they will process that through fear cir­cuit­ry. So it’s poten­tial stres­sor and it’s some­thing that sub­con­scious­ly, prob­a­bly or sub­lim­i­nal­ly, they’re scared of, so it has ram­i­fi­ca­tions for things like self-man­age­ment. How do you dis­en­tan­gle people’s fear con­di­tion­ing with get­ting the right mes­sages out there?

Evans: So go on and how do you…?

Tay­lor: It’s about hav­ing con­struc­tive con­ver­sa­tions with peo­ple liv­ing with chron­ic pain. So rather than rely­ing on self-assessed ques­tion­naires, which they might be want­i­ng to respond to, to please you,  it’s actu­al­ly hav­ing con­ver­sa­tions about what wor­ries you about your pain, what you find is dif­fi­cult to man­age with your pain, how do you view me telling you need to go and see a phys­io­ther­a­pist or you need to go up to the gym and try­ing to get them to unpick that because I’m sure if they think about it enough, they will actu­al­ly start think­ing about trig­gers that trig­ger this response to pain words or activities.

Evans: The first per­son with­in the health pro­fes­sion you will see about your pain is the GP. They don’t have time to do that sort of thing, do they?

Tay­lor: Tra­di­tion­al­ly no, but a lot of these peo­ple that they see with chron­ic pain, they’ve had their chron­ic pain a long time before they go and see the GP. I think it’s about, if you first came to see me as a GP (which I’m not, I’m an aca­d­e­m­ic edu­ca­tion­al­ist) but it’s about say­ing “look, you’ve had your pain for a long time.  We’re not going to solve this overnight, so we’re going to have reg­u­lar 10 minute slots so [that] we can start and unpick­ing your pain and unpick­ing how you feel about your pain and then look­ing at the pos­i­tives, look­ing at what you want to achieve and look­ing at how we can take steps to achieve that. It’s about think­ing ratio­nal­ly about how you can use those 10 minute slots in an inno­v­a­tive way.

Evans: Well, as if on cue, the results of four years’ research and devel­op­ment of Pain Concern’s Nav­i­ga­tor Tool, is an inno­v­a­tive way to facil­i­tate bet­ter con­ver­sa­tions between doc­tors and patients and there­fore bet­ter out­comes and still with­in that 10 minute time­frame. Full details, down­load links and sup­port­ing videos are on Pain Concern’s web­site which is painconcern.org.uk

Ann Tay­lor again.

Tay­lor: We talk about the biopsy­choso­cial approach to pain, but we just ignore the social bit. I’ve been doing a lot of engage­ment activ­i­ties across Wales to see what peo­ple with chron­ic pain, liv­ing with chron­ic pain want from pain ser­vices and a lot of it is about social sup­port. I think we should do a lot more in social pre­scrib­ing and not just rely on ‘there is the GP and then there is the pain services’.

There’s the whole move­ment around men’s sheds now which is com­ing for­ward. Things like sup­port groups, they want­ed ses­sions in the GPs, so some­body could tell them why they have pain, what it means, how they could help or sup­port to look after the wife who’s got demen­tia, so they can actu­al­ly go and do something.

The peo­ple that were respond­ing to our work­shops were very much about ‘it’s the social sup­port we want’, and they’re doing some work in Llanel­li and Ely around time bank­ing. There’s a not-for-prof­it orga­ni­za­tion called Spice and they will come in and they will set up time bank­ing. So if I was to come and help you with your allot­ment, you would do the raised beds because you’ve got back pain and then I would share the allot­ment pro­duce or I would go and help Mrs. Jones with some activ­i­ties of dai­ly liv­ing because she’s got fibromyal­gia and as a result, I would get cred­it so I could go and use a local gym, so we’re back to medieval time and bar­ter­ing, but it’s been shown to work very well.

Evans: I think that’s fan­tas­tic. You know from my his­to­ry I have fibromyal­gia and I can remem­ber my neigh­bours club­bing togeth­er to chop my tree down and this and that and the oth­er, but I felt incred­i­ble guilt that they were doing this. But if I could have offered them some­thing back that would’ve been fantastic.

Tay­lor: And I think that’s it, this is about social sup­port, so you’re no longer a vic­tim, you’re a val­ued mem­ber of the com­mu­ni­ty and that’s what Spice and time bank­ing and all this social pre­scrib­ing is about.

There was one sto­ry about a man who had low back pain and was very lim­it­ed and he got sup­port from a fam­i­ly with his gar­den and it turned out he was a war his­to­ri­an and he was a teacher.  So, he would sit with the kids in school telling them all about the war and so he could give back to the com­mu­ni­ty by teach­ing in a school vol­un­tar­i­ly about the infor­ma­tion he gleaned about World War Two.

Evans: I mean, the areas you men­tion, time bank­ing and social pre­scrib­ing in both those places, there are high-ish lev­els of depri­va­tion. Is that why these areas have been picked?

Tay­lor: Yes. You know you go up to the Welsh val­leys and you’ve got five or six gen­er­a­tions of peo­ple who have nev­er worked, so their great-great-great-great-grand­fa­ther worked in the mines and nobody’s worked ever since. They have low resilience, they have low self-esteem and so it’s about get­ting activ­i­ties social­ly to enhance the com­mu­ni­ty and to sup­port the com­mu­ni­ty, so they can sup­port these peo­ple to actu­al­ly gain more self-esteem. Because there’s no point send­ing these peo­ple with mas­sive social prob­lems, low mood, low func­tion [and] very com­plex abu­sive rela­tion­ships into pain clin­ics or pain man­age­ment ser­vices [because] they’re not social workers.

Maybe there needs to be a step where we sup­port them in the com­mu­ni­ty, we help them with their resources, we help them become more proud of them­selves and have more self-esteem, so that they can opti­mize who they are.  So that when they go into pain ser­vices, they’re already primed to make the most of pain ser­vices, because if you have a hor­ri­ble life and you have pain, I would blame my pain for my hor­ri­ble life. I wouldn’t want to say my hor­ri­ble life is due to me and I need to do some­thing, I would pre­fer to say my hor­ri­ble life is due to the fact that I’ve got pain.

Evans: You’re a victim.

Tay­lor: I’m a vic­tim, so if you take my pain away that means my hor­ri­ble life is my respon­si­bil­i­ty and I’m not ready to accept that. So it’s about how can the com­mu­ni­ty enable peo­ple to accept that maybe their hor­ri­ble lives are part­ly due to them and to give them some skills and some attrib­ut­es and some con­fi­dence to make some dif­fer­ence and then, when you start mak­ing some dif­fer­ence, then they might be ready to relin­quish their pain.

Evans: That’s Pro­fes­sor Ann Tay­lor of Cardiff University’s Med­ical School.

Don’t for­get that you can down­load all edi­tions of Air­ing Pain from Pain Concern’s web­site. Once again it’s painconcern.org.uk and there you’ll also find a wealth of mate­r­i­al and infor­ma­tion about liv­ing with and man­ag­ing chron­ic pain, includ­ing our new­ly devel­oped Nav­i­ga­tor Tool.

Now, we’ll be return­ing to the sub­ject of social pre­scrib­ing in a future edi­tion of Air­ing Pain but to rein­force what Ann Tay­lor was say­ing, I just want to leave you with the snip­pets of con­ver­sa­tion I had with the Direc­tor of the Cen­tre for Pain Research at Leeds Beck­ett Uni­ver­si­ty, Pro­fes­sor Mark Johnson.

Mark John­son: In the health­care pro­fes­sion­al set­ting, espe­cial­ly in the med­ical pro­fes­sion, I don’t think we give any­where near enough focus to the social com­po­nents of pain. We tend to focus on the bio­med­ical ini­tial­ly and then the psy­cho­log­i­cal per­haps but, actu­al­ly it’s the social cue­ing that goes on that I think is real­ly quite crit­i­cal as well. I think what the chal­lenge for health­care in gen­er­al and health­care ser­vice deliv­ery is how we man­age to inte­grate those sorts of find­ings into the way we deliv­er our healthcare.

For exam­ple, patients who have can­cer, they often seek com­ple­men­tary ther­a­pies and they like to expe­ri­ence those com­ple­men­tary ther­a­pies in nice set­tings. They don’t want to be [some­where] a bit like our lab­o­ra­to­ry, a white-walled clin­i­cal envi­ron­ment, there’s no plants in here, there’s no pho­tographs on the wall…

Evans: …there’s no piped Muzak…

John­son: …and no piped Muzak, absolute­ly, absolute­ly and then the hos­pice set­tings have real­ly tak­en that on board. I mean they’re great set­tings to be in and around and I do won­der whether those sorts of set­tings would be more amenable again in some of our hos­pi­tal depart­ments. I am aware they want to do what GP prac­tices have start­ed to intro­duce lit­tle things like gym­na­si­ums and in their set­tings, just lit­tle things patients can do while they’re wait­ing to see the GP.

I think that is absolute­ly the way for­ward because you can quite quick­ly assume a sick role by just enter­ing into some of the hos­pi­tal set­tings.  I was in a wait­ing room not so long back in a hos­pi­tal and I thought ‘Gosh, I feel unwell just wait­ing’, and I wasn’t a patient, I was a vis­i­tor. So I think there’s a lot to be done on that side of things.

Evans: I was in St. Gemma’s Hos­pice yes­ter­day and there’s an atmos­phere of it being like a spa.

John­son: Yeah, yeah, yeah … I’m a great believ­er in those sorts of envi­ron­ments for our chron­ic pain patients in par­tic­u­lar. I think we unfor­tu­nate­ly prob­a­bly over med­ical­ize some of our chron­ic pain con­di­tions [but] not all of them. If you’ve got a dis­ease dri­ving the con­di­tion, an ongo­ing dis­ease that does need atten­tion, but we are well aware now that some of the chron­ic pain syn­dromes, they cer­tain­ly do not have pathol­o­gy in the periph­er­al tis­sue that orig­i­nal­ly start­ed the pain. It’s the pathol­o­gy, if we want to call it that, which has migrat­ed to the cen­tral ner­vous sys­tem. If we con­tin­ue search­ing for the pathol­o­gy, we aren’t going to find it, so there needs to be com­plete sort of shift in the way the patients like that are man­aged. I think that’s going to be the par­a­digm shift in care going forward.


Con­trib­u­tors:

  • Ali­son Rose MCSP HCPC, Direc­tor of CSPC Phys­io­ther­a­py, Leeds
  • Pro­fes­sor Ann Tay­lor, Pro­gramme Direc­tor for the MSc in Pain Man­age­ment at Cardiff University
  • Pro­fes­sor Mark John­son, Pro­fes­sor of Pain and Anal­ge­sia and Direc­tor of the Cen­tre for Pain Research, Leeds Beck­ett University.

More infor­ma­tion:

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