Improving Musculoskeletal Pain Care in Brazil Through Education: An Interview with Physiotherapist-Turned-Researcher Felipe Reis

In this exclusive RELIEF interview, Reis discusses his path to pain research, the challenges associated with musculoskeletal pain, the pain landscape in Brazil, and more. Image credit: Naruedom Yaempongsa/123RF Stock Photo.

Felipe Reis, PhD, is a professor in the Musculoskeletal Physiotherapy Department at the Federal Institute of Rio de Janeiro, Brazil. After completing his physiotherapy training at the Federal University of Rio de Janeiro, he undertook his masters and doctoral degrees at the Federal Institute of Rio de Janeiro. His research focuses on the neuroscience of emotion and pain, as well as on improving pain education for healthcare professionals in Brazil, particularly those who treat musculoskeletal pain conditions. Reis took time to talk with Lincoln Tracy, a research fellow at Monash University, Melbourne, Australia, and a freelance writer, to discuss his path to pain research, the challenges associated with musculoskeletal pain, the pain landscape in Brazil, and more. Below is an edited transcript of their conversation.

You first trained as a physiotherapist before pursuing your master’s degree and PhD. Is this what drove you to become interested in pain research?

That is an interesting question. Until I was in my twenties, I was a swimmer. I participated in several local and national competitions, and frequently went to physiotherapy for the various aches and pains that came from my training. That’s how I first got interested in physiotherapy.

However, my interest in studying pain began when I was doing my masters and doctoral degrees. I was studying patients with leprosy, an infection of the skin and nerves, which is still a common problem in Brazil. In some patients the infection would attack the nerves in their arm, causing pain. So, they would have surgery on the nerve and be given medication to reduce inflammation, but they would still have pain. This confused me, initially; if I had surgery and had my nerve operated on, the pain should stop, right?

Felipe Reis

So I started to read papers from people like Lorimer Moseley [an expert on pain] and began to think differently about pain. I soon realized that many different factors contribute to pain, not just the injury. After I finished my PhD, I was invited to join a neuroscience lab that studies the interaction between pain, emotions, and our behavior. I’m still in that lab now!

What is the overall aim of your research?

One of the main goals of my research is to develop free tools for patients and clinicians. In 2015, we launched a website where clinicians can find the most common tools and questionnaires used to assess patients. Patients can access videos and booklets to understand how pain works, or how psychological factors like sleep disturbance can contribute to pain.

I’m also interested in understanding how we can improve pain education and knowledge for physiotherapists here in Brazil. The website began when we found some evidence supporting pain education. At the time, we thought that only a small group of clinicians had the ability to provide pain education to their patients. We thought our website would be a huge opportunity to teach healthcare professionals about how they can provide pain education for their patients in different parts of the country.

We live in a large country with substantial differences in socioeconomic status. For example, I live in Rio de Janeiro. But there are other, poorer, regions in Brazil that don’t have access to the same kind of information that we do. So, we believe the internet can provide access to education for patients and professionals in other regions of the country.

What other benefits do internet-based interventions offer?

I believe that internet access and internet-based interventions can break down the socioeconomic and geographic barriers to knowledge that many patients experience. It also allows healthcare professionals to provide supervised care for these patients. I think this works well. You can put information on the website, which is then available for 24 hours a day, meaning that people can access it any time, any place. But most importantly, it helps cut down the waiting lists and times to receive specialized care, as patients can access information and resources while they wait to have an appointment in person. I believe it’s a powerful tool that should be explored, especially in developing countries with poor resources for health.

How broad is the problem of musculoskeletal pain in Brazil?

In 2011, a national survey found that two in five patients with acute low back pain had visited the emergency department. One in six patients with acute low back pain were admitted to the hospital. Once admitted, healthcare professionals prescribed at least one medication for each patient – many of these with a limited evidence base, like paracetamol. A study from 2019 found that one in three patients with low back pain retire prematurely as a result of the pain. We also face similar problems seen in many other countries – increasingly treating patients with surgery, overprescribing of medications, and overtreatment in general.

One explanation for these challenges is the training our healthcare professionals receive. There is little taught about evidence-based medicine or evidence-based practice. Instead, they just become used to prescribing medications that they consider to be beneficial to their patients. Many healthcare providers aren’t willing to change their practices, despite us now knowing that some treatments are not effective for pain. This problem is compounded by the media, which promotes incorrect or ineffective treatments, or misinformation about cause and effect.

It’s an interesting situation. Every person in Brazil has free and universal healthcare coverage for primary, secondary, and tertiary services. But about 30% of the population also have private health insurance. This changes things, because these individuals can receive specialized care. For example, if I have private health insurance and I have pain in my knee, I can see a surgeon and have surgery on my knee. If I don’t have health insurance, I need to use the public health system, where the first point of contact is a general practitioner.

How much knowledge do patients and healthcare providers have about the neurophysiology of pain?

The first time I heard about pain neuroscience education was in 2011. I thought, “Wow, that’s fantastic, it will be so interesting to teach patients about pain neurophysiology.” Since then, I have really tried to teach my patients about the neuroscience of pain, such as explaining what neurons are and how the nervous system works. I found that while some patients understood a lot about neuroscience, they didn’t know how this information would help them in their lives.

I believe that patients need to have a better understanding to begin to make changes in their lives. But you need to deliver the information in a way that makes sense to them. This may mean not talking only about neurophysiology, but combining it with explanations of how other factors such as their beliefs, feelings, or behavior can contribute to their pain. For example, if a patient says, “I’m a little stressed today and my pain is worse,” it’s better to try to teach them self-management strategies rather than just pain neurophysiology.

I think we are struggling a bit more with getting the message across to providers in Brazil, though. If you look on the website of our Ministry of Health, we have a lot of old or outdated information for patients with chronic low back pain. We still find information about the correct posture, how to carry or lift heavy objects, and about rest, along with advice such as needing to stay in bed if you have pain. So, most of the information is not evidence based. This is a big challenge that we still need to overcome. This is particularly true when you consider that there are surgeons performing unnecessary operations on patients with low back pain.

What are some of the things we don’t know about musculoskeletal pain?  

One of the big issues that we need to address is to learn more about predictive factors for developing chronic pain. If we examine a patient with acute low back pain today, we don’t know if they will develop chronic low back pain in the future. Another thing we don’t know, particularly here in Brazil, is the association between pain knowledge or health literacy and pain behaviors. For example, do patients who live in poorer regions cope with pain differently, compared to patients with more resources? It’s important to understand the influence of socioeconomic factors and health literacy on how these patients cope with pain.

What are some of the interesting things you have learned over your career about effectively treating musculoskeletal pain?

For me, the most interesting thing has been learning about the multifactorial aspect of pain. I have some patients where the affective [emotional] aspect of pain is very important, whereas for others the social aspect of pain is important. We need to consider this view of pain, and as clinicians we need to be prepared to investigate all the different aspects of the pain experience. However, it’s not easy. Some clinicians have a difficult time incorporating a biopsychosocial model into their practice because they don’t understand it. So, I feel that understanding the different aspects of pain is important as it allows us to try to improve the parts of our patients’ lives that are most affected by pain.

You are currently chair of the Pain, Mind, and Movement Special Interest Group (SIG) of the International Association for the Study of Pain. What is the purpose of this group?

The primary mission of this SIG is to bring together clinicians and researchers from different areas, from basic research in cells and animal models to clinical research. We want to give clinicians and researchers an understanding of how the research fits together in the grand scheme of things. In doing so, we hope to help clinicians understand the knowledge and research in a language that makes sense to them.

We recently held a webinar discussing telehealth. Different professions from all around the world have needed to learn about this quickly, but many healthcare providers are not aware of what telehealth is or how to use it. For example, we were not allowed to treat patients by telehealth in Brazil before COVID-19. The webinar is all about challenges in implementing telehealth services in the current environment. We have also been working with IASP as part of its Global Year initiative; I am a member of the Global Year Task Force. 2020 is the Global Year for the Prevention of Pain, so I have collaborated with Brona Fullen, a professor from Ireland and co-chair of the Task Force, to develop resources around physical activity for pain prevention.

How do you see pain management evolving in the future?

That’s a tricky question. Pain management will evolve as more health professionals learn about the multifactorial nature of pain – not just the biological aspects – and how to treat chronic pain patients. We also need a large, multidisciplinary team working together; it’s not enough to have just a doctor or a physiotherapist working on patients with chronic pain. It’s necessary to have a paradigm shift in health care practice. It is important that clinicians recognize their role not only in providing more interventions but in developing interpersonal abilities to act with empathy to help patients deal with pain.

Thank you for your time.

Thank you, it’s been great to talk with you.

Lincoln Tracy is a research fellow and freelance writer based in Melbourne, Australia. You can follow him on Twitter @lincolntracy.