Physiotherapy for Pain and All That Jazz: A Chat with Romy Parker

Romy Parker

Romy Parker, PhD, is a professor in the department of Anaesthesia and Perioperative Medicine at the University of Cape Town, South Africa. She started her career as a physiotherapist and went on to receive her doctoral degree in psychiatry. She’s now the director of the pain management unit at Groote Schuur Hospital, working as a physiotherapist within the hospital’s Chronic Pain Management Clinic. She is also the course convenor of the Postgraduate Diploma in Interdisciplinary Pain Management for healthcare professionals, the first program of its kind in Africa, and does research on multiple aspects of pain management. In addition, she is the President of PainSA, the South African chapter of the International Association for the Study of Pain (IASP). Here, she discusses the importance of interdisciplinary teams to help manage chronic pain, the crucial role of physiotherapists on those teams, and her hopes for the future of pain management.

What first got you interested in physiotherapy?

As a teenager, I thought that physiotherapy was a glamorous sort of sports job; I originally wanted to be a sports physiotherapist. I was a sporty, athletic person myself, and so physiotherapy is what I pictured myself doing.

When I finished my physiotherapy degree, I immediately did a post-graduate qualification in sports science because I wanted to work on sports injuries. I went on to work with some high-level teams in rugby and had all the glamor of running on the field to rescue injured athletes. That’s where my career started but I soon realized that the paradigm I was working in—the kind of physiotherapy model that regards the human body as some kind of machine and physiotherapists as mechanics—didn’t always work. I felt like I was missing something.

So, I ended up taking a detour. I started working in rheumatology and that’s where I really developed an interest in pain because I kept coming across patients with severe rheumatological disease whose joints were destroyed and yet they weren’t reporting much pain. Then I had other patients who had very mild rheumatological disease but were reporting terrible pain and they were extremely disabled because of it. This is where I came across the idea that pain isn’t solely linked to tissue damage or what’s going on in the body; it’s a bit more complicated than that. I wanted to learn more about pain because of these mismatches I kept seeing between the mechanics of the body and what people were actually experiencing.

What were the challenges of trying to reconcile those mismatches, especially when it came to treating pain?

I was really lucky because, working with a rheumatological team with clinical practitioners, the rheumatologist was very clear that managing these conditions wasn’t just about pharmacology. I used to run a six-week course for patients who were newly diagnosed with rheumatological conditions. I came across Kate Lorig’s work from Stanford University looking both at self-efficacy, which is an individual’s belief in his or her own ability to achieve goals, and at disability in people with osteoarthritis. Clinically, I realized that when my patients were educated and taught problem-solving skills, their levels of self-efficacy improved, and they felt empowered. This allowed them to do much better with self-management and their pain was better, too.

So, while medication helped, we were very aware that empowering our patients made a big difference. My first foray into research we presented at the British Rheumatological Society looked at patients who were learning about self-management but also exercising together and learning relaxation techniques. We saw very clear differences not just in their perceived health but in their disease profiles as well. That raised the value and importance of non-pharmacological approaches. So, you might say I came into the pain world already converted to the idea of non-pharmacological approaches to pain management.

What is the role of physiotherapy in pain management?

Physiotherapy is pivotal in chronic pain management. Every patient with complex pain needs multiple healthcare professionals. But I think that physiotherapists are often uniquely skilled in managing these cases because we have skills in patient education and in helping patients develop problem-solving and goal-setting skills so they can re-engage with their lives and reduce disability. We also have outstanding skills in exercise prescription and exercise adaptation, and we know the evidence and value regarding the effects of exercise in treating complex pain. And we have a very good understanding of the biopsychosocial complexities of human beings, and if we are treating pain, that’s what we are really treating: biopsychosocial human beings. Taken together, there is great value in physiotherapists being the primary healthcare professionals for management of complex pain cases.

When I trained, physiotherapists were taught a biomechanical approach, but since then, physiotherapy has rapidly moved away from that to the biopsychosocial model. In recent years, we’ve seen in the literature that environments, mood, and social set-up influence pain, and we now have a biological understanding of what happens in the central nervous system and what the neuroscience is when you’re anxious or you’ve got low levels of education or you live in a poor suburb that’s riddled with gang violence. We can see what all those factors can do to your physiology and how that can influence your pain. I know I’m biased but physiotherapists bring a lot to pain management.

You’ve said that physiotherapy is often overlooked in pain management. Is that changing?

Physiotherapy has been overlooked and in many settings it continues to be overlooked. There are multiple reasons for that. One reason is a societal resistance to what physiotherapy can offer. Everyone knows, whether they have chronic pain or not, that they should exercise, but nobody likes to do it. I don’t know why, because I like to do it. But there seems to be this idea of, ‘Oh, I know that I should but it’s too difficult.’ It’s a barrier. There’s a societal impression around modern medicine that we should be able to fix any problem quickly and just get on with our lives.

That’s what society often expects when it comes to pain management. The idea that patients have to exercise, and do it themselves, that it’s hard work and that it will take time—it’s a difficult idea. Patients just want you to give them something to sort it out right away. And physiotherapy can be sidelined because, in the majority of cases around the world, healthcare professionals are trained in silos; we don’t really understand what our colleagues do.

In healthcare training, there is an implicit emphasis on our own skill set. I know that with our medical students, the implicit emphasis is on pharmacological and surgical management and then only after that do you refer the patient to physiotherapy; that’s all they are taught. Whereas the physiotherapists are learning about education, exercise and behavior change management, and then you may want to refer to the doctor for some medication. That is part of the motivation for why we offer our postgraduate diploma in pain management as an interdisciplinary course where we force the students to work together in interdisciplinary groups for many of their assignments.

When they start, they all hate it. None of us like group work. But, once they get going, they start learning what the others bring to the table, they start sharing their different viewpoints, and they start realizing that a colleague may understand an aspect of complex pain better than they do. They eventually see the value of interdisciplinary work, but you do have to push people to work together like this because it’s so easy to stay in your own silo and do what you’ve always done.

What is the role of the patient in the interdisciplinary team?

Let me use the metaphor I often use to describe what I mean by interdisciplinary, as opposed to multidisciplinary. A multidisciplinary team is like a traditional orchestra with the conductor. Everyone has their instruments to play, and, if they obey the conductor, you can make beautiful music. But the conductor is always the boss, and no one will ever question the boss. No one will ever swap instruments.

An interdisciplinary team, on the other hand, is like a jazz band. Everyone knows everyone else’s instruments. If I play one instrument, you can bet I can play yours as well. When you watch a really good jazz band, the leadership is fluid. Depending on where the music is going, a different player may take up the leadership role and take things in a new direction.

In the multi-disciplinary orchestra, the patient is just passively sitting, listening to the music. In the jazz band, however, the audience is tapping along, creating new rhythms themselves. In a really good interdisciplinary team, the patient is just as much of a player as anyone in the band. The leadership is passed around until, eventually, the leadership of that team ends with the patient. That’s the stage where patients understand how to manage their own condition. If the music isn’t going the right way, they can call on the rest of the team to help out. But otherwise, the leadership ends with the patient.

That’s where our treatment goals should always be focused: on patients. I am aiming to discharge our patients and I want to discharge them where they know that they are the leaders and empowered to direct the music. That’s one of the most important things I’ve learned over my career. It’s not what we bring as healthcare professionals. It’s about what patients can do for themselves if we can enable them to do it. When we enable our patients and give them the right tools, they can do amazing stuff.

What is the state of pain management in South Africa compared to other places in the world?

In South Africa, we have dual parallel systems. We have a private healthcare system that is very Westernized, based on the American financial model. That system uses 52% of the healthcare money in the country but serves 16% of the population. Then we have the state system, our government health services, which looks after everyone else on a very tiny budget.

So where are we with pain management in South Africa? We have pockets of excellence, and those are primarily in the government health services. That’s because there are fewer barriers to the interdisciplinary management of patients. People in the private healthcare system are starting to develop interdisciplinary teams to manage pain but there are barriers there to optimizing pain management. How do you code for a bill for a conversation between the physician and the physiotherapist? Or for spending half an hour explaining pain to a patient? How do you bill for all aspects in a way that everyone is remunerated fairly?

In government service, on the other hand, we’re all on fixed salaries. So, we can focus on giving the best evidence-based patient care. There are barriers here, too, and that comes down to sustainability and a lack of staff. There’s less than one physiotherapist per 10,000 South Africans. The nurse and doctor ratios are appalling—about 0.8 doctors per 1,000 people. So, at the hospital where I work, the waiting list to be seen in our chronic pain management clinic is nine months to a year long. We simply don’t have enough staff to get people in. But people wait because they know they will be seen by an interdisciplinary team.

There’s growing education, awareness, and understanding about what we need to offer to people for pain management. But there are big constraints on how we do it when there are so few healthcare professionals and on how much it costs.

What can be done to overcome those challenges? What will we see in the evolution of pain management, in South Africa and beyond, over the next few years?

I think we’ll see two things. We are starting to see a shift in undergraduate education on pain for healthcare professionals around the world. This is a project we’re working on here in South Africa with PainSA, our IASP chapter. We are working hard to get undergraduate healthcare professionals educated in pain science and evidence-based approaches to managing pain. This will be a critical shift in changing the future management of patients who are living with chronic pain.

The second thing we’re starting to see, though I’d like to see more of it, are public conversations that help educate the population about the complexity of pain. What is pain, really? How can a person have pain and no tissue damage? Society, for a long time, has made assumptions about pain—that something must be wrong with the body for pain to occur. But educating the public that pain can also be related to a person’s environment, or mood, or life, or some other factor, is important. This needs to be a bigger conversation going around the world.

Too often, we in the pain field end up preaching to the converted. We need to start getting out in public and getting people to think about pain more broadly in order to shift the understanding and misperceptions regarding pain. For example, I’m starting work on a project that will involve a series of podcasts aimed at the public about pain. If the average person better understands what pain is, it will make conversations with healthcare professionals much easier. It will lead to fewer expectations from patients that doctors can just fix the problem with a pill.

Kayt Sukel is a freelance writer based outside Houston, Texas.

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