Questions and Answers on Chronic Pain

Managing Director and Principal Physiotherapist Tim Ellis (BA Hons, BSC Hons, MHSC Hons) talks to Senior Physiotherapist and dedicated Chronic Pain Management Physiotherapist Johnny Kang

Tim: Hi Johnny and welcome to your role as Chronic Pain Physiotherapist at Excel. It’s great to have you here and to have this opportunity to work alongside someone who has spent so much time studying in the chronic pain management field of Physiotherapy.

Johnny: Thank you Tim, it is great to be here.

Tim: Johnny, I’m curious. How long have you been a physio and what is it that keeps you motivated to remain in the profession?

Johnny: I have been working as a physio for seven years, mainly focusing on musculoskeletal pain disorders in both private and public sectors. The variety of cases always challenges me to come up with individualised management plans and these are based on multifactorial evidence-based clinical reasoning. This challenge keeps me motivated in my profession.

There are various approaches to managing musculoskeletal pain. This is understandable because so many factors contribute to the process of pain. For instance, in different patients with acute grade ankle sprain, we may see different clinical presentations and prognosis, depending on contributing factors to pain, such as beliefs, moods, stress, sleep, family support, occupations, compensation, cultural disparities, and many more.

Tim: Yes, it is fascinating. Every human is a microcosm of 100 trillion cells, each with a double strand of DNA, so no wonder there is variation! Since you specialised in chronic pain management, how has your thinking about the profession of physiotherapy changed?

Johnny: Traditionally, physiotherapy focuses on biomechanical assessment and management. However, since I studied pain medicine and the psychological aspect of pain in the University of Sydney, I’ve realised that biomechanical management should not be the entire focus for chronic pain management.

Recently, a group of physiotherapy specialists formed to integrate psychological and social components into physio assessment and management. The clinical framework was introduced by the Curtin University research team (where Johnny studied), and focuses on considering other factors that may affect healing. The framework was designed to cover all of the biopsychosocial domains. So I am now using this approach when dealing with msk pain disorders.

Tim: So, my understanding is that this framework helps physiotherapists to take a holistic approach, but to make it more scientific, uniform and reproducible.  What are your main aims when working with the chronic pain patients?

Johnny: I aim to develop pain management strategies, and it is very important to listen to the patient’s goals, expectations, and values in life. Having a conversation with patients regarding these issues is an important process in the first session. It is crucial to remember that not all patients fully recover from chronic pain.

The patients may need to accept the fact of living with pain and find management strategies to improve their quality of life. Therefore, adjusting expectations and focusing on valued activities is vital.

After the goal setting, I look at the barriers that may impede achievement of the goals. The barriers are not restricted in biomechanical domains but psychosocial aspects, too. In chronic low back pain, for instance, correcting biomechanical issues often reduces patient’s pain and improves their function. However, if psychosocial factors are prominent, such as low self-efficacy, catastrophising thoughts and distressed mood, it may be just as important to discuss this with the patient and to keep in contact with the GP and specialist.

Tim: I agree, Johnny. We absolutely need to understand our scope of practice, and to be as effective and practical as we can be. How does your work at the pain clinic influence your private practice work at Excel?

Johnny: Consulting a complex chronic pain patient at the pain clinic helps me reflect what I need to focus when I see patients with acute pain to prevent chronicity. Most acute pain resolves within three to six months. However, there are roughly 20% of patients who fall into chronic pain. Chronicity is an important matter in our society because once patients fall into a chronic pathway, it is very difficult to reverse the process.

In private practice, utilising screening tools, such as a short form Orebro or STarT Back questionnaire, can be a good starting point. Getting into a routine sensory examination is recommended. Hence, a physiotherapist knows what types of pain they are dealing with. This is important information for the referring doctor because different medications are required for different types of pain. Physiotherapists can alert doctors about these issues as early as possible to minimise the risk of chronicity.

Tim: Good point – if we can prevent chronicity, then we should. Finally, Johnny, what key messages would you pass onto young physiotherapists who have just joined the profession?

Johnny: I have worked as an educator for a year in a public hospital and found that these days, young physiotherapists are smart, sharp, and keen to improve their professional knowledge and skills. They learn a concept of biopsychosocial and evidence-based approach from university. However, they sometimes struggle to apply these theories into clinical practice. This may be because they have not yet met a good mentor to provide guidance.

It is important to draw a big picture of physiotherapy and think about our roles in the community. There are a few components I believe that new graduates should consistently develop in the field of physiotherapy, including communication, manual therapy, subjective and objective assessment, evidence-based clinical reasoning, pain management, and prevention.

Since the biopsychosocial model is emphasised in pain management, it may be a good idea to start reading articles and get experience in other areas, such as pain medicine and psychology. Using a clinical reasoning framework is a good way to start.

Tim: Absolutely! Our field is one of life long learning, but that learning needs to be directed, remembering our obligations to our patients and the community. Thanks, Johnny, that has been fascinating and I’m looking forward to more updates in the field of chronic pain management!