On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Sandy Hilton, David Butler and Bronnie Thompson on the show to discuss persistent pain during COVID-19.

In this episode, we discuss:

-Shifting current healthcare curriculum to better educate clinicians on persistent pain

-Can passive modalities empower people to pursue more active treatment options?

-How to create more SIMS during the COVID-19 pandemic

-Can telehealth appointments adequately address persistent pain?

-And so much more!

Resources:

International Association for the Study of Pain Website

Factfulness Book

David Butler Twitter

Sandy Hilton Twitter

Bronnie Thompson Twitter

A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!

For more information Bronnie:

I trained as an occupational therapist, and graduated in 1984. Since then I’ve continued study at postgraduate level and my papers have included business skills, ergonomics, mental health therapies, and psychology. I completed by Masters in Psychology in 1999, and started my PhD in 2007. I’ve now finished my thesis (yay!) and can call myself Dr, or as my kids call me, Dr Mum.

I have a passion to help people experiencing chronic health problems achieve their potential. I have worked in the field of chronic pain management, helping people develop ‘self management’ skills for 20 years. Many of the skills are directly applicable to people with other health conditions.

My way of working: collaboratively – all people have limitations and vulnerabilities – as well as strengths and potential. I use a cognitive and behavioural approach – therapy isn’t helpful unless there are visible changes! I don’t use this approach exclusively, because it is necessary to ‘borrow’ at times from other approaches, but I encourage ongoing evaluation of everything that is put forward as ‘therapy’. I’m especially drawn to what’s known as third wave CBT, things like mindfulness, ACT (Acceptance and Commitment Therapy) and occupation.

I’m also an educator. I take this role very seriously – it is as important to health care as research and clinical skill. I offer an active knowledge of the latest research, integrated with current clinical practice, and communicated to clinicians working directly with people experiencing chronic ill health. I’m a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences.

I also offer courses, training and supervision for therapists working with people experiencing chronic ill health.

For more information Sandy:

Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.

For more information on David:

Understanding and Explaining Pain are David’s passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI in the early 1990’s. David is an Adjunct Associate Professor at the University of South Australia and an honoured lifetime member of the Australian Physiotherapy Association.

Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley – Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, Explain Pain Supercharged. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests.

Read the full transcript below:

Karen Litzy (00:00:23):

Hello everyone. And thank you for joining us today for this webinar. For those of you who are here live, you got to hear a little bit of pre-conversation which is great. And of course in that pre-conversation we were talking about all the things happening in the world today, specifically here in the United States with a lot of unrest and protests for very, very good reasons, in my opinion. And so we just want to acknowledge that and that we see it and that we are trying to learn, and we are doing our best to be allies to our fellow healthcare workers and citizens across the country and across the world for all of the other countries who have been showing solidarity. So I'm Karen Litzy, I'm going to be sort of moderating this panel of minds and I'm going to now go round and just have each of them say a little bit about themselves. So Sandy I’ll start with you.

Sandy Hilton:

Okay. Hi, I'm Sandy Hilton. I'm a physiotherapist here in Chicago, Illinois with Sarah Haag. We have entropy physiotherapy and our clinic is predominantly working with pain. It's like a hundred percent of my case load is people in pain and about 80% of that is pelvic pain in particular. But I still see, you know, the rest of humans.

David Butler (00:01:49):

Hi, I'm David Butler from Adelaide Australia. I'm a physio, although I'm completely a professional and I believe everybody has the exact same role in treating pain. I'm trying to hire, but I can't retire. And then in world, our changing knowledge and our changing potential just keeps me, keeps me on track. So yeah, any sort of pain I'm happy to talk about.

Bronnie Thompson (00:02:16):

I’m Bronnie Thompson, I'm an occupational therapist by original training with some psychology thrown in, and I'm an educator and clinician as well, but a teeny tiny bit of research, but not much. And I'm a painiac and quite proud of it actually.

Karen Litzy:

Excellent. So again, everyone, like I said, if you have questions as we go along, please feel free to put them in the Q and a part. And I will be looking at that as we're going through now, like I said, we've got some questions ahead of time, but before we get to some of the questions that some of the listeners and viewers have wanted to ask, I also want to just quickly acknowledge that we've got a bit of a mixed audience, so we've got healthcare practitioners and clinicians and we've also got people living with pain.

Karen Litzy (00:03:11):

And so as a clinician for me, it's a great opportunity. I think to address people in pain who maybe don't have the access or the ability to kind of get this information that's in their town or where they're living. So I am really, I'm really looking forward to this discussion, especially for those people that are watching that are living with persistent pain. So the first question I'm going to ask is and I'll ask this of all of you. If you were to give a piece of advice to a new professional or a healthcare professional that is sort of newly working with people with persistent pain, what would that piece of advice be?

Sandy Hilton (00:04:11):

I'm in Chicago. I'm just going to take it. I really like to stress, especially to students that, you know, we get this concept that the longer you've been in the field, the better you are at it. And, I think that maybe we make different mistakes, but everyone is learning this. And there's so much about pain that we're learning. And so if you're just starting in, I don't know that you might have an easier time because you have less bad habits to get rid of and can start with some of the better newer research and avoid some of the mistakes we made.

Bronnie Thompson (00:04:50):

So she's doing the popcorn approach. She looks at me. And so I think my advice would be, listen, listen very carefully to what people tell you and trust that they're telling you your experience. Don't try and read stuff into it, just listen and reflect, show that you're listening by reflecting what you've heard. So you can give that you've understood one another, because it's really easy to come out of school with all of this knowledge packed up and your brain thinking, Oh, I've got to do an info dump just like that. And it's not that great for the person, stop and listen.

David Butler (00:05:37):

They are lovely comments. I'd add. I would welcome anybody to the most new and exciting area of health. And there is a true pain revolution out there. And I would say to anybody, when you come in to just lift your expectation of outcome or what, might've been five or 10 years ago, because the clinical trials and our knowledge of the potential for humans to change is just increasing so dramatically. And I say, now we can say think treatment, not necessarily management because for many people recovery or some form of recovery is on the cards and what's leading the charge is the talking and the movement therapies. It's not the drug therapies for chronic pain. And, I just like to reflect as an older therapist now, patients who maybe 10, 15 years ago with maybe complex post pain surgery or Phantom limbs or complex regional pain syndrome would have thought, and I can't really help here. Now we welcome them through the door and you can get such pleasure, pleasure from treating these people no matter how long they've had the problem.

Karen Litzy (00:06:48):

Great. And, I would echo what Bronnie said is, you know, really listen and also believe, you know, they're giving you their experience. So try and take your bias out of it and believe what they're telling you and try not to talk them out of it because you see this quite a bit of, Oh, I have pain with this. And well, do you really have pain with that? Or is your pain really that much? And as the patient, it's very frustrating to have someone try and tell you what your pain is. So I'm looking at it from the person who has lived with the really chronic and at times debilitating neck pain is just listen, which is good. Believe them, and try not to talk people out of their experiences because it's very frustrating and it's very sort of dehumanizing for the patient, you know?

Karen Litzy (00:07:54):

And when I look back at when I first met David and went up to him at an APTA event and said, would you like to be on my podcast? And he said, yeah, sure, but I'm going to New York. I said, Oh, well, that's great. Cause that's where I live. And so then he met me at my, where I was working at the time and spent two hours with me. And I just, after that felt like, Whoa, like this is the first time that someone really listened and didn't interrupt and believed what I was saying and really set me on a path that just changed my life. Like, I don't know where I would be, had I not had that encounter with David. I think it was like 2011 or 2012. And so I always reflect on that and try and be that person, because I know what it felt like.

Karen Litzy (00:08:45):

And then when someone does come in and, and gives you their full attention and their time and their understanding, and then says, well, challenges your beliefs in a positive way, it was something for me that, you know, and I've talked about it many times that just completely changed my pain and my life. And so, you know, try and be that person is what I would say to people.

Bronnie Thompson:

It's like, we've got to remember that people with pain and I live with fibromyalgia, those of you that don't know that's my reality, it's our experience and what it's like to live without pain. You know, what it feels like to know the things that sit at off things that settle it down and our relationship to it, to that pain and conditions. We come in with a whole lot of knowledge about other people and what we've seen. So we are experts and a whole lot of stuff, but what we're not experiencing as this person's life, their experience via what they're wanting from us even, what's important to them. And that's where when we meet and we can kind of share the hidden paradigms things that we don't know about each other, then we've got a chance to make a huge change and that as we know, I just feel so good about what I do. I just love it. I'm such a pain geek.

Sandy Hilton (00:10:09):

And I think the pain science or the science of pain really gives as a clinician, a lot of comfort to the listen to them, believe them, you don't have to prove it. You don't have to go. And like they say, I hurt here. You don't have to go poke it to reproduce the symptoms to believe it. And that's how I was taught of you have to reproduce the symptoms so that you can document that it's true. And it was like, that's a giant piece of unnecessary that we don't even have to do anymore, which really saves us a lot of time, not to mention establishing that trust and not being one more person. That's poked them in the sore spot. But, that's the thing that I was taught in school.

Bronnie Thompson (00:10:58):

So the question is, do you think that all chronic pain patients were not treated particularly when they were having the first or second episodes of their acute pain or are they in any way destined to become chronic pain patients? Well, my story is I hurt my back. I was what, 21, 22, doing a tango with the patient and a doorway patient was bigger than me. I landed on the floor on my back and I had all the best evidence based treatment at the time, maybe not, maybe not all the ultrasound, but you know, they didn't lie. They're really and relax a bit.

Bronnie Thompson (00:11:48):

But I didn't recover. I was then seeing the Auckland regional pain Center with amazing dr. Mike Butler, who is a rheumatologist and founded, and basically was one of the first in this initiations of bringing the international association for the study of pain to New Zealand, good friend of Patrick Wall knew her stuff very well. Gave me the book the challenge of pain to read. So essentially an explain pain paradigm back in the eighties, I know pain pretty well. My pain has not gone away. So there are some people who will not have a complete recovery of all of their pain, but because none of our treatments provide a hundred percent abolition of pain and actually I'm comfortable with it. I live with the pain and it gives me some stuff that some other people don't have access to. I know what it's like to have every bit of my body feeling really rotten.

Bronnie Thompson (00:12:53):

At the same time. I'm not limited by my pain. And I think sometimes we look at pain removal is that end goal. But I think our end goal is to help people live full, productive, satisfying, joyful and enriched lives. And some people will bring the pain along with them and many people won’t have to and that's amazing. Let's let the person make that decision about what is the most important outcome. But yeah, sometimes we can do all the right things, but if you have a spinal cord injury and you've got a smashed up spine, probability is that at the moment, our technology doesn't give us a solution. We can help, but we can't always take it all away.

Karen Litzy:

David, what are your thoughts on that, that sort of movement from acute pain to chronic pain? You know, what are your feelings on that is, is like you said, are you destined to have it are I know, cause I get this question a lot from people like, well, you know, it started out with like an ankle sprain or it started out with a knee sprain and now it's turned into this. So did I do something wrong or was something not done?

David Butler (00:14:12):

I think you’re not destined to have it, but I think our treatment or therapies and the politics of treating acute pain probably gets in the way. And I also think if someone's hurt their back or any part of their body bad enough to see a health professional, the data is that 50 or 60 or 70% will have a recurrence in the following year. Now most health professionals think a recurrence is a reinjury, but if they really explored what happened, that reoccurance probably happened at a time when they would look at down and flat the immune system's a bit out of balance and they might've just done something simple, lifted up and picked something we would now from pain science, reconceptualize that as well, that's quite good. It's your body testing yourself out like a fire alarm with all the stuff you've been through in the past. It's no wonder your brain. Wouldn't want to play it again to check out how your systems are working, but that just simple piece of knowledge and usually should check to make sure nothing serious has gone on because you check and you can normally say, well, that should ease in a couple of days. That's an example of a little bit of knowledge dampening down. They don't have to go through the old acute process again of more, x-rays more tests, more power.

David Butler (00:15:31):

I think if that's correct, that observation was seen for many years, it could save governments Billions.

Bronnie Thompson (00:15:37):

Oh, absolutely. We've got a great thing. The language we use don't we, is it an injury or is it just a cranky body?

David Butler (00:15:46):

That whole linguistics? And for me and my treatment, you're now a physio by trade. I feel it says important to help someone change the story, to have a story, to take their experience out into society and let it go. That to me is as important as having healthy movement, although they obviously like go together.

Sandy Hilton (00:16:07):

I was gonna say that the saving of money for systems, for sure, but also the saving of time for people and the saving in our healthcare system. Every test you go do is going to cost you a lot of money. And, that time that it takes to get it in a time away from work and family and the concern of what the test results will be. If we can divert them wisely to not do that when it's not really indicated, that's just so good.

Bronnie Thompson:

Yeah. And then I also for, you know, I've had a test now I'm going to wait for the results and now I'm going to wait for what are they going to do as a result of those results? And then, Oh, it's the same. And it just feels very demoralizing to people. And I think that's something we need to think about with make the decision about when and we to stop doing investigations often. That's the sense of the clinician worrying that something, are they going to sue me? It’s not a good way to practice.

Karen Litzy:

Yeah. here's another, we'll do this from Louise. She says, picking up on something David had said earlier, how do we move towards being more, a professional? How do we move the pain industry toward this goal? Excellent question Louise.

David Butler (00:17:51):

There's a lot of answers to it, but a couple would be, I think you just got a quite badly out there would know sports trainers who could deliver an equally good management strategy to some physios, to some doctors, et cetera, right? This pain thing is across all spectrums, which is why the national pain society meetings are so good. And why everybody there is usually humbled and talks to all the other professionals because they realize the thing we're dealing with is quite hard. And we need all the help that that's a weekend get, but it ultimately comes back to provision of pain education throughout all the professions and that pain education should be similar amongst all the professions it's not happening yet. We've tried pushing it, but it's not out there. And it's incredible considering the cost of pain is to the world is higher than cancer and lung diseases together.

Karen Litzy (00:18:51):

Yeah. The burden of care is trillions of dollars across the world. And, you know, even in the United States, I think the burden of care of back pain is third behind heart disease, diabetes. And then it was like all cancers put together, which, you know, and then it was back pain. So, and, and even I was in Sri Lanka a couple of years ago and I did a talk on pain and I wanted to know what the burden of disease of back pain was in Sri Lanka. And it was number two. So it's not like this is unusual even across different, completely different cultural and socioeconomic countries. And, you know, David kind of what you said, picks up on a question that we got from Pete Moore. And he said, why isn't it mandatory that pain self management and coaching skills isn't taught in medical schools? Is it because there isn't expertise to teach it? Well, I mean, David's right here. He's semi retired.

David Butler (00:19:58):

Why isn’t that mandatory? That's a big, big question. I would say that the change is happening. Change is happening. I would say that at least half of the lectures or talks I give now are to medical professionals and out of my own profession or even more than half. So yeah, change is happening, but it's incredibly slow. It needs a bloody revolution, quite frankly. A complete reframing of the problem and awareness that this problem that we can do something about it and awareness that there's so much research about it let's just get out and do it now.

Sandy Hilton (00:20:40):

The international association for the study of pains curriculum and interdisciplinary curriculum would be a nice place to start. And I know some schools here in the States are using it in different disciplines to try and get at least a baseline.

Bronnie Thompson:

The way we do it as the core for the post grad program, that I am the academic coordinator for it. Doesn't that sound like a tiny, tiny faculty. But anyway the other thing that we know is that looking at the number of hours of pain, education, Elizabeth, Shipton, who's just about completed. If she hasn't already completed her PhD, looking at medical education and the amount, the number of hours of pain, it's something like 20 over an entire education for six to six or more years. In fact, veterinarians get more time learning about pain then we do then doctors medical practitioners do, which suggests something kind of weird going on there.

Bronnie Thompson (00:21:50):

So I think that's one of the reasons that it's seen as a not a sexy thing to know about and pain is seen as a sign of, or a symptom of something else. So if we treat that something else in pain will just disappear, but people carry the meaning and interpretation in their understanding with them forever. We don't unlearn that stuff. So it makes it very difficult, I think for clinicians to know what to do. Because they're also thinking of pain is the sign of something else not is a problem in its own, right? Persistent pain is a really a problem in its own right.

Karen Litzy (00:22:29):

Yeah. And wouldn't it be nice if we were all on the same page or in the same book? I wouldn't even say the same chapter, but maybe in the same book, across different healthcare practitioners, whether that be the nurse, the nurse practitioner, the clinical nurse specialist, the physician, the psychologist, the therapist, physical therapist, it would be so nice if we were all at least in the same book, because then when your patient goes to all these people and they hear a million different things, it's really confusing. I think it's very, very difficult for them to get a good grasp on their pain. If they're told by one practitioner, Oh, see, on this MRI, it's that little part of your disc. And that's what it is. So we just have to take that disc out or put it back in or give a shot to this.

Karen Litzy (00:23:25):

And, and then you go to someone else and they say, well, you know, you've had this pain for a couple of years, so, you know, it may not be what's on your scan. And then the patient's like, who am I supposed to believe? What am I going to do? And, and you don't blame the patient for that. I mean, that's, you'd feel this that's the way I, you know, I had herniated discs and I say, you just get a couple of epidurals and the pain goes away and then it didn't. And I was like, Oh, okay, now there's so my head, I was thinking, well, now there's really something wrong.

Sandy Hilton:

That's the problem. Because yeah, if you think it's the thing you did that helped you or didn't help you, then you lose that internal control.

Karen Litzy (00:24:13):

Yeah, yeah. Yeah. So I think, I think it's a great question and, and hopefully that's a big shift, but maybe it'll start to turn with the help of like the international association for the study of pain and some curriculum that can maybe be slowly entered or David can just go teach it virtually from different medical schools, just throwing it out. There is no pressure, no pressure. Okay. Speaking of modalities, we had a question. This is from someone with pain and it's what can be the appropriate regimen for usefulness of tens, for acute and chronic cervical and lumbar pain of nerve origin. So Bronnie, I know that you had said you had a little bit of input on this area, so why don't we start with you? And then we'll kind of go around the horn, if you will.

Bronnie Thompson (00:25:24):

I think of it in a similar way to any, any treatment, really, you need to try it and see whether it fits in your life. So if you are happy and tens feels good and you can carry it with you and you can tuck it in your pocket and you can do what you want to do. Why not just is, I would say the same about a drug. If you try a drug and it helps you and it feels good and you can cut the side effects, there's nothing wrong with it. Cause we're not the person living life. It's more to think about it in a population. How effective does this? And my experience with tens is that for some people it does help and it gives a bit of medium, like a couple of hours relief, but often it doesn't give long sustained relief and you have to carry this thing around. That's prone to breaking down and running out of batteries, right when you need it. So to me, it's agency, but then I put the person who's got the pain and the driving seat at all times to say, how would this fit in your life? Do you think you want to try this one out? It's noninvasive it's side effects. Some people don't like the experience and sometimes the sticky pads are a bit yuck on your skin, but you know, that's more bad. So yeah, that's my, my take on it.

David Butler (00:26:44):

I haven't used it for 40 years after the second world war. When you start to stop, when they, I was friendly with the guy who invented it and I'm thinking it'd be happy pet we'll would be happy to, with these comments that I agree with what Bonnie said. Absolutely. I would also say that, hi, wow, you have got something there which can change your pain by scrambling some of the impulses coming in. You can change it, let's add some other things which can change the impulses coming in or going out as well. So let's use that. Let's get you building something, maybe something repetitive or something contextual or something as well. So you you've shown change you're on the track. So I would use it as a big positive to push them on keep using it, but on the biggest things.

Sandy Hilton (00:27:32):

Yeah, the advantage is it's. So it's gotten so inexpensive. So for something that has minimal to no side effects and has the potential of helping them to move again, which I think is always the thing that we're aiming for. It's not very expensive. But now like several hundred dollars, right? You can order it online. Now you don't even need a prescription or approval or anything like that.

Karen Litzy (00:27:59):

Yeah. Yeah. That's true. And something that I think is also important is, you know, you'll have people say, Oh, those passive modalities, that's passive. You know, I had a conversation with Laura Rathbone Muirs. Is that how you say the last name? I think that's right. Laura. And we were talking about this sort of passive versus active therapies and, you know, her take on, it was more from that if they're doing these passive modalities, they're giving away their control. And, she said something that really struck and, kind of what the three of you have just reinforced is that no, they still have that locus of control. Cause they're making that conscious effort, that conscious choice to try this, even though it's a passive modality, they still made the choice to use it.

Karen Litzy (00:29:03):

And I think that coupled with what David said, Hey, this made a difference. Maybe there's some other things that can make a difference that I think that I don't think they're losing that locus of control, or I don't think that they're losing they're reliant on passivity, right.

Sandy Hilton:

When they have their own unit and they're not coming into the clinic to have it put on you. And you lie there on the bed while you do it.

Bronnie Thompson:

It's something that you have out in the world. It's not different to sticking a cold compress on your forehead when you're feeling a bit sick, you know, we did it. That's just another thing that we can do. So I see it as a really not a bad thing. And it is in the context, you know, if you can do stuff while you've got it on, then it's the hold up problem, as long as you like.

Karen Litzy:

Great, great. Yeah. As long as you like it. Exactly. Yep. Okay. so we've got another question that we got ahead of time and then there's some questions in the queue. So one of the questions that we got ahead of time was how do we explain pain responses like McKenzie central sensitization phenomenon in modern pain science understanding.

David Butler (00:30:35):

I'd answer that broadly by saying that the definition that we've used and shared with the public in the clinical sense is that we humans hurt when our brains weigh the world. And judge consciously subconsciously that there's more danger out there than safety. We hurt equally. We don't hurt when there's more safety out there, then danger. So somebody who's in a clinic and is bending in any way and it eases pain. There will never be one reason for it. So it might just be, that might just be the clinic. It might be the receptionist. It might be all adding up. It might be the movement. They might've done one movement. And so, Oh, I can do that. And then all safety away, we go again, the next movement helps within that mix. There may be something structural. You've done to tissues in the back and elsewhere that might have eased the nociceptors that barrage up. But by answer will always be that when pain changes, it's multiple things are coming together, contributing to them. And they'll never never just be related to nociception.

Sandy Hilton (00:31:49):

I have to say this to say, I am not McKenzie certified. So this is my interpretation of that. I like the concept of you can do a movement. That's going to help you feel better. And we're going to teach you how to do that throughout the day. Maybe as a little buffer to give you more room, to challenge yourself a little more knowing that you'll have a recovery. And I just pick that part and use that.

Bronnie Thompson:

I heard the story of how it all came about and it, and it's you know, it's an observation that sometimes movement in one direction bigger than another. And that's cool. It's like, you're all saying, let's make this little envelope a little bigger and play with those movements because we're beasts of movement.

Bronnie Thompson (00:32:50):

We just forget that sometimes we think we've got to do it one way. And you know, I can't tell my plumbers who crawl under houses. Look, you've got to carry things the way, you know, the proper safe handling thing. And I wasn't, I was the same safe handling advisors like me. But you know, there's so many ways that we can do movements and why can't we celebrate that? And the explanation, sometimes we come up with really interesting hypotheses that don't stand the test of time. And I suspect it might be some of the things that have happened with the McKenzie approach. It's same time. What McKenzie did that very few people were doing at the time was saying, you can do something for yourself that as we are the gold ones, that's what changed.

David Butler (00:33:40):

Bronnie, what's really helped us to start the shift away from poking the sore bit, come on, do it yourself. And, and I always give great credit to Robin McKenzie for that shift in life.

Sandy Hilton (00:33:53):

Yeah. And an expectation that it's going to get better. Right.

David Butler (00:34:00):

You think that’s showing something in the clinic that helps. Wow. Let's ride let's rock.

Karen Litzy (00:34:07):

Yeah. And oftentimes I think patients are surprised. Do you ever notice that Sandy, like, or David, or, you know, when you're working with patients, they're like, Oh, Oh, that does feel better. And they're just sort of taken aback by, Oh, wait a second. That does feel better and it's okay. I can do it. Yeah. And then you give them the permission to do so. And like you said, is it's certainly not one single thing that makes the change. But I think everything that you guys just said are probably the tip of the iceberg of all of the events surrounding that day, that time, that movement, that can make a change in that person. And I think that's really important to remember. That's what I sort of picked up from the three of you.

Bronnie Thompson:

But the stories like that kind of convenient ways of, for us to think that we know what we're doing, but actually within what this person by what this person feels and how they experience it. And the context we provide us safety, security. And I'm going to look after you, that's, you know, changes, motivations about how important something is and how confident you are that you can do it. We can provide the rationale important part. The person ultimately drives that. So we can also provide that sense of safety and that I'm here. I'm going to hang around while you do this stuff. Let's play with it. Let's experiment. And if we can take that experiment, sort of notion of playing with different movements in, we've got a lot more opportunity for people in the real world to take that with them. We can't do that. Or forgive people are prescribed. You will do this movement. And this way perfectly I salute, but the old back schools, Oh, I know scary, And they did get people seeing the other people were moving. And that's a good thing that we can take from it. It's always good and not so good about every approach.

Karen Litzy (00:35:11):

Now I have a question for David and then out to the group, but you know, we've been talking about Sims and dims and safeties and dangers. And so for people who maybe have no idea what we're talking about, when we're talking about Sims and dims, can you give a quick overview of what the Sims and dims, what that is so that people understand that jargon that we're using?

David Butler (00:36:40):

Okay, it's a model we use. There's lots of other similar models out there. So basically based on neuro tag theory, the notion of a network that there's danger danger in me networks out there, and there's safety in me networks, rather simple, structured thinking here, and we've looked at these this has emerged due to the awareness, the pain science that we have a network in our brain. But me as an old therapist, when the brain mapping world came in and we realized, hang on pain, isn't just a little nest up there. There could be thousands of areas of the brain ignited indeed the whole body ignited in a pain experience. And one of the most liberating bits of information for me and my whole professional career, because what it meant was that many things influence a pain experience and a stress experience, move experience lab experience, and many things can be brought in to actually try and change it.

David Butler (00:37:39):

And all of a sudden means that everything matters. So this is where dims danger in me, safety sims in me, it was just a way to collect them. So an example of a dim with categorize them could be things you hear, see, smell, taste, and touch. So for one person, it could be the smell of something burning or looking at something or hearing something noise. The things you do could be a dim. It could be just doing nothing, but then there's Sims, gradually exercising, gradual exposure seems in things you hear, see, smell, taste, and touch could be going out. One of my most common exercises I now give somebody is to go down to our local market and find four different smells, four different things to taste, four different things to touch. And then they'll say, why should I do that? Because you can sculpt new safety pathways in your brain, which will flatten out some of them, some of the pathways they're linked to pain and it comes to of the things you say important.

David Butler (00:38:37):

You know, I can't, I'm stuffed, I'm finished. I got mom's knees. We try and change that language too. I can, I will. I've got new flight plans. I can see the future, the people you meet, the places you're with. So it's a way of categorizing all those things in life into either danger or safety, we try for therapy, we try and remove the dangerous. It is often via education. What does that mean? And we try and help them find safety and health professionals out there are good at finding danger, but we're not used to getting out there and finding those liberating safety things. And of course the DIMS SIMS thing. It's also closely linked in, we believe to immune balance. So the more dims you have, the more inflammatory broad immune system, the more sims you have, you move more towards the analgesics or the safety. And so it's the way to collect them. It's a way to collect as we try and unpack and unpack a patient's story listing to it within to unpack it and then to re-pack it again with them in a different way. Did that make sense?

Karen Litzy (00:39:49):

Absolutely. Yes. I think that made very good sense. And I believe you, there is a question on it, but I believe you answered it in that explanation. It says, have you had patients that cannot find Sims or it's difficult to identify and if so, how can you teach them what a SIM is? But I think you just answered that question in that explanation.

David Butler (00:40:11):

Once they get it. They're on their way. And we send people on SIM hunting homework. So for example, the same might be places you go, okay, if you can get out, just walk in the park or walk somewhere, then power up the SIM by feeling the grass, touching the box, spelling something. And we pair it up by letting them know that if you do that, your immune system gets such a healthy blast, that it can also help dampen down some of the pain response.

Bronnie Thompson (00:40:39):

And with regard to our current situation, sort of around the world COVID-19 and all the subsequent stuff. And also the situations in the U S at the moment, is it any wonder that lots of people are feeling quite sore because we’re eating this barrage of messages to us. And so I would argue that at the moment it might be worthwhile if you're a bit vulnerable to getting fired up with the stuff said, it's a good idea to ration, how much time you're spend looking at the stuff, not to remain ignorant, but to balance it with those other things that feel good, that make you feel treasured and loved and committed. And for me, it's often spending some time in my studio, walking the dog, going outside, doing something in nature. And there is some really good research showing that if you're out in the green world nature, that there is something that our body's really relish, kind of makes sense to me.

Sandy Hilton (00:41:42):

So taking that concept into what's going on right now, there's been a challenge clinically of the things that helped people balance that out, got taken away from them. Yeah. So it was a complicated it still is. It was a complicated thing where it wasn't your choice to stop going to the swimming pool because it made you happy and it gave you exercise and balance this out. Someone closed the pool and told you, you couldn't go. And so there's all different layers of loss in that and lost expectations and loss of empowerment and all of these things. So we have had to help people rediscover things that they could access that could be those positives. And that's been hard and really working my muscles of how to help people find joy or pleasure or happiness or safety in an unsafe environment to really get that on a micro level when you've lost the things that used to be there. And, it's been like a lot, but you can do it. It just takes concentration.

David Butler (00:42:57):

An important thing. That's so important. I think a question for therapists health professionals should be a sane question should be, you know, what's your worldview at the moment. And I would ask that, and it's usually not good, but I chat and have a chat. And actually I'd like to take people through some graphs that the world is not as bad as it really is. And if you look at I've been reading a book by Hans Rosling called factfulness. And really over time, our world is getting better. There's less childhood diseases, a whole range of things, getting better, bad, and bad things, getting better. This is a hiccup. This, for example, I had a musician recently and I had a graph I could show her that say that there's now 22,000 playable guitars to a million people in the world. But 12 years ago, there was only 5,000. All right, this is just one little thing. All right, cool. There's a lot of stats that show that our world is improving, you know, children dying, amount of science, a whole range of things. And this hiccup we have that I'm hopeful humanity can get, can get through, but just a little message I pass on is therapy.

Bronnie Thompson (00:44:13):

Even though we can't do stuff, we can't access places. What can't be taken away as our memory of being there. So it's really easy to take a moment to back a memory that feels good to say, actually, you can't take that one away from me. I might not be physically getting there, but I can remember it, feel those same feelings. And then being mindful.

Sandy Hilton:

This is funny because if you look at Bronnie's background, that's one of the memories I've been using. When I lost the lakefront, I was like, okay, I'm just going to sit there and pretend that I'm not at that beach by that pier. So it's, it's fabulous. And even pictures or recordings of things that you've done before is like, okay, now there is still good stuff. I might not have it right here, but they're still good stuff. So that's really funny. As soon as I saw the picture, I'm like, yeah. And gratitude and just, yeah.

Bronnie Thompson (00:45:05):

The other thing as well, we've always got something that we can be grateful for all that. It might feel trite, you know, I'm living in winter, but I've got a roof over my head. I can have a damn fine cup of coffee and probably a nice craft. I'll at the end of the day, these are things that I can do and can have any way. So we can create the sense of safety insecurity inside ourselves without necessarily having to experience it.

David Butler (00:45:38):

Right. Just a quick comment. I would share that with patients who can't get out are saying the things you do when you're still can be as important as the things you do when you move. Right? So let's explore. If you can't do things, you can still really work you yourself with the things you do. And you're still calm. The introspection reading, thinking, contemplation memory enhancement, go through the photo album, et cetera. And I'd also like to always say to someone to link that in that is a very, very healthy thing to do to your neuro immune complex.

Karen Litzy (00:46:13):

And that sort of brings, I think we answered this question. This was from a woman who is living with chronic pain and at high risk with COVID-19. So how do we get past the fear of going out where people are crowding areas to get the exercise we need to maintain our fitness and muscle tone to reduce our pain. She said, even though I'm doing exercises and stretching, I've lost the ability to walk unaided on uneven grounds through weeks of lockdown. And the hydrotherapy pool is closed. She said, she knows, I need to get out and walk more, but shopping centers, which are the best place to find level floors are out. And a lot of places that she used to go are now very crowded because people are, don't have the access to gyms and things like that. Are health professionals able to suggest options when she lives in a hilly area with only a few but all uneven footpaths or sidewalks. And she has a small house.

Sandy Hilton (00:47:18):

That's the kind of thing that we've been doing since it's like, okay, let's problem solve this out. Because yeah, you have your carefully set way to get through this and then it's disrupted.

Bronnie Thompson:

Yeah, boy, I like having lots of options for movement opportunities. So we don't think of my exercise, but we think of how can I have some movement today and bring that sense of, we are alike to be like, if I can imagine I'm walking along the beach while I'm standing and doing something and, you know, doing the dishes or watching TV or something that still can bring some of those same neuro tags it's same illusion, imaginary stuff activating in my brain. And that is a really, really important thing because we can't always the weather can be horrible, especially if you're in Christchurch and you can't go out for a walk.

Bronnie Thompson (00:48:27):

Yeah. But you know, we can think novelty is really good. So maybe this is a really neat opportunity to try some play. And I've been watching some of the stuff that our two chiropractor friends do with you put, let's put, at least try some obstacle courses and the house so that it's not we're not thinking of it as exercise. And I've got, do three sets of 10, please physios change that. Let's do something that feels like a bit of fun. There's some very cool inside activities that are supposed to be for kids. I haven't grown up yet. I'm still a baby.

Sandy Hilton (00:49:16):

Yeah. A lot of balance and things like that you inside that would help when you have your paths back outside. Yeah, yeah.

Karen Litzy:

Yeah. Great. And then sticking with since we're talking about this time of COVID where some places are still in lockdown, some places are opening up. Bronnie and David are in an area of the world where they have very, very few cases, very, very few cases, Sandy and I are in a part of the world where we have a lot more than one. So what a lot of practitioners have had to do is we've had to move to tele-health. And so one of the questions David Pulter, I believe, as I hope I'm saying his name correctly is do we perceive that our ability to be empathetic and offer effective pain education is somehow diminished by a tele-health consult. So are we missing that? Not being in person.

Sandy Hilton:

I have found it equally possible in person or telehealth cause you're still making that connection. We do miss stuff. We can't read the microexpressions in people as easily. So we as therapists have to work harder, but for the person on the other end, think about what the alternative is.

Sandy Hilton (00:50:46):

And it's been really cool for the people with pelvic pain, that every single time they've gone to a physio it's been painful. And on tele-health it's the first time she has been able to talk to someone about all of her bits and pieces without being afraid that it's going to hurt because there was no way to see somebody inside somebody's home.

Bronnie Thompson:

You get to know something more about me. I've met more pets than ever thought. It was wonderful. This is a privilege that occupational therapists have had for a long time. And I'm so pleased that other other clinicians are getting that same opportunity, because we know so much more about a person when we can see the environment that they live with. That's just fantastic, but it's harder.

David Butler (00:51:39):

I find I've come back into clinical practice. I thought I was going to retire because I wanted to go, but also doing it. I was hopeless at first, but I'm really enjoying it. And I actually believe, I actually believe for the kind of therapies we're doing it's equal or better than face to face. Ideally, I think I'd like to have one face to face or maybe two but then to continue on with the tele health, particularly for people are in rural areas and it's almost no this kind of therapy was coming anyway, but the COVID has hastened it. So I found myself getting anecdotally here a much more emotional, closer, quicker link to patients by the screen. They were in a safe place. They're in their house. That's number one. They're not in a clinic you're there. And you can actually look at that face in the screen, as we're doing now, I'm looking at your faces, maybe one or two feet away, and I'm just keep looking at you.

David Butler (00:52:46):

And there's this connection, which is there. And there's also these other elements it brings in like, you start at 10 o'clock and you finish at 10:45. So there's open and closure, which isn't really there in some of the, in some of the clinics, the difficulty I'm having with it though is I was never in face-to-face practice a very good note taker. I used to make notes at the end. I was talking too much, but what you have to do here, my suggestion with face to face is you really need to plan and make your notes straight after. What did I tell that one on the screen, last clinical context, to sort of remind you of all the little juicy bits that we've got in the interaction. So it's really, for me, it's coming back to curriculum and mind you, I'm glad I'm not doing dry needling or just manipulating it with the talking therapy, but my suggestion is to have the habit curriculum.

David Butler (00:53:44):

So I've got my key target concepts. I know that I've addressed them in that particular session in the next session. I know I've gone back and I've done teach them the self reflection as well. Then to come back to see if I can get it all, or if I've translated my knowledge into something functional or some change. So I'm really, I'm really loving it. And I think there's something rather new and special with this, with this interaction. But maybe that's just me as a physio who sort of used to the more physical stuff. Maybe this is something more natural to the psychologist, its perhaps, but I'm with it.

Bronnie Thompson (00:54:22):

I’ve been doing the group stuff. And I found that has been, I've seen, I like it because they don't have to go and travel someplace. It does mean that we can offer it to people who otherwise can't get here. You know, they can't seek people, especially rural parts of New Zealand, low broadband is not that great in many parts as well. So it gets that it's an opportunity. I'd like to see the availability of it as an option. So we can use like we do with our therapies, we pick and choose the right approach or the right piece at the right time and the right place that doesn't have to be one or the other, like you said, you could see him a couple of times in person and then a couple tele-health and then maybe they come back again and then you do mix and match.

Karen Litzy:

We have time for one more question here, maybe two. So David, this was one you might be able to answer it really quickly. As a practitioner, what is the utility of straight leg raise slump and prone knee bend test and the assessment of chronic back pain. Is it still relevant?

David Butler (00:55:38):

Oh gosh. Oh gosh. I'm going to dodge that question and would say it, it would depend on the client who comes in so I think those neurodynamic tests, which I still do. I think the main principle from them is you're testing movement. You're not testing a damaged tissue and anytime you're doing a physical examination, the deeper thing is the patient is testing you. You're not testing them. So what that patient, what that patient offers back in terms of movement or pain responses or whatever, depends on so many things. I might however, have a client and they are out there who do have maybe a specific stickiness or something or something catchy, whatever that may well, the scar around it might well be polarized by action, where I might spend a little bit more time taking a closer look at it. Now that might be relevant. Someone might have, for example, someone might come out of hospital and have had a needle next to the IV drip, next to their musculocutaneous or radial sensory nerve there where it's really worthwhile. Let's explore all the tissues here and see that that nerve can move or slide or glide. But in the second case, I'd made a clinical decision that we probably have issues out in the tissues, which are with a closer evaluation. That's a really broad answer.

Karen Litzy (00:57:11):

I think it's a tough question to answer because it, sorry, got a cat behind me. I felt my chair moving and I was like, what's going on? Just a large cat. So last question. So how to manage tele-health when the patients may be kind of embarrassed of their house or context or spaces or family it's very common in low socioeconomic patients. So they may not want to turn on their camera.

Sandy Hilton:

Yeah. I've had that shaking well, and I've had people in their car or very clearly like I'm kind of angled cause there's a lot going on in my house and I don't have a green screen. So where it's like, and there's just a wall behind me and it's one of the reasons like I'll talk to him ahead of time of if I'm in the clinic, it's clearly the clinic, but I'll tell them I'm at my house.

Sandy Hilton (00:58:12):

Cause of COVID. So, you know, no judgment, you're going to see a wall and probably a cat and just kind of be up front in the beginning of this as a thing, I've had people that start with the phone on or turn it off or whatever, you just, you roll with it. But I have those conversations ahead of time, before we even do the call.

Bronnie Thompson:

It's about creating a safe space for people. You know, if somebody feels, you know, was not having the video, it won't be that long before. I hope we've got some rapport and it feels better. I'm just, I'm doing a bit of a chuckle because the reason I've got my green screen behind me as my silversmith studio, which has an absolute shambles because it's a creative space. So I'm just disguising it because it's works.

David Butler (00:59:07):

There is something about delivering a story of some talking in the patient's room and there's cupboard doors open and you're looking in their cupboard at the same time. And you know, looking at that, then I just look at that thing. We’re safe here.

Karen Litzy (00:59:26):

Well, listen, this has been an hour. Thank you so much. I just want to ask one more question or not even a question, more like a statement from all of you that, what would you like the people who are listening and they're, like I said, there were clinicians, there were non-clinicians on here. And I think from the comments that we're seeing in the chat is very valuable and very helpful. So what do you want to leave people with?

Sandy Hilton:

I'm gonna echo how I started. We're learning more every single week. I'd say, day but I'm not reading that often. So even if you've gone or you've treated someone and you couldn't quite figure out a way to help them, don't give up because there's more information and more understanding and more ways to get to this all the time. And I don't think you're stuck if you hurt.

David Butler (01:00:26):

I'd like to mirror those comments, explore the power of tele health, lift your expectations of outcome for those patients, people who are suffering and in pain, who are listening for those who are getting into pain treatment there's a science revolution and a real power in that revolution behind what you do. So just go for it.

Bronnie Thompson (01:00:52):

I think don't be hung up on with the pain changes or not, be hung up on does this person connect with me. We create trust. Am I listening? Can I be a witness? Can I be there for you? Because out of that will come this other stuff. There are some people whose pain doesn't get better. It doesn't go away. And that's a reality, but it doesn't mean that you have to be imprisoned or trapped by your pain. That means you develop a different relationship with your pain. And I think that's a lot of what we are doing is creating this chance to have some wiggle room, to begin to live life. That's what I'm looking for.

Karen Litzy (01:01:53):

Beautiful. Well, you guys thank you so much. And for everyone that is here listening, I just want to say thank you so much for giving up an hour of your time. I know that time is valuable, so I just want to thank you all and to Bronnie and to David and to Sandy. Thank you. Thank you. Thank you. And kind of on the fly. So I just want to thank you so much and to everyone. I guess the thing that I would leave people with is, if you're a clinician or if you are a patient, the best thing that you can do, if you are in pain is reach out to someone who might be able to help you, find a mentor, find a clinician, ask around Google, do whatever you can try and find someone who like Bronnie and David and Sandy I'll echo everything. You said that number one first and foremost, you connect with and that you feel safe with. You want them to be your super SIM, you know, like Sandy's my super SIM.

Karen Litzy (01:02:48):

So you want them to be your super SIM. And, if you can find that person, that clinician just know that that there can be help, you know, whether you're struggling as the clinician to understand your patients or your the patient struggling to find the clinician, I think help is out there. You just have to make sure that you be proactive and search for it. Cause usually they're not going to come knock on your door. So everybody thank you so much for showing up. Thank you, everyone who is on the call and to everyone who is watching this on the playback I hope you enjoyed it. If you have any questions, you can find us we're on social media and various websites and things like that. So we're not hard to find.

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