 Good evening everybody and welcome to all the participants who've joined us for tonight's webinar and also to the viewers who are watching the recording. MHPN would like to acknowledge traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and you participants are located. We wish to pay our respects to Elders past, present and future for the memories, the traditions, the cultures and hopes of Aboriginal and Torres Strait Islanders. I'm Steve Trumbull and I'll be facilitating tonight's session. I'm a general practitioner by training but my day job is as head of medical education at the Melbourne Medical School. At this moment I'm meant to be in a small Aboriginal community in the Northern Territory as a GP but unfortunately I'm a Victorian so I'm here in Victoria but not for much longer. We've got a great panel tonight. I won't be going through each person's background in detail because you've seen that in the invitation. But we have Simon Holliday who's a general practitioner in New South Wales, Catherine Gitzner who's a physiotherapist in Queensland and Michael Nicolette who's a psychologist based in New South Wales. Just to touch quickly on a few ground rules to make the webinar go well, please be respectful of other participants and the panellists. You'll see each other's comments in the chat box. We see those as well. And so please it's a good place to communicate but try and keep on topic for tonight's webinar. If you have any issues with technical problems then please do click on the support tab. It's a frequently asked questions support tab or there's a phone number listed there that you can ring for help from the help desk. Now this panel, sorry, this platform hopefully many of you are familiar with to access the chat box which I just mentioned. Click on that purple button to open that up. If you have a question please do use the blue button. Enter your question there as concisely as you can make it. We have had lots of questions ahead of tonight's webinar and we've tried to consolidate those but things will come up while the panellists are talking. You want to ask about please pop those in the question box there. There are lots of resources available for you tonight so they will be available along with the slide set from the light blue download button. So click on that. Don't forget there is the help button, the yellow help button. So if you need assistance you can message red back directly or ring that number there. Now the way things will go tonight is following our usual format that you've seen the case that's been circulated. Each panellist will give a short discipline specific presentation about the work they do relating to that case and then we'll engage in questions and answers and discussion between the panel. So that's the time that we'll want you to have submitted some questions that we can respond to. The learning outcomes are there and I'll run through those very quickly but they are important. The first one to identify associations, comorbidities and patterns of treatment seeking behaviour of people experiencing chronic pain. The second one describing tips and strategies that can assist someone experiencing mental health problems related to chronic pain. And thirdly to demonstrate the importance of collaboration and appropriate referrals when supporting a person experiencing mental health problems related to chronic pain. MHPN is all about collaboration between health professionals. As I say you've seen the case study. Jerry is a 56 year old man who's familiar to all of us I would imagine with the sort of problems he's presenting. He's had years of low back pain which was acquired at work and has been surgically treated for better or worse and he's also been on a range of medications including codeine and benzos in that mix. He's had some physiotherapy several times but he feels that his pain worsened following that so he hasn't persisted with the treatment regimen prescribed for him. He's also tried some cannabis out of desperation that a friend offered him. And he's also got some conflict going on in his life with his employers and their insurer which is unfortunately so common in these sorts of cases. He turns up in our case for the first time at Simon's clinic, Simon is the GP. He's made his 15 minute appointment for a new patient and he's there just for scripts and a repeat certificate doc which we all know is not going to be a quick consultation if it's done properly. Usually we start the discussion with the general practitioner to whom the patient presents or the client presents but instead tonight we'll start with Michael Nicholas to give us a glimpse inside that consultation and maybe a look even inside the GP's head at the sort of conceptualisation of Jerry's case that Simon might be going through as Jerry tells him about his problems. So welcome Michael, it's good to have you as a psychologist obviously with a special interest in this area. So please if you could tell us about your thinking about what the situation is with Jerry. Right, oops sorry. Right, thank you, thank you Steve. Yeah, so we're dealing with a chap with chronic pain which is pain that's persisted for more than three months, but in this case of course several years. So it's definitely chronic. Now the first conceptual aspect here is to realise that there are multiple mechanisms likely to be operating in chronic pain and particularly in this case of Jerry. There are biological contributors and I've listed a few of their processes going on in the nervous system, peripheral and central nervous system and changes that occur over time like sensitisation where small stimuli feel much bigger than they really are. There are psychological contributors and I've listed a number there. I won't go through them all but you can see a lot of those present in Jerry and then there's the social or environmental contributors and I've listed a number of the likely suspects there in the usual case. So when I'm seeing someone like Jerry I've got to have all these different elements in my mind to think about how might those be contributing. And I'll also be relying on my colleagues to actually also identify elements there as well. So I don't have to identify them all myself but let's see how this might play out. So in this case the pain has developed. We would say started off probably with tissue damage leading to pain but as pain persisted then other mechanisms start to kick in like in the both peripheral and central nervous system and that's where that sensitisation starts to become a contributor. And other changes occur as well and we believe they contribute to the maintenance of pain so even after healing has taken place the pain can persist. And it's also important to realise that he doesn't just have pain it's impacting on his activities and particularly stop doing a lot of things and we all know when you stop doing things that will lead to effects of disuse and so on. And the feed the lines the arrows go both ways because when you're putting on weight your joints are stiffer you'll do less and so on and when you do try to do things you'll aggravate your pain. Also he stopped doing a lot of things he enjoyed that gave life meaning so he starts to get depressed and get frustrated and so on have sleep problems. And then occasionally gets fed up so you then overdo things and aggravate his pain even more. But in addition he has developed a number of beliefs about his pain and this may not always be very helpful and they may become part of the problem because they'll drive this treatment seeking behaviour. When we know that there really aren't any cures for his pain and that's often difficult for patients to accept and they'll keep having this experience of failure which compounds their dysphoria, their depression. Some of the treatments of course will contribute to the problems as well particularly getting into more and more drugs and Simon will talk about that. But these interact with what else is going on particularly causing side effects which will contribute to his low mood and sleep problems. Of course there's been an impact on daily life work, his family stress, he's more dependent on others, financial stress and so on and this is occurring in a context as all pain occurs. So he's got it for example existing mental health conditions, he's got healthcare providers who may not be giving him consistent advice and that gets confusing. Employers may not understand that he himself lacks knowledge. He's got a friendly neighbour but he may be actually leading him astray and all these compound to cause excessive suffering and disability. So there's not just one thing going on with someone like Jerry, there are many elements and these interact. But when you can develop a formulation like this with combining the biological, psychological, social, environmental factors and share this with Jerry. It helps him to make sense of what has happened and why he has ended up the way he has because it then leads to what can you do next. And so these are the elements you've assessed remember and then you go on there to looking at the intervention based on what you find in your assessment. So you don't treat things that aren't there so there's not a one size fits all. Your assessment would target your findings, your treatment rather would target your findings from your assessment. That you would also share with the other providers and we will talk about that a bit later. So for example in this case if you start on the left of that diagram just briefly there may be some interventions that will help the experience of pain. It may include medication but also relaxation, distraction techniques and so on but they won't solve the problem by themselves. We also need to educate Jerry about his pain, help him get a better understanding of what's going on and we need to identify some goals with him. Things he'd like to get back through, things he'd stop doing and would like to get back through. And this will be where particularly the physiotherapy input will be in getting an exercise program not aimed at simply getting fit but helping him to get back to functional activities that he wants to do. We also need to tackle his mood, both he may as a human press on pre-existing mental health issues but also as a consequence of pain. He's like he's clearly become quite depressed and so on and we need to address that and we can address those elements of sleep hygiene as well in a number of ways. Dealing with the medication that needs to be sorted out and we'll rely on Simon to help us there to rationalise what he's on and gradually reduce the things that aren't really helping. Because he's got different providers we need to make sure that we're all on the same page so we need to negotiate with them a plan and we need to bring the family in so they understand what is happening. And ideally of course the workplace and so on if they're willing to cooperate that will be important. Now it may mean he needs to make some changes at home and at work in what he does and what his duties are and he may swap some activities with others and that's something to be sorted out. And because it's chronic we need a maintenance plan and so that's on the right hand of that diagram you'll see. We need to help him look forward to what might happen, how would he deal with these things. So we need to equip him with skills to deal with the inevitable ups and downs and setbacks he will experience with his pain rather than just going back to the medication. What can we teach him to do that allow him to manage it himself. So I'll leave it there for now and we'll carry on with I think it's Simon next. It is indeed Michael. Thanks very much indeed for that. I think your diagram through attention to the complexity of this presentation. The biopsychosocial model encapsulates just so much in this very complex person Jerry and so Simon Jerry sitting across or sitting next to you in your consulting room. How are you going to approach managing Jerry's problems. Well I must say this is not going to be an easy appointment especially because running late is a characteristic of many GPs that pay more attention to detail. So you're running late and you've got to remember that the medical benefit schedule which drives general practice is not really funded for a very careful psychosocial focus. We're more focused to fix the problem and fix the symptom. And so when Jerry says or when anybody says I just want a quick script doctor you can you can have a bit of a heart sync feeling because you know that this person's health concept. The actualisation is about getting a script or a certificate and not much else. So what I think number one job here is to buy time and you need to say this is a really important problem. We're not going to be able to cover everything today but there's some really important stuff we've got to cover today. And then you're going to start doing lots of things and you'll need a history so you can understand what's going on and that's a general medical history as well. A really important thing right at the onset for a general practitioner to do is to broaden the assessment from how bad is your pain out of 10 to doing an outcome measure. And one very quick one is a PEG PEG score from Aaron Krebs and that can take 45 seconds for the first assessment and 15 subsequently. And it gives you a good way of seeing how people are progressing when they when you first take people on often they're on bucket loads of opiates and they're on bucket loads of benzos and everything else. And they're a mess and they're really desperate for these painkillers. It's the only thing that works. It's probably very wise to try and contact the previous GP and find out what's going on and and get a handover and find out a bit about the opiates. Even if you can get the GP to do the script because there's a whole lot of regulations about opiate scripts. It varies from state to state and territory and a GP who prescribes opiates to the wrong patient can get in serious trouble. So it is a problematic area and it's wise to talk to GP previously. I think we need to engage with Jerry and recognize that this guy is really distressed and he's probably very anxious whether he'll get his quick scripted certificate or whether he'll be moralized about look down on his nose about treated like with contempt. And he's already been through that with his workplace. He feels his work his bosses have done the wrong thing by him. So he's got that injustice chewing away at him and that's that's in the back of his mind when he comes to see us. We need to let him know that we know it's really important for him to be able to get back to work so he can get pay his house off and get the family back working again and how he's very focused on getting his pain control. One other thing we've got to really think about is suicidality and we know that people with chronic pain often have high risk of suicidal thoughts and also people on opiates as well. So in terms of management I would be saying righty oh we've got to look more than your pain intensity. We do the PEG score. We'll contact the previous GP. We were going to careful with the regulators in case we get we don't want to get pinged. And we need to be comfortable about putting barriers around boundaries around the opiates and it might well be that you say OK I'm only going to I've haven't been able to catch your other GP. So I'm going to give you enough medication for three days so we can start some bifentime and we can do maybe urinary drug screen whatever it is. And that will allow you to have a double appointment and that will really change the way you manage cherry. So the next slide is your second consult. So he's back after a few days at this time you're going to do a bit more of a physical examination and find out a bit more about his opiates. And the best way is rather than using all the opiate risk measures which meant to work out whether someone is a genuine pain patient or a genuine drug addict in a funny sort of moral binary. What you best do is just find out tease tease away. What is he doing in terms of using a range of legal illegal substances to feel better or to feel good and what's happened in the past. You might need to do investigations. However, GPs are prone to often over investigate. It's a good way of putting a full stop at the end of a consult so you can get another bill. But we don't want to just send him on a pinball machine run through more CAT scans. So I think the second consult will be a great time to start some education and we'll be talking about his opiates and how opiates can actually create problems. They can even cause increased pain with sensitization. They can cause depression and they can worsen our sleep. We need to also talk to him about his benzo dive appendages on and how that they can increase the overdose risk cause problems like dementia and also depress the sleep breathing. We need to actually touch on how pain, chronic pain that he has isn't just like the pain you get when you burn your finger and you move your hand away. It's a quite a complex thing as Michael's been saying. And there's so many parts of our brain and mind that are involved with pain. So then once you've gone through a bit of education, you can write that education to how you're going to step forward with this guy. And it might well be that in that second consult you start the idea of saying they're going to have to be other people involved because while we're going to be spending a lot of time talking about this stuff, you really probably need to have a bit more time talking about the fact that you've said that if you don't get your painkiller, everything's going to go to be a disaster in life. So there's some things you need to work through and it would be good to see a psychologist, a physiotherapist, a dietician. And you might want to flag that, maybe give a phone number, contact the workers, comp people, let them know that's happening. And then you'd probably start weaning the benzos quite quickly and arrange to have him back again. On the third contact, this time you'd organise your furrows. You'd start talking about weaning on the opioids. You might look at some of these wonderful videos like Brain Man and I've watched them many times with my patients. I still enjoy them. And let people let him know that when he's having his opiates that they are changing his whole nervous system, his whole mind, many parts of his body and that is affecting the way he feels about his pain. You have to be aware that when you start to opiate taper, a lot of things will come up. People might start to go a bit chaotic, they might get aggressive, they might see other doctors. There's a whole lot of things that might come up. So you've got to be comfortable about all those sort of opiate behaviours and opiate related emotions and manage those. And that's sort of skills you learn in addiction medicine. But I think people who are managing pain with opiates also need these sort of skills. So it might well be that you need to increase the amount of supervision of each dose that he has to go to the chemist more regularly, have shorter scripts, more frequent appointments. It might be that you think he's a risk of overdose because his wife says that he's snoring at night and you might need to give him some take home naloxone or rescue naloxone where you put naloxone up the nose which reverses the opiate and stops people dying. And it might be that you're going to talk about transition to an opiate treatment program. In my experience with pain patients, that's pretty rare. Usually you can flangle through with just some more addiction like strategies and get through it like that. But some people will need a methadone program or buprenorphine program and there's a really new formulation out called depo buprenorphine. And this is revolutionised to my mind problematic pain care because no matter how off the wall or on the wall, whatever, if people are getting their injectable buprenorphine, there's no diversion, they can't double dose. There's no argument. It's just so simple. But it is got the problem of long-term opiates, but all the chaos is taken away. Finally, I think in the last part of that third consult, you find out how Jerry Spouse is going. You'd be looking at whether she's helping him do his exercises or whether she's wrapping him in cotton wool. And she herself could be depressed. She's had a hell of a time and now she's not even in her own home. And you might also think about biological things like there could be side effects between his cholesterol medication and his pain as well. The next consult, you'll be looking at more of these things a bit more. Explaining to pharmaceuticals aren't going to be the answer to his problem. We know that most pharmaceuticals aren't going to be terribly effective. We're going to be talking about his smoking, the tobacco, the cannabis, how that's affecting his mood, how it's affecting his pain, how the fact that a substance might make you feel better or if you take a bit more feel good, doesn't mean to say it's going to make your life a bit better. You might say to him, look, stoners don't have really great lives. And so even though you feel better, it's not going to fix it. And you need to press on with the opiate reduction. And we understand opiates have effects on the body apart from pain, including the hormone system, the immune system. And so it is a massive impact on many parts of the body to be on opiates. And it's important that we keep moving on that. He will have insomnia because he's cut down his benzos. And so psychological strategies for insomnia are really important. It might be the psychologists will help with that. Or some GPs are quite comfortable talking about bedtime restriction therapies and sleep diaries. We also talk about his diet, not just his weight, but also the inflammatory diet and a healthy diet. All of these things fit in with chronic disease care anyway. And then we'll be talking about how he's going with his work and his home. And if I may just say the last of the five appointments just to give you an idea, by then we should have engaged with multidisciplinary care. It would be a great time to review with Jerry on this last on this fifth appointment. How things are going. You've had a report back from the psychologist. You've had a report back from the physio. It's unlikely that you're going to be talking to these people because everyone's so busy. You might commentate on what the allied health people have said. You might repeat the PEG score and you'll find that despite the fact he's on a lot less benzos, a lot less opiates, that his PEG scores a lot better. You might need to go into that for him with his insurer or his employer just so that you can do an activity pacing style return to work where it's adjusted for his ability because being at work is a really good thing. We'll then be looking at some of the CBT aspects of what's going on for him. And also we have to remember that this guy still needs his biomedical care, his cholesterol, blood pressure, etc. And we'll be looking at those things as well. Thank you very much. Back to you, Steve. Thanks indeed, Simon. And two things you've said have really struck a chord with the participants. And I know that they're in the resources, but you mentioned the PEG outcome measure. And also you mentioned a movie. I mentioned you sitting alongside your patient watching classic Dustin Hoffman and Tom Cruise movie from the early 90s, but it's not Rain Man. It is Rain Man. And my apologies for my poor pronunciation. If you go to the Hyundai Integrated Pain Service, I'm sure that Julie will give you the links at the end. There's some wonderful series of Rain Man about pain and opiates and rehabilitation for people with a pain. And I also wanted to share with you this little Charles Schultz cartoon about how a lot of pain management is not about doctors doing things to people. It's about quality of life and social reconnection. Wonderful. Thanks for that. I do intend to have my puppy on my lap by the time this webinar finishes and I would encourage all participants to do the same. So thank you. That was really great. And we will have further conversation with you and with Michael later on in the webinar. But for now, we're going to hear from our third speaker, Kat, you're a physiotherapist. Yes, that's right. I'm a pain physiotherapist. So I specialize in pain management. I must say that takes me by surprise because I've been a GP for a long time and I know physios have a lot to do with pain, but I've not actually come across one who specializes in pain management of this style before. Are there many of you? Yeah, there's actually not that many. There's only about 100 within Australia. It is growing as a field, but it's only been really recognized over the last four or five years. So it's definitely quite new, but hopefully we're making inroads into helping out in this area. Okay, well great. Can you tell us what you would do or what maybe a more middle-of-the-road physiotherapist might do in managing case-like areas? Yeah, well unfortunately we could see from his case already that he's had a few episodes with physio that haven't been very successful and the most likely reasons for that is that it's been more the traditional style of physiotherapy with the hands-on treatment. When we're looking at physiotherapy and pain management, it is really quite a different approach. We've obviously got that bias towards the biological element of it. We tend to look at how they are physically, how they're moving, how they feel about how they move, where it's looking now in pain management and a little bit more about their fears and their worries around movement, how that integration of all the different things goes on with their social background as well and especially when you've got work cover involved, there's so many elements to look at. So really, one way of recognizing it and thinking of it easily from our point of view is firstly to recognize that there are some other problems that need addressing. Respond in a way that takes note of the psychological impact and not only the psychological impact on pain but also on pain on their psychology. It's a two-way street and this is the hard part of it. It's so complicated to tease out all these little elements which is why you need the team really. It's not something that one person could do on their own. Listening for words and people like yourselves that work in mental health, you're probably very good at this already. Physios are probably the ones that need to work on this. Listening for those words that indicate a fear or a worry or concern in some way. And picking up on those and just making sure that we are not adding to the problem by using terms or picking our own beliefs into them and about fears. For example, for Gerry, he might be very fearful of lifting from here on end because of that. So that's something that needs addressing. This referral in that early period where he was invited to do a therapist, they had managed to pick up on elements that needed help. It would have been back to the GP and have that conversation about whether he needs another referral elsewhere. Important thing with this as always is just collaboration so making sure every member of the team is giving the same messages and talking and helping Gerry out. Obviously with Gerry at the centre of all this. When I say team, I also mean family, friends. We talked a little bit about the influence of some of his friends and the work cover team as well as the GP and the medical team as well. When we're looking at it in a very distinct chronic pain management averse to acute. So maybe we missed the boat in that first phase so let's try again a bit later. We're looking at physiotherapists as a guide for the physical element. So things like self-management strategies and active strategies are actually really key. We use education quite a lot. Now it really varies as to the level of education. So there's been quite a lot of research on pain physiology education and it works for some people and it doesn't work for others. So we just have to pick what elements of education we're using. When we're talking about getting the moving again, as Michael said, it's really important to look at their functional task. Much more than a general gym program or anything where they're just getting moving. It needs to really be addressing what they want to be able to do. So for Jerry, he's not going to want to do Pilates. He's going to want to get back to work so lifting for him and just doing basic day-to-day tasks. We look at grading or pacing up. So starting a very small amount of something and then gradually increasing that amount in a way that doesn't provoke or over-stimulate his pain or just doesn't overwhelm him from any point of view. Again, just always collaborating, always talking, always going backwards and forwards with him and asking him how he's managing and talking to the other members of the team. Now, if you're really lucky like Michael, all the team are down the hallway and you can go and chat to them as you go, but most of us working in primary practice, it's a phone call or a letter or some other way of contact. So just to kind of go over those bullet points again, it's really important that if you're working with a therapist, more physical therapist, osteopath, physio, anyone along that line, that you feed back to them where the patient is at from a psychological point of view and that they feed back to you from a physical point of view so that you can use the things that you each know. So one of the things I've found really helpful is sharing strategies. So for example, I have a lady who starts to get her anxiety coming up when she does too much messy exercise. So I know what she's learned from her psychologist and we sit down and she goes through her relaxation strategies. So there's that bit of crossover. Now, we don't want to move outside of our first practice. That's very important. So we're not trying to be psychologists and I think we really need to be mindful of that, that we're not taking on things that we're absolutely not qualified to do, but we know some of the skills they're using. We can just aid them with practicing those. All facets of well-being are important and I would say to people it's not just about work. You know, go do something nice, go for a walk on the beach. Let's pace up your sports or activities. Now, I don't think there is really into sports and activities so it might be more pacing up your social activities. You know, why not go to the pub or go to a barbecue and try just a few little things. One of the main things is that everyone keep giving the same message. You know, pain is not harmed so it's okay to move so it does naturally happen that you will get a flare up of your pain from time to time and this is how you can manage it or just get yourself back under control. With the hands-on treatment, the type of information we were given about Jerry in that second half, that sensitivity, it just indicates that there's some changes to his nervous system. So he actually won't find the hands-on treatment helpful in the same way that someone in the acute phase may find it helpful. So that's the case for that at that point. And that exercise and movement is just absolutely essential and I know from your point of view that you're often trying to get people moving as well because it's important for their mental being as well as their physical being. So we like to keep it pretty simple. You can see this chap here just doing a plain on-site to stand. It's a really common movement. Everyone needs to do it at some point so why don't we just practice something simple like that. The forward lean, there's any fear of kind of falling, etc. And then that's pushing upwards. One of the things that's happening lately that is very good are these groups that are appearing to help people. Now, you see that little picture there, the man walk. That's the new group that started around Australia and it is for men with mental health problems that want to get together and just have a non-judgmental talk and a bit of a walk. You can take it pretty easily but just to have that support and have that working together. There are lots of different groups and you just have to go on the internet to find your local ones. One thing I find quite important is just explaining to people some of the physiological changes they will get, especially with anxiety are very similar to the changes that you get when you start exerting yourself, you know, getting a bit of a sweat on and a heart rate going up. Now, not everyone likes exercise. Strange. But not everyone does. So I explain it to them that exercise sometimes has to be like cleaning your teeth. You might not love it, but you do it. And it's not just for now, it's for the future. So it's something you have to keep doing. Just every day a little bit of something, whether it be a bit of cardiovascular work or a bit of strength work or just practicing a certain activity that you want to be better at. And that keeps happening. Now, to back you up, there's some nice online resources that you can use. The exercise is medicine website. It's fantastic. And then there's some nice little very similar to the brain man drawings, the 23 and a half hours. So have a look at those. I think they're listed with the resources at the end. But just to give you a quick outline of possible things we could have done with Jerry in the early system, setting a walking program. And this walking program for him may have started with a two minute walk and then pacing that up so that the time indicates when he should stop and not his pain. And maybe a 10 or 20% increase once a week or a couple of times a week. Looking at self massage to desensitize and looking at strategies that you've taught them, helping them out or encouraging them to do the exercise. So that they're moving and functioning in as normal way as possible. Lovely. Well, thank you very much indeed. Now I must say as a GP I had the pleasure of working in the same practice as an exercise physiologist, one of Melbourne's most renowned exercise physiologists I suppose. I've never been fitter. I'd say he was hugely motivating even for me. I had to change practices. I was exhausted. So he was hugely motivating. Can you just tell us a little bit about, there's been a few questions about the role of exercise physiologist and also OTs. Now, OTs are so central to mental health in so many ways, but specifically here with that physical aspect as well. Can you just mention a little bit more about your profession's view of OTs and exercise. Yeah, I mean they're both therapists tend to be a little bit better at the psychological stuff than physios. And they do bridge that gap between a lot of the time, just very simple physical doing and the functional stuff. So they would probably earn more towards the function. But having worked with an OT quite closely over the last year or so there's often a lot of crossover. There's often not a lot of difference. So we found that we had to talk about that and just really separate out who is going to concentrate on what fits. So in the case where I was working with an OT I might do slightly less functional and a little bit more of the more traditional style physio if she was doing more of the functional stuff. So it's very helpful. She would probably do a little bit more of the problem solving and cognitive thought sort of challenging stuff, which again is probably outside of a lot of the time. Physiologists again, they would tend to maybe be a little more on the traditional exercise side rather than functional. But a good one will give exercises that build the functional movements and the functional tasks that allow that functional increase. So as I said, from a physio point of view, you've got exercise physiologists, physiopaths, they're very similar in what they do. There's also been a number of questions asking about if there's a register of pain management physiotherapists. Is there an association that has a member of this? Yes. Where do we find that? Association, APA. So if you Google APA physio, you can look on there and there's a list of what they call title to pain physiotherapists. So to get your titling, you have to work in the field and done further education by looking at that list. Great. Well, thanks for that. So let's open up to the whole group now and we'll have some Q&A. There's been lots of questions in the chat box or in the Q&A section of the website. So just wondering where best to start. I'm going to go back to the beginning actually and think about the contribution of work and the employer to this. Now, I don't know if Simon remembers that. But I've seen a lot more veterans around. I've never seen a group more antagonistic towards the veterans affairs department than an injured veteran. And I see a little bit of that in the injured worker sometimes as well. It becomes almost a career or an obsession, I guess I could say in fighting work cover and the insurer and the antipathy in the system that's a good question. Steven, I think often it's blamed on the patient some sort of a problem they have. But I would suggest we look at both the workers' and even veterans affairs as a system. And I think the system actually that they are engaged with is clearly part of the problem. And we know that people with very similar injuries will respond differently according to whether it's a workers' case or not, for example. And it's not because the workers' person is banging it on, it's just that the workers' comp system puts a lot of extra pressures on you that normal Medicare doesn't. And in a way, for example, the workers' comp patient is basically asked to keep proving there's something wrong with them. Now, how do you get better at convincing some anonymous person there's something wrong with you? And this is a major challenge. And naturally, if people are stressed, if they have mental health issues, it can only exacerbate the problem. And it's very difficult. It's not like being in a maze for them and they have a great deal of difficulty working in a way through this. And they may be dealing with someone who isn't very experienced on the workers' comp end at the insurer. There's a high turnover of case managers because it's not a very nice job. And so that's one of the most frequent complaints of injured workers is they have to tell their story a hundred times to different people. So it is very important to see it as a system. And that's actually one of the things I've been researching to see if there are ways that we could improve this. And indeed, I think there are and that's one of my areas of research to show we can train the workers' comp employees to behave in a more helpful way. But also we need to help workers get a better understanding of the system and how it can be useful to them for their rehabilitation. So that's a mistake to overlook that and imagine it's all going to sort itself out. But you can address it. And it does look like the general practitioners often put in that position as well, by having to prove that their patient is busted in order to keep on gaining benefits or whatever it might be that they need. And you've said that the GP can often be part of the problem rather than part of the solution. What sort of things do you think drive GPs to, well, less than ideal management? And what can we do about that? Well, I think GPs, as I said, we want to provide quick solutions. People come to a GP with a problem and our job is there to fix their problem. It's not a problem to be fixed just like that. If we could have cured their distress, we would have done it long time before. And so that does make that whole paradigm of interaction a bit of a trouble. But we still keep saying, right, let's look for something new. We'll do this test. We'll organise this injection. We'll try this new tablet. We'll do two opiates because there might be a better synergy. And after a while, they might move to a different general practice in the same practice. And the whole thing will go on again. And if all the GPs who has been seeing this particular has been seeing Jerry in your practice have all been doing the same thing. It's a very brave GP that will say, look, you know, I'm going to change direction on the course of this year. I know that they've seen six pain clinics. I know that they've seen 20 GPs over 10 years, but I'm going to change the direction. And that's a pretty tough call for a GP. So there's this inertia and our funding model encourages to deal with the pain in that fashion because when they come in with their pain, they also have to do the same thing. And we have to check their cholesterol and talk to them about this other thing. So there's so many other things going on. Sometimes it's a lot easier just to do what the patient would like us to do and then focus on other things and get them out the door and recognizing that GPs are paid on a throughput basis. And I've seen it. But the only thing I've seen that I've met with the patient is one of those questions is whether they're on their patients is not doing it from an economical point of view. And Paul Jenkins has pointed out in the question that you have to have long appointments for each of those five appointments. Is that something you would commit to to give yourself time and to actually settle in to the relationship? One picked the very difficult, complicated biopsychosocial aspects that are going on here. If you didn't organise a few long appointments, you would be reckless. And I think it'd be justifiable to the insurance company if they asked you. Sure. And one final question for you before we move to somebody else is we've got a question from Khalid who's asking about, are you comfortable changing a client's psychiatric medication if a psychiatrist has prescribed it? Do you think GP should overcome their inertia and change something that's been prescribed by a psychiatrist? Yeah, I don't want to make a categorical statement there, but I think we do have to at some times. And I think it's OK to contact a psychiatrist and say, you know, is it a really good idea to have this burst on two anti-psychotics and three anti-depressants, plus some benzos? Could it be that we're actually causing problems? And some psychiatrists are, it's a bit like the Wild West for psychopharmacology. I know psychiatrists often don't do psychotherapy anymore. That's for psychologists, but they do do pharmacopsychotherapy. And often they do very brave and courageous combinations of psychoactive medications. I think it's quite OK to challenge a psychiatrist, if you like, just like I think because we're all responsible for giving our best care and we might like the blind man in the elephant, we've got a different point of view. It's OK to say, you know, I don't think this is quite right and can we do it better? You might learn something. You know, there's a new research out that I'm unaware of, or it might be that this psychiatrist would like a bit of help because they're struggling with the fact that he's starting to smoke dope and he's been told that he just needs another operation and the psychiatrist might not have an awful lot of chronic pain training and be trying to assume that's biomedical too. Absolutely. So thank you for that. And going to Michael, I must confess, I've just signed off three certificates over the weekend certifying patients is having no current work capacity and that that is likely to continue indefinitely. That's a hell of a thing to say about somebody, but it's what the law requires of us. Do you think? And this is a question that Kate Ingalls asked about whether we can use more positive language and whether your research is giving some early indications about how we should be, what sort of words we should be using in talking to people who do have chronic pain, particularly work-related chronic pain? You know, I agree. I think I wouldn't say someone is totally incapacitated. And I've argued with the workers, people that they should ask doctors, not just to make a medical diagnosis, but to identify the psychological and social contributors to this person's problems because they don't occur in isolation. And what you need, I think you need to be doing is saying at the moment, this this guy is unable to work. But these are the things that could be done, be worked on to help him or her get back to work or suitable work. So it's it's acknowledging the problem, but secondly, pointing to how it can be resolved, because the consequence of saying a person is totally cactus. You know, it's it's terrible that we know that being out of work is bad for your health, but physical and psychological health. It's it's a critical that as much as possible, we get people back back to work. To me, it's an it's an emergency situation. And we would throw resources at someone who's injured in a motor car accident on the highway, but for a worker, we're likely to toss them overboard. I think this is a major mistake. And it's I think we're doing a great disservice to people with these problems. Thank you for that. I fully agree it does seem to be an adversarial system that doesn't treat people for positive outcomes. Speaking of positive outcomes, there have been a number of questions also about comprehensive multidisciplinary pain clinics and their availability and approaches. Do any of the panellists have any thoughts about when we should be engaging with multidisciplinary pain clinics? Cat or Simon? Simon, can I say I think these are a great idea. But don't seem to have a role in the vast majority of people with chronic pain. I understand the figures suggest there's less than 0.2 percent of people with chronic pain end up with these multidisciplinary clinics. So they really are important, but for a minority of people, I if I could flip on that head, I think it really is important that we take a multidisciplinary approach to people's chronic pain. It might not be in a tertiary multidisciplinary clinic. It might be that my cat is a physio with cognitive skills. It might be that we are doing some cross discipline work. And I think this is a really important thing for GPs to be doing. A lot of the skills that we talk about in chronic disease management are the sort of skills that we'd be wanting to and strategies wanting to bring to bear with people with multidisciplinary clinics. Having said all that, I think it's really good that we've got multidisciplinary clinics for the minority of patients who need particular skills that we can't manage in primary care. And very occasionally, I do send people that way. But often there's a long wait, 18 months or they can't afford it. Or being a real GP, an addiction physician, it's often a long way away. And people don't want to drive there because they're back won't allow them to drive three hours to a clinic. Yeah, obviously, you know, it's wonderful that people can get access. And, you know, Michael knows having worked in one for a long time now that having the team all there at the same time, working in groups, which is another important thing about those clinics, usually, is that people are working in groups, which helps them to see others in the same situation. And in fact, generally helps them to get going a bit more. It can take the focus away from them and their problem a little. But in primary care, it's actually really tough and it's hard to get access, as Simon said. So what we've had to do in primary care is really create a network of, you know, people that you know. So I'm always on the lookout for psychologists. And, you know, I keep a little bit of a list of who there is that's available and what area they're in and who I can send to them. And just getting to know people who are in your local area that do work in pain management or have those skills so that you can set up your own little network. And as you say, communication is key. So using those, you know, whatever method you can to get in touch with people and keep each case. Yeah, it's, you know, it's Michael here, Steve. I just wanted to say as I work in a multi-disciplinary pain centre. That's why I thought I'd come to you last. But I guess we should go ahead, Michael. Yeah, thanks. As Simon says, only a small proportion can go and that's understandable if 20 percent of the population have chronic pain. We just don't have enough pain clinics to be able to do that. So what we've done is to actually create like a pyramid approach where the mass of people with chronic pain should really have to be managed in the community. But the community means people who have got skills. And so that's the challenge for community health workers and primary care is to skill up to be able to do it. Because most of the courses available for their basic degrees do not provide them with the skills to manage chronic pain. So that's that's the first task. And that's why it's becoming a specialisation within the APA. So but nevertheless, there are people who will need a more intensive approach. And that's what pain clinics can offer if they are adequately resourced. And that's another problem because this comes under the state health departments and they're always going to be strapped for cash as well. But nevertheless, it's not expensive for the patients. As Simon said, it's costly. It's not. It's free. Patients can attend our program for free. It's a three week program. They come every day, all day, Monday to Friday. So now because of COVID, we've actually developed a distance program. So we're we're able to treat people in Perth from Sydney using I.T. and we've developed workbooks to work with our physios and psychologists and nurses and doctors from from our from our clinic. We they don't even need to come down. So COVID has meant that we don't the tyranny of distance is a thing of the past. We can actually provide and we are providing. We're actually getting quite good results working directly with people in remote communities, providing they have access to NBN that they don't have that we can use a telephone. And the and the mail to send them out materials. So I think a lot of things have changed because of COVID. And I think this is going to equip us much more effectively to be able to project multi-disciplinary pain services right across the country from places where the professionals exist. And they can see people where without all the, you know, the previous problems. So the principles, though, are the same, whether they're in a clinic or whether in primary care. But both cases, you need skilled practitioners. And that that is the problem. Thanks for that, Michael. Certainly the NBN is giving us some headaches tonight, but I fully agree with you. It has broken a lot of the reliance on travel and helped people in rural areas with chronic pain be able to get support without having to bump up at roads for such a long distance. A few other questions to consider. And, Simon, I think it's back to you. Cannabis, now Jerry's found his way to a stash. What about medicinal cannabinoids? Do you see a role for them in chronic pain management? This is obviously a topic to jure. There's been there's been incredible excitement about these sort of substances for a long time. When when pain physicians decided opiates medicine, we should be using medicinal opiates for chronic pain. There was incredible excitement. It was likened to the aeronautical equivalent of breaking the sound barrier that we could finally give people opiates with when they had chronic pain, given opiates without getting addicted. And there's an incredible lot of excitement today about medicinal cannabis. Personally, I think that the excitement isn't coming from the doctors. It's coming from advocates who say I use my cannabis because I can't sleep without cannabis. I use cannabis because I've got a bad back. It makes me feel better or anxious. I can't go out and socialize without cannabis. Why should the fact that I use cannabis to relieve these psychological physical problems make me a criminal? So there's advocacy. There's also a lot of commercial interest, first like opiates and the anti-epileptic use for pain, the gabapetinoids have been really pushed by commercial interests. There's billions and billions and billions of dollars in this. And all the research is coming out of commercial sources and it's very interesting. I presented at the Australian Pain Study Conference a couple of years ago and one of the pain physicians told me his stock program advised him to buy lots of cannabis stock and he was doing very well with them indeed. And certainly from a commercial point of view, medicinal cannabis is fantastic. There's going to be lots of profit made. The research, which is all produced by the pharmaceutical companies, is indicates how wonderful it is. And I suspect we're going into this with eyes wide, wide shut. And we're forgetting what the lessons that we had with the opiates. It will take some time for us to work out what the role of opiod of cannabis is. It might be that CBD has a role because it's not really an intoxicant. On the other hand, it seems to me that the more stoned you are with CHC, the better your symptoms are and the more effective it is as a medicine. We're going to have long term problems that we're going to have to deal with, who's responsible for a traffic accident and someone who's using medicinal cannabis has. What happens if a young person gets schizophrenia? There's so many questions about this. What sort of medicinal cannabis are we using? Are we talking about the stuff that you buy at the pub? Are you talking about the stuff you buy in a pill or an oil? It's it's all over the place. I think the dust will settle and I think we will find a role from medicinal cannabis. My understanding, the meta analyses show there's very little role in chronic pain. The meta analysis show that numbers needed to treat to get a 20 a 30 percent reduction in pain intensity is something like 24. And the numbers needed to treat to get a 50 percent reduction in pain in medicinal cannabis is you can't actually find a confidence interval for it. So I think what's the space? We need to be very cynical about the fact that we're the doctors are getting where there's meat in the sandwich between the advocates for legalization of cannabis and the commercial interests that want to make it compulsory. Thanks for that. So I mean, and actually there's been a number of people asking about where to find colleagues with a particular focus of this area. Somebody Paul Grinsey has asked if there's a pain friendly health practitioner's directory anywhere. I don't know. Is there a pain association that would publish a list of everybody from pharmacists to general practitioners who might be pain friendly or at least not judgmental or hopefully trained in the in the discipline? Could I say on this one? I think. Most GPs are snowed under with chronic pain. We know that something like 20 percent of the population report chronic pain on door to door surveys in many countries. And almost half of all GP consults, the issue of pain is brought up at some point, whether it's acute or chronic. So I think we're all dealing with this. As there certainly are. I know Paul's been involved with work looking at people getting credentialed, GPs getting credentialed for pain, specialised GPs. And then hopefully there'll be some medical benefits schedule and the numeration about that. But I think we're. There needs to be lots of discussions about this and whether we need to have everybody upskilled or just have a handful of people who are, you know, the go to people to go to GPs for people with chronic pain. I think that means that's still work in progress. Thanks. So now I've only got about 10 minutes remaining. So a few more questions. There's been a number of people asking about trauma past history of trauma is a sort of a setting event for the development of chronic pain. Michael, do you have any thoughts about that? The evidence showing that being a place go ahead. I think there is some evidence like that, whether it's in childhood trauma or later or post traumatic, you know, PTSD, leading to the expense of chronic pain. I think it also trauma sort of sets the scene in a way for a person that sort of sensitises them to stressful situations and when you have an injury and your pain is persisting, they can certainly influence each other. So the arrows go both directions. And certainly if someone has chronic pain and has PTSD, for example, then you've got to treat both. You can't expect just to treat one and the other will resolve. That's unlikely to happen. The same with depression and anxiety. These things often do go together. More than 50 percent of people presenting with chronic pain will be depressed, but also many will have anxiety and it is there is evidence that the history of trauma can make it making more vulnerable to the development of chronic disabling pain. We can't always predict who will get it. There's we're not the science isn't that good yet, but certainly it makes it more likely that you're at risk of developing chronic pain. Was that sort of background? Thank you, and I can't move to the final section without thinking about Helen Buffton's question about the role of animals in helping ameliorate chronic pain. We did have a number of questions before the webinar about everything from quinoa therapy courses through to dogs. Does anybody have any thoughts about those sorts of approaches? I would say I think the point here really to me it doesn't have to be an animal could be an inanimate object if you like, whatever your preference. But I think if you can engage in something that gives your life meaning and is important to you, you will suffer less. One of the pioneers of the United States, you had a great say. I remember because I met with him a long time ago. He said that folks who have got something better to do don't suffer as much. So if you've got a way of improving your mood of giving yourself some satisfaction, enjoyment, pleasure, then that will minimise your pain and make you more functional. So it is it doesn't have to be a pet, but it can be. I just say it as something that is very individual that it's very important to look for that in trying to work with a person to look at what pleasurable things they would like to do that they can do and encourage them to do that, just like you do with people who are depressed. It's not just a matter of taking antidepressants and waiting two weeks to see if there's a benefit you can get on with this straightaway. So I can imagine I can imagine that would be especially important with children with chronic pain, thinking about things like juvenile rheumatoid arthritis and those sorts of things. Final question. Any quick comments about the approach to children? We talked about this 56 year old man. We haven't talked about older people. But what about children? How do we approach them with chronic pain? It's a whole new way that the principles are the same. The principles are exactly the same. But what you've got there also are the parents, just like with Jerry, with the worker, with the workplace, with children, you've got the parents. And so there's a great child psychologist and children's or pediatric pain clinics in Australia. And they they all their characteristic is they engage the family in working with the child with pain. So that that's it's not a matter of sort of thinking of the drug or the right injection or something. It is a matter of understanding the child's within their context of their family and working in a collaborative way. Well, thanks indeed for that, Michael. Now, our technical team is absolutely fascinated by you turning pink there. We're not sure if it's some Instagram filter you've chosen or you're just going the full wall hole, but you look very top psychedelic. So I wasn't expecting to have tonight. Let's just have a final word, though, Kat. What's your final word before we we finish up? Look, I mean, in cases like this, for us as physical therapists or definitely centered towards the physical being, working with mental health practitioners is so important and so useful for us. So, you know, we love chatting to you about it and any chance we can to work with you is always great. And I'm always encouraging junior physios to go and look out someone to go and sit in with or just go and have a chat with. So if anyone does approach you, it would be very helpful to let them do a bit of work with you and to teach them how you work so that we can work better. Shad, you know, sort of follow the word from Simon Oliver. I think it's been a really great session. I've learnt heaps from everybody. And thank you to my co-presenters and people for coming along. I think everybody deals with pain and chronic pain, and it doesn't have to be a hard sink. We can do our best for people quite often by thinking broadly rather than trying to look for a quick fix. We will be taking the best approach for the person. That might well be we need to be doing collaborative care. We are colleagues quite often who haven't got pain skilling, but we don't know how much pain training you need to give excellent care. There's nobody's done a study that you need to do. What the dose of pain training is, is it one hour? Is it a six year master's degree? Who knows what? But if we all do better pain care after training and understanding the broad the broadness of how pain is experienced and how we can take a broad multidisciplinary approach or multimodal approach, I think we'll be looking after our patients a lot better. Great. Thanks for that. And Simon, sorry, Michael, maybe one for you. There has also been questions about mindfulness. I would have mentioned that might fit into the group of approaches that really suit some people who are committed to it. Yes, that's that's right. And that's just briefly to Simon's last point about how long the training should be. You train until you're competent and we can measure that. In terms of mindfulness, it's like relaxation or yoga. All those sorts of strategies, Tai Chi, they they are very useful strategies to use that they're not enough by themselves, but they do help to engender a more positive affect or feelings, calmness. And if you can stay calm in the presence of pain, you'll suffer less. And so it is worth equipping yourself to do that or to teach it or there are websites that offer these things. So it's but it's not the mindfulness per se, the technique. It is relaxation strategies can achieve very the same sort of results. But the key thing is the patient has to do it. And that's the thing that comes through all chronic pain management. It's actually got to be self-management by the patient. And that's what we must all be doing because we don't have a magic pill. But we can help people to learn to manage it. And that and mindfulness is one of the strategies that can be very useful. Great. All right. Well, thank you for that. It's time now for us to finish up and I'll just a few things to close. First of all, obviously, to thank our panelists so much for sharing your expertise with us tonight. Also, the participants who have been so active, that's been incredibly helpful. There's a few things to get people to do before you leave us. Please, that the exit survey, please provide us with feedback, always looking to improve these webinars. So we'd appreciate your thoughts. There's a survey icon at the top right of the screen. If you fill out the survey, I'll just wait for it to pop up when we finish. You will receive follow up communication from MHPN with the recording of this activity, how to access it, if you have had NBN problems. There's another webinar coming up pretty shortly, actually, on emerging minds, which is about engaging fathers and their children. That's on the 29th of October, so not far away at all. And also a collaborative approach to working with children affected with grief, which is on the 10th of December. Also, MHPN has launched the inaugural podcast, MHPN Presents, that explores well-being and mental health. Which would cover some of the issues related to mindfulness as a lifestyle as well. You'll find that on Apple Podcasts, Spotify and the MHPN website. If you want to stay up to date for more of the episodes, please do subscribe by going on to the MHPN website. Also at a local level, if you want to keep on talking about this topic and others, please do get in touch with your project officer at your local MHPN network across metropolitan, regional, rural and remote Australia, 373 networks around the country. So it's an online map on site where you can see who's close to you and also to contact Jackie at networks at MHPN.org.au. So that will answer some questions people had about accessing colleagues in their area. Also, as with COVID-19's having an effect on MHPN as well, there are Zoom meetings available. So before we close, I would like to acknowledge people who have been with us tonight and those that you care for, people who are living with mental illness and pain in the past and those who continue to live with mental illness in the present. So thank you, everybody, for your participation and I wish you a very good evening. Thank you all.