In this week’s episode Anjelo Ratnachandra, physiotherapist, counsellor and chronic pain patient shares his firsthand experience of living with chronic pain, including the physical, mental, and emotional hurdles he overcame to adapt to life with an often-invisible condition.
Together Anjelo and Dr Adrian Lopresti explore how mindset, behavioural therapies, and a holistic approach to treatment can help patients to manage, adapt, and thrive while living with pain.
Covered in this episode
(00:23) Welcoming Anjelo Ratnachandra
(01:43) Anjelo’s history with chronic pain
(07:36) Holistic approach to pain management
(10:40) How thoughts and emotions impact pain
(14:46) Techniques for pain and emotional management
(29:39) The importance of a support network in pain management
(33:43) Physical activity and exercise in pain management
(38:24) The sleep and pain connection
(42:41) Behavioural experiments in pain
(45:01) Holistic chronic pain interventions
(50:38) Thanking Anjelo and final remarks
Key takeaways
- Stress and/or fatigue can exacerbate pain perception.
- Endorphins are natural pain killers that may alleviate the perception of pain.
- It’s important to treat the whole person, not just their painful body or diagnosis.
- Cognitive behavioural therapy or acceptance commitment strategies are beneficial strategies to develop for pain clients during treatment.
- Setting individualised goals is essential to support the improvement of pain perception.
- Social support and connection with others play an encouraging role in the pain experience and are important.
- Pain education and including the family and support network can enhance both the support and understanding for the individual experience of pain.
- It is important to understand when there is need for referral: A support network can include phycologists, dietitians, and other specialists.
- Mindfulness and relaxation techniques are paramount when working to live with chronic pain conditions.
Connect with Anjelo
| Anjelo's Website |
Transcript
Adrian: Hi, and welcome to fx Medicine, where we bring you the latest in evidence based, integrative, functional and complementary medicine. fx Medicine acknowledges the traditional custodians of country throughout Australia, where we live and work, and their connections to land, sea and community. We pay our respects to the elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander people today.
Anjelo Ratnachandra is a physiotherapist and counselor with over 20 years of experience in helping people with chronic illness and in particular chronic pain. He's a founder of Beyond Pain, a clinic located in Victoria specialising in tailored programs for the treatment of chronic pain, chronic fatigue and mental health conditions. Anjelo is an award winning therapist and someone who has personally experienced substantial chronic pain in his life.
He's the author of the book Beyond Pain, where Anjelo takes readers through his journey with pain and then provides invaluable information about the treatment of chronic pain and the important connection between the mind and the body. I've just finished reading his book, and I must admit that it is a great resource for practitioners and patients. It is Anjelo's experience on both sides of the chronic pain treatment room that we want to discuss today.
Welcome to fx Medicine, Anjelo. Thanks for being with us today.
Anjelo: Oh, thanks for having me.
Adrian: It's great to have you. So, I mean, I'm curious because I know that, you know, obviously, you trained as both a physiotherapist and a counselor specialising in chronic pain. But I know that early on in your career, you experienced some very traumatic events that have and undoubtedly affected your life. Can you tell us a bit about this?
Anjelo: Yeah, sure. Look, um, I've had chronic pain for about 18 years now, so I guess my main talent, I had a few events in my life, but the most major one was back on the 23rd of June 2006. I was living and working in London at the time as a physio, ironically working in pain management. And one Friday night I was sitting at home watching TV and someone broke the window and threw a molotov cocktail at my head. They got the wrong house. So basically the cocktail deflected off my arms as I went to pull my arms up to my face, hit the back wall and smash another shot, shattering petrol. And next thing I knew I was set alight.
So yeah, yeah, I had to put the fire out using my hands and run upstairs into the bathtub and wait till the ambulance came along. And then ended up being in a burns unit and had to have some skin grafts and a long recovery post that.
Adrian: Wow. So how long were you in hospital for?
Anjelo: I was in an acute burn unit for about two weeks. A week to two weeks. And then subsequently I had to have outpatients for about six months, three times a week having morphine shots and cleaning the wounds. And then during that period, I do have skin grafts as well.
Adrian: Wow. Wow, so you so you experienced then obviously on the other side, are you actually a patient on this occasion? What was that like for you being a patient of pain?
Anjelo: Yeah, look, it's definitely an eye opening experience. I mean, we all experience pain to a degree, but when you're have that level of pain and subsequent recovery and rehab, you really get an opportunity, you know, you really do sort of walk the path of the clients and you've got to implement what you practice. So you've got to walk the walk when you're the patient. And that was my first hospital visit or eight months prior to a collapsed lung. They call it a spontaneous pneumothorax, and I don't fit the criteria for it. I just had one. And yeah, I had to end up in hospital for five months. Sorry. Five weeks, eight months old. Yeah. So I wasn't a stranger to hospitals. I was just learning the ropes of what it was like being a patient and the recovery process and, and what we needed to do to get back on our feet.
Adrian: And what was your experience, as you know, with regard to the treatment that they offered in terms of the management of the acute pain as opposed to the management of the chronic pain, what was the hospital like and the medical practitioners like in terms of managing that?
Anjelo: Well, look, the hospitals generally go with the medication route. You know, I was very fortunate that I work in pain management, so I was able to recognise what else we needed to do and what I needed to do from a psychosocial perspective to keep my mind active and things like that. But generally speaking, the hospitals go through the first line of treatment, which is the medication and the strong medicine.
And as we know with strong medications there's lots of side effects too, which I wasn't a stranger to, and I had to manage all of that. So it really gave me a great insight as to, you know, there is a place for medications, there are a place for supplements as a place for everything, but it's just about finding the right balance.
Adrian: So was there in terms of that experience, obviously with pain and I mean, is that something that you still suffer from and the burns still continue to create pain for you?
Anjelo: Yeah, look, I do have chronic pain from the burns. I also get other sensations like one side of my face, you know, heats up in the sun faster than the other side. It feels like, like, I have cling wrap on one side of my face sometimes. And, you know, my arms, I get different sensations depending on sometimes the weather affects it. I get some kindling or electric sparks going down my arms. So you get different sensations, not just pain as we know it, but yeah, certainly, you know, when you're stressed and upset, you tend to feel more pain as well.
Adrian: Yeah. I mean, I just recently read your book and it's a it's a great read. I'd certainly recommend it for anybody. That's for both, I think, practitioners and for clients. I think there's some valuable information in there. And just your story too, I think is inspiring and the fact that, you know, obviously as a practitioner and a patient, you know, obviously you get to a level of insight and empathy that, you know, many people who don't experience that pain would have. So is there anything that you learned from being on both sides of the couch, you know, that that impacts on how you work with your clients now?
Anjelo: Yeah, absolutely, I think I think we've got to look beyond the physical aspects of pain. I think, you know, we've got to look at I'm very big on the fact that we need to look at the person, not their painful body or their diagnosis, you know, pain impacts, not just that physical sensation of pain, but the impacts someone's whole life - impacts their work, impacts their social life, personal life, their mindset, and vice versa.
So, you know, in terms of an approach, we need to really look at a holistic approach to pain management, whether it's acute or chronic, and as opposed to just focusing on from like a medical model of, okay, well, here's where the problem is. Let's try and fix that problem there.
Adrian: And when you say a holistic approach, like what areas do you think are really important components of a pain management treatment?
Anjelo: I think, you know, physical and psychological and social, all of the above. So, you know, we've got to look at how someone's mentally impacted by pain, how they're socially impacted by pain and physically we need to look at exercise stretches, mindfulness techniques, relaxation techniques, you know, getting them reconnected with society, because often a lot of people with chronic pain become isolated.
One, people say that, you know, other people can't see that pain, that I understand the pain, which is true. So they try and keep to themselves. But it's really important to reconnect with society and get back to some level of normal despite the pain.
Adrian: Yeah. So, then can at some point you've trained as a counselor? Where did that happen and when did that occur.
Anjelo: Oh look it happened years later. But I think with the insights I got from working in an internationally renowned pain clinic, working closely with psychologists and and other physios and other allied help, it really cemented my view that, you know, tackling pain, whether it's acute or chronic, needs to be a holistic approach. And while I've got the skills and the tools from these other practitioners, I really wanted to get a good framework and a good base of support. So I went back to university and started and did a counseling course to complement my physiotherapy knowledge and expertise.
Adrian: So do you think the holistic approach is something that pain management practitioners or people working in the pain area are utilising a holistic approach nowadays, or do you think it's still kind of medication management and acute pain management and, you know, what are you seeing in that area?
Anjelo: I think we are moving towards a more holistic approach. There's some good pain management programs where there's different disciplines like physiotherapists, psychologists, exercise physiologist, OT’s, etc. That's part of a team, I think. But there's still a big focus on intervention. And when I say intervention, I'm talking about injections, medications, etc.. Now I'm not against any of that, I think that definitely a place for it. But I think perhaps what we need to look at is looking at a non-invasive approach first, perhaps with medication and perhaps an allied health, sort of by psychosocial approach before we jump the gun and go to surgery and injections and things like that. I think there's definitely an opportunity to fine tune that and perhaps get people into a more structured routine and give them some skills in pain management to complement anything further that they may need to have.
Adrian: I mean, my background is I'm a clinical psychologist, so obviously, you know, we're at the emotional side and the psychological side that can have both physical and mental disease. So how do you explain that? Like if you've got then somebody coming in with chronic pain or and they coming see you as a client and then you start talking about thoughts and emotions and feelings, like how do you explain how that impacts on pain?
Anjelo: I do live by a quote from Aristotle from about 2000 years ago, he said treatment of the part should never be attempted without the treatment of the whole. That's the error of our ways, the separation of the body from the soul. And so I think a lot of people with chronic pain understands that the pain is exhausting both mentally and physically.
And if you actually talk to my clients about the fact that when they're feeling stressed and angry or upset or frustrated, do they feel more pain or less pain? And more often than not, they'll say they feel more pain, whereas if they're happy or distracted it or amongst friends and family or doing something that they enjoy, how do they feel then?
And that's, you know, and then they recognise that, well, the mood can impact their pain. They might still have pain, but certainly the intensity of the pain may be different depending on your mood. And I think people do understand that, especially with someone who has had chronic pain for a long time. They've gone through the ups and downs in terms of mood, and I think they can see what's going on.
And what's the mechanism like? How does our mood impact pain from a physiological point of view? What's going on there?
Anjelo: Oh well, the brain is an interesting piece, isn't it? So I mean, the reality is when you're happy or excited or feeling good, you release natural painkillers, the endorphins and that. And that's why sometimes some people on low dose antidepressants for pain management, it's not necessarily because they're depressed, but the medications actually allow you to release chemicals in the brain that makes you feel good. And what that does is that essentially shuts well, tries to limit or shuts down some of the pain pathways. So you feel good. You don't feel the pain as much. You’ve got those endorphin releases that you feel stressed. The body is in a heightened state. It wants know everything. It needs to know about pain because pain evolutionary is a defense mechanism, right? If you put your fingers in a stove, you get burnt or it's hot, you withdraw. So it's a defense mechanism. So the brain inherently thinks any type of pain is is a danger to you, not it doesn't know the difference between, you know, danger, top pain versus chronic non danger type pain. Pain is pain for the brain.
So I think it's that endorphin release and the type of chemical balance that you have, you know are you a highly stressed person versus are you understanding of your pain you feel like you've got control of it or do you feel you don't have control of it? So it's the release of chemicals that can impact the physiologic pathways.
Adrian: And is it just endorphins or there is other kind of chemicals that you think play an important part in that pain emotion?
Anjelo: Yeah. I mean, you know, the endorphins and the painkillers, the ones that makes you feel sort of good, the adrenalin, etc.. But then you've got chemicals like cortisol, which has the opposite effect. It's more of a stress hormone. It's just slow releasing. It makes you more alert. It's it's sort of redirects blood to your muscles, makes them more tense and so you fatigue more you know, it reduces blood flow to the brain and things like that. So that could then cause you to have the brain fog, etc. and it keeps you awake at night because it's an alert hormone. So then you don't sleep well and then the next day you probably feel worse.
So I think there's an intricate interplay of chemical oils and neurotransmitters and different substances in the brain that we're still learning about it.
Adrian: So with then from a psychological perspective, if you're seeing somebody with we're seeing your clients, your what kind of techniques are you teaching them to help manage that pain and, and work on the emotional side of things? What things are you doing with them?
Anjelo: Look, I generally try and refer them off to a psychologist or a counselor because that's their expertise. But in terms of just trying to calm the mind about doing some quick relax techniques, just some breathing techniques, so we know deep breathing, square breathing techniques can help, you know, focusing on something enjoyable or a distraction technique. Listening to music. Music is great is the favourite band or things like that, or give them some, you know, cognitive behavioral or acceptance commitment sort of strategies to look at, you know, challenging, unhelpful thoughts or or looking at, okay, well acceptance that this you've got this pain and it's not nice. So what can we do to move forward from here?
You know, what would make it a little bit better? And looking at some sort of exploration of strategy but not dismissing the pain, I think it's very important to recognise someone's struggle. And the struggle is beyond the pain. Pain is one aspect of the struggle. But recognise someone's whole struggle and then trying to give them some strategies around that.
But I think more often than not, I would absolutely recommend they go see a psychologist and get themselves assessed accordingly.
Adrian: What did you find helpful for you in terms of the management of pain? What specifically do you find helpful?
Anjelo: I think the enjoyable activities aspect is really good and having a good understanding of what's actually going on in the body, when you have pain. I think the pain education piece is pivotal in any good pain management because if we understand what's going on, we tend to be less anxious and worried about it and so if someone can clearly explain how pain is working, this is why you might be getting a flare up. This is what could happen, and then put in place some strategies to help someone give them that sense of control back, I think that's pivotal. And part of that control is also doing enjoyable activities. I think people go for me, being able to do the things I enjoy again despite my pain gave me hope. And I think that's important to reintegrate that as part of the rehab strategy, not just an exercise program, for example, just reintegrate someone to doing things they enjoy doing in some capacity or manageable capacity to start with so at least they can say, Oh, okay, well, I can start here and I can see where I'm working, but I'm working towards a goal setting is the other thing that I think, Adrian, that I think is really, really important, setting some meaningful, functional set of smart goals so that people have got something to look forward to. And I'm very big on the message and the message that I've sort of learned over the years myself is that the goals of intent, not expectations. So you don't have to put pressure on yourself to say, I have to achieve it by such a date, just an intention to achieve it. And I think we could take that message to your goal setting. Say, okay, well, I'd like to be able to do this, but there's no pressure for me to be able to do it by saying that I think they'll be really helpful.
Adrian: I know that in your book you talked about some of the things that you've done, which are absolutely amazing and one in particular with your well, you say it's I mean, obviously you say that you then had pain, you recovered. You've obviously then become an expert in pain management and then you obviously went overseas, you went hiking, you went trekking.
Anjelo: Yeah. Look, one of my childhood dreams was to check out the Himalayas. I had something about the Himalayas that always attracted me. And just during doing research and projects and things like that. And so when I had my collapsed lung in 2005, they obviously said, you know, you've had lung surgery, don't do any high altitude stuff, don't do any deep sea stuff, and you know, it's probably not safe, etc.. And then you'll never be able to do the Himalayas, forget about it. And then when I have the burns they’re like, with the chronic pain and the skin graft, forget about doing anything high intensity. And, you know, I could then really relate to my patients, my clients where you know, a lot of people, where specialists and other therapists have told them they'll never be able to do this or they'll never be able to do that.
And then I thought, well, why should someone decide what I can and can't do? Now, obviously we need to be sensible and we need to be realistic. But, you know, I'm a big believer that we should never put a ceiling on someone else's goals. If someone has a goal, let's just set it and work towards that and set the expectation that you may or may not achieve that goal, but hey, there's nothing stopping us from working towards it. So that's what I did. I sort of said, you know, there's no time frame for me to do Everest base camp. It's something I'd always want to do, but I would set myself a goal and a bit of a time frame and I'll work towards it. And if I get there, awesome, if I don't, at least I've got my fitness. I work towards my fitness. So that's what I that intention versus expectation. So yeah. And so yeah, four years later I think it was four or five years later. Yeah, I've managed to do Everest Base camp. It was tough. It was probably the toughest holiday I'd ever go on, but it was worth it.
Adrian: So yeah, so that's interesting. So, that happened. What, four or five years after the burns?
Anjelo: Yes. Yes.
Adrian: Wow. Okay. And so you had all say I mean, it wouldn't have been physically pleasant at all, I suspect. But you did it. I mean, what's, you know, how did you do that, despite the pain that you would experienced? Obviously, you know, anybody, you know, doing the base camp, Everest, it's going to be a difficult, physically exhausting experience. But for you it would have been even more difficult. So how did you overcome and work through that pain and still achieve that?
Anjelo: Look, I think it's about, yeah, it's something I always wanted to do. And that also needs to be some level of reality and pacing. So, you know, I was by far the slowest person to get to the checkpoint at the end of every day. But so I just paced myself along the way. I wasn't going to push too hard. I wasn't going to make it even more unpleasant than what it needed to be. But it's something it was about the destination for me and it's about and for me it was about, okay, well, you know, I wanted to make sure I was going at a pace that was manageable for me. I was able to take breaks when I need to take breaks, but make sure that I kept up with the rest of the group in some capacity so that, you know, I wasn't holding anyone up. But at the same token, I wasn't falling too far behind. So I think that's where the concept of pacing really comes into play and everyone's different and everyone talks about pacing and pain management. But I think it's just about looking at, okay, what do I need to do? And having a plan of attack to say, you know, don't, don't be reactive in your response to pacing. You've got to be proactive. So, taking breaks, even if you feel good, sticking to the schedule as you as you are going through it, not just trying to say, oh, you know, I feel good, I might just do a bit more because then you're not pacing, you're just you're just working to your symptoms. And that's not helpful because symptoms can change for no reason.
Adrian: You know, what was your I mean, you talked about cognitive behaviour therapy. So obviously our thoughts and what we say to ourselves affects how we feel and fix our behaviors too. And then the other treatment that you talked about was acceptance, a commitment therapy or act. And so acceptance of thoughts and feelings and working towards goals and values and things like that. So what kind of things were you saying to yourself when you're experiencing pain? I suspect there was probably times that you wanted to give up. What was your self-talk like during that process?
Anjelo: Oh yeah, it's good question. Look, I think for the most part I was like, okay, well, you know what was in my position? What would I tell them to encourage them, you know, and, and also consider things like, you know, I've come this far, I've done this, you know, yeah, look, the pain was bad, but, you know, could it be worse? Yes. Could it be better? Yes. I am in the journey that I'm in and I still got a little bit further to go and I just got to keep going through it. This is something I knew I was getting myself into. I knew it was going to be tough. So to expect anything different, you know, will be insane. So it's something that I just wanted to feel like I was wanted to achieve. So and that's why when I really talk about goal setting, it's not my goals as a therapist. It's going to be the client's goals because that adds meaning to it. So for me, if it was a therapist who's saying, Oh, you need to do this, I probably would not need it, but it's because I personally wanted to be able to do it. I found the means to put in place the strategies to then do it.
Adrian: And what do you think that was the reason? Why did you want to go to Everest? I mean, what was the meaning behind it for you?
Anjelo: Oh, look, part of it was, I guess, my upbringing as a Buddhist, but I think it's more nature like I mean, it's I guess it's raw nature. I mean it’s Mother Nature at her grandest, really. And just to see this incredible mountain is huge! Like we don't, we underestimate how big big these mountains are and you are just like this tiny ant, you know, and you see a peak. But the peak is nowhere near where you are, but it looks huge. So I just felt for me, the environment, the natural aspect, the natural beauty of it was, yeah, it's something I wanted to experience. And alongside the Buddhism aspect. And, you know, I think of Buddhism more as a way of life rather than religion. And just that just the life that these people live, they've got very little, it's very harsh environment yet so happy, you know. And it just really brings home, you know, it's not necessarily the materialistic things. It's about mindset and what we want to make of life. Really. It’s that simple at the end.
Adrian: Yeah, absolutely. Yeah. You know, I mean, obviously the how we think and our values and our goals and, you know, obviously there's one way where you can kind of manage pain, which is probably the more I say it the more I kind of cringe at that word because it's it's about kind of living a life with pain, isn't it? It.
Anjelo: Yes, exactly, despite having pain.
Adrian: And, you know, purpose and meaning. And I mean, how do you think your experiences have in terms of, you know, obviously the burns that you've experienced, the chronic pain that you've experienced? How has it made you a better person, do you think?
Anjelo: I think it's given me a lot of insight into the concept of the struggle, because the struggle is more than just the pain. It made me more aware of all the other factors that impact someone's life, you know, their personal life, the social life, their work life, the emotional, physical, and really look at the person as a whole rather than just that, like I said before, that painful body part or a diagnosis. And really it sends home that it's not about me as a therapist want the client to be able to achieve. It really has to be about what the client wants to achieve. Yes, you might give them some guidance and encouragement and things like that, but it's got to be their goals. It's going to be about them because that's what brings meaning to all of this. And when there's meaning behind what you do, it targets, emotional centers more than your practical centers. And I think that that emotional center has a far greater drive than just that pragmatic, practical approach.
Adrian: Yeah, no, I mean, you mentioned earlier that, you know, obviously doing things is and I'm a big believer. I mean, certainly our thoughts, I think it's really important and how we perceive things in setting goals are extremely important. But certainly what I think that a lot of the research shows is that it's actually action. It's actually engaging in behaviors that help you achieve a better life and a more fulfilling life. And sometimes it's a more difficult life at times because you've got challenges in place. But, you know, a lot of the research shows that, you know, the most effective intervention for low mood is to do more stuff and you can use all the self-talk. And if you're not actually engaging in action, if it's not leading to behavioral changes, then it's often quite futile. So it certainly sounds like you've engaged in several behaviors that have made your life richer.
Anjelo: Yeah, absolutely. And vice versa. I mean, you talk about mind over body, it's that whole concept of do you get fit and then go to the gym or do you go to the gym to get fit? It’s all interlinked, like we can exercise to improve our mood, but also we can improve our mood to then get us to exercise. So is one better than the other? I don't think so. I think we need to bring it together. And that's why a holistic approach is needed. You know, you could yeah, you could adopt like in, in my workshops, I tell people, you know, arms out, look up at the ceiling and try and try and be angry and you can't do it because that posture actually releases your endorphins and I guess oxytocin that stops you from being angry. But if you cross your arms and look down on the floor and hunch your shoulders over and try to be happy, you can't do it because that's a stress. You know, it's a power stress response and your body releases cortisol as a result. So you can't be happy when you're stressed. So, you know, as much as our mood can impact our behavior, behavior can impact our mood. So you can't have one without the other. And that's why a holistic approach is really needed for good pain management.
Adrian: Okay. Now the other thing I noticed when you came out for me was the importance of, you know, social support and family support. And, you know, I know that in your book, your parents came out to visit you in England to spend some time with you. You had family support. I mean, how important do you think social supports, family support in terms of pain management?
Anjelo: Really important. It's got to be a key pillar. Having chronic pain can be incredibly isolating because for most people it's an invisible illness and a lot of people don't understand. And I think having that support network around you, we need a support network for when we're feeling down or going through other stuff. We need someone else to hold you up sometimes. And I think especially with chronic pain where you're having emotional symptoms as a daily occurrence and it's a struggle, I think having that support, external support network, someone else to try and support you at times of need is critical. So having good people around you that understands your condition, not necessarily enables you to be a victim or be incapacitated, not not someone who does everything for you, I'm not talking about that. I'm saying someone who can encourage you can support you. Yeah, sure, help when you need it, but definitely still encourage you to become active, become independent, take back some sense of control and feel more confident dealing with the pain. I think. I think you need a support network like that.
Adrian: You talked earlier about pain education being important. Do you often involve the family in that educational process?
Anjelo: Absolutely. Yeah. I always offer my clients to have someone else even more than one person attend because there's a lot to take in, right? I mean, if someone's on a lot of medication or is struggling with pain, trying to explain pain, and I do it in a very simplistic, easy to understand way using traffic lights and analogies and traffic. But it's a lot to take on. And so I always encourage a family member or someone else to be there, one so that they can have a discussion afterwards so that the person in pain can understand, but also for them to understand themselves because where do they get their training or where, where do they get their understanding? So if they understand that, hey, listen, they're not going crazy, that the weather can impact their pain or the pain can be different sensations and this is what happens for that to occur, then it makes sense for them and it just reinforces what the person in pain is saying, that the pain is real and it's there, you might not be able to see it.
Adrian: Yeah, yeah. 100% agree with you. I think, you know, you know, obviously practitioners listening to this podcast today, you know, really think about how much do you involve the family, the social supports, the significant others in the work that you do with your patients, whatever condition. Obviously today we're talking about pain management, but education for the client and also education for the family in terms of educating about the condition, but also how they can best support their loved one. And I think that's such a crucial component because the stresses that the client experiences will have an impact on the significant other and vice versa. So definitely have to think about, you know, the clients you're saying and am I working with the families and do it? How do I incorporate them more? Because you know, certainly with your story, I saw that the family supports was extremely important in recovery.
Anjelo: Oh, 100%. Yes. I completely agree with you. Then. I think it's a pivotal part of this whole process of recovery and moving forward that someone has the good supports around them.
Adrian: Now, what about from a chronic pain perspective, physical activity exercise? I mean, what's the go there with regards to somebody experiencing I mean, obviously I'm talking about chronic pain, it's a very general word. Obviously, there's all different conditions within that. But have you got any general advice around exercise and physical activity?
Anjelo: Yeah. Look, I think for me it is about starting slow. I think the first step is not about focusing on getting fit and active. First step is about your body used to moving despite your pain. And so that's what a lot of people miss here. And, they go into the exercise thinking they need to get myself fitter and healthier. But actually the first step is about getting your body accustomed to moving despite your pain. And so you gotta start slow and then build up gradually. And again, talking to someone who's got a therapist, she's got pain management experience setting up with coming up with a good plan and setting a good plan in place so that if there's a graduated progression, I think it's really important we do that. We start very, very low and then slowly build up. You can always build up faster, but you don't want to start high and then struggle because then you're technically giving your brain and your body a negative experience. Yeah, saying that, Oh jeez, exercise is a struggle, I don't want to do this anymore. So I think starting slow, giving some wins, building it up is really important.
The other thing is make it meaningful. You know, you might be starting off with basic exercise at home, but you might be working towards walking or cycling or hiking or doing something that's meaningful for the client. And that can be, again, tied in with their goals and goals setting.
Adrian: So with the exercise component, I mean, certainly for me, if I was seeing a patient with chronic pain, I would refer on is a particular specialty, obviously a physiotherapist. Is that where we'd kind of refer on to look at the exercise intervention or is there other practitioners or other specialists that you'd recommend to?
Anjelo: Look, I would start with the physio, certainly there are exercise physiologists and look, there are good physios, bad physios, good GPs, etc. But I think from a given the clinical understanding that a physio would have, I think most important is a therapist with some pain experience, whether physio, an exercise physiologist. I think that's the first thing. Second thing is then out of the two I, I'd probably start with a physiotherapist and then once you've got a plan in place, absolutely exercise physiologist are great and I think it'd be worthwhile whether it's a physio or an exercise physio, to continue with someone with pain experience, I think that's the key because there are those people who's done some further training etc., understands pain and pacing and the strategies that's required for good pain management and that's not to take away from other therapists who might have had experience over years and years, but it just means that they might have some more specialist skills in this area.
Adrian: And so a referral to physiotherapist, I mean obviously you mentioned there’s probably some exercise there. What's what other people expect, you know, in terms of physiotherapists in, chronic pain, what other interventions do physiotherapists offer.
Anjelo: Yeah, it's really it's a really good point. And it comes back to what we discussed earlier about education and things like that. You know, I think a lot of physio feel worried that if we don't put our hands on a client or don't give them a certain exercise in a session, that it's not therapy but actually it is, you know, sitting down, educating someone about pain, educating about how to do pacing, self-management strategies, you know, his eyes, Tens machine, all that stuff, sitting up with an exercise program, relaxation techniques, you know, looking at some sleep strategies, etc., timing, you know, doing the basics of maybe mindset. And I'm not certainly not taking the role of a psychologist, but just introducing the concept of have you thought about how your mood can affect the pain and, and seeing whether an appropriate referral for a psychologist would be an appropriate referral for a dietician to do with the diet, etc.? You know, that's all what a feature in pain management could do. And certainly what I do in my clinic are again, I look at a more holistic approach and that's what we should be doing and referring off for additional supports as necessary.
Adrian: You mentioned sleep, say sleep, pain. What's the connection there?
Anjelo: Well, the research unequivocally shows that if you have poor sleep, the next day your pain is higher and I think the sleep allows our bodies to calm and settle down and, you know, less cortisol in your system in the morning. So you're more likely to have sort of less pain. So sleep is critical, like some of the other strategies, but we need good sleep.
And, you know, people are hesitant about getting medications for sleep and things like that. And I always tell them, you know, if you get a good sleep, get your pain under control, your nervous system is less sensitized and less active and and and alert. Everything can be calmed down a bit more. So sleep is really important. A lot of people with chronic pain who can't sleep well, they'll often tell you that they feel like they're jetlagged the next day as well. So you can't even think straight anyway. So yeah, trying to try and get decent sleep is really critical for pain management.
Adrian: So you've got if you've got somebody there that I mean, obviously good sleep will have a positive impact on pain. But if you've got somebody in there who's saying, look, I go to bed, then after an hour or two, I mean my back's killing me or I'm in significant pain. It affects my sleep. I then have to wake up. I can't fall asleep. What do you do with those clients who where the pain is significantly impacting on their ability to to fall asleep or to stay asleep? Any suggestions there?
Anjelo: Yeah. Look, I mean I think it is again about identifying what's causing them to wake up and if it is the pain, it could be a review of the medication or any sort of natural supplements that they can take to help them with their sleep. But certainly, you know, there could be other strategies like putting a pillow between your legs if it's your lower back, because you're sort of twisting up at night or moving around too much. It could be various things. It’s hard for me to say anything in particular, but I think you've got to look at have you got appropriate medication to help you sleep and stay asleep?
Whether it's pain medication or sleep medication? Are there any supplements you can potentially take that might help you with that. And yeah, looking at, you know, what are your postures like, is it what other strategies do you do before you go to bed? You know, it could be that you need to calm yourself, your body and your mind beforehand, do some relaxation, etc. And what have you done through the course that day and having a look at what you've done that might be contributing to the fact that you can't sleep and you're waking up an hour later because it's all built up through the course of the day.
Adrian: Yeah, I think that's great advice. I think, you know, often we provide advice on what to do once they've, you know once and are in bed and falling asleep. But you mentioned that you know what things you do during the day that might have impacted on your sleep and that could be your posture and how you're sitting and things like that could potentially affect your pain later on, could it?
Anjelo: 100%. So again, it comes back to the concept of being proactive rather than reactive because reactive strategies take longer to implement rather than proactive strategies. So really identifying and keeping a track of, you know, you monitor track what you do for a week or two, you know, just not doesn't have to be hour by hour, but just a weekly planner, you know, just to see what you get up to and see if your activity levels might be that, yeah, you're standing up a lot on the set. And then that night, normally the night after you're struggling. So finding patterns in your pain might help, but certainly be proactive rather than reactive. And the analogy I gave is that, you know, if you're driving a car and you refuel every time that your indicator is on a sort of tank, you never run out of fuel because you've got the quarter tank in the reserves. But if you keep going until the red light comes on, you could get stranded. So being proactive in your strategies and doing it regularly, consistently is far better than waiting until the pain is really bad and then trying to deal with it.
Adrian: I think I find a really good strategy for people is engaging in behavioral experiments. So often people will come in and say, Look, you know, they believe that this thing will make them feel worse or this behavior will make them feel better or whatever. And using my experience and this and the information that I've kind of gleaned from the clients, I then think, okay, no that doesn't quite make sense. So let's engage in a behavioral experiment. Let's kind of, yeah, do if I could do more than 5000 steps a day, my pain worse. Well, let's say it's for the next week engaging 5000 steps a day. And let's provide a rating every day for your pain and then see how that goes. It is an extremely powerful way to change people's thoughts and assumptions and, and beliefs.
Anjelo: I completely agree. Yeah. I remember when I was in London and we were there in the pain clinic, people used to come in and say, Oh, look, I've got back pain. I don't want to be in crowds because I am constantly getting knocked. And so we used to take them to, you know, Waterloo station during peak hour and get them to walk straight at a crowd and show that people actually try and avoid you. People don't try and crash into you on purpose. And, you know, people have fear of escalators and stuff and, you know, they don't want to get on the suitcase that trip up. So things like that.
And we used to do behavioural experiments where we get people to do it, but agree, you know, and you could do that integrated way, couldn't you? It's just like, yeah, we talk about when you have an accident, you know, the best thing to do is actually get behind the wheel and start driving again sooner rather than later. And, and, you know, trying to challenge that thought on, I'll never be able to drive again because if I drive again, I'll do this, this and this. So, yeah, I think, yeah, definitely behavioural experiments have a definite role to play. And from a functional perspective, you know, we get a lot of people who hurt their backs and things like that and don't want to go and lift what they hurt their back with. So we try and get them to do that in a controlled environment so that they can get their confidence up and see that, oh, well, actually no. Maybe it was just one of those things that occurred. It's not necessarily that particular item that hurt my back.
Adrian: Okay. So we've talked about obviously there's acute pain, there's chronic pain. We haven't kind of got into the difference too much today. But certainly from an intervention point of view, you've talked about, you know, physiotherapy, you've talked about dieticians, you've talked about potential medications that help support people's pain. You've the psychological side, there's, you know, potential supplements to help with, you know, pain and, and sleep potentially. So you've got food, you've got sleep, you've got exercise, you've got psychological. Have I missed any?
Anjelo: Mindfulness. But I think at the end of the day we need to understand that pain is not a sensation, it’s an experience. Right? And that's why we need all these different aspects. So the actual physical sensation aspect of pain is what we typically call nociception. But pain by definition is an experience. And so an experience culminates to not just the physical aspects, but also, yeah, your past history, your current situation, anticipations of the future, what you may have heard, see, felt, all those things come together to create a pain experience. And that's why it's so unique to an individual, because no two people can ever feel the same pain. They may be able to relate, but they can't feel it. So it's very much an individual sensation. Yeah,
Adrian: Yeah. With regards to the research, but you know, even if you expose people to, let's say you put their hand in freezing water, I suspect things like their mood, how they slept the night before, the strategies they used to manage their pain while their hands in freezing water, all those factors can significantly affect how long they keep their hand in the water and the pain sensation associated with that, even within that individual. So even from one day to the next.
Anjelo: Correct. And the meaning of the cold, freezing water, you know, what do they think it's going to do? Is it going to help them or is it going to harm them? You know, all these things actually play a huge part because if it thinks it's going to help them, they probably tolerate it longer. Whereas if they think it's going to harm them, they're more likely to withdraw sooner. So, yeah, it all comes back to the meaning and that whole holistic approach to saying you can't just look at we got to look at the, the bigger picture.
Adrian: Now if practitioners are interested in learning more about helping clients with chronic pain, are there any resources or training or things that you recommend for them? Oh, look at this.
Anjelo: There's a lot of resources out there. I think Chronic Pain Australia for clients and clinicians is a good, good start point. There's also courses, you know that pain practitioners like myself, we run our courses, there's other bigger groups like NOI group who run courses. And the universities have grads and things like that and short courses. Some of the hospitals run short courses on pain management. So I think if there's an interest, it's not hard to find courses in it. I think if you want to look a bit more holistic, I think you've got to look at courses that actually tackle the holistic approach, not like not just an intervention based approach where you're looking at, you know, dry needling or something like that. But I'm not saying that's not effective. Of course it is for some people. I'm just saying if you're wanting a more holistic approach, I think you've got to look at courses that tackle that more.
Adrian: We'll certainly had links to some of those different options in the show notes. And I'll certainly recommend your book too. I found it really insightful and particularly with regards to your own personal experiences being a practitioner in the area and then a patient in the area. It's just a great read for people to just help develop more empathy for clients. I think that's one of the toughest things, is that often we can give people advice and we think it's just as, yeah, it's just a matter of giving that advice and they'll engage in the advice that we given them.
But the reality is there's a whole range of personal experiences and emotions and, and we haven't talked about, you know, previous traumas and things that people have experienced that we've picked on their ability to engage in some of those actions. So definitely I recommend the book.
Adrian: Yeah. Look, if anyone's interested, I think that beyond pain websites, probably the best way to access that book and you can get it shipped off to you.
Anjelo: But yeah, no, thank you. Thank you. That's very kind of you to say that. No.
Adrian: All right. Well, thank you, Anjelo. I've really enjoyed our conversation today, so. Yeah, I really love your approach. And, you know, obviously, you had a really traumatic experience and significant event in your life, which to me sounds like has really impacted on you how you see the world and how you work with your clients and how you kind of live generally.
So I certainly thank you very much because I'm sure you have a significant impact on your clients and you say every day.
Anjelo: Thank you so much for having me. And look, I think you are parting quote would be from Epictetus. He said it's not what happens to you but how you react to it that matters. And I think if we can find ways to support people to respond to their pain so that they feel more in control of help, a lot of people could take that sort of approach. I think that will help.
Adrian: Terrific. Thanks Anjelo. All right. Well, thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts and other resources from today's episode on the fx Medicine website. I'm Dr Adrian Lopresti and thanks for joining us. We'll see you next on.
Emma: This podcast is intended as health care practitioner education only, and it is not a substitute for medical advice, diagnosis or treatment.
DISCLAIMER:
The information provided on fx Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.
