Delivering Pain Science Education To The Public With Cormac Ryan, PhD

We’ve hinted at the start of this show’s rebrand that there is a global dearth of attention to pain science education. Today’s guest goes even further than that. He believes that pain should be a public health concern and that pain science education should be for everybody. It’s hard not to agree with Cormac Ryan, PhD, as he presents a compelling case for raising the general public’s pain literacy. After all, we now know that pain is a complex experience that is influenced by a lot of things around us, including society as a whole. Join this conversation and learn why we need to step up our efforts to educate the public and practitioners alike on the latest scientific understanding of pain and what people like Dr. Cormac Ryan are doing about that. Tune in!

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Delivering Pain Science Education To The Public With Cormac Ryan, PhD

In this episode, we are speaking with Professor Cormac Ryan about how to deliver pain science education to the community. Professor Cormac Ryan is a physiotherapist and also holds a PhD. He teaches in physiotherapy programs in the UK. What’s interesting about his work is he’s taken pain science education and is delivering it to the community. He has set up community lectures where he educates community members about what chronic pain is and how it can be treated.

When we’re talking about pain science education, essentially, we’re talking about learning. How can we help people learn and understand what pain is so that they can better manage their pain and eventually, alleviate it? He did write an excellent paper, which is the foundation of this episode. That paper is called We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain. If you’d like to read that article, you can find that in the October 2023 edition of The Journal of Pain.

This episode is packed full of information, whether you are someone who is living with chronic pain or you are a practitioner who treats chronic pain. What’s interesting is you can find some of this information online so you can see what Cormac has put online. He has a website, which is called Flippin’ Pain. It’s available in the UK and globally.

It’s a nice evolution of the pain revolution, which started in Australia that is moved to the UK. You can see how that has taken root there and what Professor Ryan has done with that. Without further ado, I’d like to introduce you to Professor Cormac Ryan. Sit back and make sure you have a pen and paper to take some notes. Dial into some excellent pain science education on the show. Let’s begin.

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Cormac, thanks for joining me.

Joe, it’s a pleasure to be here. Thanks for the invite.

It’s great to see you again. You were on the show a few years ago. We were talking about the reconceptualization of pain and how some people fully reconceptualize pain. Some people in the middle are partial and then some people that we want to help and support. That episode focused on how we can impact the individual.

It was a very clinic-focused 1-to-1 type of contact.

We’re going to take it to a much broader yet very impactful level and talk about how we can deliver effective pain science education to the public. We’re looking at this from a health promotion perspective. I’m curious because it’s been a couple of years since we spoke. What’s the transition with you that you’ve taken this focus from the individual in the clinic over to more of the population health level?

It’s a bit of serendipity. A friend of mine, called Richard Pell, works for Connect Health here in the UK. They’re a private provider of healthcare to NHS here in the UK. They were thinking about setting up some form of public health-based approach or initiative for different regions throughout the UK where they were working. They were aware of what I was doing in terms of the pain science education space and research. They wondered if it’s something that I might be interested in working with them on and being involved in, and potentially delivering the content within the public health space.

We got the talking and that’s what we decided to do. That evolved into the Flippin’ Pain campaign, which is a public health campaign here in the UK, which is heavily drawn from the pain revolution campaign based in Australia led by Professor Lorimer Moseley. Lorimer indeed was part of the Flippin’ Pain campaign at the embryonic stages and still is involved. He still helps us and is extremely generous with his time, support, and materials.

Since that started, I’ve had a bit of a road to Damascus change in terms of my views. I had never considered the public health approach with respect to pain but when you think about it, it makes a great deal of sense. If you think about most long-term conditions, we think about something like heart disease, for example. You’ve got your clinical component where the patient sees the healthcare professional and talks about what they should be doing.

They might see different multidisciplinary team healthcare professionals, which talk about elements of what they should be doing but they’ve also got huge public health initiatives running alongside us. Be active. Keep a healthy heart. Eat lots of fruit and veg to keep your heart healthy. It’s all of these huge initiatives that people see on TV, billboards, and everyday lives that encourage them to think and behave in ways that might lead to a healthier heart. There’s no reason why we should not be applying a similar approach to persistent pain.

One of the biggest challenges in terms of long-term conditions globally is what if we applied that same approach like a cardiac rehab that takes both public health and clinical approaches? We can do enormous good in doing that, especially from the low bar we’re starting at. If you think about diminishing returns, if you spend another $1 billion or $2 on clinical care, it’s probably not going to make a big pile of difference.

You’re spending zero on public health for pain but if you shifted that up to spending millions, billions, and even relatively small sums, you could have quite a lot of bang for your buck and make some of the biggest impact. These past years they’ve changed my focus to see the additive potential of taking that more public health approach to pain. It’s something that’s not being done. There’s plenty of evidence to show that it has potential. That’s what’s changed. A bit of serendipity came my way. I jumped on that bandwagon and I’ve been impressed with how much potential there is.

Pain As A Public Health Concern

I love this point you’re making right at the top of the show. As physical therapists or physiotherapists, as you call them in the UK, we have a very important role in promoting health and well-being in the public, especially with regard to pain recovery in essence.

There’s a public health initiative here, which is a more generalized one called Making Every Contact Count. It’s exactly what it says. Whenever you make contact with patients or the public, what can you do to help them take care of themselves better? When it comes to pain, there are so many misconceptions out there and misunderstandings around pain, which draw people towards a more antiquated out-of-date approach in terms of pain management towards a more interventionist approach towards things like scans, opioids, and surgical interventions.

Guidelines are trying to push us away from it. With all our contacts, if we can keep nudging people in the right direction and drip-feeding the right information, over time, we can have a huge impact on a societal level to move people towards more active physical and psychological therapies, which is where the guidelines are pushing us.

We’re going to talk about the campaigns, the Australian one, I believe, and the one that you’re leading in the UK. Before we do that, I want to help our audience with two topics. The first one is misconceptions about pain. Maybe you can mention 1 or 2 of those misconceptions that are most common and why it’s important that we talk about these misconceptions on a broader public level.

There are lots of misconceptions. The idea that pain only occurs when you’re injured is one. The idea that the greater the level of pain, the greater the level of tissue injury is two. Also, the idea that if the pain hasn’t gone away after a long period, it’s because the injury that was there has not healed. These are three key misconceptions for me. They all point towards a biomedical understanding of pain. That understanding influences the care we seek first and the manner in which we go about managing it.

If people have a very biomedical understanding, they will naturally gravitate towards biomedical-based interventions. For the most part, the evidence doesn’t support it. In some cases, they can be iatrogenic. There is some lovely data from Webster talking about the negative impact of early scanning for people with musculoskeletal conditions, where they don’t necessarily have any red flags or clear rationale for a scan but they are still sent for one.

How that can lead in the long-term? It’s greater levels of disability, healthcare utilization, and ultimately, poorer outcomes by over-medicalizing this biopsychosocial condition. Similarly, look at opioids. If you have a biomedical understanding of pain and how it works, it’s not unreasonable to think that opioids are something that we should pursue and use. If they’re painkillers, surely, this is a sensible thing to do.

However, as we both know, opioids for persistent pain are broadly speaking a bad idea. They come with lots of associated side effects. The evidence that they are beneficial is pretty limited. On top of that, there’s a growing body of evidence to suggest that they can have a pain-enhancing effect over time, which I always find is a real kick in the teeth. You take these things and bear the brunt of the associated side effects. You do anything to try and reduce the pain. Perhaps unknown to you, it’s making your system more sensitive.

These misconceptions chaperone people towards more inappropriate use of medicalized interventions that the evidence doesn’t do. They move people away from the interventions that seem to be the most evidence-based. The term that Lorimer Moseley often uses under a biomedical approach is our best interventions don’t seem to make any sense.

For example, would you embrace something like mindfulness or meditation if your firm belief is that the cause of your back pain is your disc degeneration? It doesn’t make any sense. If those misconceptions are addressed and you can begin to look at pain through a different lens like a biopsychosocial lens and appreciate it, lots of things can influence it, especially your thoughts, feelings, and mood. Suddenly, you might think to yourself, “I can see how mindfulness might well be beneficial. I’m open to giving it a go.” Often, that’s the first step on an important journey.

Clinicians often ask me, “I know you use mindfulness and an act approach in care.” I have a hard time convincing, shall we say, my patients that they should do this or start this. Oftentimes, I say, “If you go to my website, the first thing you see is a brain. There are no pictures of joints or even of people running and being active.” Not that that is necessarily a bad thing because it’s not but the point you’re making here with these misconceptions is that we’re moving people away from the thought that pain is a problem with something structural in their body versus the problem they’re having is how pain is processed in the brain.

Those are important points to make for everyone. Here’s the second question before we go further. These public campaigns are needed because pain is on the rise. There are some statistics that support that. Can you explain to us what are some of the factors that are causing the incidence of pain to rise for people? There’s not just one necessarily but when we look at pain in the broader umbrella of health and wellness, there are some factors that do impact it.

Living In A Painogenic Society

We live in a pyogenic society. I don’t know if you’re familiar with a colleague of mine called Mark Johnson. He’s based in Leeds here in the UK. That’s a term he used. I’m not suggesting that he’s the one who coined it or that he’s the only one that uses it but it’s one he refers to a lot in his writings. It’s a good point. A lot of the things that we know influence pain in a negative way are things that are actively encouraged and facilitated by the world around us.

If you look at the constant change in modern technology and how there’s less need to be active to do so many of our jobs, physical activity is such an important part of pain management. It’s very difficult to demonstrate the causative role of physical activity in developing pain. There’s a reasonable body of evidence to show an association there, that being physically inactive puts you at increased risk of developing.

There’s much more substantial evidence to show that physical activity if you have pain is a beneficial intervention to help manage it and reduce associated disability. The opportunities to do those things are less in the society we’re in, even if we compare it many years ago. Media plays a role as well. Whilst there are some media outlets, which are super good, such as yourself. You’re peddling the best evidence and trying to reach as many people as you can.

Flippin’ Pain is doing the same thing. We are dwarfed by the messages that are much more common within mainstream media about biomedical approaches. They are the norm. For every one group within the media pushing a biopsychosocial view, there are easily 99 pushing a more biomedical view. That constant push of a biomedical view creates a society that is set up for biomedical-based interventions and approaches.

The reality is chronic pain doesn’t fit into that box. I don’t want to be disparaging about the biomedical approach. The biomedical approach has served us well in lots of situations. One only has to look at Long COVID and how important the vaccine was in facilitating better management of the pandemic. For persistent pain, it’s a bad fit. It’s that constant messaging and the fact that it’s hard to get away from that messaging. Everyone’s on their phones and computers. It’s hard to avoid that constant drip-feeding of messaging.

That makes it hard to facilitate this pyogenic approach but you could take your pick. It’s the same point for the food we eat, mental health, and well-being. We have a society where all the things we shouldn’t do are easy to do and perhaps fun to do. They facilitate this pyogenic society. Thus, it’s not surprising perhaps that we continue to see chronic pain levels go up or at least remain very high.

You’re aware that this show primarily broadcasts from the United States of America. Here, we have rather large pharmaceutical companies. When you’re watching television from the United States of America in the evening, from the time of 6:00 PM to probably 11:00 PM, we have a certain message and it’s about our pharmaceutical medication. I’ve been podcasting for years and I tell both professionals and the public all the time that there may be a place for medication in your recovery. However, those are not long-term solutions or the type of sustained relief and activity you’re looking to get back to. I appreciate you bringing those things up.

There’s another thing with regard to messages. Oftentimes, when we’re talking about these public health campaigns and messages, most of these are geared toward the public but also as professionals, we have to be aware that subliminally on some level, unconsciously, these messages may be influencing our behavior as a physical therapist, physician, or mental health provider. We should be aware of that when we’re working with patients or even developing campaigns, such as your own.

There’s no doubt about that. For any public health campaign, if it doesn’t highlight healthcare professionals as a key target group, it’s missing a trick. There’s plenty of evidence to show that many healthcare professionals have biomedical views or understanding of persistent pain as the general public, and maybe even more so. The issue is that healthcare professional sees many patients in a day so negative ripples in a pond seem to compound the issue, whereas if we can produce better education and more informed healthcare professionals, we can have that reverse effect. We can begin to reach more people with these positive messages.

There are lots of nice studies that talk about this. The one I always come back to is a lovely study by Bishop Tom Foster in 2008. In the UK, they surveyed 2,000 physical therapists and 2,000 GPs. In the survey, they asked them to rate how they view pain. They put it into a biomedical view or a biopsychosocial view. They use the HC-PAIRS to classify that. They also sent out a patient vignette and asked some simple questions about how you would manage this patient.

It was clear that those who had a more biomedical understanding were far more likely to recommend taking a passive approach to pain management. Bed rest, avoiding physical activity, and all the things the guidelines say don’t do. In contrast, those with a more biopsychosocial view were more likely to say stay active, avoid bed rest, do your usual daily activities, and all the things that are good practices to recommend.

There’s no doubt that there are healthcare professionals out there who have a more biomedical view than they should. If we can address their misconceptions, that’s where you get the most bang for your buck and we can see the greatest level of change. Campaigns such as ours, which are small and not funded to the same degree as many other swish campaigns might be, you need to look for where you can get the most value for money. You’ve put the nail on the head there in terms of where the most value for money would be probably targeting healthcare professionals.

Raising Pain Literacy

That’s a great point for people to take away as they read this episode. I’d like to hear a little bit more about your experience with Flippin’ Pain. As I was reading your paper, you did a good job in the paper at starting to talk about the importance of pain education, or what my team is starting to call pain literacy in some way, raising people’s health literacy around the topic of chronic pain.

There’s also a behavior change component to this that’s happening potentially at the same time. We’d like to see both pain literacy improve and as their pain literacy improves, their health behaviors change. What have you learned from your experience in those two areas from your research as well as the Flippin’ Pain campaign?

Pain-related health literacy, whatever term you want to use, is a major issue. There’s plenty of evidence to show that health literacy in itself has associations with outcomes in a variety of different conditions. Pain is no different. Pain health literacy is such a broad multifaceted term because it doesn’t just talk about understanding a topic but it also talks about things like how you analyze or process that information and use it subsequently in healthcare contacts. That’s something that we need to get better at when we’re trying to facilitate pain-related health literacy.

I love the word you use there and I want to tag that for a minute. The word you use is the process. We’re bringing people through a process of change rather than a one-time educational intervention that we hope. It does potentially happen in some people but this change we’re looking for is a process that typically happens over time.

In the public health space, we’re only seeing a person for 90 minutes in a session. Within the Flippin’ Pain campaign, a lot of our town hall events are 90 minutes long. You’ve got a captive audience for that. It’s like a gateway that shows the consumer or the attendee a different way of looking at things but they then have to go through that gate and begin to look at things in that way.

If they don’t, it’s going to peter out and you’re going to have very little effect but the reality about drip-feeding messages is if we go that gateway or maybe they don’t go through it, a year down the line, they get another similar type of message. Maybe at that point, they’ll get through the gate and begin to process the information in a different way and look at it from a different perspective.

It’s important with public health campaigns like this to not be too simplistic in terms of outcomes and always looking for a huge change after each intervention. That’s perfectly fine looking for that within a clinical setting, if you wish, where you see people over multiple points and provide a rounded multidisciplinary, multifaceted intervention.

If you’re having 90 minutes of some guy talking about pain on a stage followed by a panel of people talking about it, you’re not looking for the same level of change. It’s pointless to try and hope for that. You’re looking to nudge people in the right direction but many more people than one person at a time. You’re trying to get that and bring that change in approach that will lead to long-standing change in how you view it, which is easier said than done for sure.

When we talk about the public, for example, the countries of the United States of America and the UK, there are distinct groups that we may have to change our messaging around. It brings us to the topic of health equity, accessing people who may not have access to adequate education, knowledge, and support. I’m wondering what you learned about health equity and the messaging for different groups.

It sparks back to where we started our discussion. It’s this idea that I used to work in the field with that 1-to-1 clinical contact, and I still do. It’s more about talking to audiences in a more public health space and how they are different, and they are different. There are also some similarities between them. You’re also still trying to take a person in the audience on a journey. Often, those audiences are collections of groups within the community.

We’ve done sessions on fibromyalgia specifically. I appreciate that there are important nuanced differences between different pain conditions but I don’t think it’s also unfair to say that what makes us similar as persistent pain groups heavily outweighs those individual differences. A lot of our messaging is still the same, even if we’re talking on the topic of phantom limb pain or fibromyalgia. To the consumer, it’s everything because they’re like, “Does this relate to me,” which means they’ll go to the event. “Do I connect with what’s being said? Does it help to shift my thinking a little?”

You still have to get that connection, help the audience, and see the relevance of what you’re saying just like you would in a clinical contact. You need to be slightly more generalized. You can’t be as specific but if you can find uniting points, pretty much everyone with pain will go, “I can see how that relates to me.” You can find those little beauties, drop those in, and help people to make that connection of, “That’s relevant to me.”

In the Flippin’ Pain campaign, we looked at some data we’ve had over 2023. We’ve been running the campaign in a place called the Tees Valley, which isn’t too far from me. Teesside University is in the catchment area of the Tees Valley., It’s an industrialized area. It will have its areas of communities that are disadvantaged and seldom heard.

We’ve looked at our audiences from the perspective of their postcodes and from that, it’s calculating what is called a multiple index of deprivation. I don’t particularly like the term deprivation in terms of the context but that’s what it’s called. I can’t very much give it a different name. In that index, it rates people’s postcodes based on a 1 to 10 with 1 being the most disadvantaged and 10 being the least disadvantaged or most affluent.

What we found is that about 20% of our audiences are in that 1 and 2 decile category so the most disadvantaged categories. That’s pretty encouraging. We are reaching these communities to an extent but there are two caveats there for me. One is we know that disadvantaged communities are disproportionately affected in terms of prevalence and impact. One might expect to see, in terms of need, more people from those communities than we’re seeing at the moment. We’re seeing a relatively equal spread of people attending.

The second thing is those postcode-based metrics. Although they are extremely useful and, for want of a better word, the gold standard here in the UK in terms of assessing the level of disadvantage, they leave a lot to be desired as metrics. Something tells me on a hunch anecdotally from talking to the people who attend. Even though they may live in a postcode that would suggest they are from quite a disadvantaged background, when you chat with them, you get the sense that that’s not quite the case.

They are perhaps more middle class and more in those middle deciles but they happen to live in a postcode that suggests they’re in a disadvantaged community. I’m still not sure that we’re truly hitting. I’m reaching the people who need it the most. We’re writing a grant to try and explore how we reach out to these guys within a public health way to try and change understandings around pain. If we want to make a difference on a public health level, we have to look at this through a health inequalities lens. If we deliver these campaigns and predominantly get middle-class people, the risk is we widen the health inequalities gap. That’s something that we don’t want to do.

I was going to ask you as we start to wrap up what your next steps are and it sounds like you’re taking some significant steps by looking for grant funding and research to reach people we may not be reaching. Even people have this misconception that everyone has an internet connection and a cell phone in their hand where they’re watching things. That’s not necessarily true.

What’s Next For Flippin’ Pain

That’s an important element of the Flippin’ Pain campaign. It is a blended approach. We do lots of town hall events in person. We record them and put them on our YouTube videos and the website so people can go and see them. There’s plenty of online traffic but the meat and drink of what we do is in person with people. That’s extremely important with disadvantaged communities, especially.

The area I’ve talked about has a reading age of eight years old. It’s so important to be there in the present. You can get added information from body language. People can ask individual questions from the audience. In terms of trust, people are far more trusting but one of the elements we do in the campaign is that when we do these town hall events, as often and best we can encourage, we try to get on our panel, people with lived experience from the locality.

People with lived experience are front and center of the campaign for a million different reasons but especially because it engenders trust. You want that audience member to trust and believe what’s being said. You can relate to the person on the stage and that goes a long way. Lived experience is front and center of what we do but especially if it’s local lived experience. That’s even more valuable.

As we wrap up in terms of the future of these sorts of campaigns, there are two things I’d like to talk about, which are reciprocity and evaluation. Reciprocal determinism is the term I wanted to use. It’s about people who come to these events and become agents for change themselves. They’re the ones who become the people who start to seek out a change to the system, like better healthcare systems, social care systems, laws, and governing policies that will bring about a less pyogenic society. The more people we reach that way, that’s an important thing to try and create.

There’ll be a tipping point. If we can gain enough momentum and reach enough people that the public starts demanding change, they start to say, “Why are you allowing all this negative practice and non-evidence-based stuff to happen? We want a more evidence-based approach.” If the public starts to want that, then real change happens. There’s people power. On a practical level, that’s something that would be amazing to see. We’re a long way from it yet but you have to start somewhere.

A core part of that is evaluation. We don’t know the extent of what the impact of these public health campaigns is. We won’t know until we do thorough high-quality evaluations. Only at that point when we know for certain whether this is indeed the right way to go but to do that takes enormous effort and funding. It’s not traditionally a place that gets a great deal of funding pain within a public health space. I hope that funders begin to see the value of checking whether this is the right way forward. Once we get the data, then if it is supportive, that will get more places on board, and that facilitates that groundswell movement. Without the data, it’s hard to create.

You’re talking about long-term epidemiological data based on these public health campaigns that they’re running. We need that and there should be more money put toward that. The first point that you made though, as I listen to you, I find it to be potentially a more rapid and more hopeful way for us out of this. If individuals with pain or entire communities can take this information and then start to spread it like wildfire, then we may see change happen even before we can collect the data, the public will tell us, “This works. Thank you. I’m going to share this with my friends, family, and colleagues.” That’s a nice pro-social way to end this conversation.

It would be brilliant if as a healthcare professional, your patient came through the door and said, “I’ve got this pain that has been here for about a year. I’d like to try and get a bit more active. That’s what I need to do. I’m worried about it and that worry isn’t helping. I’d like to talk through that with you.” Imagine if the conversation started that way. What a wonderful open door that would be for good practice. We can get there but we’re a long way from there.

With your help and everyone else who’s reading this episode, we’re a giant step closer. I appreciate you being here, Cormac. It’s been great speaking with you about this topic of how we can bring pain science education to the public in a more health-promoting way. How can our audience know how they can learn more about you and follow the work that you’re doing?

I’m based at Teesside University. You can find out about me on the website. I’m also a co-lead of the PETAL Collaboration. Pain Education Team to Advance Learning is what it stands for. We’ve got a website. It’s a neat group that looks at the publication in which we talked about pain education for whole communities. I’d like to thank all the co-authors there. They’re some exceptional people writing on that paper. It was a joy to pull it together. You can check out the PETAL Collaboration website as well.

Finally, I’ve got to plug the Flippin’ Pain campaign and its website. It’s a good resource. One of the most satisfying things is when we go and deliver these town hall sessions in various parts of the UK. Healthcare professionals say, “I always direct my patients to your materials and resources.” That’s a nice thing to do that they’re being used. You can check us out at www.FlippinPain.co.uk.

Cormac and I would like to thank you for joining us to talk about pain science education in the public sphere. We ask you to share this episode with your friends, family, and colleagues on whatever social media you’re active on. You can find me on all platforms and tag me, @DrJoeTatta. It’s been a pleasure being with you. We’ll see you next time.

Important Links

• Professor Cormac Ryan
• We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain
• Flippin’ Pain
• Episode – Is Partial Reconceptualization Of Pain A Success Or A Failure? With Dr. Cormac Ryan – Past episode
• PETAL Collaboration
• @DrJoeTatta – Instagram

About Corman Ryan

Cormac is Professor of Clinical Rehabilitation at Teesside University in the UK and a pain champion for the Flippin’ Pain public health campaign – a public health campaign which seeks to address misconceptions about pain.

Cormac has published over eighty peer-reviewed journal articles and obtained more the £1m in competitive funding. Cormac is the Co-editor in chief of Pain and rehabilitation – the journal of the Physiotherapy Pain Association, a peer-review journal with a 20 year history.

Cormac’s research interests are primarily in the area of chronic pain, its impact on patients and interventions to manage the condition. These fit within the Rehabilitation sciences theme of HSCI. Cormac’s other key research interest is physical activity and physical activity monitoring with an emphasis on the measurement of sedentary behaviour and strategies to reduce sedentary behaviour. Other areas of interest inclide the bio-psychosocial model of rehabilitation, chronic low back pain, return-to-work, pain education and the role of the patient therapist relationship.