Welcome back to the Healing Pain Podcast with Joshua W. Pate, PT, PhD(c)

If you’re following the latest in pain science or maybe you’ve attended certain lectures, you know that pain science education is on the tip of everyone’s tongue these days. Whether you come from the explain pain camp, that’s my personal favorite, or maybe the pain neuroscience education camp, pain biology and intervention, more and more professionals are using to treat chronic pain. There’s a good reason for this. We have a growing body of evidence that states that pain education can improve things like pain, pain catastrophizing, fear avoidance, as well as pain interference, so much so that the experts now agree that every practitioner should be greasing their wheels with pain biology education as an intervention to help people cope. Even though pain education has seeped its way into the foundation of your practice, the one thing we still don’t know is which patients with chronic pain are more likely to improve their knowledge following pain biology education.

Joining us to discuss pain science education and how to assess the reconceptualization of pain is Joshua W. Pate. He is an Australian physiotherapist and a PhD candidate with a passion for teaching people about pain so they can develop active sales management strategies. His PhD includes investigating a child’s concept of pain as well as the validation of the concept of pain inventory. Joshua has also created two TED Ed videos that can be used as part of a targeted pain science education program. Both of those are cool and super high tech. I recommend you check out the one on phantom limb. On this show, Joshua will explain why someone’s concepts of pain matters, which patients are more likely to improve their knowledge after a two-hour pain education session, why the neurophysiology of pain questionnaire may not be appropriate to use with children and finally, what language kids use to describe their concept of pain.

If you want to study along with us, Josh has shared two of his key papers that you can download for free. The first is called A Child’s Concept of Pain and the second is Pain Neuroscience Education on YouTube: A Systematic Review. For free access to both of these papers, all you have to do is pick up your cell phone and text the word, 136Download, to the number 44-222. I’ll send it right to your inbox. If you’re on your computer, you can open up a new window and type in the URL, www.IntegrativePainScienceInstitute.com/136Download. Take a moment to download those two free resources that Josh has provided. He’s doing some exciting and inventive work in the area of pain science education as well as pediatric pain management, and I can’t wait to introduce his work to you. Let’s begin and chat with Joshua.

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How To Assess The Reconceptualization Of Pain with Joshua W. Pate, PT, PhD(c)

Joshua, welcome to the show. It’s so great to have you here.

It’s great to be here. Thanks for having me.

I know you’re in Australia and you woke up early to hang out with all of us. We appreciate you being here. I interviewed JP Caneiro, who you know as well. Off the top of my head, I asked him, “Why did you decide to go back as a physio? Why did you decide to go back for your PhD?” All of us probably at one point or another, have looked into furthering our education, whether it’s through courses or graduate training or PhD work. What led you into looking into PhD for you?

I was always interested in research when I was first studying to be a physiotherapist. When I was working clinically, one of my colleagues who became my PhD supervisor tempted me into doing a little taste test as a Master of Research and I continued getting paid. It was a good offer and I got to work with some fantastic people. I went down that path. The bulk of my time was still clinical. That’s how I was convinced to go into that path. As soon as I started, I was pretty sure that’s where I was going to head. That led to PhD scholarship. By then I was like, “This is going to be such a great opportunity.” I’ve been able to work with some cool world-leading people in Pain Science. I have been learning so much over the last years in that field. It’s been cool.

Tell us some of the great people, some of those names who’ve done papers and helped you along with your PhD we know well. Tell us some of the great people you’ve worked with.

My PhD supervisors, Verity Pacey, works in hypermobility, particularly in kids. Mark Hancock is a back pain researcher. He’s fantastic with methodology and things like that. Julia Hush works in pain science. We’ve collaborated with people that you’ve interviewed on the podcast before. Professor Lorimer Moseley and David Butler, they’re both from South Australia. Laura Simons who’s at Stanford, you’ve interviewed her as well. She’s amazing. Their team at Stanford are doing some work developing a tool for kids. It’s been good.

As a part of your PhD, you’ve looked into pain neuroscience and pain education, but you also have an interest in pediatric pain. That’s the connection because Laura is a pain psychologist at Stanford.

One of the cool things with working in that field of pain is that you’re not working with people in your discipline. I think there’s a lot to learn from working with others.

A key paper, as part of your PhD, came out in April 2019 in the Journal of Pain Practice. The title of that paper is, Which Patients with Chronic Pain Are More Likely to Improve Pain Biology Knowledge Following Education? Everyone can read how awesome that paper is, but tell us what the aim of that study was.

This was a study that informed the majority of my PhD. It seemed like people were changing their knowledge if you gave them a two-hour education session but what were the factors that are either clinical variables or psychological variables specifically, or demographic variables which all of those things that we’re collecting are predicting their ability to change knowledge? In the pain clinic I’m working at, everyone gets invited to come to a two-hour education session before their multidisciplinary assessment. We have this captive audience of data. They’re all filling out their referral questionnaires. It was a great opportunity to have a look at which ones are getting the most out of it. That was the onus, to find out what are those variables that are predicting that knowledge change.

For those that don’t know because pain education is still quite new to some practitioners, there are lots of different types of practitioners and people who follow this show, why is pain biology education important in part of a multidisciplinary approach to pain management?

You’ve called it pain biology education, sometimes in the literature, it gets called pain neuroscience education or explain pain. There are lots of different terms and it’s all the same thing. I’ll give a quick caveat on that question in that the theory that’s undergirding me, sometimes it gets called reconceptualization or conceptual change theory. The idea that someone learns something new and it potentially replaces the old. There are some competing theories with that of maybe the old idea co-exists and the deeper I’m going into my PhD, the more I’m looking at that stuff. What’s fascinating is that when you give this education, patients seem to have this increased confidence or there’s some mediating variable that then leads to better functional outcomes. The way I think about it is this education is a foundation, and to go on and do things like graded exposure or exercise or all different pain program treatments, they can keep coming back to that idea of pain doesn’t equal damage. Those are core concepts that they learn in the pain neuroscience education.

From the research that’s out there, does pain education have an impact on pain as well as a disability because they are actually two different things?

They are very different things. There are systematic reviews that do show small to moderate effects sizes on its own but the treatment was never designed to be delivered on its own. It’s an interesting question and the jury’s still out on a lot of the specifics of that question. Clinically, there are a lot of people using it and are finding it beneficial, but that doesn’t necessarily mean it’s evidence-based. For me the big question was, “How do we measure if someone’s actually changing their concept of pain without having a tool particularly in that pediatric population?”

In the study you were mentioning, the tool that’s used is the Neurophysiology of Pain Questionnaire. That’s a twelve-item true or false quiz. I’ve given that to pain specialists and they scored six out of twelve. It’s not necessarily a perfect measure of the essential knowledge of pain signs, but it taps into some interesting beliefs and the questions are quite difficult. It was designed for an undergraduate program of physical therapists. There are pros and cons of the adult tool, and that’s what’s led me into my PhD of developing it. Let’s try and simplify this as much as we can and see if it’s still effective at that point.

In this study, you had about 55 participants. You spent two hours providing a pain education, pain neuroscience, pain biology intervention with them. What are the key parts if you chunk that down to two-hour intervention? Pain education is a big term. What are the key parts of that two-hour intervention? Can you talk about some of that?

The intervention itself in terms of pain neuroscience was more in that first hour. It covers a broad range of topics. The people who turn up to a pain clinic often have had pain for a long time. They’re very familiar with the suffering side of it but less familiar with actually the biology of what’s going on. We start with things like distinguishing acute from chronic pain but head into how does the dangerous system work? We thought during the 1600s about pain would be proportional to tissue damage and the pain was about danger. Now, it’s this new idea that people like Lorimer Moseley are driving of pain is about protection. It’s one of many protective outputs of the brain that threads through the whole education session.

We cover all sorts of different things and even some competing theories like the Gate Control Theory and a few different models that are helpful. There are some great online resources. We show a couple of videos, and try and get that science that underpins the beliefs that we think is helping as much as we can. In the paper, it has a nice little outline of what’s involved in the education if you want to look specifically in that content but I think it’s helpful to have that overview of what’s contained in it.

Interesting though, you even have the Gate Theory in there because so many people have pushed that off the table, pushed it to the side and say that it’s old, but it may have a little bit of benefit for certain patients.

The reason that it’s in there is that it’s literally a couple of sentences in a five-minute video that’s developed for all of Australia and New Zealand’s pain clinics. It gets a mention and I thought it was worth mentioning. Sometimes we get so caught up in delivering one type of model. I think that the idea of pain being modulated as an experience, centrally is a good one too.

Tell us which patients are likely to improve with pain biology education.

The negative finding was probably more interesting and more exciting. What we did was we dichotomized people who had finished high school and those who hadn’t. The people who are more educated had a bigger change and a bigger improvement in their pain biology knowledge. Univariately, in terms of predictive modeling, it got quite complex but age was also related. When we did a multivariate analysis, only education stayed in the model. That means people who are more educated are more likely to learn, which is an interesting finding but it’s not going to change the world.

What was fascinating is we assessed all these other variables. Things like depression, anxiety and stress using the DASS, the Stress Scale, the pain catastrophizing, pain self-efficacy, we had all these other variables collected. None of those predicted this knowledge change. There’s quite a lot of literature from students studying exams that anxiety will predict outcomes and things like that. We didn’t see that in these populations. It gives us confidence that it’s another little tiny rationale that we can deliver this education to people before their assessment. We don’t have to necessarily screen out those hugely distressed patients that are struggling with their pain at that present time.

When I was reading through the paper, that’s what stood out to me because psychological variables like depression and anxiety are poorer clinical predictors of someone’s function. In your paper, it was so interesting how that wasn’t a variable and give a lot of weight too.

I suppose one limitation to mention here is the questionnaire itself. It may not be perfectly measuring the construct of someone’s concept in pain and it measures some knowledge elements. That’s interesting, but there is some blurriness and there’s an unsure option. We didn’t assess whether or not someone changed from unsure to true or true to unsure because I think each of those different combinations has clinical implications too. We were looking at the total score out of twelve in those changes.

Age is an important factor to discuss though. If you think about the average physiotherapy clinic in the US anyway, where I’ve worked, most of your clients are in middle age or older. That may have a factor as to how you apply pain education or if you have to modify it for people who are potentially older.

This sample was quite generalizable in the sense that we didn’t exclude anyone. It was people with age twenties, a couple of people in their 90s. It was nice to see that big, broad range. I think the implication in terms of age is let’s try and keep things simple. If age isn’t a predictor, let’s try and make sure that we’re including as many people as we can in this. Using scientific jargon and things like that sometimes isn’t as helpful. It’s our natural language when we’ve done a trading course that we’ve read lots of textbooks and things, we start using those words. It’s almost like you have to reload to use the simple language and there’s a real skill to that.

I think health literacy is something that we don’t pay too much attention to, but pain education has done a great job at bringing that conversation to the table as far as health literacy goes. It was a two-hour intervention. Is that enough time? Is it too much? It’s nice obviously, you’re working in a multidisciplinary pain clinic doing clinical research. Have we assessed the amount of time to deliver this type of intervention?

This study, importantly, didn’t look at the effectiveness and we need to be clear on that. We did see a change in what predicted the change. You can imply that, but we didn’t randomize and we don’t have a measure that the two hours was an effective intervention because we didn’t have a control group. That’s important but there are some literature and research that has looked at how much education does someone need. A lot of the early research was individual, one to one pain neuroscience education, and more and more is heading to groups. There’s an interesting document for the Australia and New Zealand pain clinics where it says which patient for which program. The general summary of that is we don’t have strong evidence of who needs high-intensity programs and who needs low-intensity amounts of education and things like that.

It hasn’t been teased out yet. That’s part of the motivating factor for me to want to do research. How can we work out how many resources to put into each patient? There are some people who don’t seem to need much education. You tell them, “It’s safe for you to move, you’re not going to damage anything,” and they’re fine. There are other people who need hours and hours. I remember I listened to JP’s interview and he was saying that they’re doing thirteen weeks of Cognitive Functional Therapy. That has a lot of education and exposure training. Some people need a lot of time to see the evidence in themselves before they can trust that it’s true for them.

I know you’ve also done a lot of work in the realm of pediatric pain and I’d like to hear a little bit about that. My first question is, should a clinician use the Neurophysiology of Pain Questionnaire with pediatrics or with children and adolescents?

Yeah. We published a paper in children. That was a study of all the pediatric pain researchers and clinicians around the world that we could find. We asked them, “Is it important to assess a child’s concept of pain?” They said, “Yes.” “Is it a useful thing to do?” They said, “Yes.” The third question was, “Are the current available adult resources, things like they explain pain time concepts and the Neurophysiology of Pain Questionnaire, are those things useful in assessing a child’s concept of pain?” The overarching theme was the language is too complex and a child may not need to learn all of those things.

I think that’s an interesting message. I would lean on the side of no. There are plenty of clinics that I’m mainly in contact with who are using modified versions of that tool in the meantime, while they’re waiting for my tool to be validated. It’s an interesting one. The result of that study was, “We have this rationale now. We don’t want to just modify the tool. We need to start from scratch and understand what does a child think about what pain is, how pain works, and why it is an experience, which is that definition that’s threaded throughout the research that we’re seeing.”

You know clinicians who’ve taken that questionnaire, I’m assuming they’ve modified it and made it simpler for kids.

Most of them have kept the same number of items and they’ve tried to change it. For instance, there’s a question that says, “Descending neurons are always inhibitory.” Using the word always, it being true or false, a child understanding that let alone an adult or someone trained in pain, that’s a hard question.

I think a lot of clinicians can even struggle with that.

We did have to simplify things, I think.

The new tool you’re validating, is it a certain age range that you’d be able to use on this one? Obviously, pediatrics at times can be identified up to about 18, 21 years old.

That was a challenging question and I think clinically the demand was, “If we’re going to develop a questionnaire, they need to be at least eight because that’s what the literature says when they can reliably fill out a questionnaire. We wanted to set the maximum age at the smallest possible demographic. When a child turns between twelve and thirteen, they develop the ability to think abstractly. Before that, they’re very concrete. We wanted to try and get that. We defined it by age and there are a lot of resources out there for teenagers. If we’re going to develop simple pain education resource for concrete thinkers, let’s develop the tool for them. My gut is that then it will apply to those more cognitively higher ages and quite easily because, if an eight-year-old can understand it, then hopefully a fifteen-year-old can understand it, and a 30-year old and a ninety-year-old can all understand it too.

Maybe that pediatric tool has a lot of use for adults as well. There are obviously adult populations that have a challenging time with reading, comprehension and things like that.

I work in Western Sydney at a pain clinic. It’s hugely socioeconomically diverse and even there one in six people don’t speak English. There are lots of challenges with having that complex questionnaire because the words, even things like DASS go way over people’s heads. It’s a tricky thing. If someone’s on a lot of medication that’s impairing or giving them that brain fog that they talk about, it’s almost like they need the questions to be targeted at a younger age group or at least a simpler language for it to work in a valid way.

Speaking of language, in working with kids, obviously language and development vary. What type of language do kids use to describe pain or describe their concept of pain?

We have a paper that’s been under review and it should be out pretty soon. It was a qualitative paper. We sat down with kids, we let them talk, and ask them questions that were identified in that international expert survey. We asked them to draw whatever they think of when they hear the word pain. We got them to label diagrams, to think about stuff and to write things down. It was a fascinating study in the sense that we tried not to inform what they were saying. We wanted to hear without any education, what’s the child going to say about pain? I suppose one of the interesting findings I’ll share, but the paper will be out soon, is that when we asked kids to draw whatever they think of when they hear the word pain. The kids who had an experience of chronic pain, they drew injuries and they also drew emotional elements, things like tears and broken hearts and things like that.

Whereas the kids who didn’t have chronic pain, they simply drew injuries and none of them drew emotional experiences. This wasn’t quantitative. We can’t definitively say that’s always the case but it was an obvious difference between the two groups that the children were drawing on their experience. When I say their experience, they haven’t developed that sense of self yet. One of the kids, their mom, had a knee replacement and the neighbor had a knee replacement. When we asked that, they just said, “If you have pain, you have to have a knee replacement.” That’s that concrete thinking coming out of, “This is what happened to everyone around me and that is what has happened if you have pain.” I think this is also true for adults. Even for you and I, we are constantly drawing on our own personal experience, which is biased, but we’re constantly drawing on that to develop our own ideas and to conceptualize things in different ways. It does take quite a bit of effort to change the way that someone is thinking.

It’s interesting that they drew those pictures like that. It’s almost like little kids are putting together the biopsychosocial model on their own almost. Do you have some of those images? Will those images be in the study?

They’re in the paper. The other cool diagram that we did was a simple body diagram of, “Label where you think the brain, the spinal cord and the nerves are in the body.” The variability across both groups was enormous. I’d love to roll this out on a big scale because some of the kids drew all three of those things inside the head of the person, and others there were nerves going outside the body and all sorts of things. We grew up with our phones that were connected by wires. If you hit your thumb with a hammer, we naturally think of sending messages through a wire and it goes through the nerves that make sense. Whereas kids seem to have this idea that it goes to the brain a bit like Wi-Fi almost. There were some interesting ideas that we need to keep up with the progression of technology influencing the way that we’re thinking about how biology works.

The social context is completely different when it comes to an analogy like a phone on a wire versus a cell phone, how does the signal get there? I never even thought about that. I was raised with the long phone wires, you could drag from the kitchen all into your bedroom and have a conversation. Now, kids pick up their cell phone, go down the street, and chat.

It works. The internet does it. It’s an interesting thing.

Speaking of technology, I know another great paper you have, which is in the March 2019 edition of Peer Journal called Pain Neuroscience Education on YouTube. You did a systematic review, which I thought was cool. It’s probably the first and only one I’ve seen looking at pain neuroscience education on YouTube, which we know is full of all sorts of different types of material. Tell us about that study.

In the International Association for the Study of Pain Conference in Boston, I met up with my collaborators, Laura Simon’s lab at Stanford. One of her postdocs, Lauren Heathcote, was running this project. We got involved in that together, and this was an interesting paper. In terms of research becoming clinically relevant, the crossover was a matter of days. From publication to hearing people applying it in the clinic was days. There’s research that can take up to seventeen years. This was exciting on that basis alone but what we did was we went through and did some simple broad searches of YouTube. Things like what is pain and stuff like that and found all the articles. We basically followed the structure that’s being given in other studies but it’s very closely aligned to a normal systematic review of journal articles.

We ended up with this smaller number of over a hundred videos. We graded them on different criteria according to the Explain Pain target concepts or a very similar version of that that was established at a meeting we were at. We mapped each video. Did it address the idea that hurt does not equal harm? Did it address that pain is protective? By that way, we were able to rank the videos or at least find the videos that were either addressing one target concept well or they covered a broad range of concepts. For the clinician who wants to address one specific misconception, right through to the clinician who wants to use this video to support the overarching message of pain neuroscience education. It’s a cool paper. You can open up the supplementary appendix files. It has the whole list of all the codes and everything. All the raw data is there for you to have a look at.

The videos you chose to look at were actually ten minutes or less.

There were some specific parameters based on what we thought was clinically useful. There are some great videos, for instance, TED Talks are often about fifteen to twenty minutes and things like that that were excluded. There’s potential that we didn’t capture everything but the vast majority, we haven’t had a whole lot of people contact us saying, “What about my video?” Although, I should say that since that time has come out, I have developed some resources myself through TED-Ed and those videos would have been included and I’m like, “I missed this.” In the next version of the review, I’m sure it will be included.

The take-home message is that ten minutes or shorter could have important clinical application for educating people.

Potentially, we decided thinking that would be a reasonable amount of time to spend showing someone a video. If clinicians following haven’t tried in a one to one setting, even pulling out their laptop or their phone, and showing, “Here’s a cool video I saw,” or giving them the link as homework for the weekend. “I’ll see you next week. I’d love to hear what you think of this or email me if you’ve got any questions,” that ability to reinforce what you’re saying is cool. The video that ticks all the boxes quite well was the Tame the Beast video which was developed by Dave Moen and a team in South Australia. It’s featuring Lorimer Mosely. His voice is in the animation but it covers lots of topics, nice and clearly. The only criticism that people have is that sometimes it’s a little bit too much information or it has a little bit too much background assumptions that people understand things like classical conditioning. Overall, it’s an amazing video and I think they did a fantastic job. That could be a resource that people tap into.

I know you’ve gotten creative developing your own videos, too, pretty high tech, which is awesome.

I have been working with TED-Ed, which a lot of the highest-ranking videos were because of the team at TED. They’re phenomenal teams. They have directors, publishers, producers, narrators and people who mastered the audio. It’s quite an amazing organization. In terms of our pain program clinically, we’d often use the analogy of phantom limb pain or the example of phantom limb pain to explain that people have map in their brain, and to empower them that it’s safe to move because you’re changing the map. That’s hinting the idea that pain is so much more complex than we initially think. I was always explaining the same thing over and over. I thought, “It’d be great if we could have a resource that would do this in an amazing way through animation.”

We’ve got in touch and we developed this video. If you look up on YouTube, it’s called something like The Fascinating Science of Phantom Limbs. It goes through and it has this awesome 3D animation going through the peripheral nervous system up into the brain. It shows the homunculus in a 3D model. It’s amazing. A lot of the credit should go to the animators. They did such a cool job, but to be able to convey those ideas in lay language, having to simplify and to get rid of the scientific jargon was a real challenge. I think the benefits are huge. Literally hundreds of thousands of people have watched this. Thousands of people have completed the associated lesson, and I even get emails from people. I had this boy contact me. He was doing a school project on phantom limb pain and had some follow-up questions. It’s such a cool thing. Science is becoming a global goal for everyone to progress this together. That’s a really, nice thing to be a part of.

Information is obviously very important, especially when it comes to chronic pain, but all chronic health diseases, the more information people have, the better they get them. I get emails from people who listen to my podcast who say, “I’m able to walk now from listening to your podcast.” I’m like, “That’s because that’s pretty much education at work.” It’s incredible. I’ve watched some of these TED videos that you’ve helped create. I often wonder, and maybe we can talk about this, as practitioners we go through training, whether it’s undergrad, PT or a Master’s in PT, or DPT, and we learn technical things as practitioners, as licensed healthcare providers. You spent years focused on the technical information and you come out into “the real world.” You’re expected to break that down into simplified information for your patient to understand. What can we do better in the area of whether it’s education or training to help? A lot of practitioners have a difficult time making that leap from a university where I studied a whole four-credit Neurophysiology class to explaining this to a 65-year old patient with fibromyalgia.

This has only been a question for twenty or so years ago because before people would learn neurophysiology and it would stay as the backbone of why we’re doing things, but you would never tell a patient about it. Whereas now that it’s becoming more accessible, and we’re seeing benefits of patients learning, we need to re-skill in that area. There are a lot of people around the world who are writing courses and things to try and train people in this. The main part of my PhD is developing this questionnaire. It’s called the Concept of Pain Inventory. We’re validating it and hopefully, be out, but one of the things it will drive is to target specific concepts that people could be educated about.

It’s a five-point Likert Scale, from strongly disagree to disagree, to unsure, and to agree to strongly agree. For instance, the first item is, “Pain is a feeling that is made by the brain,” or something along the lines of that. I think that the idea of having the brain’s involvement in pain if someone strongly disagrees, there’s huge implications for that if they’re unsure or if they agree or if they strongly agree. Having a tool like that will help bridge that gap that you’re talking about between having all this knowledge and wanting to explain all this off, and where does the patient start. Without an assessment tool, I don’t think it’s that easy. Otherwise, you’re disseminating information and it’s going onto potentially deaf ears because they don’t want to hear about it.

Whereas if people are ticking unsure, you can then ask them, “Why did you tick unsure? Is it that you’re not interested or is it that you’d like to know but you don’t know yet?” I’m hoping to tap into that divide, that gap between health professional knowledge and patient knowledge. There’s room for being mass media campaigns. There’s room for a whole lot of different educational interventions to try, help professionals get to that point where it’s a comfortable thing, and it’s empowering. It shouldn’t feel like extra work to tackle on the end of your treatment, “By the way, the pain you’re feeling is actually complex and it’s not about the damage you’ve got.” It needs to undergird everything we do and that should hopefully inform future research in different fields as well on physio.

Knowledge translation is so important. I think we need more of it. Conversely, when you mentioned going back to the early part of the podcast, a two-hour intervention. Maybe there are practitioners saying, “I’ve got Lorimer’s book at home. I’ve got Explain Pain Supercharged and maybe I’m going to throw together a two-hour intervention,” which is if anyone wants to do that, it’s awesome. More people need to make bold moves, change practice patterns and things like that. However, do we know how much education a practitioner needs for them to be competent before they go out and do something like that?

In Explain Pain Supercharged, at the back, there’s a whole bunch of different curriculums for different scenarios like that. I think that’s an interesting question. Someone like Dave Butler would probably be in a good place to answer that. I’ll have a stab. Everyone needs a different amount of education. If you are grounded in the biomedical model and you’ve been doing that for 50 years, it’s going to take some serious shifting to change things to the biopsychosocial model. Whereas if someone’s graduated, they’ve massaged someone and natural recovery has occurred, they think that they’ve gotten magic hands. They’re going to need a different amount of education. If someone is intellectual and they’re deeply rooted in whatever theory they understand, they’re going to need a different amount of education.

It varies and if you look at the professional development courses, they vary in how much they are. For me, when I was a physio student, that was the first time I was exposed to explain pain and things like that. It didn’t take that much because it makes physiological sense, but I didn’t have much grounding in seeing someone get immobilized and see their life change because of it. I was almost raised on that newer model of active treatments have pretty good evidence. Passive treatments have good short-term benefits but not good long term. To make the leap from that wasn’t as being, but it’s a huge shift we’re asking of professionals in some ways.

It can be. I’ve done some research and I’m involved with the group who’s doing some research looking at how much pain science or the biopsychosocial model is taught in DBT programs. The results we’ve gotten so far from probably about twenty schools in the US varies. You have to say to yourself, “If someone’s coming from a school in Australia where you have people who are introducing these concepts, then you need less. If I went through a traditional biomedical model, which I did go to in 1997 way back when I graduated, there wasn’t even any pain science, that I may need more if I didn’t stay abreast of what’s happening in the literature.”

One of my supervisors, Julia Hush, has done an amazing job at Macquarie University in terms of mapping the IASP Pain Science Curriculum to the postgraduate physio course. That’s the first cohort of students around the world who have had that. It’s embedded, they’re constantly reflecting back onto high-quality pain related education. Hopefully, the idea is that the next generation of graduates from those schools will have it. It will be natural for them. It will be interesting to see down the track of how this practice change once like mass professional change occurs in alignment with the evidence. The evidence is now building quite strong for pain science.

What’s next for you, Josh? Tell people how they can learn more about you or where they can access your work and follow you?

I post a fair bit on Twitter, not as much as some of our colleagues, but my Twitter handle’s @JoshuaWPate. I post things on there and you can get in touch with me through that. I can send you my email address and things like that. I’m developing some kids’ resources, some simple children’s books and a few different types of resources. There’s another TED-Ed video coming out. Now that we’ll have a tool that will be valid, we know where to start with this, rather than trying to base it on a textbook. What’s the language children are using, and can we incorporate that into the education we’re providing? I have this big dream of preventative education. If babies and toddlers are getting exposed to helpful scientific ideas, they’re not being brought up with this idea that pain equals damage. It’s a classic one. If that’s embedded in a generation that pain is much more complex than having tissue damage. I can’t imagine it, they’re going to be so hard to measure, but the potential impact of that and financially, the burden of pain is enormous. If we can enable people to self-manage, it could have huge impacts. I’m trying to dream big and I think that’s what happens at the end of a PhD. It’s an exciting time for me.

You’ve got a good start as far as the kids go. Keep dreaming big because your work has been great so far. I’m sure it’s going to continue like that. Your intersection of the pain neuroscience with physiotherapy in pediatrics is so needed because so far, it’s mostly been on adults and so much of it’s been back pain. Of course, we always study back pain first because it’s ubiquitous but there are a lot of pediatric physios out there who are interested in that information. Keep going, Josh. You’re doing an awesome job.

Thanks, Joe. That’s nice of you.

I want to thank, Josh, for being on the podcast. You can reach out to him, follow his work on pain neuroscience, as well as pediatric pain, at @JoshuaWPate, that’s his Twitter handle. You can tweet to him and say, “I loved the podcast. It was awesome.” Of course, make sure to share this with your friends and family on Facebook, Twitter, LinkedIn, or maybe in your favorite Facebook group where there are people who are interested and passionate about Pain Neuroscience and Explain Pain.

Important Links:

• Joshua W. Pate
• Phantom Limb – The Fascinating Science of Phantom Limbs YouTube video
• A Child’s Concept of Pain
• Pain Neuroscience Education on YouTube: A Systematic Review
• www.IntegrativePainScienceInstitute.com/136Download
• JP Caneiro – Past episode
• Professor Lorimer Moseley – Past episode
• David Butler – Past episode
• Laura Simons – Past episode
• Which Patients with Chronic Pain Are More Likely to Improve Pain Biology Knowledge Following Education?
• Neurophysiology of Pain Questionnaire
• Tame the Beast
• Explain Pain Supercharged
• @JoshuaWPate – Twitter
• https://Researchers.mq.edu.au/en/persons/joshua-pate
• https://www.MDPI.com/2227-9067/5/1/12
• https://www.ResearchGate.net/publication/329728468_Pain_neuroscience_education_on_YouTube_a_systematic_review
• https://www.NCBI.nlm.nih.gov/pubmed/30450792
• https://www.Ted.com/talks/joshua_w_pate_the_fascinating_science_of_phantom_limbs?language=en
• https://twitter.com/JoshuaWPate/status/1130630487221817344?s=20 – TED-Ed Video
• https://www.youtube.com/watch?v=eakyDiXX6Uc – The Mysterious Science of Pain
• https://joshuawpate.com/ – Joshua’s site

About Joshua W. Pate

Joshua W. Pate is an Australian physiotherapist and PhD candidate investigating a child’s concept of pain; the ‘what’, ‘why’ and ‘how’ of pain. The Concept of Pain Inventory (COPI) is currently being validated in his PhD to enable targeted pain science education. His passion is teaching people about pain to build a foundation for them to learn active self-management strategies.

Joshua’s recent TED-Ed video on phantom limbs has been extremely well- received by the ‘pain world’ and the general public, and he hopes to make more resources that educators and clinicians around the world can use as part of targeted pain science education.