Welcome back to the Healing Pain Podcast with Dr. Felipe Reis, PhD

In this episode, we are discussing how to move effective pain education forward in developing countries. Our expert guest this week is Professor Felipe Reis. He is a Brazilian physiotherapist and professor of physical therapy at the Federal Institute of Rio de Janeiro. His research focuses on pain education, emotion and cognitive neuroscience. He is a visiting researcher at McGill University, an Associate Researcher with the Pain in Motion Group and Chair of the Pain, Mind and Movement Special Interest Group at the International Association for the Study of Pain.

Felipe will discuss his research and continued work in improving pain education for both adults and children in developing countries. He will compare the chronic pain epidemic in Brazil versus other countries and discuss how pain education is being rolled out in the curriculum of physical therapy schools in Brazil. How to develop pain education tools for people with chronic pain and his own unique and innovative cartoon book for children which is called A Journey to Learn About Pain.

If you are a practitioner who treats children or adolescents with pain and you’d like to use this book or perhaps you are a parent of a child with pain, you can download for free. All you have to do is text the word 153Download to the number 44222 or you can open up a new browser on your computer and you can type in the URL, www.IntegrativePainScienceInstitute.com/153Download. It’s super generous of Felipe to be providing this great resource for all of you. Let’s begin and let’s learn all about pain education in developing countries and how to create effective pain education tools for both children and adults with Professor Felipe Reis.

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Initiatives For Improving Pain Education In Developing Countries With Dr. Felipe Reis, PhD

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

Thank you so much for having me. It’s a pleasure to talk with you a lot about things that we’re doing here in Brazil. It’s a great pleasure for me.

Thanks for joining us all the way from Brazil and I’ve had JP Caneiro on the show and he’s Brazilian, but I think you’re the first physiotherapist and pain expert I’ve interviewed who is living and working in Brazil. I know it’s a large country with lots of challenges with regard to pain care. I know you’re working on that every single day in your practice and your research. I’m excited to chat with you but tell us a little bit about your work in Brazil and how you got interested in physiotherapy and pain care.

Several years ago, I started to work with leprosy patients and see a lot of patients having a lot of neuropathy and leprosy in Brazil is a very common disease. We had a lot of patients with pain or neuropathic pain that underwent some surgeries like neurosis disease and also a high dose of corticoids, but they didn’t get better. I started to think that we have a surgery that has a mechanical effect, like keeping the nerve free, but the patients still have pain and a lot of different psychological aspects too. I started to think that there are a lot of other factors involving the patient’s pain. I started to read a lot about that. It was 2005 or 2006 maybe that I got to very interested in pain and especially in neuropathic pain. After that, I made my Master’s thesis and also my PhD thesis in pain in leprosy patients. I was invited by our friends to work in a lab that studied the neuroscience of emotion, behavior and cognitive aspects. I developed a lot of research about pain and emotion and neuroscience aspects. Somehow from 2010 maybe and to now, my main field of research is neuroscience aspects of pain, emotion and cognition and how does it impact a patient’s behavior.

Whose lab did you work with when you were working on your PhD?

I worked in a lab with a dermatologist and she’s also very interested in understanding patients’ pain too. After that, I did some research with some patients. A couple of years after my PG, I keep my work with leprosy patients, but then I started to look for other musculoskeletal pain like low back pain. I changed my interest completely. Also, I’m working now with all kinds of pain. We have some study with headaches and also musculoskeletal pain because in our lab, we are much more interested in the mechanisms of pain. Not only that, but we are also interested in giving some tools for clinicians and also for patients to understand a little bit of pain and also to have good information on the internet.

Give us some background and maybe describe, what is pain like as far as it being a problem and a challenge in Brazil? How is it similar and how does it potentially differ from the United States?

I believe that we face the same problems as other countries too. For a country that has a free public service for health, it’s necessary to think about the cost too and also the impact of some interventions for the populations. Here in Brazil from 2010 to now, we have an increase of low back surgeries and also opioid use, but we are not facing the opioid crisis like the US and Canada. Most part of the population doesn’t have money to buy opioids because it’s more expensive than other drugs. The prescription rates of opioids increased from 2010 to now. We also believe that we still have a lot of surgeries that are not necessary. Also, some advertisements from the government to the population that is not completely correct. It means that they don’t follow the guidelines.

In other aspects, we have a large country. There are some places in Brazil in the Amazon region, you have to go by boat. It’s six hours, twelve hours from the capital of the States. It’s very far and difficult to access and people maybe don’t have good health services there. That’s characteristic of our country was the main factor, the main thing that we start to think about is to develop our websites. The main mechanism that we start to think are that people need to know good things about pain. People need to know the correct information about pain and how can we approach those patients? How can we give this information to the clinicians around all the parts of Brazil? The internet is the way.

You’re saying that Brazil has a socialized medicine or public or government-provided health service and the government is the one who creates the advertisement and the education around pain. Can you give us an example of one way you’d like to see that improved and how the government of Brazil could improve that?

There are some recommendations for patients with low back pain that they need to look after their posture and also the way they sleep, the way they carry things and the way that they move the drug. The recommendations from the Health Ministry are completely different from the guidelines. If you want to understand some aspects of low back pain, you go to the Health Ministry website, you’ll see a lot of information that is not correct. It’s complete nonsense.

It’s difficult to get the information to the rural parts of Brazil so people can access it. Tell us what’s happening in physical therapy school and in physiotherapy schools in Brazil with regard to pain education, pain neuroscience education and how things are moving in that direction.

In 2015, we wanted to understand what happened in the physical therapy courses. All the courses in Brazil or how many courses in Brazil have this specific pain course. The IASP recommends a specific course or specific content for physiotherapists. We start to think but we know that we have a lot of schools in Brazil. When we did the research, we had 800 schools in Brazil. It’s a lot of schools. How many schools have a specific pain course? We investigated all the 800 courses and we found that only 6.5% has a specific pain course which means we had the courses from 566 schools and only 26 schools have specific courses for pain.

It’s interesting because some schools that have the pain course, the contents are not the same that IASP recommended. It’s not a complete course. The way that we teach pain for our PT students is not in agreement with IASP recommendations. We are trying to make this information available for everybody and try to change. I don’t have this number, but I believe that things are changing. We have some teachers and also some directors that contacted me saying, “I’m starting to give my students at PT specifically pain courses here.” I believe that several years more and we will have good schools with more pain courses.

When you look for the data on 800 schools, is that 800 physiotherapy programs?

Yes.

That’s a lot of programs. I think in the United States, which is a relatively large country, I believe we only have about 250 physiotherapy programs. That’s a lot of physiotherapists.

We have a lot of physiotherapists and a lot of PT schools too.

Do those schools follow the same other curriculum standards that they all follow the same standards?

Yes.

Tell us about the work you’ve done specifically with regard to pain education and developing pain education tools to help move this along.

In 2015, it was very common here to see in national conference people saying that we need to give pain education for patients with chronic pain. We start to think that not all PTs could do pain education intervention. We start to think that it could be very interesting if you give some material and also some resources for clinicians and any type of clinicians, even if they didn’t have any contact with pain education courses. They have to find information about pain education and how to do that and be able to do it with their patients. In 2015, we started to think, “How can we do that?” We found that the website would be the best thing to do. We developed a website with tools for clinicians and tools for patients and for kids.

In the professional area, health professionals can find some questionnaires, like a kinesiophobia questionnaire, catastrophization, anxiety and depression. The most common scales that we use in the assessment of chronic pain patients. They can also find a booklet about pain education and how to do that. They can find a board game that we developed for pain education. It’s a board game that you can play with your patients. It’s interesting because this board game was translated into Spanish, English and also in French. It’s a free resource for everybody in different languages.

On our website, they can find the first online intervention for patients. It’s like a program in nine steps that cover acceptance, pain, neurophysiology education, psychological aspects, sleep, hygiene, how to deal with activities and how to get back to exercise and how to improve the relationships. It’s a program that the patients can go step-by-step, reading some information. The patients click on the number PPT and a presentation begins with no more than three minutes. It’s very fast. The patients can see a picture with two lines explaining some aspects of pain. It’s called the Recovery Path. It’s a story about one character called Davi and Davi crossed all the steps to get better. Patients can understand that and how the other aspects are involved in pain.

Is that program in English or is it in Portuguese?

This program is in Portuguese.

Some of your resources are available in English as well?

Yes, we have the board game, it’s called the DolorOmeter. It’s the board game. It’s very interesting because it’s the story of patients with pain that you can say that’s low back pain. We start to have a high pain intensity. Like this patient, his name is Oscar and he has eight in the pain intensity and let’s try to get better. Start to read some sentences and the patient has to judge if it’s true or false. If it’s true, when patients say that’s correct, the pain has to decrease and if it’s false and the patient’s wrong, the pain intensity increased. You can see that the things the patient thinks about the sentence, their beliefs, like a sentence say it’s not good for chronic pain patients to do exercise. Is it true or false? The patient says it’s true, that’s correct. It’s false and you can increase the pain intensity in the board game. It’s interesting because you can access the beliefs of the patients at the same time because we need to use the patient’s beliefs to judge if it’s true or false.

I love that you gamified things. You see the gamification now in lots of things online, but I haven’t seen it in the pain world yet. Gamification is an interesting area that I really should probably reach out to and talk to more people about. You mentioned the name of that is the DolorOmeter, which means the pain-o-meter literally.

That’s it. It’s interesting because you can download it. The board game, the cards and also the rules, you can download on the website and also on the Pain in Motion website. You have to print it and use it for your patients completely free. We don’t get any money to do that.

You also did some interesting things for kids as well.

In 2018, we developed a comic book. We presented the comic book at the IASP Conference in Boston. The comic book was very challenging because we know that all the talks that we should say to the patients, it’s important to tell the patients about the neurophysiology of pain. It’s interesting to talk about sleep hygiene and also the importance of activities. How should you tell these things to kids? It’s very difficult. My other colleagues and I start to think that the best way to do that is in a comic book. How can we get all these concepts in a comic book and make sense? Develop a story that has three specific main characters, two kids, Clara and Freddie and a scientist called Professor Dexter. Professor Dexter has a big computer that knows everything and Professor Dexter lives in the neighborhood. One kid starts to complain about the headaches that he usually have and the other kid, Clara, says to him, “Let’s go to Professor Dexter’s house to see if he can explain what pain is.”

When they arrive at Professor Dexter’s house, he starts to explain pain physiology, the concepts of neurons, neurotransmitters, nerves, the brain and the importance of psychological aspects and sleep hygiene. That comic book is very interesting and we also present the book to pain specialists and change the story if necessary. We also present it to the kids. It completely validates. We are preparing the manuscript to submit to our journal soon. We had three Brazilian scientists, me and two other guys, Professor Alejandro and Professor Lee and other three scientists from different parts of the world. We have Tonya Palermo she’s a psychologist from Seattle. She’s a specialist about pain for adolescence. Adriaan Louw, everybody knows that Adrian is a specialist in pain education. Kelly Ickmans is a scientist from Belgium from the Pain Motion Group. She works with pain in kids. Her group developed a game for pain education for kids too. We six developed the book. We first think, “Let’s develop a book in Portuguese,” but now, “Let’s develop the book in Portuguese and also in English.” It’s a good time to do that. The book is also in English too. I think that it’s a good resource because it’s a free resource too. I believe that’s the first book for pain education for children to have in the world.

Congratulations on that. When I first came upon your work at the International Association for the Study of Pain, the World Conference in Boston, I saw that children’s book and took a look at it. I think it’s great because there are not a whole lot of resources for children out there. One thing struck me really interesting about that comic book is that it’s simple and concise, which as we know in the world of pain science, pain science is not something that is simple and concise. It can be very complex but distilling those lessons down into lessons that are simple and concise is where the magic happens. I started looking at it and I’m like, “There’s even an application here for adults because pain literacy is such a challenge for many people with pain around the world.” Is pain literacy a challenge in Brazil?

Yes, health literacy in Brazil is a challenge too because most parts of the population have low years of education. They have difficulty in understanding how they can use magical information in their lives. To understand pain is also difficult for them too. We are interested to see, for example in our cohort study. If you applied the pain book in a school, what happened with these kids many years after that? It’s interesting about that. We don’t know but I believe that we need this type of resource to be applied in schools and also to discuss. In fact, the book is not too specific to the treatment, but to be used as an adjunct therapy for the patients and also for the parents to understand what is happening to their kids and how to deal with them because I think that parents have a huge influence in the kid’s pain.

You’ve done a lot of work, obviously everything from leprosy to chronic low back pain to pain in children. What’s next for you? What are you interested in researching next?

The main thing that we are investigating now, we are working with heart rate variability in our lab. We are trying to understand the emotional aspects of pain, especially fear. We have some good results with our students. We can understand that chronic pain has emotional aspects involved in the pain experience. Some parts of the brain involved in the pain processing are also responsible for emotional processing too. For example, the prefrontal cortex, the amygdala, insular and other parts. We have some modifications in their parts of the brain. We start to think that, “Maybe this patient has emotional impairments too.”

We know that emotion for us humans serve for social interaction. I can read facial expressions and also adjust my behavior according to someone’s facial expression. I can recognize the face of happiness and also sad and we investigate if patients with chronic pain were able to recognize emotional expressions like I have subjects and we found that it’s not the same. Patients with chronic pain were not able to recognize some facial expressions. They recognize not yet, in time. They are slower than other subjects like health subjects.

The other aspects of heart rate variability. We are starting to understand the connections between the brain and the heart. It’s a two-way connection. The brain influences the heart and the heart influences the brain. We found that when patients with low back pain see a lot of images with movements of the trunk, the sympathetic nervous system increased their activity. When compared with healthy subjects, the responses are completely different. We believe that even if it’s not cultural things, emotional aspects can develop emotional responses like modifications in the person’s sympathetic nervous system that are not conscious of the patients. In these experiments, we use only the passive utilization of the images and the sympathetic nervous system had more activation and the parasympathetic nervous system is only seeing the images. I believe that is the first study that did this and it’s protocol-specific. Heart rate variability and also the breathing, we don’t understand a little bit about that. It’s important to start to look at that. We started to use some validations with heart rate variability studies.

When the information comes out, we’d love to have you back on the show so you can tell us more about heart rate variability and pain. It’s an interesting topic that I haven’t covered on this show. I look forward to that. Tell everyone how they can reach out to you and connect with you.

You can find me on the Pain in Motion website because I’m an associate member of the Pain in Motion website and also in our websites or on Twitter. It’s good to find me and also very easy.

I want to thank Felipe for being on the show as we’re talking about initiatives for improving pain education in developing countries, especially in the country of Brazil. Make sure to share this episode out with your friends and family, especially if you have friends and family in Brazil or physiotherapy colleagues in Brazil who are interested in this work. It’s important work.

Important Links:

• Pain in Motion Group
• International Association for the Study of Pain
• www.IntegrativePainScienceInstitute.com/153Download
• Felipe Reis
• JP Caneiro – Previous episode
• DolorOmeter
• Twitter – @FelipeReisifrj
• DorlorOmeter (English Version) – https://Drive.Google.com/drive/u/3/folders/1gnxEn7FbDZ1U4Ik7wuH0U5K1NoNqYEg7
• The book for children: “A Journey to learn about Pain” – https://Drive.Google.com/file/d/1_OqghLxnT2tQVIzQ6qpHPY8TZ86ylNZr/view

About Dr. Felipe Reis

Prof. Felipe Reis is a is a Brazilian Physiotherapist and Professor of Physical Therapy at the Federal Institute of Rio de Janeiro. He received his Masters and Doctoral degrees in Science from the Federal University of Rio de Janeiro. His research focuses on Pain, Emotion and Cognitive Neuroscience. He is a visiting researcher at McGill University, an Associate Researcher with the Pain in Motion Group, and Chair of the IASP’s Special Interest Group on Pain, Mind and Movement.