Welcome back to the Healing Pain Podcast with Dr. Chris Williams
Thanks for joining me for another episode of the show. It’s an honor and a pleasure to spend this time with you. If you follow along with other episodes, you may have noticed that we’ve taken a somewhat narrow focus on the effective treatment of pain either from an individual perspective or identifying which methods have evidence that we can utilize and weave into our existing clinical practice. We’re going to take a wider, broader focus and look at the impact of chronic pain as a global health priority. Joining us as our expert guest is Dr. Christopher Williams. Chris is a research fellow and health services researcher with a background in both exercise science as well as physiotherapy.
He currently has a joint role within the public health unit where he established and leads the musculoskeletal health services program, a research practice program that focuses on improving the coordination of public health and clinical services to optimize the management of health risk factors associated with a musculoskeletal condition. This program collaborates with stakeholders from multiple settings including clinical care units, community health, and industry partners to optimize both prevention as well as treatment. His work focuses on developing and testing new approaches to prevention and care as well as practice change methods to influence the use and adoption of evidence-based approaches.
On this episode, you’ll learn what makes pain a public health issue and how it differs from a population health issue, how pain management fits into public health, what we can learn from public health to help reduce the burden of pain, the biggest challenges we face when dealing with pain in a public health model and how research at times has failed to inform clinical practice and what we can do about it. I’m excited to be sharing this episode with you with regard to the impact of chronic pain as a public global health priority. Without further ado, let’s begin, and let’s meet Dr. Christopher Williams.
Watch the episode here:
Pain As A Global Public Health Priority With Dr. Chris Williams
Chris, thanks for joining me on the show. It’s great to have you here.
It’s a pleasure to be here, Joe. Thanks for taking the time to talk to me.
We’re always interested to hear what you all are doing in Australia because it differs a little bit from how we’re approaching pain in the US at times. We’re going to talk about pain as a public health issue. It’s an important issue and one that’s interesting and new for this show. Tell us how you became interested in studying public health as a physiotherapist.
I started as a physiotherapist and then completed my PhD in Sydney with The George Institute and more or less for family reasons, moved to a city a little bit north of Sydney called Newcastle, which is where I grew up. Also, by chance that we’re working with a population health unit, which is a public health unit essentially, but the core focus of the population health unit is to address population health needs particularly focusing on physical activity and those big chronic disease, risk factors, high BMI, healthy eating, smoking cessation and alcohol misuse. I was working for a little while with those guys as an evaluation officer. More or less tried to unite the musculoskeletal aspect with the population health problems that we’re working on. That was unique but a nice fit for our research. Our program has taken off from there, where we’re combining that population health focus with the musculoskeletal problems in clinical services.
Tell us the difference between public health and population health. If we can define that a little bit first so that people can see the difference and distinction.
The terms can be quite fluid, but it’s probably a good idea to be defining what you mean when you talk about these things. Public health refers to the health situation of the public at large and it’s probably subject to things like government regulation to ensure medical professionals are doing their job properly. For example, another way to define it would be something like how we as a society collectively ensure the conditions of the people in the society can be healthy. They’re policy-type concerns, whereas population health might be more concerned with specific individuals within the society. Identifying specific groups and understanding the health challenges of those specific groups. We can define those groups by location, characteristics, or there could be country. There’re many ways to define a population group, but in population health, we’re concerned with the outcomes of those individuals within that group. That’s how we think about those differences. It’s subtle but it helps us orientate the activities that we might do in a public health space or a population health space.
How does pain management or the care of pain fit into public health?
That’s a tricky one. It probably fits into both public health and population health, but we would consider pain as a public health issue purely because everyone gets pain. This comes back to the biology a little bit, and more importantly, it concerns historical issues around how pain is managed. What care is accessible for people in society, how governments have regulated medical professions and policy around pain management as a public health issue, that’d be my best go at describing how pain is a public health issue.
When you’re talking about policy, it’s probably not something that shows up on too many physios’ radars, but we do have an influence as a profession with regards to public health and the treatment of pain.
I think a lot of us have probably experienced that with the COVID-19 restrictions. Number one, people might be more reluctant to go to the physios, the chiropractor, or the health provider. Yet some insurance companies, for example, don’t have a policy around accessing telehealth models of care. That’s a nice and relevant example of where the pain is a public health issue. A lot of people experiencing pain, but they can’t access care.
What teaching points can approaching pain from a public health perspective help us either effectively evaluate, manage, and treat chronic pain for their variety of conditions that are out there?
I’d be interested in your thoughts here based on the education that you’re providing in this space. We tend to think about pain in public health more from an advocacy perspective. If we want to mobilize a workforce, we need to be better advocates around the things that we can do for pain management. That can happen in professional groups or it can happen more broadly across the population.
Does that place physiotherapists in a position where they should be taking an active role in things like public health campaigns to create messaging that’s effective for proper pain care, pain management or the conceptualization of pain and all those are topics that come up?
I agree and it probably depends on the type of campaigning. I think this is where the public health message and the population health message gets a little bit convoluted. It could be around things like weight loss for pain management or better activity or physical activity for pain management campaigns around these, which tend to be more population health issues, the defined populations that we’re talking about this. Certainly, around the conceptualization of pain and know what pain is and how we should manage it effectively when we get it. I think they’re good vehicles or focuses on public health campaigns and advocacy for any professional group.
In Australia, is this showing up in university education? I know in the US it’s starting to show up in some of the more health promotion and wellness-type classes that have been integrated into the DPT curriculum. In CAPTE, which is our accreditation standards here in the United States, it doesn’t have a whole bunch with regard to pain as a public health concern for physiotherapists.
As far as I know, it’s not well integrated into the education of our pre-qualification training. There’re certainly groups that are professional societies and groups that are trying to bring this further forward. The pre-qualification training in Australia, as far as I understand, is not focused on the public health or population health aspects of managing chronic pain. I think it’s important to the Australian government’s credit that they’re trying to shake things up a little bit, but to do so across professions rather than in a solid approach. At the moment there’s a review going on of pre-qualification and post-qualification training in Australia to be more comprehensive of the public health issue around pain.
A physiotherapist would pursue another degree in Public Health or they would concentrate on that in their PhD with regard to public health like you did. That’s one avenue that they could take or 2 out of 2 different avenues.
A Master’s of Public Health is a common way to engage with the public health of a healthcare system. I don’t know how common that is for physiotherapists or other allied health professionals. I think the issue is marrying those two things. We can learn about public health or population health, but marrying that with clinical practice or a certain profession may be a way of managing patients with pain, certainly a group of individuals in our society who have a particular health issue and knowing that the public health approach is not commonplace.
Tell us a couple of examples of how your research specifically has looked into aspects of public health. I know you mentioned chronic back pain or lower back pain before. Have you specifically looked into low back pain with regard to public health?
We’re talking a lot about public health. Most of our work I’d put in the population health arena. We do a lot of work in the health services of defined populations. That might be patients who are accessing or being referred for orthopedic surgery consultations for back pain or patients with back pain or osteoarthritis. Those patients have a unique characteristic potentially to patients who are accessing physiotherapy care or general practice or patients in the communities. Those patients tend to have a much higher health need. They might be more likely to have things like diabetes or cardiovascular disease.
We’ve noticed that there’s a higher rate of smoking in that particular population group. The patients that are going to these tertiary care models tend to have much more complex health needs. The research that we’re doing at the moment is number one, trying to help the system deal with the volume of those patients because there’s a lot of patients that are being sent or referred to these centers. Number two, trying to investigate the best way to support these patients. Acknowledging that if we help their back a little bit, it will be much better. We try and provide a more comprehensive care model and test the effectiveness of that comprehensive care model.
Within those comprehensive care models, does that include multidisciplinary care? Does it include training practitioners to be transdisciplinary in their own practice? It’s interesting because both the public health and the population health issues have lifestyle factors at the core. As a profession, we’re still a little unsure at times as to how deep we can go into each of those lifestyle factors or even if we should go into lifestyle interventions around certain topics such as nutrition, for example.
We’re liberal in whether we would go for a multidisciplinary approach or a transdisciplinary approach or even try and provide more integrated care within the one consultation or professional group. I’m not convinced of either approach is better. The key issue in our view is that patients are not getting this care and we’ll try and arrange care based on what’s available. If it’s a physio that’s providing the care, they’re providing weight loss advice and things like that. I think that’s a good thing as opposed to a dietician and a physio.
Sometimes the dietician isn’t available if it’s another health professional that’s providing some counseling around smoking cessation. I think that the key issue that we’re concerned with is number one, understanding or acknowledging that these are a part of the patient’s health challenges. Number two, that they’re not receiving this care. Our data suggests that only 10% of patients who come from primary care to tertiary referral hospitals have been advised about any of these broader health determinants.
10% is extremely low. I would expect that in the US but even hearing it from a country outside the US is concerning. Multidisciplinary care, a lot of people look at that as the gold standard specifically with regard to musculoskeletal pain. When I think of public health and population health in the US especially, I think of the economy and economics that are behind all of this. Have we looked at models yet at delivering interventions and education in a way that is effective for chronic pain as a public health issue?
The answer is yes. There’s good evidence on the cost-effectiveness of multidisciplinary approaches. The problem is they’re not widely available. I think that’s the challenge for patients. The thing we need to keep in mind is that the patients are the ones that are challenged with this. We’re talking about their journey in healthcare and even as we say, there’s good evidence to support a multidisciplinary approach and good economic data to say that it’s cost-effective, it’s just not available. We need to be flexible in how it’s delivered and probably coming back to my point about being liberal in how we arrange this care. That’s in with one care provider touching on these different aspects of care. I think that’s a good thing it’s better than not receiving.
It makes things like health coaching come to the forefront and seem like interesting viable communities that are even taught now in some physical therapy programs, aspects of behavior change, and coaching.
Don’t get me wrong. I’m not suggesting that these models don’t need to be tested. I think we should embrace an environment where we’re continually assessing the effectiveness of what we’re providing patients but at the same time, we need to be realistic in what we can deliver.
Tell me about The Good Science Company and you’re working that’s happening.
The Good Science Co. is a new entity that we’re building here in Newcastle, Australia. This is based around our thoughts on the need to rethink science and how we do it. The Good Science Co. is about getting science to the hands of people that need it rather than letting the science sit in academic journals. We want to do a better job of translating that evidence to the clinicians or the community at large. Underpinning that is the approach that we take and we want to make sure that the evidence that we’re generating is useful. It starts with a good problem and we go about answering that problem or the question in a robust way and then thirdly, go disseminating and making the evidence available to the people that do need it.
It can take upwards of 10 to 20 years for some of that information to reach people.
Unfortunately, a large proportion of the research doesn’t get published.
Even good quality research that have interventions that are beneficial?
Yes. It’s hard to decipher between what types of evidence is published and what isn’t, but we know that of publicly funded research, I think the figures are around that 10% to 15% mark gets used in practice and then there’s that 15 to 20-year time lag of the evidence that is used in practice.
That number always was interesting to me. I’ve always wondered if it’s the time it takes for the research to land in a curriculum at school? Is that in continuing education? Is that somewhere in the public health sphere and get to the people who need it?
I think it probably includes all of that. We probably need to be cautious of the reality of these sorts of steps, there’s probably a bit of drama around now these 20-year timelines. If we had a close look, I reckon we’d find things like good research. The things that are targeting important issues in the conduct of research where there are co-design and collaborative processes with clinicians and health services.
I think the uptake of those and the use of that evidence would be much higher. That probably speaks to the principles of The Good Science Co. We’re an indebted research group which means we work within a health service. Our research is geared toward entering problems or working towards problems for that particular health service, rather than us sitting in our office and coming up with ideas that we’re interested in. We’re a technical group rather than a traditional academic group.
If a researcher has information with regard to public health in supporting the public, how can they disseminate it faster from your perspective?
Don’t get me wrong. I don’t think we’ve nailed this yet but we’re thinking about it all the time and I think that’s the point I’d probably make is to think about how you disseminate the research and get it to the public. On one hand, we’ve got an issue at the top of research that’s done and the focus of the research. I think we need to tick that box. We need to be answering an important problem, but then being creative and innovative in how we disseminate research to the public or the people that it’s geared to help and that can’t be just publishing in an academic journal.
What you’re doing is fantastic in hopefully getting research and evidence and ideas from research and evidence to the public at large and in clinical groups. I think we need to be much more creative in how we do things. One strategy that I have undertaken was to employ our communications experts. There’s an army of people that do a fantastic job in society and other industry groups around marketing and communications but for some reason in research, we don’t utilize those skills well. In The Good Science Co., we’ve got a fantastic science communicator and marketer who’s helping us think of new ways to get that information to people better and faster.
I would say even in clinical practice, we’re not good at disseminating what we do, how we do it, and who it’s for at certain times. Although it’s interesting now with social media, there are free tools to reach people. That’s become a little easier at times, but at the same time, you have a separate problem of more noise.
That’s a nice point and a good question I think is how do we make ourselves different. Maybe coming back to a public health concern is how do we help the public understand what is noise and what is good quality information.
That is a key question because so often if you’re on social media, it’s an echo chamber of you and all your friends. For argument’s sake, someone reads this show, loves what Chris has to say about public health and pain. It’s getting shared with all of our friends and colleagues, but at the same time in the other echo chamber, there’s someone who’s promoting the new key supplement to fix the pain. If they have a louder voice than you, it can drown out more effective evidence in certain ways. As pain professionals, I include everyone within the medical field who’s a licensed health professional has a seat at the table with regard to pain. As physio specifically, it’s interesting to watch how we tackle that from a public health perspective.
I have some colleagues who are good at infiltrating those spaces. I would have to say that the clinical community amongst my colleagues is better than my research colleagues. I think there’s a lot for us to learn nonetheless, but probably more as a whole to learn.
Although if I hear what you’re saying correctly, it can be quite a long campaign from a researcher to come up with an idea, create the documentation necessary for the funding, run this study whether it’s an RCT or another type of study, get the results, and publish it. After publication, they would have to somehow figure out a venue or an avenue for bringing that to the public. That sounds like a multiyear process.
There’s a lot to do there. I think the issue though is that we release the results of that process at the end and that’s often publication and results are not available for example to health services to utilize when we know what the finding is of a study. We need to question the purpose of the work. I’m being critical of academic and uncomfortable work because I’m an academic for the most part. We need to be careful with subscribing too much with how we’re measured and that’s with the amount of funding that we have, the number of papers that we publish, and the citations of those publications by and large.
Think more about the purpose of the research that we’re doing. The purpose is not to publish research. The purpose is not to get millions of dollars in funding or that’s helpful to do good research. The purpose is to generate information that’s useful for people to use. If we’re creating barriers for that information to be used expediently, then we’re not doing a good job as far as I’m concerned. In that pipeline or that process that you talk about, I’m sure there are parts of it that we can tweak to make the process more expedient. In terms of the process of research, we can be more flexible with methods. We can be co-designing research trials with health service partners or clinicians and co-conducting that research as well.
It’s in a consumer engagement space, but what happens is that that research then becomes part of the practice and part of the dissemination model is working co-design with those important stakeholders. As soon as the evidence is available, as soon as you know the result and they’re aware of the result and can implement or translate that happens immediately rather than waiting for it to be published in an academic journal. The publication process is long and arduous and probably unnecessary, so I’m reluctant to go down that path in the conversation now, but it’s something that needs to change in my view.
You have two important points though. The first thing you mentioned is a partnership with researchers and clinicians because the more brains in the pot, the better it might be. If the clinicians are involved in it, they may more readily adapt it, which I think is important. It’s always fascinated me as a primary clinician that if there are clinical researchers out there doing clinical research, how come it’s not hitting the clinic as fast or as effectively as it should be? If it’s not clinical research, then we should call it something else.
It’s a loaded term and I’d probably question the meaning of what it’s currently doing at the moment.
What do you have next on your plate as far as the research goes?
There’s a lot going on at the risk of sounding cliché, I’ve got a number of hats because I do work in a public health unit. I’m supporting some COVID-19 research, which is not vaccine development or anything like that. We’re concerned with how the community responds to pandemics. Supporting people in self-isolation, for example, understanding what requirements people have to comply with testing regimes for COVID-19 and those sorts of things. I’m not leading much of that research, but I’m involved more from a methodological point of view.
Nonetheless, it’s been eye-opening for me to be involved in that process. I’m grateful for that opportunity. In terms of my direct team, we’re continuing to focus on the population health aspects of pain management. We’ve finished a trial of a healthy lifestyle intervention for low back pain. It’s a multifactorial intervention. Our focus is on weight loss, smoking cessation, alcohol minimization, healthy eating as well as a pain management education.
Some concepts around pain biology and combining all those concepts with behavior change strategies. That’s involving dieticians and physiotherapists as well as a health coaching model. We’ve finished recruiting for that study and we’ll follow-up the patients for another six months and then hoping to expediently release the results. It’s probably a real testing ground for us is to how we can do that working with Lauren, our communications manager, otherwise we’re focusing on sleep issues.
We’re doing some work with children and adolescents to try and understand things like why is pain impacting kids and what are the pain presentations that lead to more impact than a child kicking their toe or having a sore foot that has no impact on their life. We’re trying to think of pain as a consequence rather than a primary health state and understand the things that cause pain to be a bigger consequence on someone’s life and a sporadic or incidental episode.
Otherwise, we’re diving deep into some methodological concepts and trying to think hard about the things that we do in research and apply that same lens to our research as we might to clinical practice. I think one of the double standards we have as academics and researchers is that the way we do research is largely anecdotal and based on our experience. The way we’ll run an RCT is we’ll have to recruit patients who are an RCT. That’s based on how we’ve done it in the past.
If we apply that standard to clinical practice, I think we don’t apply that standard to clinical practice. We expect that clinical practices are based on evidence and we’re doing research on research to make sure that that research is of the highest quality standard, but also that it’s efficient and we’re not wasting taxpayer dollars when we do research by conducting inefficient recruitment strategies or inefficient follow-up.
The topic of efficiency is one, efficiencies and how do we systematize this so we can move things fast is something that is fascinating to me from a public health perspective. As from an individual, delivering care to people. I want to thank Chris for joining us on the show. Chris, everything that you talked about health promotion, exercise, lifestyle, and physical activity are all things that everyone’s interested in. How can they learn more about you and follow all the work that you will be doing in the future?
There are a couple of things that you can check out. We have a website which is HelpMyBack.org.au. We can give your audiences access to those resources within the website. My university profile is at NewCastle.edu.au, profile, Christopher Williams. You can check out some of the papers there and we can forward some of our papers to you to forward to your audiences. We published a systematic review of weight-loss interventions for common musculoskeletal problems which largely includes osteoarthritis and back pain.
Anything you send, we will share. If it’s open access, which we always hope that the research is, we can ask you to give it away as a free download and everyone can check out HelpMyBack.org.au and check out Chris’s work there. Let’s get information there on treating chronic back pain. I want to thank Christopher Williams for being with us on the show. Make sure you share this episode with your friends and family and colleagues who are interested in chronic pain as a public health issue.
About Chris Williams
Dr Williams is a research fellow and health services researcher with qualifications in exercise science, physiotherapy. Dr Williams has a conjoint role within within a public health unit in regional NSW, Australia where he established and leads the Musculoskeletal Health Services Program – a research-practice program which focuses on improving the coordination of population health and clinical services to optimise management of health risk factors associated with musculoskeletal conditions in adults and adolescents. The program collaborates with stakeholders from multiple settings including clinical care units, community health and industry partners to optimise the coordination of prevention and treatment services. His work focuses on developing and testing new approaches to prevention and care, as well as practice change methods to influence the use and adoption of evidence-based approaches.