Transcription
Hello and welcome to today's webinar. My name is Felicity Thou, and I'm a physiotherapist and a campaign manager for the Flipping Pain team. Today I'm talking to Associate Professor Tasha Stanton in the third and final installment of our Flipping Arthritis Series. This is a pre-recorded event where I'll be putting the questions to Tasha that we didn't get to in Parts One and Two, and we'll also have time at the end for Tasha to talk us through some of her most current research. So stay tuned!
Flipping Pain is a public health campaign aimed at flipping how we think about, talk about, and treat persistent pain and related conditions like arthritis. With people affected by it, we share information with both those individuals and the healthcare professionals who support them. Our Flipping Arthritis Series has been funded by Haywood Middleton and Rochdale Integrated Care Partnership for people affected by arthritis across Greater Manchester, but all are welcome to join.
If you've not seen Parts One and Two, you can find them now on the events page of our website or by searching for Flipping Arthritis on YouTube. So, I'm delighted, as I say, to welcome Associate Professor Tasha Stanton all the way from the University of South Australia to join us today.
Tasha, let's launch into some questions.
Yeah, well thanks so much for having me! I'm always excited to get a chance to chat and dig into the details.
Excellent! No, we're pleased to have you; it's brilliant. So let me get my questions sheet ready here. As we say, we talked about a lot of this in the first two webinars. So, as I said, if you're just watching this for the first time, do go back and watch Parts One and Two before this. But let's dig a bit deeper because there were some common themes that emerged.
One of the things that came up—and we had asked again in the interim—was it's quite scary to start activity, right? It's quite scary to start activity when you are fit, well let alone when you live with persistent pain or even layer that with depression or a rheumatoid arthritis or inflammatory problem, lymphedema. There was a strong ask for, I guess, reassurance that is it okay to start anywhere? Is there a point where it's not worth it? Or is there a point where you would recommend people start?
Yeah, so I think this is actually a really important message that it's not just things like running or doing really hard, vigorous effort activity that's important to health, to osteoarthritis, but actually lower levels of exercise and doing anything—anything increasing—is actually really critical and can play an important role.
The thing is if you're not doing very much right now, thinking about starting something huge and a lot of activity—that's way too much, and that's just not doable. We actually risk the chance of potentially making ourselves worse or less likely to want to keep up with that, certainly because it won't be very fun.
So starting slow and starting to really slowly kind of increase that over time is a key aspect. But it's also really important to talk about the evidence that's there that suggests that lower levels of exercise are still really important. So there have been some studies done that have looked at walking programs, for example, in people with knee osteoarthritis.
These studies have shown that when you do kind of walking for fitness—which is titrated or set to the level that that person's starting at—what we see is that people get improvements in their function. So they're first of all better able to walk; they can walk longer distances with less pain. These improvements that they have in function are not coming at the cost of worsening symptoms of pain in the joint.
It's sort of suggesting that even something like walking at the level you're used to and slowly but surely increasing kind of the time and the distance that you do that can have really positive benefits to your functional status, but also possibly to pain.
There's also been work where they've followed a really big group of people over time and said, okay, how does the amount of activity they're doing at the start predict how they go later on? For example, there was a study that looked at nearly 2,000 different people, and they looked at what happens to how much they're walking, right now, at your baseline measure, and does that predict their function later on?
They found that it did. So that every additional about a thousand steps per day was associated with reducing functional limitations— or to flip that the other way around— increasing numbers of walking steps per day by about a thousand was actually associated with better function.
What they found was that when you kind of get around the level of about 6,000 steps per day, that seemed to be the amount that had the most protective capacity at reducing or preventing declines in function in people who had osteoarthritis or were at risk of developing osteoarthritis.
So that's pretty lovely evidence to suggest that even when we do something like walking, it provides important benefits. Because you think about it: that's loading through the joint; that's helping nourish your cartilage; that's helping nourish almost your whole body—your mind, if you do it in nature, your mood.
I think all of these things, first of all, come with additional benefits, but this is just, I suppose, reassuring you that these small—what might seem to be small—changes, on a broader scale, they add up to something big. So they're really important to do.
Okay, excellent, and a thousand steps—now for some that will be a lot—but it's kind of remarkable if you ever watch, when you look at it, you think, "Oh wow, I've only just been doing the housework, and I've done a thousand steps!" It's often a manageable chunk.
Absolutely! And I think that's actually a really nice suggestion. We often have our phones with us, or we have different watches, or you can even get those little pedometers that you stick on your waistband. That can be a really interesting sort of detective activity to get an idea of how many steps you're doing per day.
Because that gives you an idea of how much or where you might want to place your goals. Because, yeah, you're right: you might be surprised at how many steps you accrue just going around the house.
Yeah, absolutely! It also reminds me of—we just off air, were talking about our recent Flipping Pain tour. One of the gentlemen that we had on our panel was a local Teesside gent who lives with arthritis in his spine, and he started—I mean, he was using a wheelchair for a lot of times to go out and about to the shops and things like that—and he was only able to do two or three steps.
That was his lowest point. He decided to use that, and I remember him saying, "I wanted to go outside my comfort zone." No, it wasn't easy to do because his comfort zone was, you know, so close to home.
So he went from his front door to the end of his driveway—two or three steps and back—and he started there and built up. Now he's doing holidays in Switzerland, in the mountains. You can read his story on our website on the real stories—it's Mac's story.
But if somebody's at that point, is there still benefit in doing something so small? Because the benefits in the future will be so great.
Absolutely! And I think that is—it's just sometimes when we think about the big end goal, like let's say, "I want to be able to do XYZ," that can become unmanageable, and it can become too much. When those goals feel too big, that's demotivating.
So I think actually thinking about, "Okay, what can I do today?" and then just focusing on the subsequent days can be a good way to start. So if we have this bigger goal, it can be really helpful to break it down into manageable chunks—little bits that when you get there, you're like, "Yes! I've done this! This is an achievement. I've made it there; I'm one step closer to my overall goal."
Excellent! Brilliant.
We had a question come in on the webinars that we weren't sure of the answer to off the top of our heads at the time, and that was about CBD oil, which we hear a lot about. A lot of people say, you know, "Is it okay to take that as a supplement? Is there any evidence for it that it might reduce pain in order to help people build up their physical activity?"
Yeah, it's a wonderful question, and yes, I did a bit of a deep dive into this area. So basically, CBD—if anyone's not heard of it—it's a natural substance that they extract from the cannabis plant, and they often mix it with an oil, such as coconut or hemp oil.
The important part—and I guess the part that sometimes got stigma—is it actually doesn't contain any THC, and that's the component that's associated with the feeling of being high from sources like marijuana. So it is not that part; it's only the CBD part, and that's thought to target different pathways that are involved with your feelings of pain and with inflammation.
At present, there have been animal studies that have looked at the effectiveness of CBD oils and different products, and they've shown that that has positive effects on reducing inflammation and some positive effects on what they call pain-like behaviors or threat and defensive behaviors in animals.
The challenge, of course, is that what we find in animal models doesn't always translate to humans—and we see this a lot. But it suggests that there might be something there.
There has been some research looking at CBD in terms of nerve injury or something like it's often called neuropathic pain. But right now, there's not enough evidence that has been done in osteoarthritis or even arthritis more generally, or what we might term musculoskeletal pain—so things like low back pain, neck pain—there's not enough evidence to support its use.
There— I think there's been one study that I've seen that looks at the kind of topical or CBD oil looking at its evidence for osteoarthritis and another type of arthritis called psoriatic arthritis. They found in that study that the CBD was no more effective than placebo, but that's one trial.
So I'd say at present we don't have—we do have anecdotal evidence. Some people report that they felt that it's really helped; it's reduced pain. But we don't have good research evidence, and ultimately that's what we have to base our recommendations on.
Because there haven't been many trials done, it means that to really be able to give a full answer, we do have to test it. But right now, it's not recommended by some of the bigger guideline organizations, such as NICE, for example; that is, in the UK, that's the National Institute for Health and Care Excellence.
I think at present it can be legally bought—CBD oil—as a food supplement in the UK from health food shops and some pharmacies, but it's not licensed as a medicine to use for arthritis.
Some of the side effects that can occur with it—some people can report nausea, some dizziness, kind of just feeling a bit unwell. We're not seeing serious side effects as things that you see from more powerful anti-inflammatories, but it's still relevant to consider that the evidence we don't quite have enough yet to really make a full recommendation on it.
Thank you very much! So it's sometimes good to go into the evidence on these things that people are using a lot—as you see off the shelf—and sometimes it's surprising actually we haven't got that scientific evidence yet to support it.
Yeah, and lots of that is not related to us not wanting to test it. Oftentimes, as you speak to any researchers in this area, it can be really tough to get the funding to do those trials properly.
Some of that, we certainly are—when we see those gaps, we try to push and fill them—but that is often a large consideration for what might seem to be slow progress.
There we know! One thing that had come up in our past webinars that I think is useful to go over again—it's something that comes up in clinic as well—where you talked in the webinars about the phrase, um, a question did come up at the time.
Let's talk about it again: can you grow back your cartilage? If you're looking at an x-ray where it looks like there's very little joint space left, maybe you've been told in the past it's bone on bone. We know that's not strictly accurate, but is it possible to improve your cartilage again?
Yeah, it's a great question. I would say that we don't fully know yet. So we know we have good evidence that when you load the joint—so when you put you do walk, you do exercise—doing anything like that that loading is actually essential for the cartilage's health.
Because your cartilage doesn't have a blood supply, it's loading that keeps providing nutrients coming from the fluid that's in your joint. This is a really important aspect in terms of what we understand about the physiology of cartilage.
In terms of the idea of bone on bone, it's important to point out that even if it looks like there's no cartilage left and things are touching, you still do have layers of cartilage there, so it's not gone, gone.
There hasn't been much research done to track that, but there has been work that has shown—it was monitored among people who are at risk of developing osteoarthritis because they've undergone a specific surgical procedure that takes out some of the kind of big thick cartilage called your meniscus.
They've followed people like that who had this surgery. After the surgery, people are at risk of developing osteoarthritis. What they did is they randomized people to either start exercising three times per week over four months, or they were randomized to no intervention at all.
So they had the surgery, and then they just recovered afterwards. What they did was they actually looked at this very specific molecule, and it's called, oh, I mean I'm going to mess it up—it's one of those tongue twister words, glycosaminoglycan. We're going to call this GAG because that's much easier.
So they looked at GAG, and that's actually a marker of cartilage health. What they found was that the exercise group had an improvement in their GAG levels compared to the control group.
Excuse me, when you don't have an intervention, when you're not moving, when you're not exercising, you don't get an improvement in those levels. But when you do, actually your cartilage health improves.
What was really cool is they found a really strong association between how much that GAG content increased—so how much their increase in health occurred—as well with an increase in physical activity level.
So right away, that's actually really nice evidence to suggest that what's occurring within the cartilage you have, it's improving its health by moving. This is even after you've undergone a surgical procedure for your knee.
To me, that's really exciting! If we look at some of the animal data, we start to see a little bit more information about the effects of loading on cartilage, but, as I've said before, what we see in animals often doesn't always translate to humans because there's a lot of different things going on.
So I tend to probably put a little bit more weight into the human data.
Excellent! It reminded me as we were talking there about things like osteophytes or bony spurs that people might have heard that they have on their scans. They sound pretty scary, don’t they?
Sounds like pretty scary things! But would you mind talking a little bit about those things that crop up that sound terrifying?
Yeah, well, I think one of the things that's really helpful to know is that when we have changes in any of our tissue, those changes typically occur because of something. Oftentimes, what we see in osteophytes is it's thought that what they're actually potentially doing is giving you a more stable platform.
So, when you slightly change the way that you load or you take force or pressure through a joint, that differing force means that your bone can remodel; it can change. There's lots of evidence that shows if you've had a big surgery on your joint where they twist things around, the density of your bone changes and remodels according to the pressure that's going through it.
So many of those things that we see, they're often remodeling. While they can be seen as really, really scary and like bad things, another way to really look at it is that they've given you this solid platform on which to base your movement.
Oftentimes, they can be helpful, and you see an increase in that feeling of a more stable joint. It's almost a little bit of thinking about them sometimes in a different way. It’s your body helping you out rather than a bad thing that's changing.
It's kind of amazing to think that we can adapt, I guess that's the whole hope of it all, isn't it? That's the whole message. We adapt to what we throw at it—our bodies.
We just have to throw the right things at it and in the right doses.
Yeah, and I think that is so cool because you think about bone, and for me it seems so set—like literally, they're bones—but they can adapt, and they can change. Like that blows my mind!
Brilliant! We had a question come in. I think it's important. We talked in one of the webinars about do we need a diagnosis from a healthcare professional for arthritis? We talked a little bit about that.
I believe that was on the first webinar, but somebody asked, "If you haven't had it confirmed through a healthcare professional, how do you know which kind of arthritis you have?"
I wonder if you wouldn't mind detailing the typical presentation of osteoarthritis and maybe just a little bit about if you haven't got that, maybe what you might need to see your GP about?
Sure! Oftentimes, osteoarthritis presents as joint pain that can occur at rest, can occur with movement, but that often isn't paired with very prolonged feelings of stiffness in the mornings.
So it might be you have some stiffness that can either change with the activity that you do—like sometimes if you sit too long it might get stiff—but it often improves when you move. If you do too much, it can get stiff, and it improves when you rest—all these different things fall into the category of osteoarthritis.
Typically, we also use age criteria. So if you're over 45, you have symptoms of knee pain, and you don't have prolonged morning stiffness, that fits the clinical picture of osteoarthritis.
That's what the NICE guidelines that I referred to before suggest as sort of the clinical criteria to diagnose osteoarthritis. They suggest that when those things are present, having a scan often doesn't tell us too much extra.
It's not necessarily needed.
There are situations though where you might find that it is relevant probably to talk a little bit more to your GP, and that's when you have really prolonged, severe morning stiffness, and maybe ones that are affecting you bilaterally on both sides and in numerous joints.
So it might be that it's both knees that are sore and super stiff, but actually also so are your hips and so are your wrists and so are your elbows. Those are situations where it might be something such as rheumatoid arthritis, which is typically associated with more distinct and higher levels of inflammation.
That often has a very different treatment course. Lots of the things are still similar in terms of like education and exercise is very good, but there are what they call the disease-modifying anti-rheumatic drugs or DMARDs that can be used to treat some of that higher levels of inflammation.
So I think if you're not sure, it's never bad to check in and see what type of arthritis you have. But what I would say is that for many cases, if you fit the picture of soreness in the joint and stiffness isn't sort of the main thing that's not going away in the morning, you're likely to fit this other category of osteoarthritis, and would very much benefit from slowly but surely increasing some of your activity levels and thinking about what type of foods you're having in an aim to try to reduce these body-wide low levels of inflammation.
Is it a common type of arthritis? I don't know the stats off the top of my head.
Osteoarthritis? Yeah, it is.
Excellent! We had a question emailed in, and that was a really great question. We talked in the past webinars about how we talk about our pain and how we perceive our pain. You know, the way we think about it can have an impact on our future pain levels.
Someone had emailed in and said, "How do I talk differently to my family and friends about pain?" Most often this person has asked, "How's your knee?" So that's the go-to question, and she'd love to be able to explain quite simply what she's trying to do, and she says without boring people.
Do you have any advice for this person?
Oh, what a great question! I think it is a common challenge, isn't it? I mean, one of the ways that we often suggest is to possibly think of nice ways to challenge the words that people might be using about a certain body part.
So if they're saying, "Your bad knee," then we might have funny little ways that we might challenge it by just exploring the aspect of how their words can actually influence what we feel as well. That can be through a discussion, quite frankly, of saying, "You know, I really appreciate you asking about that. It's lovely to know that people care about me and are wondering how I'm doing. I would like to ask if you wouldn't mind not calling it my bad knee because I've actually found out some really interesting stuff that suggests that actually, things like that can contribute to the way that I feel about it and the pain that I feel.
Would you want to hear more about that?" It's crazy!
That might be one way into it where we might then have a discussion about how actually there are many contributing factors to pain. There are all of these different areas that provide credible evidence of danger, and words, and what we hear about our own body—that's actually one of them.
And so while, of course, it's not the driving cause of pain, it's all little things that add up. One metaphor that the NOI group uses a lot is this idea of the bilby in the bathtub.
So bilbies are little cute animals in Australia, but the idea is if we think about sitting in the bathtub and the water is starting to get pretty high and you've got all these other animals in the bathtub.
You've got a moose; you’ve got something else, and they're representing the different contributors to pain. So let's say it could be the moose is representing the fact that you do have changes in the joint. That’s happened; maybe another one is reflecting the inflammation that might be present there; another one is reflecting actually the fact that you saw a really scary scan, and it freaked you out.
Well, appropriately, it freaked you out, and then you've got this little bilby that dives into the bathtub. Of course, it all overflows. Now, it’s not the bilby’s fault, of course, but it highlights the aspect that there are multiple contributors to pain.
I think kind of finding those little unique metaphors or stories that we can use to actually practice how well we know our information and the education by actually telling it to other people.
I think there is a real opportunity to provide that information and for you to be a resource for your own family because I am very doubtful that no one else in the family may have some aches and pains.
So it could be very, very useful information for them as well.
Absolutely! And I guess they could share a resource like this— the webinar with their family and friends.
It's a fascinating scenario because people, of course, are interested in how your knee pain is because that's what they've always talked about to you. And you might start talking about your knee pain and it might actually be really helpful for you, but if you're starting to think, “Oh, this isn’t,” then that’s a really useful way of approaching that.
I think most families and friends have the best intentions, don’t they? They have your best interests at heart, so they're going to be glad to do something that would help, we hope.
The same person had a second question: very simply, "How do I stay motivated?"
Which is a huge question because of course we know that that road to recovery is never a straight line; it’s never a nice, easy route! Any advice for this person to stay motivated on that route to increasing physical activity?
Yeah, I think that is such a hard thing to do. For anything we do in our lives that can be hard or challenging, staying motivated is a key aspect, and one of the most difficult things to do.
I guess I would suggest a couple of different methods.
The first being thinking about tactics, and so tactics are things that you're purposely doing to reflect and show the progress that you've made. As we were referring to, it's talking aloud about what you've learned and the steps that you're taking, and it can be just to yourself or it can be to other people around you.
I don't know—athletes do this all the time in terms of sport psychology—“This is what I've done; these are the things.” It's reminding yourself of already the many steps that you've already taken.
You can, as we mentioned, explain what you learn to others—it solidifies what you know—but I think a key bit of this is you want to focus on your current effort and achievements rather than just that final goal.
As we sort of referred to before, if we just think the final goal is way far ahead, it can be demotivating because it seems too far. So it's focusing on those step-to-step progressions.
It also means valuing our own insights are actually really important. So it's thinking and reflecting upon your own thoughts and experiences.
So, you know, what have you done so far? How have you felt doing that? What's the one that's next to come? How are you feeling about the progress that you're going to make or what you're going to do?
That can just keep us really grounded within the experience that we're having.
Then, I also think, to keep energy levels up—that really is staying motivated—it can be finding a partner in crime. It can be finding someone else that's going through this journey and go through it together.
It could be: you know, finding people that give you energy and that are happy to actually hear you talk about this different journey that you're on.
It can be when you have these kind of short and long-term goals and you're making steps toward them, properly relish in that achievement!
Like, really celebrate these steps! Maybe you've got a month's goal, and you make it to the end—throw a party!
Throw a party for your knee! That could be a really important thing to really say, "I have done this," because I think what's really hard is that it can be easy to not celebrate what we consider little wins when actually that's critical to keeping motivation up.
We do very similar things in research—we get so many rejections with everything, and we have these big projects, and then by the time you finish it, "Oh my gosh! I'm so tired of it! I don't even want to celebrate!"
Nah, you've got to celebrate those wins along the way so that actually you stay motivated towards that goal.
I think when you have in your mind a clear plan about what you want to do, that does make it easier to stay motivated because you will have those individual steps that you have planned that then you can reflect upon, you can celebrate.
I think just feeling that you're doing these things purposefully and you're doing these things yourself—like you're taking control of your life, of what's going on.
This is a big "you" thing! For me personally, I find that really quite motivating, knowing that what I'm doing is purposeful and it's empowering.
So those are kind of a little bit all over the place tips and strategies, but I do think it's multifaceted. I do not think it's one thing that keeps our motivation up, and it's us sort of checking in and seeing where we're feeling.
When we don't feel very motivated, going to that, having that person, or that event, that walk in nature—something that brings us back to feeling like we want to do it.
Brilliant! I think we're not good at celebrating our successes, are we?
We are not! So creating the big things and all the small things, and I don't think that's brilliant and going back to the previous question from the same person, it brings those people back in and shows them how important this is to you and how much you want to move forward.
Absolutely!
Yeah, I'm all for throwing a party for your knee!
Not enough reasons to celebrate!
It does, brilliant! Thank you very much for that, Tasha. That was the questions that we didn't get a chance to answer.
We also spoke at the beginning about how we were going to discuss some of your more recent research. You are really at the forefront of arthritis research, so I’m excited to hear this.
So yeah, if you wouldn't mind sharing a bit about where perceptual dysfunction, I believe.
Yeah! So this is an area that I've just been intrigued with for quite some time because when I was working as a physio, I worked with a fair number of people who had painful knee osteoarthritis as well as people who had undergone surgery for different things.
There was a group of people that would report that their knees or their limbs didn't feel right to them. They really had to pay attention when they were moving it—they weren't very sure where it was located in space. It just felt wrong to them—like too big.
It felt like it was swollen, even though it wasn't. So that kind of just got me down this route of trying to understand what's going on there.
Not everyone may have experienced this, but you might have had feelings where you're more likely to trip with that leg or stub your toe on the side that you have a sore knee or a sore hip.
Those are kind of little things that maybe there might be something going on in terms of how your brain is processing the incoming sensory information from your limb and how what it's doing to use that information.
Some of my work showed that people with osteoarthritis—and this is people with painful knee osteoarthritis—they weren't as good at localizing touch.
So if we touched them on the skin with two points, and they had to tell us whether it was two points or one point, what we found was that it was less precise.
The information coming from touch isn't telling people with knee osteoarthritis as precisely as it is for people who don't have knee osteoarthritis.
Similarly, we found that some of the brain maps that help us coordinate and plan different movements don't seem to be working quite as well.
This suggests that information from touch and from the proprioceptive sense—your ability to know where your limb is located in space—doesn't seem to be as precise.
Meaning that maybe that makes sense why we're more likely to feel like we're tripping or not knowing where our limb is located in space.
The reason I was quite interested in those is because, actually, in other chronic pain conditions, if we train those different senses—train touch, train proprioception—oftentimes pain reduces.
So it kind of raises the possibility that these might be new potential treatments for people with osteoarthritis that don't involve drugs; they don't involve invasive surgery.
They involve actually training how good our senses are working so that it can better give you information about your joint or your limb.
Then we also— That's sort of—you're not aware that those things really are different, the way that we tested them.
We also developed a questionnaire that helped us explore the awareness of your knee. It included items like, "How often does it feel like your knee is not really part of your body?" or "How much attention do you need to focus on your knee?"
"My knee feels like it's bigger or swollen." That gives us almost a score of how frequently people feel these different, kind of weird sensations about their knee.
We found that this score seems to matter. For example, people with higher scores on this questionnaire—suggesting there might be more changes to how this sensory information is being processed in the brain—we found that the higher scores on this were related actually to higher clinical impairment.
So, higher pain levels, it's related to higher disability, higher fear of movement, and anxiety.
This made us sort of think, "Well, maybe this matters." So we took a look, and we had the scores that people had on this questionnaire, and we had people undergo an exercise program.
They had 20 minutes, two or three times a week over three months. This was lower limb stretching and strengthening exercises that were supervised by a physiotherapist.
We found that people that had higher scores on this questionnaire—suggesting their sensory processing doesn't seem to be as precise—potentially for this body part, we found that those with those higher levels of body perception disruption did less well with exercise.
So 80 percent of them were non-responders to exercise, so they didn't have a large reduction in their pain.
This suggests that this might matter. Maybe if we're not sure where our limb is located, and we're undertaking exercise, maybe it makes us less able to engage in exercise programs. We don't really know!
But then we also explored if this might have a role in people who have undergone a total knee replacement surgery, and they’ve unfortunately developed persisting pain after that surgery.
What we did is we took a sample of people that were undergoing surgery for their knee, and we followed them over time and measured—using this questionnaire at baseline to look at levels of perceptual impairment.
We actually found that their baseline level of this perceptual impairment didn't predict necessarily who developed pain, but in the people that developed this persisting pain after surgery, they did not have an improvement in this perceptual dysfunction—this perception of their body.
So almost it was very slow to change a little bit, but they still had very high levels of this, which suggests that maybe this perceptual dysfunction or this change in body awareness might be contributing or playing a role in surgical outcomes.
Again, many of these things we might be able to target. These kinds of body awareness changes with various treatments that don't involve drugs and don't involve another surgery.
So, yeah, we're really excited to see if some of these things might have really nice effects on either helping pain or potentially preventing post-surgical pain from occurring after surgery.
All this stuff is super new, but it's things that I guess we're really interested in exploring because I just have such a thing for—I want to look at aspects that we don't necessarily have to go back in and operate again because it's hard for people to undergo those surgeries, it's stressful.
What can we do? We've got to understand this more! So yes, that is ten years of research in about five minutes.
No, that is fascinating! I appreciate that. I've got some questions that I appreciate as you say this is new stuff, so you may not have the answers yet. The answer may be in a few years' time.
But are you kind of saying—even if you're speculating at this point—do you think that somebody who's got these symptoms, who's like, "Yeah, you know, I feel clumsy on that leg; I feel like it feels much bigger than it is," etc., that they might not respond as well to physical activity, or do you think that they might not respond as well to physical activity until that joint position or sense is treated and improved?
Yeah, great question! I think it's actually probably two things. Based on the data that we have, I think that they will respond to physical activity, but it will be slower.
So although when I was talking about, you know, 80 percent were non-responders, we were pretty strict with our criteria—like they had to have a 50 percent reduction in pain, so it’s a really big change in their pain.
They still did have some reduction, but it just suggests that that might take longer.
It does not exclude the possibility that if we target that first, they might have a similar trajectory as people that we don't see this in. It’s important to point out that in that study, we didn't have a control group, so we just had the people undergoing exercise.
This means that some of those changes over time just occur naturally, as we often see what it's a technical term called "regression to the mean."
Often we get people that come into trials when their pain is quite bad at the start, and it would settle down anyway. So we do need to do more work to really understand that a bit more, but to me, it just raises an interesting question because we don't know.
If we start to look at that and see what targeting that early has, that could be really helpful. Because I don't know about you, but if I start walking and doing things, and I'm not seeing improvement, I'm going to think that's not working for me, right?
So trying to motivate and convince someone to keep going even though they're not seeing improvement just because their trajectory is going to be less fast—that’s actually a real barrier.
So to me, it raises a really important question to follow up on.
Excellent! And the—You mentioned that there may be treatments that don't involve surgery. What might that look like in the future if we were treating this sort of thing?
Yeah, of course! So some of that there are some that are a little bit more established—that's called tactile discrimination training—where what you're trying to do is just determine where you're being touched on a limb.
So you have lots of different points. We give different types of stimuli, so it might be, you know, the end, the pointy end of a pencil versus the eraser end.
You have to say, you know, point one, you touch point one, and it was dull, so it's requiring you, I suppose, to attend to that area and discriminate very distinctly where you're being touched.
We know different training like that can help refine some of the maps that you hold regarding touch in your brain.
That one is one that has been used before in other conditions.
Another treatment—and it's actually people may have heard of it or aspects of it, and that's graded motor imagery. That is used for often conditions like complex regional pain syndrome, but some of the stages of graded motor imagery may be relevant in doing that.
Particularly the first stage, where you're doing what are called left-right judgments. You see an image of a body part, and you have to determine whether it's a left or a right body part.
Based on brain imaging studies, we know that when you're making these decisions, you're actually needing to mentally maneuver your own kind of virtual limb into that posture of what you see.
So if you practice that task, that can be helpful to try to retrain and improve some of those brain maps.
It might also be proprioceptive-type training where we can move a joint in a certain direction or a certain amount, and we have to get you to tell us how much it moved and what direction!
Or doing different matching tasks to try to match this one, and then you close your eyes and you have to do your best to match the same angle.
It's practicing precision in these different movements.
There’s also—in terms of—we do see some evidence to suggest that if we give people a picture of their own knee, they'll actually choose a knee that's larger than their actual knee size.
This might be something that we can target. We've done some—we call them body illusions—where we use a technology called mediated reality.
It involves real-time video, so you see your own body in front of your eyes; you can move it around—it’s yours—but then, with a computer program, we manipulate what you see.
We can make your knee look big and stretched out, almost like nice and tractioned and elongated. We found that one illusion reduced their pain by 20 percent, and if we repeated it—10 times—it reduced pain by 40 percent!
So some of these things—these weird things where we’re manipulating how a body looks to you—actually have links. We know that there are links between your different senses, and it seems to matter to the pain you feel.
All of those things are ways that we could start to explore this as a treatment to target changes in body awareness or perception.
Brilliant! So what I'm thinking is if somebody is thinking, "That's me; this sounds like me," that there are things there that they could take to their physiotherapist—like graded motor imagery—to work on.
I wondered if the questionnaire that you mentioned is that out now for healthcare professionals to use, or is that yet to be published?
Yeah, no, it's out! I'm very happy to share a version of it.
There was—it was originally created actually for back pain. So I think there's a back version, a knee version, and there may be a shoulder version as well.
Because it’s actually very similar-type things if it’s almost—it comes from the stroke literature!
The idea of neglect, where suddenly you don't pay attention to one side or one part of your body—and this isn't neglect—it's not anything like that.
It has items that capture similar things, so yeah!
Very happy to share those.
I think they're interesting things because all of us feel some of this sometimes. If you don't feel this, don’t feel worried that something's wrong with you, that you're, "Oh my gosh, I'm never gonna respond! I'm not going to do well with exercise!"
No, that’s not the case at all! Because remember even in the study that I talked about where we had people exercise, 20 percent of people that did have these higher levels of perception dysfunction, they still did really well with exercise.
So it's not a be-all, end-all; it’s not a bad thing! But what it helps us to do is just to better understand each individual's experience.
Because that's the thing—we all know this: every single person is different, and so the more questionnaires or tests or techniques that we have to better describe your picture, the better we can make hypotheses and guide where we might want to try our treatment.
So please don’t feel alarmed or worried if you think that that fits you, but rather think, "Huh! I might have another opportunity for improvement."
So it's just part of the picture!
Brilliant! Thank you very much, Tasha.
And that brings us to the end! So thank you very much again, as I say, to Tasha.
Thanks to everyone who's watching. Before you stop the video, I would like to draw your attention to the survey that you'll find if you're watching this on YouTube; there'll be a link just underneath this, and if you're watching it on our website, it's under the thumbnail of our video.
That is a link to the survey that is still open! As you can imagine, we do what we do because we hear back from you guys about what works and what doesn’t.
It really helps us get the funding for these sorts of events and make our future events even better if you can tell us what you enjoyed and what we can do better!
So if you can fill in that survey, we’d much appreciate that. If you've enjoyed this series of webinars and you've gained something from it, let us know!
We’re at info@flippingpain.co.uk; it’s flipping without the G, as you can see there. You can also get us on social media at Flipping Pain.
I must thank Haywood Middleton and Rochdale Integrated Care Partnership for all their support for this series of webinars.
A huge thanks to Associate Professor Tasha Stanton, and thanks everyone for watching!
Thanks again! Bye-bye!