August 1, 2024 • 46 mins
Dealing with pain through injury, whether it be physical or psychological pain, is a major part of the day to day difficulties for anyone dealing with an injury. Adding pain to stress, isolation and uncertainty brings with it a bevvy of complications, but what if there was a way to work through that pain without yet more medication.
Dr Tania Gardner is a Lecturer in Physiotherapy at Sydney School of Health Sciences and Senior Physiotherapist in the Department of Pain Medicine, St Vincent's Hospital. She joins My Social Support Network's founder Dr Caroline Howe to discuss chronic pain management and the idea of joy in recovery.
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Episode Transcript
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S1 (00:01):
Hello and welcome to the My Social Support Network podcast,
a series to guide you along the path to recovery
while on workers compensation. In this series, we will answer
questions from you and provide information from experts and people
with lived experience currently going through worker's compensation and those
who have made their way to the other side. Through
these interactions, we'll be giving you tools, advice, but most importantly,
(00:24):
encouragement on what can be a stressful time when you're
also recovering from an injury sustained in your workplace.
S2 (00:31):
Pain is really common. 20% or 1 in 5 people
in Australia will experience pain, so people who have chronic
pain are not alone.
S1 (00:40):
On today's program, Doctor Caroline Howell is joined by Doctor
Tanya Gardiner from the Department of Pain Medicine at Saint
Vincent's Hospital in Sydney to speak about pain, pacing and
the joy of movement with exercise through recovery. We want to.
S3 (00:53):
Welcome Doctor Tanya Gardner from the University of Sydney, who
is a pain physiotherapist. Tanya has a PhD in pain
led goal setting and has been developing the reboot online,
which is the first multidisciplinary pain management online program. And
it's part of This Way Up platform. We want to
thank her for all her insights and can't wait to
(01:14):
get chatting. Tanya, I'm so excited to speak to you
for multiple reasons. One, because you and I have known
each other for a very long time, and I'm so
grateful that you have found time to speak to us today.
S2 (01:30):
Thank you for having me. So I'm excited to be here.
And and when I did see your podcast, I thought,
what a great idea. And yeah, just really wanted to
be able to to give back as well. So so
thanks for having me.
S3 (01:42):
I'm going to start with the question around what is pain?
S2 (01:47):
Oh that's a big question. So what is pain. And
I think that is such a loaded question. Um, and
there's no simple answer. Pain is complex. Um, it is
a necessary perception that we need. It's a signal for
us when we have actually injured ourselves, and it's a
(02:07):
warning signal that something is going on that we need
to pay attention to. And when that system, the pay system,
works really well, pain is great because it saves us
from further injury, um, and helps with the healing process.
But with a lot of people who have pain and
have pain long term, that system isn't working as well
(02:30):
as it should. But I think pain is also an experience. Um,
it's a physical experience, but it's also an emotional experience.
And when we look up the definition of pain and
there's an International Association for the Study of pain actually
defines pain as a sensory and emotional experience. So it's
not just that physical pain, but there's an emotional aspect
(02:52):
to pain as well, which is, I think, really important
to to grasp. Pain is really common. So chronic pain, 20%
or 1 in 5 people in Australia will experience pain.
So that is uh, super common. So people who have
chronic pain are not alone. And the way you experience
pain is really individual. It depends what's going on for
(03:14):
you and for you as a person, for you, as
a person, within your social context and for you as
a person and what's happening in your body. But it
can feel really isolating and it can feel like you're alone.
But I think one thing if you take away from
today is that you're definitely not alone when it comes
to chronic pain.
S3 (03:34):
You know, so many things start to come up in
my mind when you talk about that, because we have
physical injury and now there is this rise of psychological
injury as well. And people feel pain. Mhm. How does
our body then start to process pain. And what does
the brain do. Because it's very difficult to explain to
(03:55):
people that when they experience a psychological injury they may
also feel pain. And then when you have a physical injury,
you're going to feel pain but also the emotional side.
So what does the research say about that or your work.
Talk about that.
S2 (04:11):
Yeah. So I guess I don't really discriminate between physical
pain and psychological pain. I think it's all meshed in
into one. And I think I think of it like
a soup. Right. So we've got lots of different ingredients
in a soup. Um, and sometimes that soup has got
lots of emotional pain in it. Sometimes it's got the
physical pain. Um, but there's always a bit of bit
(04:33):
of both in there, and that might change depending on
the person, or it might change depending on the time
or what point in time you're going through your pain
journey as well. But we do know physiologically that, um,
the perception of pain, um, occurs in the brain. Okay.
And so, you know, if we think about what happens
(04:55):
when we do injure ourselves, let's say right now while
you're listening to this podcast, your brain is constantly getting
messages from your brain, from your body. So and your
body is telling your brain that you're sitting or standing.
It's telling your brain that you have, um, a jumper
on if you're wearing glasses, if you're feeling a certain temperature.
(05:17):
And so your brain is constantly getting all these messages,
and your brain's deciding at any one point in time
what to listen to. What messages do I need to
be listening to that might give me a sense of
danger or or harm. And so that's always happening. But
of course, your brain's going to turn off those messages
(05:38):
that aren't harmful. So it's not going to listen to
the message that you're sitting because it doesn't need to.
It knows from history that you're in a safe space
or it doesn't listen to those messages that you've got
clothes on. So your brain is constantly deciding what to
pay attention to when we injure ourselves, when we have
an acute injury. So let's say we cut our finger.
(06:00):
Our finger will send a message up through the spinal cord,
up to the brain to tell the brain there's something
happening here on my finger. There's been some kind of
pressure applied to my finger, and it's ended up with
a cut. So your brain will listen to that message.
And because we've got an acute injury, we do need
to look after that part of the body. And your
(06:23):
brain will pay attention to those messages and it will
send out a perception of pain. So it's not until
that brain processes all of that information that we actually
feel pain. And so then we feel pain, and then
we also activate other parts of our brain. So it activates,
you know, our arm muscles to move our finger out
of the way or it will, um, open up memory
(06:46):
centers so that if we've cut ourselves in the past,
it will tell us what to do. It will give
it an emotional response as well. So it might be
that we're fearful of it, or we might not be
so fearful of it, depending on on on who you
are and what you know. Um, so the messages from
the body are processed by the brain, and then the
(07:06):
brain will decide whether we need to feel pain. Um,
and then it will send out those messages of pain
If it doesn't think we need to feel pain, it
will just turn off all the messages from the body
or inhibit those messages. And then we don't need to
to pay attention to that. And that's a great system.
We need pain to protect us when we do have
(07:28):
an injury, um, or some kind of, um, tissue damage.
And then as the tissue heals, the pain perception dies
down and over about 6 to 12 weeks after an injury,
we tend to see that pain perception die off and
we don't feel that pain anymore. And so the system
works really well. But some people, and we don't know
(07:50):
why one person does or doesn't, some people that pain
perception keeps on going on and it doesn't die down.
And so after the tissue is healed, there's no more damage.
But the pain perception keeps on going. And so we
know things like, I guess ongoing stress and emotional distress
(08:11):
will keep on activating those parts of the brain that
actually process all those pain messages. We know if there's
social context, um, trauma, um, that can also keep on
those pain perceptions if there's fear about what's happened. So
if you've injured yourself, you've had pain, and then you
(08:32):
start to feel fear about the injury or beliefs, that
movement is going to increase that pain. We also know
those belief systems and thoughts actually activate the pain center.
So there's lots of things that we know that keep
that pain perception going. We just don't know why one
person will have that chronic pain response compared to another person.
S3 (08:57):
It's so interesting hearing you talk about it and from
a completely different perspective. So my background is as a
rehab counselor, and we often talk about being able to
take those steps forward and how the physical and psychological
pain are very connected. And we also then layer in
the social pain aspect as well, because when we see injuries,
(09:22):
a workplace is full of people and whether it is
a physical injury or it's a psychological injury, you tend
to find that the next thing that will happen is
that people become isolated and there's almost no stop system
for someone who has been injured now becomes isolated. There's
no circuit breaker. And that pain response, whether emotional or physical,
(09:47):
just keeps on firing. And it becomes almost like this
brick wall that gets layered around people that they can't
easily find. You know, that ladder to jump over because
they've been encapsulated by. And when you explain it, it's
the brain protecting you. It makes so much sense, because
if my brain is going to protect me from the
(10:08):
things that I now perceive as not safe, then I'm
better off being in this space. But unfortunately, it doesn't
actually help.
S2 (10:16):
Yeah. So, you know, the brain is processing and allowing
these messages or is processing the messages as dangerous, but
they're no longer dangerous. So there's that malfunction. But I'd
love to pick up on that brick wall analogy. So
one of the first things we do in our group
pain management programs is we start to talk about that
(10:36):
brick wall of pain, and that's what it often feels
like for people. They're stuck behind this brick wall. And
often it's, um, it's perceived as just pain. But that
pain brick wall is made up of so many things,
so many bricks. And so it could be, you know,
the stress of work, the financial stress, the isolation, anger,
(10:58):
failed medical appointments. You know, how many times did do
you go to the doctor and, um, or a specialist
or a physio and nothing works. Social isolation, relationship issues,
it all makes up this big war of of pain. Um,
and one of the things we try to do with
pain management programs is really first, identify what the brick
(11:20):
walls are for for you as a person, but then
start to work on one brick at a time and
start to loosen one brick, and then we find another
brick loosens. And that's, I guess, the analogy that we
would work with, um, in the pain programs.
S3 (11:33):
I'm smiling because many years ago. Oh, gosh, I would
have been about 24. You know, at 24, you know, everything.
And I stood in front of a group of refugees
who had recently arrived, and I was like, let's go
get a job and let's move forward. And then I
did a task and I gave everybody a piece of paper,
(11:54):
and I said, why don't you draw me what life
looks like for you in five years time? That's how.
How not knowing I was. And this man looked up
at me and he said, how dare you? And I said,
what's wrong? I said, great activity. And he said, how
dare you think that? I can see that far ahead
when I can't even see tomorrow? Yeah, and he was
(12:18):
the one that introduced that idea of a brick wall
to me. He said, I feel like there's a brick
wall in front of me, and it's so interesting that
you said that, because what I then started to do
is I would actually give people a piece of paper
and I would say, draw the brick wall and put
one problem in each brick and pick one thing that
(12:38):
you can control, because I think layered into that is
that sense of lack of control that you actually feel
like you cannot control anything. So if you can give
people just one little thing that they can do, you
can then find that the other bricks start to fall
away as well. Yeah.
S2 (12:55):
Yeah. Absolutely. So we would call it pain self-efficacy. So
it's that, uh, confidence in yourself that you can actually
move forward with your pain. And so yeah, absolutely. Working
on something that you can achieve is really important. And
then I think there's that lack of, of of self-efficacy.
You've lost that lack of self. Who are you now
(13:17):
if you can't do what you used to do, what's
my role now? If I've got pain and I can't,
you know, be involved in everything that I used to
be involved in. So I think it's really important when
you're thinking about that brick wall because it's overwhelming, right?
You're stuck. You're stuck there. And we want to try
and help you move forward with that. So, um, the,
(13:38):
the walk and can feel really big and really high.
So we just want to start with something small, one
little brick. But it does. It's really nice to see
when we're working with people that those bricks can start
to loosen the ones next to them as well.
S3 (13:52):
What have you found works? What are the things that
you're finding actually starts to help people move forward?
S2 (13:59):
Yeah, I think the first thing I do with patients
is just talk to them about pain. I think it's
important to understand that your pain is real. So I
know often, you know, when you hear that the pain
is all in the brain, often people will walk away
and think, oh, she thinks it's just in my head.
And that's complete opposite. Your pain is real and all
(14:22):
pain is in our brain is processed in the brain.
But your pain is real. And I think it's really
important to be listened to and validated. Um, but then
also start to understand what pain is and, and how
chronic pain works. I think that's the first step, because
what I guess I would be doing with talking about
(14:42):
chronic pain is I'm asking you to change your belief
about pain in a really big way. So we grow up, um,
really always being told to avoid pain, to not do
things that cause us harm and pains that signal that
something is harmful. And now, as a pain physio, I'm
telling you. Well, you know, the pain isn't a signal
(15:02):
of harm anymore, and that's a big shift. The next step,
I think, is acceptance. But I don't think that's an
easy one. That's a really you can accept and then
drop off and and that's a bit of a journey
I think. Um, and that gets easier as you start to,
I guess, re-engage with things, um, and start to, to
live and doing things that you enjoy. And then there's
(15:25):
lots of different tools that we would be teaching patients
for pain management. So I like to, to talk about
giving someone a toolkit for pain management. And each tool
is useful. It's more or less useful to different people
different times. So there's probably not one thing that helps
the most. It's about giving yourself a toolkit for pain management.
(15:48):
There's lots of things in that tool kit, so the
first one would probably be movement and movement with some
joy and movement with some mindfulness. Um, so I don't
talk about exercise. I talk about movement. And we know
in terms of exercise or movement with chronic pain that
any type of movement is going to help be helpful.
(16:09):
We've looked at all different types of activity, physical activity,
and they're all helpful. So there's no one exercise that's
going to be better than another. It's really about choosing
something that you want to be doing and moving in
a paced way. So often when we feel good, we
go out and we do heaps of activity, and then
(16:30):
we end up burning up and crashing out the next day,
and then we end up over the long term having
less tolerance to activity. So pacing, I think, is one
of the key strategies that I see work with with
patients with chronic pain. It's a tricky one to learn,
particularly if you're someone who is a doer and doesn't
find saying no easy. So if you're push push pusher,
(16:54):
that's going to be a challenge for you. But it
it works with chronic pain. So you know, in the
corporate world, in daily life we do sometimes have to
push through. Right. And it works for us. But with
chronic pain it just doesn't work. And we need to
learn how to pace. And that's pacing. Might be pacing
your washing, doing the washing. I might be pacing reading
(17:16):
it might be pacing, walking, whatever you want to get
back into doing. Pacing is the first thing I would
be doing, um, with you and starting off really, really
low and gradually, um, increasing that really slowly. So pacing
is one tool.
S3 (17:32):
Well, I just want to ask, how would you go
about moving with joy? Now I have a two. And
the thing is, a couple of years ago, just by accident,
I started a business called Joy fit. And it was
I became a personal trainer, and the reason for that
was that I had noticed many people with cancer, of
(17:57):
which my sister and my neighbor were one, were told
by their doctors, don't move. And what had happened was
I started joy fit so that people could, you know,
not be worried about am I wearing the right colored
spandex today? And is my hair nice and my fingernails,
you know, just to show up and move with joy?
And so we would have these activities like I would
blow bubbles or the lady who was having the cancer
(18:19):
treatment would blow the bubbles, and everybody else would have
to smash the bubbles. And if a bubble hit the floor,
they'd have to do ten burpees. Hilarious fun. But what
is your perception of? I can see some of the
faces online. Don't think that that's hilarious fun at all,
but I trust trust me it is. But what would
your interpretation of movement with Joy be?
S2 (18:38):
Yeah, so I think, you know, being that physio I
guess and and part of our role I guess is
trying to get people to move. And I often see
a lot of fear and anxiety around that. And I
get it. If you're feeling pain and your belief system
is still telling you that pain is harmful, it's no
surprise that you're going to be fearful and anxious. But
(19:00):
then your brain actually learns that response. It starts to,
you know, if you're going down a track and you're
going down the same track all the time, you're going
to wear that track down. That track gets really deep.
And it's the same sort of thing in terms of
that response to movement. So it ends up that just
the thought of moving then gets the fear and anxiety
(19:20):
response in your body. So it's about trying to find
a way of moving either in a space or getting
the environment that is joyful for you. So I'll give
you an example. I had a patient who had a pacemaker,
and she was a senior lady, and she came to
the clinic because she developed this shoulder pain, this chronic
(19:43):
shoulder pain after getting the pacemaker in. And of course,
when we get a pacemaker in, you know, obviously that's
really scary. Um, she was quite anxious about the pacemaker, etc..
So I was, you know, having a chat to her
and just sort of trying to learn what her journey
was and her story was around the pain. And I
found out that when she was younger, she was a
ballerina and she did lots of ballet dance. And when
(20:05):
she started to talk about that, her face changed. She
became you could just see this joy in her face.
So for her, you know, homework, I guess, is I
asked her to choose some music that she loved to
dance to. Um, and then I asked her just to
do one simple exercise to start getting her to move.
(20:26):
That's it. And then she came back two weeks later
and she had just it was just a different, different person.
She had chosen some music and she had actually started
to move her arm and do a lot more than
I'd asked her to do. But she did it with
that music, and so she had joy already, sort of
instilled in her from the response of the music. Um,
(20:47):
and then to add in the movement with that, um,
was enough to, to sort of, I guess, get her
unstuck in terms of that fear and anxiety response. Other
people might be, you know, they love going to the
beach and they love listening to the sound of the waves.
And so it's about just get down to the beach.
And even if you just, you know, walk from the
(21:08):
car to, to a bench and sit and listen to that,
that's movement with some enjoyment. So it's about setting up
that environment. And sometimes it's it's that external environment that
gives you joy. And that's enough to then start to
blend that movement with that enjoyment. And then after a while,
you're starting to build a new track in your brain.
(21:30):
that sort of connects movement with joy rather than movement
with anxiety and fear. So it's working out what what
you enjoy doing.
S3 (21:40):
How do we then, you know, in your work that
you've done? And part of the reason that I was
so interested to talk to you is because I've often
found that people in that physiotherapy space tend to look
at things from a very medical model, but you proactively
have looked at things from multiple angles. And so that
(22:03):
biopsychosocial model. Yeah. Is there a link in the research
between that physical and that social pain?
S2 (22:10):
Absolutely. Yeah. Yeah. So, um, we do know that patients
with chronic pain will feel isolated and isolate because for
lots of reasons. But often it is because they feel
like no one else understands or they don't want to
be a burden on other people. Um, but we know
that if you can reintegrate yourself with a social environment
(22:34):
that gives you some joy and social connection, right? Is
so important with joy and how we feel connected to others.
And that's why group programs often work really well, because
you're sort of developing this group becomes a support network
for everyone within the group, which is lovely to watch.
I really love watching that growth in a group. And
(22:54):
so it helps in terms of pain management because you've
then got a safe space. Um, I guess that gives
you some joy and safety in a social group. So
it's really important, I think, to to maintain that social import.
S3 (23:11):
I think that that's just one of the barriers, particularly
in workers comp, that you can come up with, is
that treatment and processes are very aligned for physical injury.
And then when you move into that psychological injury space,
people feel pain and they stop moving and they're scared
to go outside. And that brick wall is very, very similar.
(23:32):
But it's so good to hear from you, who is
currently doing all the research in the space that the movement,
that that socialization, taking those small steps is just as
critical and important in psychological injury and recovery as it
is in physical injury recovery.
S2 (23:49):
Yeah, absolutely. And so part of my PhD was looking
at patient led goals. So I did some goal setting
with patients with chronic back pain. And you know as
a physio I thought oh we'll see whether this works
or not, but we'll give it a go. Um, and
what was really interesting is one, it worked amazingly. So
patient's pain actually decreased as they set goals and and
(24:14):
were able to implement the goals. What was really interesting
for me were the types of goals that people set.
So I just let them set any goals, didn't have
to be activity, didn't have to be sort of physio,
and only half of the goals were sort of activity based.
The rest of them were all about relationships, work, relationships,
(24:34):
coping with pain and reintegrating into things like dance or
getting back to playing music. Um, and so it was
about taking small steps towards that. And so, you know,
part of the strategies for the goals might one week one,
it might have been just look up where your dance
classes are. That's it. You don't have to go out
(24:56):
and do anything. And then the next step might be
just go and sit and watch a dance class and
see whether that's what you want to do. And so
it was that slow build up of the skills and
confidence to get back into doing things. And then once
people did start to do that, their pain actually improved,
which is a result we weren't expecting. So that was
(25:18):
really nice to see. But you need to do it
slowly and you need to not overwhelm, I think yourself,
because if you're getting overwhelmed, you'll have a stress response,
and that's just going to feed back into that pain
response as well. So it's got to be slow and gentle,
and you need to be gentle and kind to yourself
while you're doing it.
S3 (25:35):
I've got so many things to say all at once.
A couple of weeks ago we interviewed someone for financial
counselling and she's just a financial counsellor, not coming from
a health background, but she too said you need to
take things in very small steps, one problem at a time,
so that you keep the stress response down. If you
talk to a psychologist one step at a time, don't
(25:59):
be too hard on yourself. And now, as a physiotherapist,
one step at a time. I find it baffling that
even now, we very rarely have these multidisciplinary conversations. When
we talk about wellbeing, we talk about social goals, physical goals,
psychological goals, financial goals, spiritual goals. And yet everyone says
(26:20):
the same things. But we're not all saying it together.
And so it becomes very confusing for people. Yeah. So
it's lovely to hear that we're all on the right track.
And one of the pressures I find for people in
the workers comp framework, though, is time frames within workers
comp are not aligned to recovery goals for individuals, which
(26:42):
automatically increases pressure and therefore delays recovery outcomes. I was
talking to an academic from Griffith University today, and they
were talking about a PhD student up there who was
doing a PhD on the benefits of synchronized movement. And
what is so interesting is that if you can synchronize movement,
(27:05):
they're finding that it it is they're doing the neuroscience
behind it. People's brainwaves are starting to sink in. It's
reducing their level of stress and it's increasing their sense
of belonging.
S2 (27:20):
Yeah. Interesting. Yeah yeah yeah yeah. I guess the other
thing with, you know, I would do with patients is
mindful movement, Um, which is probably what's happening is probably
similar mechanisms going on there where because often patients with
chronic pain have lost that proprioception, they can't feel where
their body is. There's a a dysregulation in that feedback
(27:44):
from the body. In the brain it gets a bit foggy.
So I think it's working on two levels in terms
of improving that proprioception. But it's also, you know, we
know that mindfulness will also help to, I guess, unwind
that stress response. And so again, we're connecting movement with
something that's, um, decreasing the stress response. And that track
(28:07):
of joyful movement, um, is starting to be worked on again.
But yeah, interesting in terms of the connectivity that, that
they're finding.
S3 (28:15):
Yeah. It's some and also the different things that people
just decide to explore. How would a worker who has
experienced an injury best explain to the insurers or the
doctors some of the things that we've heard today? Because
if we can empower people listening to know what to
(28:36):
ask for or to ask for that help, what what
would be a tip that you could give them?
S2 (28:42):
I think it's about talking about the chronic pain model
and sort of talking to your GP about, you know,
this is my understanding of chronic pain and maybe having
that discussion around that chronic pain model so that both
both of you are on the same page in terms
of acute pain or chronic pain. And I think, to
(29:03):
be fair, we're only now starting to see a shift
in the education and training of of healthcare professionals. Um,
and so it's going to take a while, I think,
for that to, to come through. So a lot of
GP's don't get a lot of pain management training. So
it's about starting that conversation with them about the chronic
(29:24):
pain model and starting the conversation about, well, what tools
can I use and and where can I go to
to learn those tools? There are there's an online pain
management program which I developed when I was at Saint
Vincent's Hospital. So it's a free online pain management program.
So that might be a nice way to start talking
(29:45):
with your GP. And your GP just needs to hop
on and register on. It's called This Way up, and
then they can prescribe the course or program to the person,
and maybe they can work through it with their GP
and go through this eight lessons and they learn all
the different tools and strategies. So that's one way, I
think of starting the conversation about chronic pain and pain
(30:08):
management and then talking about, you know, what are those
bricks in the wall get? You know, the GP probably
needs to understand what those bricks are, so they can
also help. In terms of what strategies can we use
to to start knocking down one brick at a time?
There's lots of common bricks that everyone has, but everyone's,
you know, bricks are individual, so you need to you
(30:30):
need to start to think about what are those bricks
for you and which one do you want to knock
down first and start thinking of a plan. And then
of course, trying to get clinicians that are actually have
got some pain management training is always a plus as well.
S3 (30:44):
In terms of transitioning back to work, how could someone
in working through pain, physical, psychological or emotional? How can
they challenge themselves or use pacing to feel better and
be able to return back to life.
S2 (31:05):
So thinking it's about returning to work. When I work
with patients, often I just I ask patients what they
want to get back to doing, what's important to them.
What has your pain stopped you from doing, and what
do you want to start working on? And I think
that's the best space to start with, because working on
something that you want to do, it's not a physio
(31:28):
telling you what to do. It's not your boss telling
you what to do, it's not the insurance company. And
so that for me would be the best way to
work with people, because I saw with my research that
when we let the person decide what they're going to
work on, they improved.
S3 (31:45):
And I think that's the best way of doing it,
even in workers comp. Because you're right, there are lots
of pressures, But we're talking about adults who were adults
before they had that injury. Therefore, people need to be
able to make a choice and take that control back
on what they want to do next.
S2 (32:03):
Yeah, I think it's um, you've then also got to
accept where you're at and accept what's happened to then
move forward.
S3 (32:12):
We just had a question from one of the the
group which is about the pain of injustice. Mhm. What
what are your thoughts around that and how do you
manage that from that pain management perspective.
S2 (32:25):
Yeah. So that comes up a lot. Why me. Why
did it happen to me. You know we have people
that have all sorts of injuries. Um and often we
can't give an answer to that. And I work really
closely with the psychologist when we run these groups and
there is no answer, we can't. We have no control
often of what happens. And that's really hard to accept that,
(32:48):
you know, we often think, well, we can control everything,
but often we can't. And so it's that uncertainty that
also feeds into the anxiety and fear of, you know,
if this has happened, what else will happen? Um, and
so it's about facing those emotions that you're feeling with
the injustice, but also need you're needing to come to
(33:09):
a point where you're accepting that that's what's happened.
S3 (33:12):
In fact, if you think about that, if that that
sense of injustice becomes a part of a brick in
the wall, you know, if you can actually write it down,
even if it's on a piece of paper and looks
like a brick wall, understanding it is about filling in
the bricks. Understand what is getting in the way between
here and your future. And the next thing is, once
(33:35):
you can see it, you've got the opportunity to accept it.
It is what it is. And that then allows you
to find the right people or the right tools to
actually start to work on one small brick at a time.
If you do more than that, you will lose all
your energy and you go back to square one. And
(33:55):
then how to set goals and bring in joy and movement.
Does anybody have any questions for our most wonderful doctor,
Tanya Gardner, who is joining us today from the University
of Sydney? And may all her students hear her brilliance
as she sprinkles through the airwaves this afternoon.
S4 (34:14):
Um, so sort of tied with repercussions for the employer,
I think the case is is also becoming vulnerable again
to being bullied and harassed. It's hard for us to
allow ourselves to be vulnerable when we don't have the
tools to protect ourselves in a physical injury, for example,
(34:37):
a sprained ankle. You might have that. But then to
protect yourself, you do exercises, for example, to strengthen that
ankle and you're more careful about not spraying it again,
but with a psychological injury based on bullying and harassment,
what tools can be available to us to see it
coming and protect ourselves from it down the track?
S2 (34:58):
Um, so I guess it's about first making sure you're
safe and making sure that the environment you're in is safe.
So that's my first thing in terms of response. We
can't control how other people behave, but we can control
how we respond to that. So it's about learning, understanding
your response to that and maybe, um, starting to to
(35:21):
modify that response in yourself towards that other person's behavior.
That's as much as you can do if you want
to stay in that environment and stay safe.
S4 (35:31):
Yeah, well, it's basically any environment we might go into.
So even even that, where do we learn how to
respond to that sort of treatment. Yeah.
S2 (35:40):
So that's all part I guess of, you know, CBT
and cognitive behavioral therapy starting to to identify when you
get that response inside of you, that might be a
negative response or a fearful response. And then starting to
first notice that. And so for me, I tend to
find that I notice my body sensations when I get
(36:02):
nervous or I'm about to get angry. Um, it comes,
you know, my stomach churns, I can feel it in
my chest and my head. And then I usually I've
learned how to go, okay, what's what's setting, what's about
to set off. Um, what am I thinking about this situation? Um,
and they're starting to challenge it because often it's, uh,
(36:23):
we have this self-talk that is really, um, sabotaging. Often
it's quite negative or judgmental about ourselves. And so it's
about starting to have little thought swaps, I guess. Um,
I call them thought swaps. Um, so swapping some more
helpful thoughts so that we can then start to, I guess,
(36:45):
what we call like a parachute down onto our response
to settle everything down. So that's stress response. Um, can die,
die down. But that takes a lot of practice and
a lot of hard work. Um, and we need to
start to be ready to explore what we're saying usually
about ourselves when, when that happens. Um, so I would
(37:07):
suggest that might be one way of starting to do that.
And sometimes it's just about writing a thought diary. So
I'll get patients, you know, they'll, they'll tell me about
something that they, that they respond to. And I'll say, okay,
well next time that happens, write down what you felt
physically and what you were thinking, what what thoughts popped
(37:27):
to your mind straight away, and what was driving that
response and what did you do? Did you back down?
Did you respond with anger? What was your response? And
then start to explore some patterns that might come up
for you as well.
S3 (37:42):
And that would also blend into that idea of building
a resilience toolbox, because in understanding your thought patterns, then
you know you can more quickly filter through the resources
and the tools that you need because it's terrifying to
start to do this. We've got another question. Thanks, Caroline. Um. Hi, Tanya.
(38:03):
I just wanted to ask.
S5 (38:04):
So since the beginning of my claim, I've become very
sedentary and I'm very out of breath. I'm also recovering
from some major surgeries and trying to get back into
just everyday living of like walking to the shower or
walking to the letterbox. Or it's a mental game, but
also it's a physical game for me. And so I'm
(38:26):
interested in knowing how do I push past that initial
trigger of pain that I get, so I can't stand
flat footed for more than about five minutes. I have
to shift my weight. I have to sit down, gather
my breath. I walk around our property with a plastic
chair in my hand all the time so I can
sit down every 200m. Um. I have been prescribed THC
(38:48):
and that's been working wonders. Like absolutely amazing. I have
been able to move more. I'm not out of breath
when I'm using it, but when I'm not using it,
I just can't push past that initial pain threshold of
like the first five minutes of being out of breath
and needing to sit.
S2 (39:04):
Mhm. Yeah. Um, so sorry that that's, you know, you've
gone through what you've gone through first off. And what
you're telling me I think is really common as well.
So I hear, you know, the sort of the five
minutes of walking and not being able to do things
and particularly people working or living out in rural regional
areas where they have these huge properties. Um, used to
(39:25):
do a lot of work with South Coast. So you're
not alone, I guess, is what I'm what I'm trying
to say so you can move forward. And, um, and
I've seen people people do that. It's about, first off,
starting with something that you want to do. What would
if you had to pick 1 or 2 things that
you wanted to get back to doing, what would they be? Um,
(39:45):
and then picking the top one. Um, and working out
what you can do at the moment. So, you know,
it might be that you can stand for five minutes
and you want to improve your standing. Let's just use
that as an example. I would say to start off
at four minutes. So what you want to do is
do your activity for as long as you can before
(40:05):
the pain starts, because as soon as the pain starts,
then that pain system just fires off and it's a
lot harder to settle down. And so you practice your
four minutes for a week or two, and then you
might increase it by 20s and really slowly increase that
activity and want you to take notice of what's happening
(40:25):
for you. Also, psychologically, are you getting anxious? And if
you are getting anxious, what are you saying to yourself
about increasing that activity or about the pain? And it
might be about starting to challenge those thoughts and beliefs
about pain as well. So remembering that chronic pain and
pain you've had for a long time is not a
(40:45):
signal of damage or danger anymore. Um, and so starting to,
to challenge that. But physically, we can start to really
slowly improve your tolerance to any activity that's important to
you is what I would get you to start to,
to think about. And then you can just slowly build
up on that. And I've seen it happen just starting
(41:07):
off really small. And you probably think like you're not
doing much, but you're actually retraining that pain system and
retraining the brain. And the good news is, is that
we know that we can retrain the brain. Um, and
it's retrainable. So you've just got to do it, but
do it really slowly and gently and be conscious of
why you're doing it. You'll get there. But you've got
to start off, you know, go slow.
S5 (41:28):
Yeah, it's the negative self-talk is probably what I'm very
challenged with because I just beat myself up about being
so unfit and yeah, yeah, useless and all these different
things that come, come to mind. So.
S2 (41:42):
Yeah. And be kind. So, um, you've sounds like you've,
you've gone through a lot and you survived it, which
is fantastic. Well done. Use that strength and resilience to
move forward as well. You've got strengths there that you
probably not giving yourself kudos for.
S3 (41:56):
What is your research found around that kind of Covid recovery.
And you know.
S2 (42:01):
So fatigue is huge. So that's the biggest thing that
we're sort of hearing from long Covid sort of clinics.
And again, with fatigue. Um, so it's it's quite interesting
for me to see a lot of the, um, the
commonalities between long Covid, um, also chronic fatigue syndrome. So
a lot of patients with chronic pain will have chronic
(42:22):
fatigue syndrome, a lot of other sort of, um, immunosuppressed
sort of conditions as well. We're thinking there's probably some
kind of immune response also happening in chronic pain patients.
But coming back to the long Covid fatigue is the
big one. Um, and again, that pacing that we talked
about is really important. So, um, in terms of your
(42:43):
stress response and fatigue and energy levels, again, if you
push too hard and too fast, your body's going to
just respond with stress. Um, and that will again facilitate
that fatigue. So it's about pacing and just, you know,
doing that slow, slow and gradual increase with your activity
and being okay with that. I think the hardest thing
(43:05):
when I'm teaching patients about pacing, um, particularly if you're
a go go getter, is that people get frustrated with
the pacing. And so, of course it doesn't work because
they get frustrated and stressed with the pacing and then
their pain increases. So you need to really shift your
way of, um, of how you're behaving, I guess, and
(43:27):
be okay with doing a little bit and going slow.
And if you're not used to that type of pattern, um,
that can be a challenge for you.
S3 (43:36):
Which again, goes back to that acceptance.
S2 (43:39):
Mm.
S6 (43:39):
Yeah.
S2 (43:40):
Yeah. Acceptance. And I think acceptance and pacing if you
can get those two, that's when I see people fly
and and do really, really well. Um, but it's probably
the two hardest things to do. Um, so yeah, sometimes
it's a journey to get there.
S3 (43:58):
Tanya, I want to thank you so much for coming today.
I have been so excited about having you on the podcast,
because we both come at wanting to support people from
very different perspectives. Yet there's this underlying tone of us
all wanting to do the same thing, and what keeps
coming up is choice and control. If people feel like
(44:21):
they're in control, they're going to start to get better.
But how do we create these scenarios for people to
give them the permission to be back in control, which
is difficult after an injury. If someone did want to
speak to you directly to ask more questions, how would
they do that?
S2 (44:39):
Yeah, they can just reach out, um, and, and email
me through my Uni of Sydney email, which is up
on their website. Absolutely happy to answer any questions as well.
S3 (44:50):
Thank you Tanya. It has been a pleasure. And everybody else,
I can see you all synchronized waving in a way
that creates belonging for all of us right now. Thank you. Well,
you've been listening.
S1 (45:00):
You may have found some of these concepts challenging, so
if you are needing help, please reach out. For more information.
You can follow us on our socials or if you
require urgent support, please reach out to the police or
the ambulance on 000 lifeline on 13 1114. That's 13
1114 Beyondblue on one 302 24636. That's 1300 224 636. The 24
(45:29):
hour mental health access line, which is one 800 015,
double one. That's one 800 01511. And if you think
you could benefit from some legal advice, reach out to
the Iro. Who could recommend some lawyers or someone to
help you with your current legal case. Our special guest today,
Doctor Tanya Gardner, is from Saint Vincent's Hospital Pain Medicine Clinic,
(45:53):
which you can read more about at w w w
dot s v h s.org a u that's w w
w dot s v h s.org.org. Thank you for joining
us today and we'll be back next time.
Hello and welcome to the My Social Support Network podcast,
a series to guide you along the path to recovery
while on workers compensation. In this series, we will answer
questions from you and provide information from experts and people
with lived experience currently going through worker's compensation and those
who have made their way to the other side. Through
these interactions, we'll be giving you tools, advice, but most importantly,
(00:24):
encouragement on what can be a stressful time when you're
also recovering from an injury sustained in your workplace.
S2 (00:31):
Pain is really common. 20% or 1 in 5 people
in Australia will experience pain, so people who have chronic
pain are not alone.
S1 (00:40):
On today's program, Doctor Caroline Howell is joined by Doctor
Tanya Gardiner from the Department of Pain Medicine at Saint
Vincent's Hospital in Sydney to speak about pain, pacing and
the joy of movement with exercise through recovery. We want to.
S3 (00:53):
Welcome Doctor Tanya Gardner from the University of Sydney, who
is a pain physiotherapist. Tanya has a PhD in pain
led goal setting and has been developing the reboot online,
which is the first multidisciplinary pain management online program. And
it's part of This Way Up platform. We want to
thank her for all her insights and can't wait to
(01:14):
get chatting. Tanya, I'm so excited to speak to you
for multiple reasons. One, because you and I have known
each other for a very long time, and I'm so
grateful that you have found time to speak to us today.
S2 (01:30):
Thank you for having me. So I'm excited to be here.
And and when I did see your podcast, I thought,
what a great idea. And yeah, just really wanted to
be able to to give back as well. So so
thanks for having me.
S3 (01:42):
I'm going to start with the question around what is pain?
S2 (01:47):
Oh that's a big question. So what is pain. And
I think that is such a loaded question. Um, and
there's no simple answer. Pain is complex. Um, it is
a necessary perception that we need. It's a signal for
us when we have actually injured ourselves, and it's a
(02:07):
warning signal that something is going on that we need
to pay attention to. And when that system, the pay system,
works really well, pain is great because it saves us
from further injury, um, and helps with the healing process.
But with a lot of people who have pain and
have pain long term, that system isn't working as well
(02:30):
as it should. But I think pain is also an experience. Um,
it's a physical experience, but it's also an emotional experience.
And when we look up the definition of pain and
there's an International Association for the Study of pain actually
defines pain as a sensory and emotional experience. So it's
not just that physical pain, but there's an emotional aspect
(02:52):
to pain as well, which is, I think, really important
to to grasp. Pain is really common. So chronic pain, 20%
or 1 in 5 people in Australia will experience pain.
So that is uh, super common. So people who have
chronic pain are not alone. And the way you experience
pain is really individual. It depends what's going on for
(03:14):
you and for you as a person, for you, as
a person, within your social context and for you as
a person and what's happening in your body. But it
can feel really isolating and it can feel like you're alone.
But I think one thing if you take away from
today is that you're definitely not alone when it comes
to chronic pain.
S3 (03:34):
You know, so many things start to come up in
my mind when you talk about that, because we have
physical injury and now there is this rise of psychological
injury as well. And people feel pain. Mhm. How does
our body then start to process pain. And what does
the brain do. Because it's very difficult to explain to
(03:55):
people that when they experience a psychological injury they may
also feel pain. And then when you have a physical injury,
you're going to feel pain but also the emotional side.
So what does the research say about that or your work.
Talk about that.
S2 (04:11):
Yeah. So I guess I don't really discriminate between physical
pain and psychological pain. I think it's all meshed in
into one. And I think I think of it like
a soup. Right. So we've got lots of different ingredients
in a soup. Um, and sometimes that soup has got
lots of emotional pain in it. Sometimes it's got the
physical pain. Um, but there's always a bit of bit
(04:33):
of both in there, and that might change depending on
the person, or it might change depending on the time
or what point in time you're going through your pain
journey as well. But we do know physiologically that, um,
the perception of pain, um, occurs in the brain. Okay.
And so, you know, if we think about what happens
(04:55):
when we do injure ourselves, let's say right now while
you're listening to this podcast, your brain is constantly getting
messages from your brain, from your body. So and your
body is telling your brain that you're sitting or standing.
It's telling your brain that you have, um, a jumper
on if you're wearing glasses, if you're feeling a certain temperature.
(05:17):
And so your brain is constantly getting all these messages,
and your brain's deciding at any one point in time
what to listen to. What messages do I need to
be listening to that might give me a sense of
danger or or harm. And so that's always happening. But
of course, your brain's going to turn off those messages
(05:38):
that aren't harmful. So it's not going to listen to
the message that you're sitting because it doesn't need to.
It knows from history that you're in a safe space
or it doesn't listen to those messages that you've got
clothes on. So your brain is constantly deciding what to
pay attention to when we injure ourselves, when we have
an acute injury. So let's say we cut our finger.
(06:00):
Our finger will send a message up through the spinal cord,
up to the brain to tell the brain there's something
happening here on my finger. There's been some kind of
pressure applied to my finger, and it's ended up with
a cut. So your brain will listen to that message.
And because we've got an acute injury, we do need
to look after that part of the body. And your
(06:23):
brain will pay attention to those messages and it will
send out a perception of pain. So it's not until
that brain processes all of that information that we actually
feel pain. And so then we feel pain, and then
we also activate other parts of our brain. So it activates,
you know, our arm muscles to move our finger out
of the way or it will, um, open up memory
(06:46):
centers so that if we've cut ourselves in the past,
it will tell us what to do. It will give
it an emotional response as well. So it might be
that we're fearful of it, or we might not be
so fearful of it, depending on on on who you
are and what you know. Um, so the messages from
the body are processed by the brain, and then the
(07:06):
brain will decide whether we need to feel pain. Um,
and then it will send out those messages of pain
If it doesn't think we need to feel pain, it
will just turn off all the messages from the body
or inhibit those messages. And then we don't need to
to pay attention to that. And that's a great system.
We need pain to protect us when we do have
(07:28):
an injury, um, or some kind of, um, tissue damage.
And then as the tissue heals, the pain perception dies
down and over about 6 to 12 weeks after an injury,
we tend to see that pain perception die off and
we don't feel that pain anymore. And so the system
works really well. But some people, and we don't know
(07:50):
why one person does or doesn't, some people that pain
perception keeps on going on and it doesn't die down.
And so after the tissue is healed, there's no more damage.
But the pain perception keeps on going. And so we
know things like, I guess ongoing stress and emotional distress
(08:11):
will keep on activating those parts of the brain that
actually process all those pain messages. We know if there's
social context, um, trauma, um, that can also keep on
those pain perceptions if there's fear about what's happened. So
if you've injured yourself, you've had pain, and then you
(08:32):
start to feel fear about the injury or beliefs, that
movement is going to increase that pain. We also know
those belief systems and thoughts actually activate the pain center.
So there's lots of things that we know that keep
that pain perception going. We just don't know why one
person will have that chronic pain response compared to another person.
S3 (08:57):
It's so interesting hearing you talk about it and from
a completely different perspective. So my background is as a
rehab counselor, and we often talk about being able to
take those steps forward and how the physical and psychological
pain are very connected. And we also then layer in
the social pain aspect as well, because when we see injuries,
(09:22):
a workplace is full of people and whether it is
a physical injury or it's a psychological injury, you tend
to find that the next thing that will happen is
that people become isolated and there's almost no stop system
for someone who has been injured now becomes isolated. There's
no circuit breaker. And that pain response, whether emotional or physical,
(09:47):
just keeps on firing. And it becomes almost like this
brick wall that gets layered around people that they can't
easily find. You know, that ladder to jump over because
they've been encapsulated by. And when you explain it, it's
the brain protecting you. It makes so much sense, because
if my brain is going to protect me from the
(10:08):
things that I now perceive as not safe, then I'm
better off being in this space. But unfortunately, it doesn't
actually help.
S2 (10:16):
Yeah. So, you know, the brain is processing and allowing
these messages or is processing the messages as dangerous, but
they're no longer dangerous. So there's that malfunction. But I'd
love to pick up on that brick wall analogy. So
one of the first things we do in our group
pain management programs is we start to talk about that
(10:36):
brick wall of pain, and that's what it often feels
like for people. They're stuck behind this brick wall. And
often it's, um, it's perceived as just pain. But that
pain brick wall is made up of so many things,
so many bricks. And so it could be, you know,
the stress of work, the financial stress, the isolation, anger,
(10:58):
failed medical appointments. You know, how many times did do
you go to the doctor and, um, or a specialist
or a physio and nothing works. Social isolation, relationship issues,
it all makes up this big war of of pain. Um,
and one of the things we try to do with
pain management programs is really first, identify what the brick
(11:20):
walls are for for you as a person, but then
start to work on one brick at a time and
start to loosen one brick, and then we find another
brick loosens. And that's, I guess, the analogy that we
would work with, um, in the pain programs.
S3 (11:33):
I'm smiling because many years ago. Oh, gosh, I would
have been about 24. You know, at 24, you know, everything.
And I stood in front of a group of refugees
who had recently arrived, and I was like, let's go
get a job and let's move forward. And then I
did a task and I gave everybody a piece of paper,
(11:54):
and I said, why don't you draw me what life
looks like for you in five years time? That's how.
How not knowing I was. And this man looked up
at me and he said, how dare you? And I said,
what's wrong? I said, great activity. And he said, how
dare you think that? I can see that far ahead
when I can't even see tomorrow? Yeah, and he was
(12:18):
the one that introduced that idea of a brick wall
to me. He said, I feel like there's a brick
wall in front of me, and it's so interesting that
you said that, because what I then started to do
is I would actually give people a piece of paper
and I would say, draw the brick wall and put
one problem in each brick and pick one thing that
(12:38):
you can control, because I think layered into that is
that sense of lack of control that you actually feel
like you cannot control anything. So if you can give
people just one little thing that they can do, you
can then find that the other bricks start to fall
away as well. Yeah.
S2 (12:55):
Yeah. Absolutely. So we would call it pain self-efficacy. So
it's that, uh, confidence in yourself that you can actually
move forward with your pain. And so yeah, absolutely. Working
on something that you can achieve is really important. And
then I think there's that lack of, of of self-efficacy.
You've lost that lack of self. Who are you now
(13:17):
if you can't do what you used to do, what's
my role now? If I've got pain and I can't,
you know, be involved in everything that I used to
be involved in. So I think it's really important when
you're thinking about that brick wall because it's overwhelming, right?
You're stuck. You're stuck there. And we want to try
and help you move forward with that. So, um, the,
(13:38):
the walk and can feel really big and really high.
So we just want to start with something small, one
little brick. But it does. It's really nice to see
when we're working with people that those bricks can start
to loosen the ones next to them as well.
S3 (13:52):
What have you found works? What are the things that
you're finding actually starts to help people move forward?
S2 (13:59):
Yeah, I think the first thing I do with patients
is just talk to them about pain. I think it's
important to understand that your pain is real. So I
know often, you know, when you hear that the pain
is all in the brain, often people will walk away
and think, oh, she thinks it's just in my head.
And that's complete opposite. Your pain is real and all
(14:22):
pain is in our brain is processed in the brain.
But your pain is real. And I think it's really
important to be listened to and validated. Um, but then
also start to understand what pain is and, and how
chronic pain works. I think that's the first step, because
what I guess I would be doing with talking about
(14:42):
chronic pain is I'm asking you to change your belief
about pain in a really big way. So we grow up, um,
really always being told to avoid pain, to not do
things that cause us harm and pains that signal that
something is harmful. And now, as a pain physio, I'm
telling you. Well, you know, the pain isn't a signal
(15:02):
of harm anymore, and that's a big shift. The next step,
I think, is acceptance. But I don't think that's an
easy one. That's a really you can accept and then
drop off and and that's a bit of a journey
I think. Um, and that gets easier as you start to,
I guess, re-engage with things, um, and start to, to
live and doing things that you enjoy. And then there's
(15:25):
lots of different tools that we would be teaching patients
for pain management. So I like to, to talk about
giving someone a toolkit for pain management. And each tool
is useful. It's more or less useful to different people
different times. So there's probably not one thing that helps
the most. It's about giving yourself a toolkit for pain management.
(15:48):
There's lots of things in that tool kit, so the
first one would probably be movement and movement with some
joy and movement with some mindfulness. Um, so I don't
talk about exercise. I talk about movement. And we know
in terms of exercise or movement with chronic pain that
any type of movement is going to help be helpful.
(16:09):
We've looked at all different types of activity, physical activity,
and they're all helpful. So there's no one exercise that's
going to be better than another. It's really about choosing
something that you want to be doing and moving in
a paced way. So often when we feel good, we
go out and we do heaps of activity, and then
(16:30):
we end up burning up and crashing out the next day,
and then we end up over the long term having
less tolerance to activity. So pacing, I think, is one
of the key strategies that I see work with with
patients with chronic pain. It's a tricky one to learn,
particularly if you're someone who is a doer and doesn't
find saying no easy. So if you're push push pusher,
(16:54):
that's going to be a challenge for you. But it
it works with chronic pain. So you know, in the
corporate world, in daily life we do sometimes have to
push through. Right. And it works for us. But with
chronic pain it just doesn't work. And we need to
learn how to pace. And that's pacing. Might be pacing
your washing, doing the washing. I might be pacing reading
(17:16):
it might be pacing, walking, whatever you want to get
back into doing. Pacing is the first thing I would
be doing, um, with you and starting off really, really
low and gradually, um, increasing that really slowly. So pacing
is one tool.
S3 (17:32):
Well, I just want to ask, how would you go
about moving with joy? Now I have a two. And
the thing is, a couple of years ago, just by accident,
I started a business called Joy fit. And it was
I became a personal trainer, and the reason for that
was that I had noticed many people with cancer, of
(17:57):
which my sister and my neighbor were one, were told
by their doctors, don't move. And what had happened was
I started joy fit so that people could, you know,
not be worried about am I wearing the right colored
spandex today? And is my hair nice and my fingernails,
you know, just to show up and move with joy?
And so we would have these activities like I would
blow bubbles or the lady who was having the cancer
(18:19):
treatment would blow the bubbles, and everybody else would have
to smash the bubbles. And if a bubble hit the floor,
they'd have to do ten burpees. Hilarious fun. But what
is your perception of? I can see some of the
faces online. Don't think that that's hilarious fun at all,
but I trust trust me it is. But what would
your interpretation of movement with Joy be?
S2 (18:38):
Yeah, so I think, you know, being that physio I
guess and and part of our role I guess is
trying to get people to move. And I often see
a lot of fear and anxiety around that. And I
get it. If you're feeling pain and your belief system
is still telling you that pain is harmful, it's no
surprise that you're going to be fearful and anxious. But
(19:00):
then your brain actually learns that response. It starts to,
you know, if you're going down a track and you're
going down the same track all the time, you're going
to wear that track down. That track gets really deep.
And it's the same sort of thing in terms of
that response to movement. So it ends up that just
the thought of moving then gets the fear and anxiety
(19:20):
response in your body. So it's about trying to find
a way of moving either in a space or getting
the environment that is joyful for you. So I'll give
you an example. I had a patient who had a pacemaker,
and she was a senior lady, and she came to
the clinic because she developed this shoulder pain, this chronic
(19:43):
shoulder pain after getting the pacemaker in. And of course,
when we get a pacemaker in, you know, obviously that's
really scary. Um, she was quite anxious about the pacemaker, etc..
So I was, you know, having a chat to her
and just sort of trying to learn what her journey
was and her story was around the pain. And I
found out that when she was younger, she was a
ballerina and she did lots of ballet dance. And when
(20:05):
she started to talk about that, her face changed. She
became you could just see this joy in her face.
So for her, you know, homework, I guess, is I
asked her to choose some music that she loved to
dance to. Um, and then I asked her just to
do one simple exercise to start getting her to move.
(20:26):
That's it. And then she came back two weeks later
and she had just it was just a different, different person.
She had chosen some music and she had actually started
to move her arm and do a lot more than
I'd asked her to do. But she did it with
that music, and so she had joy already, sort of
instilled in her from the response of the music. Um,
(20:47):
and then to add in the movement with that, um,
was enough to, to sort of, I guess, get her
unstuck in terms of that fear and anxiety response. Other
people might be, you know, they love going to the
beach and they love listening to the sound of the waves.
And so it's about just get down to the beach.
And even if you just, you know, walk from the
(21:08):
car to, to a bench and sit and listen to that,
that's movement with some enjoyment. So it's about setting up
that environment. And sometimes it's it's that external environment that
gives you joy. And that's enough to then start to
blend that movement with that enjoyment. And then after a while,
you're starting to build a new track in your brain.
(21:30):
that sort of connects movement with joy rather than movement
with anxiety and fear. So it's working out what what
you enjoy doing.
S3 (21:40):
How do we then, you know, in your work that
you've done? And part of the reason that I was
so interested to talk to you is because I've often
found that people in that physiotherapy space tend to look
at things from a very medical model, but you proactively
have looked at things from multiple angles. And so that
(22:03):
biopsychosocial model. Yeah. Is there a link in the research
between that physical and that social pain?
S2 (22:10):
Absolutely. Yeah. Yeah. So, um, we do know that patients
with chronic pain will feel isolated and isolate because for
lots of reasons. But often it is because they feel
like no one else understands or they don't want to
be a burden on other people. Um, but we know
that if you can reintegrate yourself with a social environment
(22:34):
that gives you some joy and social connection, right? Is
so important with joy and how we feel connected to others.
And that's why group programs often work really well, because
you're sort of developing this group becomes a support network
for everyone within the group, which is lovely to watch.
I really love watching that growth in a group. And
(22:54):
so it helps in terms of pain management because you've
then got a safe space. Um, I guess that gives
you some joy and safety in a social group. So
it's really important, I think, to to maintain that social import.
S3 (23:11):
I think that that's just one of the barriers, particularly
in workers comp, that you can come up with, is
that treatment and processes are very aligned for physical injury.
And then when you move into that psychological injury space,
people feel pain and they stop moving and they're scared
to go outside. And that brick wall is very, very similar.
(23:32):
But it's so good to hear from you, who is
currently doing all the research in the space that the movement,
that that socialization, taking those small steps is just as
critical and important in psychological injury and recovery as it
is in physical injury recovery.
S2 (23:49):
Yeah, absolutely. And so part of my PhD was looking
at patient led goals. So I did some goal setting
with patients with chronic back pain. And you know as
a physio I thought oh we'll see whether this works
or not, but we'll give it a go. Um, and
what was really interesting is one, it worked amazingly. So
patient's pain actually decreased as they set goals and and
(24:14):
were able to implement the goals. What was really interesting
for me were the types of goals that people set.
So I just let them set any goals, didn't have
to be activity, didn't have to be sort of physio,
and only half of the goals were sort of activity based.
The rest of them were all about relationships, work, relationships,
(24:34):
coping with pain and reintegrating into things like dance or
getting back to playing music. Um, and so it was
about taking small steps towards that. And so, you know,
part of the strategies for the goals might one week one,
it might have been just look up where your dance
classes are. That's it. You don't have to go out
(24:56):
and do anything. And then the next step might be
just go and sit and watch a dance class and
see whether that's what you want to do. And so
it was that slow build up of the skills and
confidence to get back into doing things. And then once
people did start to do that, their pain actually improved,
which is a result we weren't expecting. So that was
(25:18):
really nice to see. But you need to do it
slowly and you need to not overwhelm, I think yourself,
because if you're getting overwhelmed, you'll have a stress response,
and that's just going to feed back into that pain
response as well. So it's got to be slow and gentle,
and you need to be gentle and kind to yourself
while you're doing it.
S3 (25:35):
I've got so many things to say all at once.
A couple of weeks ago we interviewed someone for financial
counselling and she's just a financial counsellor, not coming from
a health background, but she too said you need to
take things in very small steps, one problem at a time,
so that you keep the stress response down. If you
talk to a psychologist one step at a time, don't
(25:59):
be too hard on yourself. And now, as a physiotherapist,
one step at a time. I find it baffling that
even now, we very rarely have these multidisciplinary conversations. When
we talk about wellbeing, we talk about social goals, physical goals,
psychological goals, financial goals, spiritual goals. And yet everyone says
(26:20):
the same things. But we're not all saying it together.
And so it becomes very confusing for people. Yeah. So
it's lovely to hear that we're all on the right track.
And one of the pressures I find for people in
the workers comp framework, though, is time frames within workers
comp are not aligned to recovery goals for individuals, which
(26:42):
automatically increases pressure and therefore delays recovery outcomes. I was
talking to an academic from Griffith University today, and they
were talking about a PhD student up there who was
doing a PhD on the benefits of synchronized movement. And
what is so interesting is that if you can synchronize movement,
(27:05):
they're finding that it it is they're doing the neuroscience
behind it. People's brainwaves are starting to sink in. It's
reducing their level of stress and it's increasing their sense
of belonging.
S2 (27:20):
Yeah. Interesting. Yeah yeah yeah yeah. I guess the other
thing with, you know, I would do with patients is
mindful movement, Um, which is probably what's happening is probably
similar mechanisms going on there where because often patients with
chronic pain have lost that proprioception, they can't feel where
their body is. There's a a dysregulation in that feedback
(27:44):
from the body. In the brain it gets a bit foggy.
So I think it's working on two levels in terms
of improving that proprioception. But it's also, you know, we
know that mindfulness will also help to, I guess, unwind
that stress response. And so again, we're connecting movement with
something that's, um, decreasing the stress response. And that track
(28:07):
of joyful movement, um, is starting to be worked on again.
But yeah, interesting in terms of the connectivity that, that
they're finding.
S3 (28:15):
Yeah. It's some and also the different things that people
just decide to explore. How would a worker who has
experienced an injury best explain to the insurers or the
doctors some of the things that we've heard today? Because
if we can empower people listening to know what to
(28:36):
ask for or to ask for that help, what what
would be a tip that you could give them?
S2 (28:42):
I think it's about talking about the chronic pain model
and sort of talking to your GP about, you know,
this is my understanding of chronic pain and maybe having
that discussion around that chronic pain model so that both
both of you are on the same page in terms
of acute pain or chronic pain. And I think, to
(29:03):
be fair, we're only now starting to see a shift
in the education and training of of healthcare professionals. Um,
and so it's going to take a while, I think,
for that to, to come through. So a lot of
GP's don't get a lot of pain management training. So
it's about starting that conversation with them about the chronic
(29:24):
pain model and starting the conversation about, well, what tools
can I use and and where can I go to
to learn those tools? There are there's an online pain
management program which I developed when I was at Saint
Vincent's Hospital. So it's a free online pain management program.
So that might be a nice way to start talking
(29:45):
with your GP. And your GP just needs to hop
on and register on. It's called This Way up, and
then they can prescribe the course or program to the person,
and maybe they can work through it with their GP
and go through this eight lessons and they learn all
the different tools and strategies. So that's one way, I
think of starting the conversation about chronic pain and pain
(30:08):
management and then talking about, you know, what are those
bricks in the wall get? You know, the GP probably
needs to understand what those bricks are, so they can
also help. In terms of what strategies can we use
to to start knocking down one brick at a time?
There's lots of common bricks that everyone has, but everyone's,
you know, bricks are individual, so you need to you
(30:30):
need to start to think about what are those bricks
for you and which one do you want to knock
down first and start thinking of a plan. And then
of course, trying to get clinicians that are actually have
got some pain management training is always a plus as well.
S3 (30:44):
In terms of transitioning back to work, how could someone
in working through pain, physical, psychological or emotional? How can
they challenge themselves or use pacing to feel better and
be able to return back to life.
S2 (31:05):
So thinking it's about returning to work. When I work
with patients, often I just I ask patients what they
want to get back to doing, what's important to them.
What has your pain stopped you from doing, and what
do you want to start working on? And I think
that's the best space to start with, because working on
something that you want to do, it's not a physio
(31:28):
telling you what to do. It's not your boss telling
you what to do, it's not the insurance company. And
so that for me would be the best way to
work with people, because I saw with my research that
when we let the person decide what they're going to
work on, they improved.
S3 (31:45):
And I think that's the best way of doing it,
even in workers comp. Because you're right, there are lots
of pressures, But we're talking about adults who were adults
before they had that injury. Therefore, people need to be
able to make a choice and take that control back
on what they want to do next.
S2 (32:03):
Yeah, I think it's um, you've then also got to
accept where you're at and accept what's happened to then
move forward.
S3 (32:12):
We just had a question from one of the the
group which is about the pain of injustice. Mhm. What
what are your thoughts around that and how do you
manage that from that pain management perspective.
S2 (32:25):
Yeah. So that comes up a lot. Why me. Why
did it happen to me. You know we have people
that have all sorts of injuries. Um and often we
can't give an answer to that. And I work really
closely with the psychologist when we run these groups and
there is no answer, we can't. We have no control
often of what happens. And that's really hard to accept that,
(32:48):
you know, we often think, well, we can control everything,
but often we can't. And so it's that uncertainty that
also feeds into the anxiety and fear of, you know,
if this has happened, what else will happen? Um, and
so it's about facing those emotions that you're feeling with
the injustice, but also need you're needing to come to
(33:09):
a point where you're accepting that that's what's happened.
S3 (33:12):
In fact, if you think about that, if that that
sense of injustice becomes a part of a brick in
the wall, you know, if you can actually write it down,
even if it's on a piece of paper and looks
like a brick wall, understanding it is about filling in
the bricks. Understand what is getting in the way between
here and your future. And the next thing is, once
(33:35):
you can see it, you've got the opportunity to accept it.
It is what it is. And that then allows you
to find the right people or the right tools to
actually start to work on one small brick at a time.
If you do more than that, you will lose all
your energy and you go back to square one. And
(33:55):
then how to set goals and bring in joy and movement.
Does anybody have any questions for our most wonderful doctor,
Tanya Gardner, who is joining us today from the University
of Sydney? And may all her students hear her brilliance
as she sprinkles through the airwaves this afternoon.
S4 (34:14):
Um, so sort of tied with repercussions for the employer,
I think the case is is also becoming vulnerable again
to being bullied and harassed. It's hard for us to
allow ourselves to be vulnerable when we don't have the
tools to protect ourselves in a physical injury, for example,
(34:37):
a sprained ankle. You might have that. But then to
protect yourself, you do exercises, for example, to strengthen that
ankle and you're more careful about not spraying it again,
but with a psychological injury based on bullying and harassment,
what tools can be available to us to see it
coming and protect ourselves from it down the track?
S2 (34:58):
Um, so I guess it's about first making sure you're
safe and making sure that the environment you're in is safe.
So that's my first thing in terms of response. We
can't control how other people behave, but we can control
how we respond to that. So it's about learning, understanding
your response to that and maybe, um, starting to to
(35:21):
modify that response in yourself towards that other person's behavior.
That's as much as you can do if you want
to stay in that environment and stay safe.
S4 (35:31):
Yeah, well, it's basically any environment we might go into.
So even even that, where do we learn how to
respond to that sort of treatment. Yeah.
S2 (35:40):
So that's all part I guess of, you know, CBT
and cognitive behavioral therapy starting to to identify when you
get that response inside of you, that might be a
negative response or a fearful response. And then starting to
first notice that. And so for me, I tend to
find that I notice my body sensations when I get
(36:02):
nervous or I'm about to get angry. Um, it comes,
you know, my stomach churns, I can feel it in
my chest and my head. And then I usually I've
learned how to go, okay, what's what's setting, what's about
to set off. Um, what am I thinking about this situation? Um,
and they're starting to challenge it because often it's, uh,
(36:23):
we have this self-talk that is really, um, sabotaging. Often
it's quite negative or judgmental about ourselves. And so it's
about starting to have little thought swaps, I guess. Um,
I call them thought swaps. Um, so swapping some more
helpful thoughts so that we can then start to, I guess,
(36:45):
what we call like a parachute down onto our response
to settle everything down. So that's stress response. Um, can die,
die down. But that takes a lot of practice and
a lot of hard work. Um, and we need to
start to be ready to explore what we're saying usually
about ourselves when, when that happens. Um, so I would
(37:07):
suggest that might be one way of starting to do that.
And sometimes it's just about writing a thought diary. So
I'll get patients, you know, they'll, they'll tell me about
something that they, that they respond to. And I'll say, okay,
well next time that happens, write down what you felt
physically and what you were thinking, what what thoughts popped
(37:27):
to your mind straight away, and what was driving that
response and what did you do? Did you back down?
Did you respond with anger? What was your response? And
then start to explore some patterns that might come up
for you as well.
S3 (37:42):
And that would also blend into that idea of building
a resilience toolbox, because in understanding your thought patterns, then
you know you can more quickly filter through the resources
and the tools that you need because it's terrifying to
start to do this. We've got another question. Thanks, Caroline. Um. Hi, Tanya.
(38:03):
I just wanted to ask.
S5 (38:04):
So since the beginning of my claim, I've become very
sedentary and I'm very out of breath. I'm also recovering
from some major surgeries and trying to get back into
just everyday living of like walking to the shower or
walking to the letterbox. Or it's a mental game, but
also it's a physical game for me. And so I'm
(38:26):
interested in knowing how do I push past that initial
trigger of pain that I get, so I can't stand
flat footed for more than about five minutes. I have
to shift my weight. I have to sit down, gather
my breath. I walk around our property with a plastic
chair in my hand all the time so I can
sit down every 200m. Um. I have been prescribed THC
(38:48):
and that's been working wonders. Like absolutely amazing. I have
been able to move more. I'm not out of breath
when I'm using it, but when I'm not using it,
I just can't push past that initial pain threshold of
like the first five minutes of being out of breath
and needing to sit.
S2 (39:04):
Mhm. Yeah. Um, so sorry that that's, you know, you've
gone through what you've gone through first off. And what
you're telling me I think is really common as well.
So I hear, you know, the sort of the five
minutes of walking and not being able to do things
and particularly people working or living out in rural regional
areas where they have these huge properties. Um, used to
(39:25):
do a lot of work with South Coast. So you're
not alone, I guess, is what I'm what I'm trying
to say so you can move forward. And, um, and
I've seen people people do that. It's about, first off,
starting with something that you want to do. What would
if you had to pick 1 or 2 things that
you wanted to get back to doing, what would they be? Um,
(39:45):
and then picking the top one. Um, and working out
what you can do at the moment. So, you know,
it might be that you can stand for five minutes
and you want to improve your standing. Let's just use
that as an example. I would say to start off
at four minutes. So what you want to do is
do your activity for as long as you can before
(40:05):
the pain starts, because as soon as the pain starts,
then that pain system just fires off and it's a
lot harder to settle down. And so you practice your
four minutes for a week or two, and then you
might increase it by 20s and really slowly increase that
activity and want you to take notice of what's happening
(40:25):
for you. Also, psychologically, are you getting anxious? And if
you are getting anxious, what are you saying to yourself
about increasing that activity or about the pain? And it
might be about starting to challenge those thoughts and beliefs
about pain as well. So remembering that chronic pain and
pain you've had for a long time is not a
(40:45):
signal of damage or danger anymore. Um, and so starting to,
to challenge that. But physically, we can start to really
slowly improve your tolerance to any activity that's important to
you is what I would get you to start to,
to think about. And then you can just slowly build
up on that. And I've seen it happen just starting
(41:07):
off really small. And you probably think like you're not
doing much, but you're actually retraining that pain system and
retraining the brain. And the good news is, is that
we know that we can retrain the brain. Um, and
it's retrainable. So you've just got to do it, but
do it really slowly and gently and be conscious of
why you're doing it. You'll get there. But you've got
to start off, you know, go slow.
S5 (41:28):
Yeah, it's the negative self-talk is probably what I'm very
challenged with because I just beat myself up about being
so unfit and yeah, yeah, useless and all these different
things that come, come to mind. So.
S2 (41:42):
Yeah. And be kind. So, um, you've sounds like you've,
you've gone through a lot and you survived it, which
is fantastic. Well done. Use that strength and resilience to
move forward as well. You've got strengths there that you
probably not giving yourself kudos for.
S3 (41:56):
What is your research found around that kind of Covid recovery.
And you know.
S2 (42:01):
So fatigue is huge. So that's the biggest thing that
we're sort of hearing from long Covid sort of clinics.
And again, with fatigue. Um, so it's it's quite interesting
for me to see a lot of the, um, the
commonalities between long Covid, um, also chronic fatigue syndrome. So
a lot of patients with chronic pain will have chronic
(42:22):
fatigue syndrome, a lot of other sort of, um, immunosuppressed
sort of conditions as well. We're thinking there's probably some
kind of immune response also happening in chronic pain patients.
But coming back to the long Covid fatigue is the
big one. Um, and again, that pacing that we talked
about is really important. So, um, in terms of your
(42:43):
stress response and fatigue and energy levels, again, if you
push too hard and too fast, your body's going to
just respond with stress. Um, and that will again facilitate
that fatigue. So it's about pacing and just, you know,
doing that slow, slow and gradual increase with your activity
and being okay with that. I think the hardest thing
(43:05):
when I'm teaching patients about pacing, um, particularly if you're
a go go getter, is that people get frustrated with
the pacing. And so, of course it doesn't work because
they get frustrated and stressed with the pacing and then
their pain increases. So you need to really shift your
way of, um, of how you're behaving, I guess, and
(43:27):
be okay with doing a little bit and going slow.
And if you're not used to that type of pattern, um,
that can be a challenge for you.
S3 (43:36):
Which again, goes back to that acceptance.
S2 (43:39):
Mm.
S6 (43:39):
Yeah.
S2 (43:40):
Yeah. Acceptance. And I think acceptance and pacing if you
can get those two, that's when I see people fly
and and do really, really well. Um, but it's probably
the two hardest things to do. Um, so yeah, sometimes
it's a journey to get there.
S3 (43:58):
Tanya, I want to thank you so much for coming today.
I have been so excited about having you on the podcast,
because we both come at wanting to support people from
very different perspectives. Yet there's this underlying tone of us
all wanting to do the same thing, and what keeps
coming up is choice and control. If people feel like
(44:21):
they're in control, they're going to start to get better.
But how do we create these scenarios for people to
give them the permission to be back in control, which
is difficult after an injury. If someone did want to
speak to you directly to ask more questions, how would
they do that?
S2 (44:39):
Yeah, they can just reach out, um, and, and email
me through my Uni of Sydney email, which is up
on their website. Absolutely happy to answer any questions as well.
S3 (44:50):
Thank you Tanya. It has been a pleasure. And everybody else,
I can see you all synchronized waving in a way
that creates belonging for all of us right now. Thank you. Well,
you've been listening.
S1 (45:00):
You may have found some of these concepts challenging, so
if you are needing help, please reach out. For more information.
You can follow us on our socials or if you
require urgent support, please reach out to the police or
the ambulance on 000 lifeline on 13 1114. That's 13
1114 Beyondblue on one 302 24636. That's 1300 224 636. The 24
(45:29):
hour mental health access line, which is one 800 015,
double one. That's one 800 01511. And if you think
you could benefit from some legal advice, reach out to
the Iro. Who could recommend some lawyers or someone to
help you with your current legal case. Our special guest today,
Doctor Tanya Gardner, is from Saint Vincent's Hospital Pain Medicine Clinic,
(45:53):
which you can read more about at w w w
dot s v h s.org a u that's w w
w dot s v h s.org.org. Thank you for joining
us today and we'll be back next time.
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