Welcome back to the Healing Pain Podcast with Saurab Sharma
Thanks for joining me. We’ll be talking about effective pain management in low and middle-income countries. I had touched base on this topic with Dr. Felipe Reis. He’s a physical therapist and a researcher in Brazil, where we discussed initiatives for improving pain education in developing countries. I realized at that moment it was such an important topic that I wanted to reach out across the globe and find other professionals, other physiotherapists and other health professionals that are working on safe and effective pain management in low and middle-income countries. You may think to yourself, “I don’t live in a low-income area. I don’t live in a country that’s developing,” but many of the social determinants of health that we grapple with in Western countries are also problems in developing countries. There’s something for all of us to learn about this topic.
As we work our way into this topic and we meet our expert guest, let me share a couple of bullet points with you about what’s happening with regard to pain management in low and middle-income countries. The first to note is that musculoskeletal pain disproportionately affects people these countries. About 20% of the general population of those countries experience chronic musculoskeletal pain. This estimate increases by 2 or 4 times among the working populations. It is the leading cause of disability in people between the ages of 50 to 70 years old. It’s the second-leading cause in people aged 70 or above. Joining us to discuss pain in low and middle-income countries is Saurab Sharma. He’s an assistant professor at Kathmandu University of Medical Sciences in Nepal, and also works at its affiliated hospital as a consultant musculoskeletal physiotherapist.
He is pursuing a PhD in researching pain at the University of Otago in New Zealand and his research aims to improve pain care in low and middle-income countries. Saurab is also providing a free white paper on this topic that you can download. It includes how we can strengthen health systems and respond to the burden of pain in low and middle-income countries and to support healthy aging. To download this free white paper, all you have to do is text the word, 1733 Download, to the number 44222, or you can open up a browser on your computer and type in the URL, www.IntegrativePainScienceInstitute.com/173download. Let’s begin and let’s meet Saurab Sharma.
Watch the episode here:
Pain Care In Low And Middle-Income Countries With Saurab Sharma
Saurab, welcome. It’s great to have you on.
Joe, it’s a pleasure. Thank you.
I know people are excited to hear all the great work that you’re doing in research in pain education. I know you practiced as a physiotherapist for a little while before you got involved in research. Tell us how or why you wanted to start to focus on pain education.
As a physio student in my undergraduate, I first experienced back pain, which was bad. I did not know that it could be bad and disabling. I could not stand. I was advised that I should not be bending or lifting or doing any manual or physical work. I did that. I was compliant for many years until I graduated and I learned about evidence-based practice. That was when I learned about a knowledge on pain science and guideline-based care. I realized how wrong I was. It’s not only me. Many people in India where I graduated have wrong beliefs about back pain and their knowledge about wrong type of management advising bedrest and low-value care. I thought education is one way to bring everyone on board with a contemporary knowledge of pain in science and updated knowledge or a guideline-based care on all the musculoskeletal problems. That’s how I got into pain.
It’s a common story. A lot of practitioners who work in the realm of pain, whether they’re physical therapists or other practitioners, have their own pain story, whether it’s their own personal pain story or potentially a family member or a friend. Tell us what you’re doing as far as research because you’re studying for your PhD.
The goal of my PhD is overall to improve assessment and management of being in Nepal and also to formulate a guideline or a pathway for other developing countries to incorporate high-value care for pain in Nepal or throughout. That’s the overall goal or aim of my PhD. Translating cross-culturally validating outcome is to assess pain and related factors. All the outcome is that are recommended by core outcome sets for back pain and chronic pain. I translated them into Nepalian and validated them so that it could be used in clinical trial. I developed being education material for Nepali. That’s using patients on stories and metaphors. I followed the principles of explained pain developed in Australia. What it means is I developed a curriculum for what people with low back pain should know about pain and used local patient stories and metaphors to explain pain to them and also incorporating guideline-based care for management of back pain.
Tell us about the burden of pain in Nepal.
It’s huge. It’s almost everyone else. Back pain is the number one cause of years lived with disability in Nepal and other pain-related problems such as neck pain and other musculoskeletal problems such as osteoarthritis. These are also among the top ten burden. Problems such as diabetes, which is also associated with neuropathic pain, is one of the top ten burdens. Likewise, depression and anxiety, which can have cause and effect relationship are also in top ten. Pain is overall a big burden, but interestingly, there aren’t many studies on pain in Nepal. That’s what I thought. That’s when I conducted a scoping review of all literature on pain in Nepal of this since conception. That paper will be published in Pain Reports Journal, which is an open access journal of IASP. Pain is a big burden based on global burden of disease studies.
Can you share some of the early nuggets from that paper? I know you mentioned it’s not out yet and we’ll look out for that. I’ll share it on social media when it comes out, but maybe share some of the larger take home messages that you may have found.
When I did this scoping review, I thought I would not retrieve many studies on pain in Nepal because PubMed searched and retrieved only about 30 papers. We plan to incorporate a local Nepalese database that has index to all the local Nepalese journals published within Nepal, but not indexed in other databases. We found 116 papers. It’s quite surprising. I was happy to see so many papers out there, but the problem is not many people read them because it’s not easily accessible and people do not know about the Nepalese database, which is called Nepjol. That’s the overall. About 75% of papers are published in local databases. Only 25% are published in journals, which I indexed in PubMed or other international databases.
You have to dig and find the special resources to grab that data that’s available in the Pub, but it’s not being shared widely.
Three-fourths were all clinical studies. All the clinicians’ works are recorded as a paper, mostly retrospective data or utilize their clinical work as a randomized trial and published it. It was quite interesting to know that there is one-third of paper, which are randomized controlled trial. I always thought that randomized controlled trials weren’t done in Nepal. I did not rate the quality of evidence there, but reading at few controlled trial studies were not randomized. There was no control group, but still the author said it’s randomized controlled trial. It’s a rough evidence that research was new. We aren’t very knowledgeable on research yet, but the exciting things are also there.
There are studies on outcome measures, which will lead a good foundation to future research. There are one population-level studies with a representative sample on headache, which is good. We are getting there but not yet on chronic pain or back pain or other musculoskeletal problems. The majority of studies on medical management of pain, so all drug therapy for different pain problems and mostly postsurgical pain. There are a few studies, about sixteen on musculoskeletal pain, fourteen on headache and thirteen on back pain, which is also great. What we found and was most intriguing was most of these studies were done on low-value care. Medical management, which does not have a high evidence for treating pain problems except post-surgical pain, and also surgical management of non-specific pain like shoulder pain, knee pain and back pain and epidural injections.
There are some problems out there as well. There were studies on diagnostic imaging, for example, a CT scan for headache on a large number of patients and imaging for neck pain and back pain, which is also a problem because it’s nonspecific pain. They are amazing. The real problem is that people in Nepal are poor, as you know. They spend a lot of money out of their pocket to perform these investigations and perform surgeries. It’s a huge burden on individual level and also a societal level because that is taking us away from our goal of achieving sustainable development goals and elevating poverty. The advises like bedrest for back pain that puts people out of work for a prolonged time, a patient gets worse. There are problems but again, this scoping review informs research for future and yet a knowledge gap.
We’ll look out for that scoping review. I know in addition to that not too long ago, you wrote a paper in 2019, health system strengthening is needed to respond to the burden of pain in low and middle-income countries and to support healthy aging. You mentioned that Nepal is a low to middle-income country, and people are paying out of pocket. There may not be health insurance or a health system to support chronic pain and/or aging. Can you talk a little bit about what pain care looks like in Nepal potentially versus let’s say the United States or Australia?
The current pain care is delivered by the idea of health professionals. The first line of care is delivered mostly by an orthopedic surgeon or physicians. It’s not like other developed countries where experts are referred. In Nepal, experts see the patient at first go. When a patient goes to an orthopedic surgeon, they would definitely want to see what’s wrong and probably advise for surgery. We are lucky that most orthopedic surgeons are knowledgeable and they would want to refer a patient to a physiotherapy or other non-surgical management. In their education, they would say things like, “If you don’t make it better in 1 or 2 weeks, you’ll have to undergo surgery because you have disk bulge or torn menisci.” That induces fear in a patient, and they would know that they wouldn’t get better and they would have to come back for surgeries. That’s the ultimate cure.
That’s how pain is managed. We prescribe a lot of medications because that’s what our patient expects mostly in a rural area. We got camps to treat people with the musculoskeletal problems and they expect pain to go and they expect medications. That’s how doctors are expected to prescribe medications. In such camps, you go for one visit and people are suffering. Most people also receive injections for pain relief. This is overall how pain is managed, but physios are also first line of care. The general population have direct access to physiotherapy. Those who want to come for physiotherapy management can directly visit us.
It’s almost as if physiotherapists there are functioning as primary care providers for musculoskeletal pain.
Most of our patients come to hospital. In the hospital system, the patient visits orthopedic surgeons or medical doctors before they come to physiotherapy. Most of physiotherapists receive patients who are referred only a part of. I’m not sure about the number. About 10% of people visit a physiotherapist directly before visiting other healthcare professionals.
Is the noncommunicable diseases as prevalent there as it is in the developed countries with regard to non-chemical disease and how it influences the persistence of pain?
It does. We are Westernizing or globalizing, but all the noncommunicable diseases are also a big problem. Cardiovascular disease, diabetes and almost everyone are diagnosed with hypertension and thyroid-related disorders and they are prescribed medications. Noncommunicable diseases are growing in Nepal and that contributes to overall inactivity and obesity and that also contributes to pain. It has bi-directional associations to all the pain-related problem leads to inactivity because they are advised to be inactive and rest. That increases other burden of noncommunicable diseases such as diabetes or hypertension and is the other way around as well.
Is the physiotherapy curricula that’s taught in Nepal starting to look at non-communicable disease and start to treat it from a more lifestyle perspective? Are they looking at physical activity, nutrition, and the environment in the influx of the three? What can physical therapists do as far as incorporating some of those aspects into their treatment plan?
We only have one physiotherapy school in Nepal. There was one school that started, but I’m not quite sure if it is a fully functional. I would only say one school so far, and that’s where I teach. In our curriculum, we have incorporated a curriculum that’s elsewhere. We have incorporated physiotherapy management or lifestyle intervention for management of chronic diseases, including pain. We also revised curriculum for pain that is more inclined or more in line with IASP recommended curriculum. We are heading in a positive direction. Students are getting a quality education in Nepal in regards to chronic disease management and pain management.
That’s great to hear about because new schools that are developing in a developing country to have some of that early information from IASP. Even at the World Health Organization, as we look at healthy people, 2020, 2030, a lot of that revolves around lifestyle medicine and how lifestyle medicine influences noncommunicable disease, but also chronic pain as part of that. People reading this, what can citizens of the world do to help people in Nepal improve with regard to pain care?
Many things could be done. For me, the way I learn more knowledge on pain and other health-related problems is via research. All resource countries and other universities could support physiotherapy students or other medical students for higher degrees and deliver quality education. We can have a workforce in Nepal that is capable to do high-quality pain research and also influence policy and decision-makers. That is one thing that could be done. Another is funding. Many organizations, even NIH in the US support research in developing countries. Most of the research money goes into communicable diseases. I know that there are huge problems in different parts of the world, but it’s also time of our organizers to focus on a noncommunicable disease and especially pain-related problem, which is a big problem globally.
More research and change in policy. It sounds like those policies are global policies as well as local policies that may influence pain care in your country. We’re going to start to fast forward life here a little bit and say you’re done with your PhD, you’re almost there, you’re coming to the end of that. Are you going to continue with research in this area or are you going to focus more on teaching there in the university?
I would love to continue doing research, but the top position that I have is a teaching job. I’m expected to teach a lot and do clinical work twice a week. We work six days a week. Four days of teaching and two days of clinical work. I would probably not have a lot of time for research, but the ways I’m figuring out to continue doing research is applying for bigger grants. We have collaborated with researchers in University of Dundee in Scotland to conduct huge studies on pain in Nepal. If grant funds have been researched in Nepal, I could buy in some time out of my clinical and teaching work and continue doing research. Those kinds of grants would also help a few PhD students to conduct research in Nepal. That’s why it would be more people than me alone, so that way we would probably continue doing research in Nepal.
Collaboration is important with other researchers and facilities around the world to help move some of this forward in some of the developing countries. It’s been a pleasure speaking with you. How can people learn more about you and keep up on your work and your research?
I have a website that I run but not updated frequently because I’m busy with my PhD. It’s called www.LinkPhysio.com. That was started a few years back with an aim to improve evidence-based physiotherapy in Nepal and other neighboring countries. I bring in expertise from people all over and write OGs in a way that is easy to understand, to preach about things that I know and about evidence-based management for different health problems. For those who would be interested in contributing, you are always welcome to write to me over email. The other way would be finding me on Google Scholar or PubMed and getting in touch.
We’ll look for you out on Google Scholar and PubMed, but you can check out LinkPhysio.com to find out information about Saurab Sharma with regards to pain education and pain science in low and middle incomes, and how we can facilitate higher value care there and collaboration on a global level. I want thank Saurab for being with us. Make sure to share this out with your friends and family on Facebook, LinkedIn, Twitter or wherever you’re social with your fellow researchers and people who are interested in high-quality pain care and research. It’s been a pleasure being here with you. We’ll see you next time.
- Dr. Felipe Reis
- Saurab Sharma
About Saurab Sharma
Saurab Sharma is an Assistant Professor at Kathmandu University School of Medical Sciences, Nepal and also works at its affiliated hospital as a consultant musculoskeletal physiotherapist. He is currently pursuing a Ph.D. researching pain at University of Otago, New Zealand with a collaboration with leading pain researchers in Europe, North America, and Australia.
His research aims to improve pain care in low- and middle-income countries. His Ph.D. research focuses on improving patient-centered care for pain in Nepal.
He is an active promoter of evidence-based physiotherapy and pain management in Nepal.
Saurab has received several scholarships to study pain in Nepal including scholarships from the International Association for Study of Pain (IASP) and North American Pain School.
He serves as a board member for Pain, Mind, and Movement Special Interest Group of IASP, and a member of Global Alliance for Pain Patient Advocates (GAPPA) task force of IASP. He is also an advisor of the Nepal Physiotherapy Association.
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