Dr. Joe Tatta: Dr. Tasha Stanton is a senior research fellow working for the body and mind research group in Australia. She’s a physiotherapist that completed her PhD at the University of Sydney and has received over one point $7 million in research funding to study pain neuroscience. Dr. Stanton has published over 40 peer-reviewed journal articles, has been a keynote or invited speaker at 22 national international conferences. She’s also the editor for the popular body in mind research blog and she’s joining us all the way from Australia. Dr. Tasha Stanton. Welcome to the healing pain summit. It’s great to have you here. I know you’re joining us all the way from Australia.
Dr. Stanton: Oh, thanks very much. It’s my pleasure.
Dr. Joe Tatta: So I’m very, very excited to talk to you about osteoarthritis and how it affects pain or how pain affects her osteoarthritis, however, you’d like to kind of look at it. But I think it’s worth talking about first, what is pain and maybe just, you know, reviewing kind of a definition of that to help people out.
Dr. Stanton: Sure. Um, and I think it is a good place to start because I think in general we, we consider pain to be something that’s so simple and it’s something that all of us have experienced at some point in our lives. But the hard bit is it actually isn’t simple. It’s this incredibly complex phenomenon that involves so many different parts. In essence, I mean if you look at the basic definition, it’s um, a response in terms of needing to protect our body. Something’s going on and it’s a feeling sensation that’s occurring due to the brain deciding that actually the body is in real or perceived danger. And um, as part of that, we know that the actual tissue damage that’s occurring, that’s one danger signal that’s going up to the brain. But there’s so many other things that are considered. So this can include things like your past experience with something, your expectations about something or your beliefs about pain.
Dr. Stanton: Do you believe that that’s indicative of worse tissue damage and all those things are taken into account in order to create this experience of pain. So what we kind of get is this often disconnect between how much tissue damage there is and how much pain people experience. And I think a lot of people may have experienced some this themselves. Like have you ever had a paper gut and just been absolutely astounded at how much it hurts. It’s a tiny little injury but it really, really hurts. So, um, I think in general that it kind of encompasses this idea that it’s a really complex thing.
Dr. Joe Tatta: Yeah, I think it’s a great place to start. Cause I think, I honestly, you know, I had this, my second summit and last year was a little bit more kind of nutrition based functional medicine basin and this show really tried to bring in more of the pain science, more of the pain psychology. So I guess the question I have for you, and you know, the question we want to get off to, um, the attendees cause we have clinicians as well as patients is that game is actually an output of the brain. And I guess the next question would be how important is it to really understand pain to kind of modular?
Dr. Stanton: Yeah, it’s, it’s absolutely essential because I think if we are considering pain, um, only is indicating how much tissue damage is present and not thinking that there are other things that can change that experience or modulate it. Then right away we’re really limited by what we can do because every time, let’s say we have a sore back and we’re reaching over to pick something up, if it’s painful, that means there’s potentially more damage occurring. And yet we know from pain neurobiology that that isn’t the case, that indeed there’s a lot of other things that are changing that experience. So things for example, like expectation can literally alter the ability of that signal, that danger signal from the tissue to get up to the brain. Everything can be on more sensitive such that what used to be this tiny little signal going up is now potentially a lot larger because the brain is saying, actually this is really important.
Dr. Stanton: Pay attention to this. And things like being afraid of further damage. We know that that, um, often causes people to be more limited than others in doing exercise and partaking in normal function. And that has real life consequences that stopping people from getting better from things, stopping people from, you know, being able to participate in everyday life. Um, and so we do know, I think what’s really interesting is that when we target some of those beliefs and some of the meaning behind pain through things like pain, education, how pain actually is constructed, then oftentimes disability decreases people. Um, overall quality of life is, is, is better and people are moving better, their motor control is improving. And that’s a really big deal for someone that, you know, has had pain for a long period of time and is really not participating in everyday life.
Dr. Joe Tatta: Yeah, it’s so interesting to me how as we shift toward treating chronic pain in a more holistic way, we’re really talking about education as one of the foundational ways to enlighten people about their pain experience and start to alleviate their symptoms.
Dr. Stanton: Yeah, and I think what’s interesting with that is that oftentimes we put things like emotion or beliefs into this, you know, psychological category and we really forget that they have biological physiological effects. Like, even if you look at at pain, experimental pain literature, um, if you could a really cold thing that’s painful on someone’s hands let’s say, and you pair it with a blue light or a red light, people will perceive that stimulus and it’s the exact same as being significantly more painful if it’s paired with a red light. And also they’ll actually perceive it as being painfully hot, not painfully cold. So our beliefs and our thoughts about things can literally change the physiology and our experience itself.
Dr. Joe Tatta: That’s a great take home. So I think the take home is that your perception can alter your pain experience basically.
Dr. Stanton: Yes. Yes, absolutely.
Dr. Joe Tatta: So as a physical therapist, you know, I’ve been really looking forward to this interview cause everyone asks me about osteoarthritis and how’s osteoarthritis relate to pain and how’s your pain experience? I think we, you know, as, as PTs, both you and I probably had thousands of patients that come in and say, Hey, my doctor gave me this X. Right. And it showed that I had degeneration or arthritis. So talk to us about the link between arthritis and pain and is there a link there and what does it really mean?
Dr. Stanton: Yeah, sure. So I think that was actually one of the reasons I became really interested in studying osteoarthritis was that you look, you take a look at the literature in terms of of how much or how well does tissue damage that we see on x-rays and joint damage. How well does that relate to an experience of pain? And the truth is is it’s not very well at all. Um, so we again have this disconnect between how much joint damage there is and how much pain people are experiencing. I know personally working as a physio, when I had people come in and sometimes I’d look at the extra and I’d be like, Oh, this one gotta be in a lot of pain. And actually they’re not. They’re doing really quite well. Maybe it’s a little bit of niggling pain, but then you get also people that are in horrible pain and comparatively they don’t have as many changes on next day. So I think, again, what we see is that we know that when we talk about pain for anything, we can’t treat it as a simple one to one experience with joint damage or tissue damage. And I think the same holds for osteoarthritis. Um, and then it becomes understanding a bit more potentially what might be driving some of that pain in order to be able to treat it better.
Dr. Joe Tatta: So, so the question is when a physician, cause it’s primarily physicians who are, you know, kind of ordering the x-rays or the imaging is that, is the way they explained the imaging effecting someone’s pain level?
Dr. Stanton: Um, that’s a really good question. And I think, um, we don’t know for all types of osteoarthritis if that’s the case, but there’s some pretty good evidence to suggest that, um, how your beliefs about something are very, very important. So therefore, if when you’re being told about it, it’s being framed in a way of, you know, this is degenerative, this is actually starting to, you know, break down it’s wear and tear, which makes you think, well, if it’s where, then if I ever, I do more aware of the Tara is going to get worse. Um, but in, in essence we don’t know that and it isn’t always predictive. So that has real, um, possibility to shape people’s beliefs about their, their own joint and actually what they’re capable of doing. Because if you really believe that you’ve got this terrible damage going on in, in your knee, let’s say your choices for activity are likely to be much different than someone who believes, well, there’s pain, but I do know what can be modulated and it isn’t totally explained by what’s going on. So when I do more, I’m not further damaging it. So I think it’s really important actually.
Dr. Joe Tatta: So you know, from, from, you know, pathology like typical pathology we know that I’m afraid is can start quite young and people in the 20s and obviously it can progress so to speak up to, you know, the hundreds, um, is that a true indicator of damage? So I think that’s the question cause people are very concerned about themselves being damaged. My knees damage, I immediate need, may need a joint replacement, I may need to have arthroscopic surgery. So I guess the question is, is talking about damage and does that really relate to someone’s, um, not only their pain but also their function? I would say,
Dr. Stanton: yeah, the relationship isn’t, isn’t fantastic. Um, and so I think framing it in terms of damage is sometimes the wrong way to go about it because there you’re, you’re kind of, I think determining the outcomes that people can get based on actually framing that initial problem. And, um, certainly with osteoarthritis, I think there’s a lot of, um, we see for example, even when we look at the outcomes of large trials with exercise, that strength exercise and aerobic exercise, um, any water-based training as well as really good evidence for increasing, reducing pain and increasing function. And yet there’s often barriers to people being able to, to partake in that physical activity. And I think potentially one of those barriers relates to their education about their knee and what they perceive in terms of, um, thinking is exercise safe for them to do or is it further damaging what, what is already they considered to be a terrible problem.
Dr. Joe Tatta: So a couple of clinicians and researchers have been talking about central sensitization and a lot of people have talked about it in terms of fibromyalgia or in terms of, um, post traumatic stress disorder. Does that apply also to ask people about Sierra arthritis?
Dr. Stanton: Yeah, so there is some evidence to suggest that, um, they have increased sensitization, central sensitization. Um, and there’s also been some recent literature showing that, um, there systems that inhibit pain might also not be working as well. So not only are things more sensitive going up, they’re better able at amplifying that message, but also then the systems that normally dampen it down action might not be working as well. And then you get this double whammy, so to speak, where, um, everything is promoting an increase in, in pain, um, with maybe relatively little activity or, or, um, or, or, uh, damage potentially.
Dr. Joe Tatta: So the patient comes to you with kind of this Alta perception about what exactly your osteoarthritis is. How do you work with them to change that perception as part of their rehab and their pain experience?
Dr. Stanton: I think some of it is really about education, about pain itself and, and really having a strong understanding of what can influence that signal that’s getting up to brain and what can also influence how your brain is doing with, with all of those things. So one example is, um, we, you can T you use metaphors, that’s often a really nice way. So for example, with central sensitization, the metaphor of a radio is used and where the nerve connects to your spinal cord, it’s saying that’s the volume knob. And so think about it like a radio. If you hear a radio, when you turn up the volume doesn’t mean that the announcer speaking louder, it doesn’t, it just means you’re amplifying that person’s voice and it’s louder just like that. If that is turned up and you’re a very sensitive, it doesn’t mean that there’s more damage.
Dr. Stanton: It literally just means that you’re amplifying the signal that’s already there. So then what you’re getting isn’t necessarily what’s going on. And we do also see that image, the brain in pain. There’s not one pain center in the brain. You get this diverse network of areas that activate. And um, with that, then what we see is that when people, let’s say always associate, um, pain movement and the re anxious about it, potentially what we’re getting is we know that neurons that fire together wire together. So pretty soon we’re starting to get this ability to generate this complex activation in the brain with nearly maybe one of those things present. Maybe just anxiety, despite the fact that that nociceptive signal isn’t even there, that danger signals in there. So, yeah, it really suggests that there could be a lot of things going on. I know you do some fascinating work as far as research around osteoarthritis and dipping experience.
Dr. Stanton: Can you tell us a little bit about that? Sure. Yeah. So I think BB interested in how people with osteoarthritis actually perceive their own body. How well are they knowing at where it’s located, where they’re going touch. Cause what we see in actually other chronic pain conditions is that, um, this perception of the body seems to be important to the pain experience. And when you target this, these altered perceptions actually pain can decrease. So I was interested in saying, well look, do we see the same thing in people with osteoarthritis? Um, and, and what I found is, is that we do, so if you give people with who have painful handoffs or I tritus up a picture of their own hand and you manipulate it in size and ask them to choose which picture best represents the true size of their hand, they will choose an image that’s significantly different than healthy controls. It’s significantly smaller, which suggests that just in general, their sense of their own body seems to be altered. And what’s more is, um, in people with painful knee osteoarthritis, when I test how well irritable, they’re the systems that are coding for touch at the knee. Um, it’s significantly larger two point discrimination thresholds as compared with healthy controls. And I’m with people with pain in other areas of their body. And not only that, they’re very poor at knowing whether that painful joint is located in space. And, um, so when we do some tests that look at, uh, the brain maps, that code for movement, it seems that those are implicated, um, in this, in this lack of ability to know whether the body is located. And I think together this creates a picture of not knowing very well where that joint and that painful body part is located, which if we kind of think in terms of a theoretical model, if the point of pain is to protect something, if you really don’t know where that’s located, I’d argue actually potentially you have to be more protective. Your safety buffer is larger, meaning that you’re potentially reacting to things more so than you need to.
Dr. Joe Tatta: Hmm. Fascinating. So it’s almost almost sounds like when you’re talking about people with eating disorders and they have a kind of altered body image or body perception sounds right. Similar to what you’re finding with osteoarthritis or people with pain.
Dr. Stanton: Yeah, that’s right. It seems, and it, it’s something that seems to be inherently altered, uh, about the, what we don’t know is whether that’s that they already had that before they had pain and this is something that maybe predispose them to having more symptoms, um, or whether it’s something that develops with pain. Um,
Dr. Joe Tatta: so what’s fascinating to me is you’re a physical therapist, but you’re talking about the brain and a lot of what you’re talking about is kind of more on the, almost the cognitive level. So when you’re working with a patient one-on-one, how do you weave in the traditional physical therapy with kind of more of the paint science is, is it fluid and happening together or is it kind of you separate them in different sessions?
Dr. Stanton: It’s a really good question. And I think it’s, it’s probably really dependent on the person that’s coming in because I think for some people it’s very challenging to suggest, well for a lot of people to be fair, that how much pain, your fear you’re feeling isn’t necessarily indicative of damage. And so I think time needs to be taken for that message and there has to be things that, that almost challenge that message using that person’s own history. And then once kind of that can be established and, and you know, that is is it’s feeling and being accepted, then I think that’s when other maybe more brain focused treatments can potentially be started and um, probably in, in sync with how it can do an increase activity and try to increase, you know, strengthen of the muscle surrounding the joint and um, probably what we, I guess considered more traditional, um, physiotherapy treatment.
Dr. Joe Tatta: Yeah. Which is interesting cause I in the United States slowly but surely there’s starting to be an integration of kind of traditional physical therapy with some of the pain science and if needed a pain psychologist companies coming in or if it’s someone who is obese because we have obviously has an obesity epidemic here, you may bring a nutrition reality. Are you sitting seeing the same kind of integrative strategy story to kind of happen?
Dr. Stanton: Um, I would say yes and no. I think there definitely is a lot more collaboration between, um, different professions. I think we’ll start, Friday’s is actually a really, um, it’s a unique condition in the sense that um, oftentimes they’re not seeking active care and despite having quite a bit of disability for it. And part of that is I think it doesn’t fit sometimes the traditional model of a, of a private physio therapy and also unless they’ve had a total knee replacement or something, excuse me. It also doesn’t fit almost the model of a, of an outpatient department at a hospital. So yeah, it is. It is. I think it’s really a challenge actually to get, um, relevant and targeted care for people that maybe are functioning decently well with osteoarthritis before they go down and then really seek help once the have got very bad.
Dr. Joe Tatta: So if there’s someone watching the summit who has quote unquote bad osteoarthritis, I don’t even like to use the word bad because even that can be, so they’ve been told their osteoarthritis is bad, but maybe their physical therapist is telling them, you know, you could probably get through this with an exercise program. What advice do you have to them?
Dr. Stanton: I would say that it’s, it’s always worth giving it a go and seeing what sort of outcomes that you get. Because I mean, surgery comes with risks and oftentimes if people have had osteoarthritis for while and they’ve had a fair bit of pain, it tends to have cascades of effects. So it means that they’re not as active, they’re not, as, you know, moving around as much. Meaning that oftentimes that’s gaining a bit more weight, which then also increases the risks of surgery. So while we know that for the most part, um, total knee replacement and that type of surgery has very good outcomes, um, there are a proportion of people that develop post operative pain and that can be quite severe. So it’s also not a complete fix-all type surgery. Um, so I think it’s, it’s probably saying it’s worth the time to try and it’s worth, um, I guess having to think about and try to understand that condition a bit better. Um, there’s a, we do a little bit of stuff with um, visual illusions as well that I think sometimes can be helpful almost in, in challenging some of those things because pain can, can change right away when you’re doing it. And then that’s quite challenging because why should it, why shouldn’t change right away if pain is only indicative of tissue damage.
Dr. Joe Tatta: And it was also interesting to me from what you’re saying and from what we know from experience is that even if you get the joinery place to get the surface replaced, yes. Some of the appropriate reception changes, obviously the strength and flexibility, um, your awareness, your body image or perception, all those things are still have to be worked on even if the joint is replaced.
Dr. Stanton: Exactly right. That’s exactly right.
Dr. Joe Tatta: So can you tell me a little bit about the research you’ve done around kind of altered body perception, how that works itself into paint and the paint experience?
Dr. Stanton: Yeah, sure. So we’ve done some visual illusions with people with osteoarthritis and so they’re quite cool actually because what it involves is people were, you know, video goggles and then we video their their knee and we’ll give you that example in real time. And then what they’ll see is that body part changing in front of their eyes. So we do like this big stretch illusion where they look down at their knee, they see it getting big and long, and at the same time we pull on their calf muscle and it gives them this very strong sense that their knee is actually stretching out and growing. And it’s quite nice because the brain is very good at creating those senses when you give it congruent information. Um, but in preliminary work that I’ve done, we’ve found that what this does is it decreases pain in people with osteoarthritis.
Dr. Stanton: And, um, so we did it. We compared it to a lot of different other control conditions and using that illusion, um, significantly decrease pain, um, immediately people with osteoarthritis. And I think what was quite intriguing about that is it made us wonder, Oh look, it’s, if this is working in terms of pain, if we can, you can almost, um, change how the brain is responding in, in the sense of pain. Would it be possible to do this for other symptoms such as the feeling of stiffness? And so what we did is it was kind of fun study and uh, we applied the people who had back pain that tended to be, would it be the ones that had lots of degenerative changes on x-ray? And they, um, we applied a force to their back and all it did was just push down. They’re lying on their tummies.
Dr. Stanton: It’s pushing on their back. And we paired that force with a noise. And this, the first Louise be used was a really creaky door. And what we found was that immediately hearing that noise to that pressure in the back changed and altered their perception of their back. And um, when we made that noise less creaky over time, it actually caused them to completely reverse how they were perceiving their back. So it suggests that some of these things we might be able to look at using them in the future for, for different treatments because the brain is very good at pairing information together when we get it at the same time. And that’s something that I think that we’re not, we’re not using all the time and physiotherapy and that has a real potential in the future.
Dr. Joe Tatta: Well, that’s fascinating because I think when we, when we think of pain, we obviously think of the part of the experience. That’s sensation. Yes. You’re saying you’re using vision and what you’re hearing to alter the sensation, but it fits perfectly in with the pain description because it’s a combination of all your sensation. So it can be smell, sight, hearing, touch, even taste is involved.
Dr. Stanton: That’s exactly right. And I think we as physio is quite, we appreciate quite well the fact that our brain creates this perception of our body using so many different pieces of information. And so we can provide slightly different pieces of information. We have the potential to alter that perception and alter bodily feelings like pain and stiffness.
Dr. Joe Tatta: Hmm. Interesting. So you know, so if a creaky door, I’m assuming a creaky door is kind of like a, almost like a alarming sensation. Sounds like my working properly. Yes, yes. What might be a sound that might Sue someone or help alleviate someone’s pain?
Dr. Stanton: Sure. So we did, I’m using one of the control conditions in this preliminary work we used. It was almost like, um, let’s say for lack of a better description, it was a whoosh sound that almost like implies nice, smooth. And we found that that had a similar effect, um, as high as that creaky noise that decreased over time. It was able to reverse, um, some of those ultra perceptions, which was really intriguing because it suggests that it’s not just sound in general, that the quality and the nature of the sound actually has specific effects.
Dr. Joe Tatta: So I guess my bigger question then begs, we’ll paint science in the future include not only movement but trying to include in a traditional physical therapy program, other aspects of the pain experience and pain sensation.
Dr. Stanton: I think definitely, and I think that’s a really fruitful way forward because the more that we understand about the brain, the more that we realize it is inherently multisensory. It integrates information from all different areas and, and we’re perfectly placed as physios to use that. I think
Dr. Joe Tatta: it, you know, somebody, it’s interesting because I had, I had a speaker on and she was talking about creating a positive environment for your patient. Look, you walk into some doctor’s offices and the news blaring in the news can be quite alarming to people. It’s aggressive music playing in the background. So I think as a clinician, if you have a practice, you have to kind of start to set the tone and create a healing environment.
Dr. Stanton: I so agree with that because there’s nothing worse than going in somewhere and immediately you’re on edge because you’re like, why is that music so loud? This is awful. No, great suggestion. Okay.
Dr. Joe Tatta: So can you tell our viewers and listeners how they can learn more about you?
Dr. Stanton: Sure. So, um, you can go to the university of South Australia’s website and I’ve got a staff profile there. Um, or, um, I’m one of the commissioning editors on the, uh, body and mind website and use.org don’t use dotcom. It’s bad, but it’s a website that basically what we do is we talk about different pain science findings, um, that have just been published, um, that are relevant both to researchers, clinicians, um, and as well patients and try to, I guess have a go have a conversation about them, discuss those results in everyday terms. And it’s quite nice for him, I think, to, to open up some of those discussion channels.
Dr. Joe Tatta: Yeah, it’s a great blog. It’s one I follow frequently. It’s called body and mind.org correct?
Dr. Stanton: That’s correct. You bet ya.
Dr. Joe Tatta: So please check out Dr. Tasha Stanton on body and mind.org look at her bio on her website at the University of Adelaide. And I want to thank her for being on the Healing Pain Summit. You have an opportunity to help spread our message, so make sure you click the button below or you can share it out on Facebook and Twitter and we’ll see you in the next interview.