Transcript

Bart Van Buchem (00:01.65)
Hello and welcome to the Pain Podcast presented by Le Pub Scientifique. My name is Bart van Buchum. I'm a pain specialist physiotherapist and with me, Tim Beames, co-founder of Le Pub Scientifique. And it's a bloody hot day, Tim. I went for a run. It took me at least one hour to stop sweating. And you told me that yesterday, or at least the day before, took you two hours to stop sweating.

Tim Beames (00:28.458)
Yeah, yeah, exactly. But well, yeah, exactly. Depends on which way you look at it. Yeah, yeah, yeah. And what it did to me is it made me very thirsty. So here we go. We're pouring a pint of science for everybody today. Yeah, hydrate you all.

Bart Van Buchem (00:30.214)
Which is probably a good thing, right? Or not?

Bart Van Buchem (00:46.888)
Ugh.

Wherever you are during your run, your bike ride, because we have had messages from listeners who were typically listening to this podcast when they riding their bikes or doing their exercise. So this one's for you. And today's topic will be an interesting one, I guess, which is about

when pain persists.

And reframing success beyond pain reduction, if you like. So what happens? We can see success in pain care doesn't necessarily defined by reduction in pain. Sometimes we see people expanding in life connection and possibilities, which is great. But obviously, and I think there is a right for people to feel like, my God, still, the pain is still there. Right. And that's the, that's the massive challenge that

still there. And I even had a patient a day ago, like last night, I see like the 57 year old guy have this pretty severe back pain for years already. And he, does pretty well on many, many ways, but it's so frustrating, so frustrating that he has to start his day with a lot of pain that there I'm not going to this case, but it's the, and the common question and

Bart Van Buchem (02:20.028)
His question as well was like, you know, when is this pain going to get better? when is it eases a bit at least it's a struggle every day, although he's very successful in many ways. So, lots of upside apart from some downside. So probably this is a nice way of introducing this. Probably this is something you experienced yourself, Tim as well.

during your clinical work.

Tim Beames (02:52.846)
Yeah, yeah. Well, look, it's like a pain score is a typical, isn't it? And from a science point of view, it's often what is taken as a primary measure, an outcome to see whether something is effective in the treatment of pain. it's fairly understandable that we then, you know, bring that back into the clinic as well. So, yeah, and some people come to you, I had this this week, in fact, I had someone come to me and they said something.

of you probably want to know about my pain.

But not everybody works that way, do they? So, you know, some people would really struggle to be able to come up with a number. And I certainly remember joking about this on courses and with people in the past. Now I'm a bit more curious about this, but there will be people who come and you'll probably want to hear about my pain and, know, my pain is like a...

100 out of 10 or a 20 out of 10 or something like that. I think that what they're really trying to do is they're just trying to communicate the severity of what they're experiencing and how bothersome that is for them. And they're doing it in the best way that they can. But then there are people where putting something into a numerical scale is impossible. And there might be neurodivergent populations, for instance, who really struggle with this.

There's actually a really beautiful paper written by someone who's neurodivergent interrogating the idea of a pain scale. I forget the authors, apologies, but saying like, if we get given a pain scale, it's meaningless to us. We're like, you know, come up with something better. And there are many other ways of coming up with something to communicate what you're going through.

Tim Beames (04:49.166)
not just words, it might be action, sound effects, song, poetry, art, you you name it. You know, there's other ways of expressing what you're going through. So just a pain score, I think there's problems there. And then we've got reframing the point of view of needing to get rid of, know, fixing pain in order for you to see success. And again, yeah.

Bart Van Buchem (04:57.373)
Yeah.

Bart Van Buchem (05:02.973)
Yeah.

Tim Beames (05:18.862)
If that is the only measure, then we are really challenged. yeah, and again, I actually had a message yesterday from someone I've worked with for some time, they've been doing great and they have had a period where things have been challenging. But despite that, they are still doing...

you know, and able to do lots more. they're living with pain, living well with pain, but pain is still a part of their lives as well. But it's not to deny that that's a part of their lives. But the reason I bring that up is that they were able to reflect and say, you know, I'm really struggling. The last month's been challenging, but I realized that this is much better than I was, which is amazing reframing of it. So, yeah.

Bart Van Buchem (06:11.942)
Yeah, absolutely. Which probably brings us to where it is appropriate. Let's figure out, because there is a problem with the Pains course, Obviously, I think you pointed out really nicely where the context and even by definition, there is a problem because there's so much variability and context dependency and it looks like the number says so much more than just...

the number and some people just don't have any, let's say association with numbers, right? It doesn't reflect. It doesn't reflect a feeling at all. even though people are, and I think another one is a one which is like a problem with the pain scores is probably ones that if you ask me a lot, people get biased. So, so it, get worse, but the pain scores doesn't reflect.

the worstness if you like, or not even the improvement. So yeah, I'd do much better, but the pain score is not reflecting that. that's probably the pain, but pain score says probably something to be careful about. So when is it appropriate? What will be your condition that you say, that's a good measure for now.

Tim Beames (07:24.376)
Yeah.

Tim Beames (07:29.888)
Yeah, yeah, yeah. Okay, I'm gonna come to that, but can I just, cause it just jumped up in my mind, but just to put it in context, as you were saying, like how variable things are within a person, because I remember treating someone with complex regional pain syndrome where they say, Tim, I thought I had pain that was 10 out of 10, but I realized it can get worse. And that was really a wake up call for me. This is maybe 15 years ago. And I was like, wow, is that really what can happen?

Your frame of reference varies over your lifetime, doesn't it? But coming back to your question, when is it appropriate? Well, from a science and a research point of view, then that might be the valid measure that we're using and therefore we need to honor that. But we also need to realize where that might fall down or which populations that might fall down for.

And when someone comes with that expectation, think meeting and being able to meet their expectations is important. I am particularly keen, yes, that might be a part of it, but I'm particularly keen to also understand what that means to that person's life. So yes, you've got pain that's eight out of 10, but what does that mean to you? And that's really where I would want to go and understand things.

So what does that mean? That means that maybe it means the decisions I'm making are life limiting. So I'm not playing with my kids or it's affecting my sleep or my mood is altered because of it or I'm anxious about what might be going on or I experienced many pain flares. So there might be a number of different ways, but then this is...

born out in that person's day-to-day living.

Bart Van Buchem (09:29.852)
Yeah. So using a pain skill will be probably helpful in terms of standardization. If we collecting data.

And maybe for some people, was just thinking for some people and I, from my personal clinical experience, some people do somehow do very well on numbers, right? So they, they, they scaling themselves all the time. So they do feel really comfortable because it, it, it basically summarized a lot of words in a single number. And it's the start of a conversation where you can think of why, what happened.

What does this number represents? What's the five of today says to the five of a month ago? What's the difference or the similarities? Which interesting, right? So I guess that we probably tackled the problem of the pain scores that it's probably a data driven scientific standardization model applied to the clinical practice, but not necessarily always helpful or potentially

Tim Beames (10:33.272)
Hmm.

Bart Van Buchem (10:41.284)
It could, and I, and I think that that's the problem. What I see it, it could dilute into something that you losing connection and you think a person does well, but they're actually feeling terrible or the other way around. Right. So just taking, I remember when you're working in a hospital and I there, especially the Dutch hospitals in anesthesiology departments were,

through hospitalization after, let's say post-surgery conditions where, all right, you got a five or a six or more, tramadol, eight or nine, oxycodone. All right, so it was basically driving the pharmacological and pain-reducing meds at this stage and...

Tim Beames (11:32.974)
Hmm.

Bart Van Buchem (11:35.386)
I don't have to be honest, I don't have very extensive experience in the hospitals, but I can see there is a good reason for doing, let's say sufficient pharmacology administration, right after surgery. But at the same point, is it always like that? So what does this number means?

And from my little experience, I see in the very, very beginning that people say, okay, this is a 10 out of a 10. You can say, well, you're suffering. don't, this is like the one thing you can think of. You probably just need something to ease and slow down, chill out and need another 24 hours to evaluate. You probably will be much better after surgery in 24 hours. So I can see the benefit, but the longer and the more you

Tim Beames (12:21.742)
Thank

Bart Van Buchem (12:29.628)
take these, these measures, the less helpful or likely harmful at some point. Yeah, yeah, because I think it depends on the content or where you see people like long standing chronic conditions like CRPS, maybe people have pain for five, six, seven years. And sometimes we're talking about here is people like having a very anticipated pain.

Tim Beames (12:39.247)
the sort of persistence of it, yeah.

Bart Van Buchem (12:58.63)
we know is going to be painful and we're trying to reduce it as much as we can. So when is this pain measure still helpful for people in a chronic pain state?

Tim Beames (13:11.182)
Is that a question for me? Well, again, just coming back, when is it helpful? I think my personal belief is on its own, it's not enough. It's not enough. And I'm thinking as you're talking about that, I'm sort of my mind's wandering off to, know, you could have pain that's eight out of 10 and that's sort of the whole of their life, but you could have pain out of

Bart Van Buchem (13:11.334)
Yeah, there's a question for you!

Tim Beames (13:39.726)
10, eight out of 10, and it's a little part and then in fact, they've got a whole bunch of stuff happening in life at the same time. So I'm wondering about the impact that pain has on them. Really. yeah, and there might be look, and there might be measures. And if people are numerical, there might be measures that help us to make sense of things and to make sense of change. It may be it's a patient specific functional scale or pain self efficacy.

questionnaire or there might be a bunch of other different validated measures that that that we can we can use.

Bart Van Buchem (14:16.038)
Yeah, well, that's probably where we should go into right now. Let's see what the other meaningful measures of progress. It's probably something. There are some some questionnaires, obviously, or questions. Where do you feel like apart from the pain skill, or instead of the pain skill, what will be your, your, your framing, framing into progress and how to make it

Tim Beames (14:22.829)
Yeah.

Bart Van Buchem (14:46.652)
helpful or measure at least the progress you can see in a chronic pain state during treatment.

Tim Beames (14:52.386)
Yeah, yeah, yeah. So, yeah, so some of the markers I've already said, they're the meaningful markers that I would be looking at is the impact that has on someone's mood, sleep, relationships, work or ability to work, play. Yeah, so that, so they would be the sorts of things. And then, then, and then as a specific pain measure.

pain flare ups as well. So I would be interested in it. Absolutely. This is what often is what brings someone to you. But it's often more than that. Again, now I forget sort of where all my conversations sort of melt into one. I wonder whether we talked about this before, but I spoke to someone probably two weeks ago now. And we're doing just an initial consultation and their original

A goal from our conversation, know, what do you want to get from working together was I want my pain to reduce. Great. You know, I totally understand that if pain is there. And the one amazing thing about pain is it's so good at doing its job, but you can't ignore it. So, of course, if you want to get on with life in another way, then it seems totally.

total sense that you want to reduce pain. And by the end of the conversation, they reflected back to me, which I thought was really amazing, was I thought it was that I need to get rid of pain. But actually, what I realized I want is I want to be strong again, and I want to be robust enough to be able to play with my kids. And that, like that reframing and that sort of opens up a conversation then doesn't it? Because it says,

you know, would we be able to do that with pain? Would that be okay? And a big part of conversations, I know you have these as well, we've talked about this, is that we can't force that outcome. We can create conditions, we can control some of our actions, but we can't control the perceptual phenomena, we can't force the outcome.

Tim Beames (17:13.454)
So we can lay the foundation, we can make wise choices. And then some of that comes down to things like how much support someone has, whether they have autonomy. Financially, whether there's the social environment, there's a whole bunch of different factors that could be constraints or that they can leverage to help them to move forward in this as well. yeah, there's a whole bunch then.

of practicalities of, you know, what's realistic for this person in their world to move forward. So, yeah.

Bart Van Buchem (17:50.588)
Yeah, that's a lovely way of putting it, I guess. what I hear you saying, which is the other measures like sleep, mood, pacing, relationships, work, maybe the feeling of being in control, or at least having some say. I really, I like the way how, for example, like headaches are measured.

not necessarily by its intensity, but the frequency. especially when it's episodic, how many flare ups, because that's very indicative for the, the, the real threat of is, is so bad. You have to stop doing what you do. Right. And the average level of pain doesn't necessarily create that situation.

So even these numbers and secondly, just to add on that, if people do have the flare up, it's the, the general feeling or the, the, experience around this flare up. So people might've flared up and then freak out. And now they flare up and they are sort of, right, I know what I need to do. I know what to do. It's still the worst feeling ever, but it's in a way I'm not.

freaking out. not going into a full blown anxiety or panic attack, which is a big win. And I think that's something to put in perspective. But it's hard to tell people before I think that's a challenge, right? So well, in first year, mood will improve and then likely maybe your pain will will reduce, which is a bit of a nocebo message in itself, right? So

we could we could see how do you reframe the narrative? What's the the way of especially in setting this expectation because when it happens, it's not really a problem. Because in my experience, when people do experience a much better mood, and they feel more happy, feel more in control, they're not going to blame you for saying, well, that's great. And even despite the pain, but they experience it, it's the tricky

Bart Van Buchem (20:08.466)
part in my view is where it starts when you have to set expectations. So people come in, so when is the pain going to get better? When is it gonna ease? And then a common question from, especially from the CBT approaches, if you like, so we're not going to change the pain. We're focusing on activities and participation. Do you have any suggestion how to, how you can reframe the narrative of

meaningful measures of progress.

Tim Beames (20:40.75)
Yeah, well, we've had a chat about acceptance in the past and I'm not keen on that message of we're not going to change the pain because I don't know one, but also we are biological systems that are constantly adapting and changing. you know, just thinking about the constituent parts and the whole of us is that we are changeable, we are constantly changing.

So I would say it's, and I think I've heard Lorimer say something along that lines, it's biologically not just plausible, it's inevitable that change will happen. We run a pelvic pain group with male pelvic pain and we talk about impermanence as a part of that. and then, know, just stealing a little bit of what we do within the male pelvic pain is a part of

Bart Van Buchem (21:23.773)
Yeah.

Tim Beames (21:40.714)
The journey is that we map out someone's narrative. We literally get people to map it out. So to draw something, to come up with songs, poetry, et cetera, to represent where they are now. But also we do a task where we're looking at representing who they will be in the future as well. I find that's a really powerful.

and to see what's meaningful for you as well. You what do you truly want in life? And it's really, yeah, it's really quite an amazing part of that process. And then we can start to put things in place in order for you to more likely get to that point as well. So to realize that and to enjoy the journey along the way as well, because the outcome is, as we said, something we can't control, but we can control the actions along the way.

So being able to check in, notice, experience joy, happiness, calm, contentment, whatever that might be along the way, I think is a key part of a recovery process. And if we're able to do that, then we have more and more time and humans naturally have the negativity bias, don't we? So we see the problems and the difficulties and

Bart Van Buchem (23:02.472)
Yeah.

Tim Beames (23:05.602)
And the challenge is, but being able to train yourself to notice that actually despite them, or at the same time, we can still experience some joy, some happiness, et cetera. And that is a part of that, if you want narrative change that we can map out with our clients and can be really powerful as well.

Bart Van Buchem (23:27.206)
Yeah, so those are the fundamentals of not necessarily pain, I guess it's it's it's probably would also account for mood disorders and people struggling with burnout type of issues where yeah, what we're improving not every physiotherapist or OT would feel comfortable going is this is this a typical psychology area or would you consider this as a vital part of

Let's say.

allied health professions should also dive into the world of identification with your life goals and what meaningfulness, etc.

Tim Beames (24:15.298)
Well, without stealing thunder from the OTs, would say they've always done that. we're just sort of slowly getting in line with their way of thinking. And thank you to the occupational therapists. And we apologize wholeheartedly for not listening to you for longer. Yeah, I think everybody should be there, but I'm completely biased and realize that that's not the case.

And there are certain.

Bart Van Buchem (24:44.968)
But it takes a lot of time as well, right? So this requires a relationship, especially if you don't have the time, it has to happen in a very limited framework. So what will be the one or two things you should do, like a homework exercise to get people sort of thinking, or at least if you want to give them the take home message, how they can figure out what these meaningful goals could be.

Tim Beames (25:14.19)
Hmm.

Bart Van Buchem (25:14.408)
Especially if you don't have the time to spend long sessions and debating discussing about this.

Tim Beames (25:21.772)
Yeah, yeah, I mean, I guess there's questions in there. This would be good for, you know, it'd be nice to hear what listeners have to say about this. You know, how do you frame it? It might be something like, what would a good week look like to you? You know, what would it include? What would you be doing even with pain? What would that feel like? And what would it look like? So that's the sort of thing I would be looking at.

Bart Van Buchem (25:30.621)
Yeah.

Tim Beames (25:50.644)
I actually, and this is really how I'm working with the people I'm working with, so it might vary for different populations, but I try and broaden the lens. So instead of looking daily or even minutiae, like hour to hour, like broadening the lens, widening the lens to me is not just in a week, but it's in a month. So what would your month look like? What would it include? And being able to within that...

picture being able to notice the successes and celebrate the successes and reward the successes. So that would be, you know, a part of how I would be aiming to reframe some of that narrative as well and getting someone to, yeah, just look at themselves in a slightly different way. The other...

Bart Van Buchem (26:24.516)
Exactly, yeah.

Tim Beames (26:45.708)
I think quite a large part of this is seeing pain as the problem, you know, and if that's the problem, it's inevitable that that's what you need to get rid of. So, you know, there's challenges of us working, understanding, figuring that out as well with that person. And a big part of that is what I do with my patients as well. I actually...

I don't see that as helpful. I think that's quite an unhelpful thing if we constantly see pain as an enemy and it's being done to us, you know, and we're in battle with it. It's like we're at war with pain. If we can, and it's very challenging to begin with, but if we can see the benefit of pain, of pain perhaps being a friend and being able to

to show you something and maybe we could respect it, welcome it. Those are challenges, but I would say, know, couldn't we listen to it and respect it and just ask it, you know, thanks for being here. What are you telling me?

Bart Van Buchem (27:55.878)
Yeah, like a bodily sign if you like, like, yeah, yeah, I like that. Because I always felt uncomfortable with using a pain as a friend because it's, it's hard to believe that that pain is in it. In the context of chronic pain is helpful. Let's say from a day to day stuff, was a yeah, definitely pain will be very helpful just because it when I'm pushing my boundaries, probably it's telling me that I'm closing, closing into my boundaries and I should

be careful or should prevent myself getting into an injury. But in, in a chronic state, it's probably over or it tells something else. I like the, the way you said it, like I said, like a bodily signal. And I was thinking like, like a blood pressure, it can be a bit higher, could be a bit lower, but it's tell you something about the condition of your body. what I just want to add here and as some people do, especially in these chronic pain states, when stress,

really strongly correlates with the pain measure. So some people do have that, right? So the pain goes up and that at some point they, it's after the stressful period, for example, and they see the, the, the correlation is very strong. And one of those goals is like, let's see, we can undo that correlation. That will be a great way of seeing if we can sort of, you can have pain without being a stress, but it could be elsewhere the other way around, which

brings you then that actually, in some places, and I think that's very, I think that's pretty safe to say that there is, there is an existence of spontaneous pain in chronic pain. Sometimes pain doesn't tell anything. It's just how the body works. It's, it's not even, it's not helpful or unhelpful. It's you're being challenged by the same pain.

Tim Beames (29:46.258)
There's even a name for it, isn't there? Peroxism or pain. So yeah, coming with no rhyme or reason, completely spontaneous. Yeah, yeah, yeah, totally.

Bart Van Buchem (29:51.045)
Exactly.

Bart Van Buchem (29:54.63)
Yeah. And instead of mixing up and putting relationships to, or correlations between this is what I've done, I shouldn't do it again. I think it's, it's a main thing trying to get these measures away. And these measures could be somewhat helpful to see whether it doesn't correlate as much as you thought, because it was probably correlating with the last episode, but it didn't over the month. That's what I like the

The measurement, you said, you pointed out like, let's, let's see, not the week or the day or the hour, but let's, let's see it as a month, like a pattern rather than diving into deeply in too deep into it. So you losing track. Yeah. Like it's too much information. It's unhelpful. And I think that's where the, the narrative sort of, how should I measure or how should I evaluate?

my condition related to pain and all the other bodily functions that are part of you. yeah. So, so we're, we're about to wrap up, this session and I think we, some key taking points I would talk, yeah. T key talking points we had, the shift from elimination to expansion. what, what life can, what life I can live.

even with this pain. there is this beyond the pain. There is this, the way you look at it, what the meaning of it is. And there is a step-by-step approach. Obviously you cannot tackle it all at once. It's about connection. You pointed out really nicely. People have little need a little bit of trust in you as a clinician, where you have goals that probably go beyond the pain.

but sometimes it's inevitable that pain will be part of the goal because it does affect everything. And then it's probably helpful to see what this relationship with pain and the person might be. And I think we pointed out in the last episode as well, where sometimes you just, there are ways of...

Bart Van Buchem (32:04.402)
where you should be able to at least temporarily reduce your pain. And if you're in agony, it will be very helpful if you have ways to temporarily ease your pain. And if you don't have access to this type of help, probably you need to help people to get that because in that stage, you need some control over these times, regardless where the pain is located. We think we're not gonna...

gonna dismiss pain measures, but we just have to understand where they come from. measures could be helpful, but also likely to be very unhelpful, especially for people in long term conditions, pain conditions. It's more likely that it doesn't tell you the story of the suffering. tells you like everything. It's not just about the pain of what I was saying. So, yeah, I think

Tim Beames (32:58.222)
That's it. Pain is so much bigger than pain, isn't it?

Bart Van Buchem (33:02.95)
The pain, pain. Yeah, absolutely. Yeah. So, yeah, I think we, we, we should invite you just try asking your next patient. What would a week look like for you? Even if the pain would be still there. can you think of something that would be helpful to do and where you can actually untag untangle the correlation between pain and your activities.

What is safe? it safe or is pain really your enemy? And what does this number says if you're using these numbers? Yeah, it's like an eight out of 10. So what does it mean? Why is this an eight out of 10, another nine out of 10 or seven out of 10? So yeah.

Tim Beames (33:45.272)
Yeah, bring a friend, bring a colleague into the conversation, to the pub. Yeah, and let's hear what you have to say, because we're growing, we love hearing how people are using these skills and strategies and conversation.

Bart Van Buchem (33:52.379)
Absolutely.

Bart Van Buchem (34:04.998)
Yeah, an easy way to encourage your colleagues is just send them the link of this podcast or send them to our website. Have a look and we experienced and seen over the time that if you're alone, if you're working in a clinic and you feel slightly on your own, that it will be, there's so many people around in the world who are seeking for like-minded people, are facing the same challenges and will be.

very happy to meet and connect through LAPUP. So without further ado, I guess we're gonna wrap it up. I hope you enjoy this. It was a good one. Lovely conversation, Tim. Thank you for your insights.

Tim Beames (34:52.728)
Thank you. Yeah. And you've stopped sweating. So it's even, even better.

Bart Van Buchem (34:57.36)
Hahaha

Absolutely, like a true parasympathetic exercise. was, yeah, absolutely. No, I'm, I'm, I'm okay now. So next for the next run, I guess, hopefully the temperatures will be slightly more comfortable for the run for the next exercise. So I'll be all right. Thank you for listening and see you next time.

Tim Beames (35:19.726)
Cool, cool. All right, thanks everybody for checking in.

 

Thank you.