2021 Global Year About Back Pain: Interview with the Co-Chair

A Conversation with Dr. Owen Williamson

Dr Owen Williamson practiced in Australia as an orthopedic spine surgeon and pain medicine physician, prior to moving to Canada in 2011, where he continues in clinical practice as a pain medicine specialist. He is an Adjunct Professor in the School of Interactive Art and Technology, Simon Fraser University, and Adjunct Associate Professor in the Department of Anesthesia, McMaster University, and the Department of Epidemiology and Preventive Medicine, Monash University, Australia. His research interests include virtual reality in the management of chronic pain and the development of integrated pain management networks. He is the Chair of the Academic Pain Directors of Canada, and led the call in 2018 for a Canadian National Pain Strategy that resulted in the striking of the Canadian Pain Task Force. He is also the Chair of the IASP Ethical and Legal Issues in Pain SIG. 

How did you get started in pain research/management? What do you do in your current job? Why did you choose back pain?

The pivotal moment in which I became engaged with the pain world was at the Australian Pain Society Annual Scientific Meeting in 2000. As an orthopedic surgeon specializing in spine and trauma surgery, I was invited to participate in a panel discussion, and was immediately drawn to the interdisciplinary approach to solving the wicked problem of pain. Since that time, I have become engaged in the study and practice of the epidemiological, philosophical, pharmacological, clinical, ethical and political aspects of pain medicine.

Since moving to Canada in 2011, I have practiced as a pain medicine physician. I work in a tertiary (metropolitan) and secondary (regional) interdisciplinary pain clinic. The ups and downs of clinical practice provide a constant reminder that the purpose of pain medicine is to reduce pain, improve function, relieve suffering in, and give voice to, people living with pain. My academic bases are in epidemiology and preventive medicine, anesthesia and pain medicine, and interactive arts and technology. I love working with those who advocate for people living with pain and am a passionate advocate for the development of a Canadian National Pain Strategy.

Why did I choose back pain?  As a spine surgeon, I realized that 85% of patients I was treating with back pain did not need surgery but did need someone to help guide them through the biopsychosocial maze of their predicament. To me, this seemed a worthy pursuit.

Have your research interests changed throughout your career? What are you currently studying?

My research interests might have appeared to change during my career, but I think they represent different manifestations of the same enquiry into the nature of pain. I have studied the epidemiology of pain following trauma, the interactions between chronic pain and mental health disorders, the pharmacological treatment of pain and the delivery of pain services. I am still however drawn to the invisibility of pain, a pervasive phenomenon, that through its invisibility, challenges the observation-biased scientific paradigm.

Within the School of Interactive Arts and Technology at the Simon Fraser University in British Columbia, Canada, we are exploring the effect of virtual reality on a diverse range of pain-related situations, including distorted body perception, relaxation, rehabilitation, and empathy training for partners of people living with pain.

What do you think are the current challenges in managing the global burden of back pain?

I think the biggest challenge in managing the global burden of pain is ensuring that people living with back pain have access to individualized care that is safe, effective, affordable and timely.

From a global perspective, back pain is a “wicked” problem, socially complex, multi-causal with many interactions, with no clear solution. and beyond the responsibility of any one organization or government department.

Understanding and dealing with interactions between chronic pain and the social determinants of health involves considering factors beyond the domain of the health sector, such as education, income, social status, the physical environment and social support networks.

Whether LBP is best dealt with by specific public health policies, within frameworks of national pain strategies, or a combination of both is yet to be determined.

What do you think are or will be the next hot topics in back pain research and management?

Since 1990, there have been over 50,000 publications on back pain but despite this the global burden of back pain has increased. Why is there this disconnect? Wittgenstein wrote “one thinks that one is tracing the outline of a thing’s nature over and over again, and one is merely tracing round the frame through which we look at it”. Perhaps we are limited by the frame of our current pain paradigms and need to seek other approaches to understanding pain as an invisible phenomenon.

Hot topics in pain research will involve trying to bridge the divide between nociception and pain, the body and the mind.

Attempts to identify biomarkers of pain will continue, and there will be debate about the validation of potential biomarkers. As long as self-report remains the gold standard, researchers, clinicians, lawyers and legislators will struggle with the response to discord, ie people with negative biomarkers who say they have pain, or people with a positive biomarkers who say they don’t have pain.

Hot topics will also include the acceptance and implementation of guidelines and system approaches to care.

Just as I’m unable to predict the hot topics in back pain research and management, I am unable to predict an individual’s response to any intervention. In the face of uncertainty, I conduct an evidence-informed empiric trial. How then do we manage individuals who do not respond to a guideline recommended intervention? How many empiric trials are reasonable?

Attempts to determine the best approach to providing care to people with back pain will continue. Should stepped-care models which direct increases in intensity of treatments if initial treatments fail or stratified-care models which direct the intensity of initial treatments depending on predicted outcomes be used to reduce the burden of back pain?

Finally, hot topics should include the development and implementation of evidence-informed health policy. From a policy perspective, how do we ensure people in low or middle income countries have access to care, while avoiding inappropriate use of resources in high income countries? What outcome measure should we use and what end-points should determine whether a policy should be rescinded, modified or continued.         

Can you explain what translational pain research is and how can be communicated to and for the benefit of the patients and general community?

Translational pain research is the process by which observations in the laboratory, clinic and community are turned into interventions that improve the health of individuals and the public - from benchtop to bedside, and beyond. It is an iterative process, and to ensure success in terms of relevance and usefulness, must involve active collaboration between researchers, clinicians, educators, funders, legislators, and most importantly, people with the lived experience of pain.

People with the lived experience of back pain can assist researcher in defining research priorities, advocating for funding, translating results into simple concepts, and assisting in the development of education programs that can provide realistic messages through diverse media outlets.

I am particularly excited that IASP has created the Global Alliance of Partners for Pain Advocacy (GAPPA) to recommend processes to ensure patient advocates are able to engage with IASP Chapters and SIGs and provide their voice and perspective to these groups, the World Congress on Pain and other IASP programs. I particularly look forward to their continuing participation in the Global Year About Back Pain.

How have you seen back pain prevention and management strategies change throughout your career?

I have seen many back prevention and pain management strategies come and go throughout my career.

The biopsychosocial frame has expanded the list of factors associated with the development of acute back pain and the transition of acute to chronic back pain. Although many interventions aimed at reducing the impact of modifiable factors have been proposed to reduce back pain and associated disability and cost, such interventions have not been broadly effective.

It appears that interventions based on education and exercise are most effective at preventing back pain. Ergonomic interventions, such as lumbar supports, lifting devices, workplace modification, job rotation, and modifications to production systems, appear less effective than exercise in preventing occupational back pain.

Educational interventions alone however do not appear to be effective in preventing LBP, in children, adults, or in the workplace. Mass media campaigns designed to alter societal views about back pain and promote behavior change have now been performed in several countries with mixed results.

Surgery, interventional pain procedures, and pharmacological, physical and psychological interventions all have a role in the management of back pain, alone or in combination, but as is evidenced by the global burden of back pain, there are currently no simple solutions to the problem of back pain.

What excites you about the Global Year About Back Pain?

I am excited that the Global Year About Back Pain aims to focus the attention of IASP members and the wider community on the problem of back pain so that together we can identify barriers and propose solutions for improving the prevention, investigation and treatment of back pain.

I am excited that the Global Year About Back Pain provides an opportunity to collaborate with IASP members and the wider community to develop community education and advocacy tools that will facilitate the global delivery of individualized trials of evidence-based interventions for the prevention, investigation, treatment and rehabilitation of people living with low back pain.

I am excited about collaborating with people with the lived experience of back pain in order to ensure the relevance and impact of our task.