Romy Parker, PhD, is a professor and director of the Pain Management Unit in the Department of Anaesthesia and Perioperative Medicine at the University of Cape Town in South Africa. She is an active researcher, as well as an experienced physiotherapy clinician working in chronic pain management as part of the Chronic Pain Management interdisciplinary team of Groote Schuur Hospital. Her research focuses on pain, with emphasis on developing and testing mechanism-based treatments relevant to a South African context.
Parker recently spoke with PRF Correspondent Y V Raghava Neelapala, PT, MPT, a PhD student in the School of Rehabilitation Science at McMaster University, Hamilton, Ontario, Canada, to discuss her career journey, her current research projects, and the skills and knowledge that make for good physiotherapists. Below is an edited transcript of their conversation.
You were a physiotherapist initially, and later did your PhD in the field of psychiatry. Can you elaborate on your career path?
When I finished my physiotherapy training, I did a postgraduate qualification in sports science and worked in the field of sports injuries, particularly in rugby. After many years of working in that field, I got a bit tired of athletes who I thought just weren’t listening to what I had to say. So I then started working, strangely enough, in the field of rheumatology.
When I worked in rheumatology, that was really when I was challenged by the strangeness of pain, because I had patients with severe rheumatological disease. Their joints were destroyed, their knees were a mess, and yet they were living full, rewarding lives and hardly ever complained of pain. I had some patients with early rheumatological disease – who had no joint damage and were responding well to their drugs – and yet they were in pain all the time and were disabled. That was when I was challenged by this idea that there was pain, and then there were disease processes, which were not always directly linked to each other.
That’s when I started asking questions, and I went on to do my master’s in pain in Edinburgh at Queen Margaret University. Then I came back to South Africa and started working on my PhD in psychiatry. This was because my supervisor was a psychiatrist but also because we recognize that pain is about the brain, right? I was asking questions about pain in people living with HIV and AIDS, because at that stage we already had some quite good insight that pain in people with HIV was not related to disease, viral load, or opportunistic infections. So what was this high prevalence of pain in people with HIV about?
So that’s when I started my research career, really focusing on pain problems that are particularly relevant to my society in South Africa, to the millions of South Africans who don’t have access to expensive healthcare, who manage at a primary healthcare level. I started thinking about how we develop effective but sustainable treatment options for those patients. I have a particular passion for making sure that our treatments are effective but are also culturally relevant and sustainable for these resource-poor settings where the majority of people in my country are living and struggling.
Can you share you views on the role of the physiotherapist in a multidisciplinary chronic pain rehabilitation program?
I know I’m biased because I’m a physiotherapist. But I believe that physiotherapists are pivotal in chronic pain management, particularly with the growing evidence of how poor pharmacological management is and how good nonpharmacological management is.
Well-trained, psychologically informed physiotherapists bring massive benefit to chronic pain management. In many cases, the physiotherapist is the key member of the team who essentially should be the case manager. Education, exercise, behavior change, and lifestyle management approaches that we use are integral long-term strategies that people with chronic pain need. The other members of the team are bringing treatments that allow the patient to engage with physiotherapy: The pharmacology turns down the volume enough so that people can engage with physiotherapy, and the psychological input allows them to deal with fears or traumas so that they can engage with physiotherapy.
What are some of the research projects you are working on currently?
One of the exciting ones is around PEEP, the Pain Education Empowerment Program, which is a six-week outpatient-based program for patients with chronic pain. We have a program called Positive Living, which is designed for people living with pain and HIV, and we have a Living with Osteoarthritis program. But essentially, the principles are the same.
Our patients come to the clinic for two hours once a week, and we follow a curriculum that involves education and activities around self-management, pain neuroscience, exercise, stress management, sleep, mindfulness, nutrition, and benefits and side effects of medications.
The final week is a recap where we go through all the tools that they’ve acquired, and we engage them in conversations around what happens next. Where do they want to go with their lives? What do they want to do? Do they want to get involved in a community group? Do they want to get involved in a charity? And they start setting goals about moving in that direction.
We have some nice evidence over the years about the effectiveness of this program, but with lockdown, our outpatient clinics were closed down, yet we still have people suffering in pain. We were particularly concerned about people’s pain being worse because they’re in isolation.
The study that we’re running at the moment is e-PEEP. Here, we’re running PEEP on an electronic platform, and we needed to be clever about it. We first thought, let’s Zoom – everybody’s Zooming! But most South Africans don’t have computers and certainly don’t have WiFi in their homes, so they have no Internet access.
But South Africa has some of the highest cell phone usage in the world, so we thought, can we do this on cell phones? WhatsApp is very widely used in South Africa, so we set up PEEP to run over a WhatsApp group. Time is a challenge, so instead of two hours of contact, we do one hour of contact once a week. We do a video call with the clinician, who is a physiotherapist or a psychologist, and four patients. We provide a lot of educational material, including podcasts, videos, infographics, and links to useful websites. We have run this program for six weeks, and at the moment we’re interviewing the patients to find out if it’s feasible and acceptable.
What does the exercise component of PEEP look like?
The exercises that we use in PEEP are generic. We really don’t obsess too much about getting the plane, and the angle, and the starting position absolutely right. We’re more interested in using exercise for its hypoalgesic effects, which means that really any exercise will do, and to use exercise to reduce fear of movement and as a method of graded exposure to activity.
If a patient says to me, “I’m not going to mosque because I can’t get down on my knees,” well, one of the exercises that we’ll do will be getting down on your knees. If my patient says, “I’m not playing football with my grandchildren,” then one of the exercises will be kicking a ball around to get them to engage.
We focus a lot on movement variability because we know that patients with chronic pain lose that. We all know, as physios, that they will move like robots, so we get them doing all sorts of weird things like mimicking their favorite animal, walking like teenagers, and walking like old people. Fun is the big word and a big emphasis; we make sure that our exercise programs have lots of laughter, giggling, and being silly. It’s got to be fun because the majority of our patients don’t want to exercise.
What are the challenges encountered while delivering the e-PEEP program?
Some of the challenges we had were that we might have bought people data so they can use WhatsApp on their phones, but the coverage in their area is terrible, or they live in a small house and there are all the children running around making noise while they’re on the video call. We hope that we’ll be writing about our experience with the program and publishing it soon to share some of the lessons we’ve learned and to encourage people around the world to try to be flexible about how we can make a plan.
How have you handled the problem of delivering pain neuroscience education to patients with limited formal education?
This is really where the e-PEEP has been amazing because, previously, we would give people printed workbooks and many of our patients really struggled to read, never mind read in what might be their second or third or fourth language. It’s really challenging. The podcasts and videos that we’ve developed are in different languages so that people can listen in their own language.
We use the lessons that Lorimer Moseley and David Butler have taught us about using metaphors to explain things, and we’ll use metaphors that are culturally or socially relevant to the part of the country we’re working in. In South Africa, amongst the physiotherapists, we have developed a whole range of stories and metaphors that are culturally relevant. One of the most common ones we use is the burglar alarm. This is because most homes and cars in South Africa have burglar alarms, and we’re all familiar with those burglar alarms that just go off when nobody is breaking into the house and how this drives everybody crazy. So that’s a useful metaphor.
In the Northern part of our country, there are anthills; the ants make a nest above the clay ground. If you grew up in that area, as a child you know that if you go to an anthill and you make a hole in it using a rock, then all the ants come out to fix the hole and they attack you. But you also know that if you do that every day, after a while, if you just walk close to the anthill, if you stomp your foot, all the ants come out because they don’t want you to do that.
There are parts of our country where fogbanks come in from the sea and it looks like smoke, and these are areas of the country where bushfires are a dangerous thing. So you see the fogbank coming in, and you respond as if it’s fire and smoke and a disaster, but it’s just a fogbank. That’s another metaphor that we use for people in that area because it’s something that they’re very familiar with.
In our teaching in South Africa, we have continuing professional development teaching courses, which we are now doing on Zoom. We always ask people if they’ve come up with a metaphor that is culturally appropriate and to share it with the community so that we are increasing our repertoire of stories that we can use to explain pain. We are trying to find as many different ways as possible so that we can engage with everybody, from the 94-year-old great-grandmother who never went to school to the university graduates.
What are the future directions of this program?
First, I do think that we need to go back to treating our patients face-to-face. They need contact, and community. But I think we’re going to move to a blended approach, where we will have the WhatsApp groups and be able to send them the information, and then they’ll come to the clinic and engage so that we’ve got the best of both worlds.
We have been trying to roll out these PEEP programs at a primary healthcare level to empower physiotherapists and occupational therapists to run these programs at the rural and city clinics – everywhere – because our data in South Africa is that one in five adult South Africans is suffering with chronic pain. So we’ve certainly got a burden, but one of the things that clinicians feel challenged by is their own skill in delivering information. If we can use this blended approach and give them the resources that they will then share with the patients, it is much easier for them to then facilitate the groups.
Our vision is that South Africans with pain should be able to receive treatment from a well-informed healthcare professional who understands pain at a primary healthcare level. The idea that pain is something that’s managed at specialists’ centers at a tertiary level – it’s not sustainable, and it’s not fair on our patients; they deserve to get treatment at home. So I think this model is really quite exciting because it does facilitate that.
Do you notice any superiority of telehealth over in-person consultations?
Telephone, Zoom, or whatever platform you use is better than nothing, but I still believe in face-to-face interaction. People need to see people; there’s something that happens between people when they’re in a room together that you can’t quite capture in this environment.
I had a consultation with a patient on Zoom recently, and she’s doing fantastically well, and her complex regional pain syndrome is cured. But she still asks when I am going to see her properly. She still wants human contact; although we’ve treated her all the way through lockdown and cured her, she still wants the face-to-face interaction. I think that’s human beings.
Earlier you stressed the need for well‑trained, psychologically informed physiotherapists. What are the skills required for this?
The primary skills that we need, as physiotherapists, are communication skills. Not communication skills where we stand up and tell people things, but true communication skills to make sure that we’re meeting our patients and engaging with them, that we’re developing therapeutic alliances and are partnering with our patients.
When I was an undergraduate, we weren’t taught communication skills at all. Now, our programs have some communication skills, but it’s kind of regarded as a nice thing to do; we spend hours mobilizing joints but then you get one workshop on communication skills. We need to be paying a lot more attention to this. The key thing is listening and really hearing what the patient’s ideas, concerns, and expectations are of their treatment, and making sure that we’re meeting that.
The second skill is to be truly biopsychosocial in your own philosophy and approach to physiotherapy. We often talk about the biopsychosocial as physiotherapists, and then we practice the biomedical; we like to be mechanics. We have to be truly embedded in and comfortable with the idea that human beings are complex, and that psychology is physiology, and that every thought and feeling is a chemical reaction in your brain, which changes the functioning of your autonomic nervous system, your gastrointestinal system, your muscles, and your immune system. Human beings aren’t discrete systems; everything interacts.
What is your advice for early-career researchers like me who are about to start doctoral studies?
Find a topic that you’re passionate about. Learn from everybody who you can, including yourself. Particularly in the world of pain, don’t be afraid of asking questions – stupid questions, any questions. My experience is that just about everybody who works in the field of pain is passionate about it, loves it, and will engage with you no matter what, and the chances are you’re going to have thousands of teachers. My comment to you, as somebody from a developing country: Don’t think that the developed world has all the answers. In the long term, we are going to teach them how it should be done.
Y V Raghava Neelapala, PT, MPT, is a PhD student in the School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.