Chronic and persistent pain in the workplace: insights from the Flippin' Pain campaign

In this episode, Dr Helen Fitzhugh of the Evolve team speaks with Professor Cormac Ryan, Professor of Clinical Rehabilitation at Teesside University. Cormac talks about the Flippin' Pain campaign to help people reach a modern, evidence-based approach to understanding and dealing with chronic and persistent pain. He talks about its relevance to the workplace, the feedback the campaign has received from people with lived experience of pain and his team's next steps towards a new Flippin' Pain in the Workplace project. 

You can visit the Flippin' Pain website at:   https://www.flippinpain.co.uk/ 

Transcript

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00:00:04 Helen Fitzhugh

Welcome to the Evolve Workplace Wellbeing podcast.

00:00:07 Helen Fitzhugh

This podcast is part of a toolkit of free evidence-informed workplace wellbeing resources provided by the Workplace Wellbeing Research Team at the University of East Anglia in the UK.

00:00:18 Helen Fitzhugh

You can find the resources on www.evolveworkplacewellbeing.org 

00:00:29 Helen Fitzhugh

Hello, everyone.

00:00:30 Helen Fitzhugh

This is Dr Helen Fitzhugh of the Evolve Workplace Wellbeing team at the University of East Anglia.

00:00:35 Helen Fitzhugh

Today I'll be speaking with Professor Cormac Ryan at the University of Teesside, who specialises in the management of chronic pain.

00:00:42 Helen Fitzhugh

We'll be speaking about a project called Flippin' Pain and how that's relevant to the workplace.

00:00:47 Helen Fitzhugh

Welcome, Cormac.

00:00:48 Helen Fitzhugh

It's lovely to see you.

00:00:50 Cormac Ryan

Hi, Helen.

00:00:51 Cormac Ryan

Thanks so much for the invitation.

00:00:53 Helen Fitzhugh

Thank you for coming on.

00:00:53 Helen Fitzhugh

That's great.

00:00:54 Helen Fitzhugh

So as usual, would you mind introducing yourself to our listeners?

00:00:59 Cormac Ryan

Certainly.

00:01:00 Cormac Ryan

So I'm Professor of clinical rehabilitation at Teesside University.

00:01:04 Cormac Ryan

I'm also a community pain champion for the Flippin' Pain public health campaign, which I'm sure we'll come on to a little bit more later.

00:01:12 Cormac Ryan

And I'm also a 

00:01:15 Cormac Ryan

Co-Deputy Lead of the Workforce Inclusion Theme of the ARC, which is the Applied Research Collaboration in the North East, North Cumbria Area.

00:01:28 Helen Fitzhugh

Great.

00:01:28 Cormac Ryan

Which I think is a very cool title.

00:01:31 Helen Fitzhugh

It's a very cool title and it shows us that you're very embedded in thinking about workplace wellbeing, which is the topic of our podcast.

00:01:39 Helen Fitzhugh

So that's great.

00:01:39 Helen Fitzhugh

Thank you.

00:01:40 Helen Fitzhugh

So

00:01:41 Helen Fitzhugh

I think probably we need to stop keeping people in suspense and say what Flippin' Pain is.

00:01:48 Cormac Ryan

So Flippin' Pain is a public health campaign which tries to change the way that people think about, talk about and treat persistent pain.

00:01:56 Cormac Ryan

There are many myths or misunderstandings or misconceptions, whatever you want to call them, about persistent pain and how it works.

00:02:05 Cormac Ryan

And these myths, they act as barriers to good management.

00:02:11 Cormac Ryan

And within the campaign, we believe that knowledge is the key to success.

00:02:14 Cormac Ryan

If we can take this scientific information of how pain works, a modern understanding to bust

00:02:21 Cormac Ryan

these myths and give it to people who need it the most, the people with pain, their friends, their relatives, their healthcare professionals and more and more healthcare professionals in the workplace and workplace colleagues.

00:02:34 Cormac Ryan

We believe we can knock down a lot of these barriers to good management.

00:02:39 Cormac Ryan

And so the campaign has very much targeted the general public, but of late, of late, I mean, over the past two years, we've really identified that the workplace is such a crucial

00:02:51 Cormac Ryan

area to target, an area where misconceptions are really, really common, and also an area where, for want of a better word, people are.

00:03:02 Cormac Ryan

If you're running a public health campaign, one of the real problems is getting people to come and engage with your messaging.

00:03:10 Cormac Ryan

And invariably, you find out that you need to go to them.

00:03:16 Cormac Ryan

and an awful lot of them are in the workplace.

00:03:18 Cormac Ryan

So it's a really great place to deliver public health messaging, as long as I think it's particularly pertinent to the workplace, which I think the messages really, really are.

00:03:33 Cormac Ryan

And so I think it's a lovely fit bringing this public health intervention into this setting.

00:03:41 Helen Fitzhugh

That's great.

00:03:41 Helen Fitzhugh

And I know that you do a very full and entertaining workshop on Flippin' pain and the modern sort of understanding of pain.

00:03:52 Helen Fitzhugh

I wouldn't expect you to do it all now for us on the podcast, but have you got a small precis of the kind of thing that you share with people?

00:03:58 Cormac Ryan

Yeah, so we've got six key messages.

00:04:03 Cormac Ryan

That persistent pain is common and commonly misunderstood.

00:04:06 Cormac Ryan

Hurt does not always mean harm.

00:04:08 Cormac Ryan

Everything matters when it comes to pain.

00:04:11 Cormac Ryan

Medicines and surgeries are often not the answer.

00:04:14 Cormac Ryan

Understanding your pain can be key and recovery is possible.

00:04:18 Cormac Ryan

So those are our six key messages.

00:04:21 Cormac Ryan

And we try and hone in on each one and give each one a kind of a showcase of it.

00:04:26 Cormac Ryan

But I'll draw into, I guess, the two most particularly relevant ones, which is that hurt does not necessarily mean harm and everything matters.

00:04:35 Cormac Ryan

So the idea of hurt does not always mean harm is trying to help the audience members to understand the difference between pain and injury, that they are two fundamentally different things, that they sometimes hang out together

00:04:53 Cormac Ryan

but not always.

00:04:54 Cormac Ryan

And a bit like old school friends, over time with chronic or persistent pain, they often drift further and further apart from each other.

00:05:05 Cormac Ryan

So we would usually open up by giving some nice case studies from the literature.

00:05:11 Cormac Ryan

There's a real classic case study published in the British Medical Journal in 1995 of a builder who jumped from one platform to the next, and as he did so, a six-inch nail went up through his boot

Helen Fitzhugh

Oof!

00:05:24 Cormac Ryan

Yes, indeed.

00:05:26 Cormac Ryan

That's the reaction you're looking for from the audience.

00:05:32 Cormac Ryan

To digress just briefly for a minute, public engagement and indeed, whether it's done in the workplace or any other place, is all about making it entertaining and interesting for the audience member.

00:05:46 Cormac Ryan

If it's dry,

00:05:48 Cormac Ryan

You're just not going, they're only going to be there for the free pizza or whatnot.

00:05:52 Cormac Ryan

You're not going to be listened to.

00:05:53 Cormac Ryan

You need to make it engaging and entertaining.

00:05:56 Cormac Ryan

So much so that actually they go, wow, has an hour passed, where did that go?

00:06:01 Cormac Ryan

Rather than, oh my God, will this ever end?

00:06:05 Cormac Ryan

And case studies like that are wonderful because they produce that ooh reaction and there's really good visuals from the case study and all the rest of it.

00:06:13 Cormac Ryan

But this particular individual,

00:06:16 Cormac Ryan

was in agony, rushed to accident and emergency where they gave him some really strong painkillers like fentanyl, had little or no effect, brought him into the operating room, removed the boot, and what they found was miraculously, and that's the term they used in the case study, the nail had passed between his toes.

00:06:34 Cormac Ryan

So there wasn't a scratch on this guy, yet he was in terrible, terrible pain.

00:06:41 Cormac Ryan

It's a really, really beautiful example of hurt,

00:06:45 Cormac Ryan

does not necessarily mean harm.

00:06:47 Cormac Ryan

You can have terrible, terrible pain with little or no injury.

00:06:52 Cormac Ryan

And then the reverse is true.

00:06:54 Cormac Ryan

And then we will flip over to this other case study of a sort of a different type of example of a chap who wandered into accident and emergency complaining of headaches.

00:07:04 Cormac Ryan

And when they scanned him, they found a 12 centimetre blade in his head.

00:07:09 Cormac Ryan

It turns out that the night before he'd gotten a little tipsy,

00:07:13 Cormac Ryan

and had fallen over.

00:07:14 Cormac Ryan

And when he woke up the following morning, he could find the handle of his favourite knife, but he couldn't find the blade. [laughter]

00:07:25 Cormac Ryan

No prizes for guessing where the blade was.

00:07:29 Cormac Ryan

And it gets beautiful example here of significant tissue injury with little or no pain at the time.

00:07:36 Cormac Ryan

And it's about

00:07:38 Cormac Ryan

They're really extreme examples, but they neatly illustrate the concept that pain and injury are two separate things.

00:07:48 Cormac Ryan

And loads of people will often, and again, this is an important part of that public engagement is that is helping people to relate to the information.

00:07:57 Cormac Ryan

So, you'll always say, well, you're probably thinking, well, this information here doesn't relate to me.

00:08:05 Cormac Ryan

These two guys are super weird.

00:08:07 Cormac Ryan

They're not normal human beings like me or my family or my work colleagues or my patients.

00:08:15 Cormac Ryan

So then you say, well, put your hand up if you've ever been playing football or engaged in an activity and noticed you were bleeding and have no recollection of when that happened.

00:08:25 Cormac Ryan

And pretty much everyone in the audience puts their hand up because it's happened to everyone a couple of times.

00:08:31 Cormac Ryan

And then if they don't put their hands up and there's always one, you say, have you ever woken up with a bruise on your leg and gone, where did that come from?

00:08:39 Cormac Ryan

they're all examples of tissue injury, little or no pain at the time.

00:08:44 Cormac Ryan

And then sometimes you open it up to the crowd and they'll go, oh God, you know,

00:08:49 Cormac Ryan

This has happened to me.

00:08:51 Cormac Ryan

And that's then where it kind of the magic happens.

00:08:53 Cormac Ryan

You hear about people's stories are always the most compelling, far more than what's on some scientific paper.

00:09:00 Cormac Ryan

But if you can make the two match up and you can explain it, then that's kind of where the magic happens.

00:09:07 Cormac Ryan

But that then brings you on to the second key message, which is that everything matters when it comes to pain.

00:09:12 Cormac Ryan

And it was this key message

00:09:14 Cormac Ryan

more than any other that really brought me to the workplace setting.

00:09:19 Cormac Ryan

So if you think that the reason why there's this dichotomy between pain and injury is that pain is not a marker of the state of the tissues.

00:09:30 Cormac Ryan

It's a marker of perceived threat by the central nervous system, the brain and the spinal cord, and indeed your wider unconscious.

00:09:44 Cormac Ryan

It's a marker of how much perceived threat that unconscious system feels that there is or believes that there is with regard to you or a bodily area.

00:09:59 Cormac Ryan

If the unconscious believes that you're under significant threat, it will want to draw your attention to it as the conscious person and get you to do something about it.

00:10:12 Cormac Ryan

And to achieve that, it produces the experience of pain.

00:10:20 Cormac Ryan

And its whole sort of purpose is to draw your attention to a potential problem and get you to do something about it.

00:10:30 Cormac Ryan

So it's an absolutely brilliant, brilliant system.

00:10:33 Cormac Ryan

And it's one that is

00:10:36 Cormac Ryan

extremely difficult to ignore, which is why it's so, so powerful as a motivator.

00:10:42 Cormac Ryan

The problem is, much like a car alarm, it goes off if your car is being broken into, but it also can go off just from a gust of wind, or indeed for no reason at all because the alarm is faulty.

00:10:58 Cormac Ryan

But it sounds just as annoying, just as unignorable, and

00:11:05 Cormac Ryan

just as attention grabbing.

00:11:07 Cormac Ryan

And with persistent pain, you can have two broad, broad categories.

00:11:13 Cormac Ryan

One is primary persistent pain.

00:11:15 Cormac Ryan

I use the term persistent and chronic interchangeably.

00:11:19 Cormac Ryan

Apologies, generally I'll use the term persistent when I'm talking to a public audience, the term chronic when I'm talking to a professional audience, but they mean the same thing.

00:11:30 Cormac Ryan

You can have primary persistent pain or secondary persistent pain.

00:11:34 Cormac Ryan

Primary persistent pain is when there's no obvious structural cause of the pain.

00:11:40 Cormac Ryan

The pain's gone on for three months or more and there's no particular rhyme or reason for it going on.

00:11:47 Cormac Ryan

So this would be, an example of this would be non-specific lower back pain, which of course is the leading cause of disability worldwide and one of the leading causes of work loss.

00:12:00 Helen Fitzhugh

Sickness Absence. 

00:12:01 Cormac Ryan

huge, an enormous contributor, probably only eclipsed by mental health issues here in the UK.

00:12:09 Cormac Ryan

But also conditions like fibromyalgia, etc.

00:12:12 Cormac Ryan

They're all good examples of little or no obvious structural

00:12:18 Cormac Ryan

cause, yet really significant pain.

00:12:21 Cormac Ryan

So there'd be primary persistent pain conditions.

00:12:23 Cormac Ryan

Then you have secondary persistent pain conditions.

00:12:26 Cormac Ryan

These are where the pain has continued for three months or more and there is an obvious structural issue.

00:12:34 Cormac Ryan

An example of this might be pain associated with a long-term condition like MS, for example, or post-stroke.

00:12:46 Cormac Ryan

People can sometimes get

00:12:48 Cormac Ryan

significant pain.

00:12:50 Cormac Ryan

It sounds nice like there's these two completely discrete bins, but of course the reality is it's far messier than that.

00:12:56 Cormac Ryan

And there's quite an overlap in between.

00:13:01 Cormac Ryan

However, I would argue, and I think there's a reasonable body of evidence to say that most chronic pain

00:13:10 Cormac Ryan

is in the primary persistent pain category where there's no obvious structural cause.

00:13:16 Cormac Ryan

And I think that's largely because modern medicine is so good.

00:13:20 Cormac Ryan

We're so good at sorting out pain from an obvious structural cause.

00:13:26 Cormac Ryan

It's when there isn't one, that's when we become flummoxed.

00:13:32 Cormac Ryan

And that's actually when applying the modern medical approach arguably causes more harm than good.

00:13:39 Cormac Ryan

either through nocebo effects, which are of course the opposite to placebo effects where non-specific factors or approaches cause harmful outcomes, as well as, the word escapes me here, but iatrogenic, that's the word I was looking for, iatrogenic effects as well, where someone will apply a health intervention with obviously positive meaning

00:14:08 Cormac Ryan

and it having then negative effects, like for example, a surgical approach for a primary persistent back pain, for example, that might in and of itself then cause other negative outcomes to occur.

00:14:24 Cormac Ryan

So coming back to where I was, primary persistent pain is where the pain continues long after normal tissue healing will have occurred if there indeed there was

00:14:35 Cormac Ryan

structural issues there in the 1st place.

00:14:38 Cormac Ryan

And if we adapt a biomedical approach to primary persistent pain, broadly doesn't end all that well.

00:14:48 Cormac Ryan

And that's why clinical guidelines encourage us to take more biopsychosocial approach to the management of chronic pain, to adapting more active physical and psychological therapies.

00:15:01 Cormac Ryan

But those approaches make absolutely no sense

00:15:05 Cormac Ryan

if you've got a very outdated biomedical view that pain is simply caused by injury.

00:15:11 Cormac Ryan

And if we think about the workplace, I think it's fair to say that many people who experience pain in the workplace will be of the opinion that pain is due to some form of tissue injury.

00:15:27 Cormac Ryan

And that the work itself will have caused the injury

00:15:34 Cormac Ryan

or be worsening the injury.

00:15:38 Cormac Ryan

And if that's your understanding, then it's perfectly logical for both the worker and their line manager or their employee to decide well the best thing for you is to come out of the workplace.

00:15:54 Cormac Ryan

The best thing for you is either to go off sick

00:15:58 Cormac Ryan

or to substantially change your role or do something else completely to stop injuring yourself.

00:16:08 Cormac Ryan

And the reality is that the evidence for this is actually super, super weak.

00:16:15 Cormac Ryan

There's a really sort of neat series of studies that was done in 2010

00:16:23 Cormac Ryan

So I appreciate that's 16 years ago, but I don't think as humans we've changed all that much in 16 years.

00:16:30 Cormac Ryan

I still think the studies are very relevant.

00:16:33 Cormac Ryan

A series of systematic reviews where they explored different movements and activities.

00:16:42 Cormac Ryan

They used back pain as their template and they asked the question, what's the evidence that this activity causes

00:16:53 Cormac Ryan

back pain.

00:16:54 Cormac Ryan

And they applied a very rigid methodological approach in terms of causes.

00:17:02 Cormac Ryan

So they were looking beyond simple association.

00:17:06 Cormac Ryan

And there were, I think it was eight different criteria that would indicate that something is causative of something else.

00:17:14 Cormac Ryan

If we think about the easy ones to relate to this, such as smoking and lung cancer, for example.

00:17:22 Cormac Ryan

how, sure, there's loads of causation data, or correlation data, but there's also things like the sequencing of the relationship and the dose response.

00:17:35 Cormac Ryan

So those who smoke 10 fags a day compared to 100, you know, that's going to influence things.

00:17:42 Cormac Ryan

So there's a number of different criteria that will allow one to confidently say that X

00:17:51 Cormac Ryan

causes Y rather than the fact that they kind of might coexist.

00:17:58 Cormac Ryan

This series of reviews looked at everything from walking to standing to lifting to awkward postures right across the range.

00:18:09 Cormac Ryan

And consistently, they found that there was little or no evidence that these movements caused back pain.

00:18:20 Cormac Ryan

And they furthered it up by saying that if such a relation does exist, it would be small and relatively inconsequential.

00:18:35 Cormac Ryan

It doesn't mean that the body's not important.

00:18:37 Cormac Ryan

Of course it is.

00:18:38 Cormac Ryan

Of course it's relevant.

00:18:40 Cormac Ryan

Nor does it mean that being at work can't aggravate symptoms.

00:18:48 Cormac Ryan

Of course it can.

00:18:49 Cormac Ryan

It's perfectly legitimate, I think, to have that view.

00:18:55 Cormac Ryan

But to say that work causes persistent long-term musculoskeletal pain, I think that's

00:19:04 Cormac Ryan

an argument that currently does not hold up and the evidence would actually push against it.

00:19:11 Cormac Ryan

And I think that's why if you look at the guidelines in terms of return to work for long-term conditions like back pain, et cetera, they're all, you know, try to return to work or stay in work if you can.

00:19:28 Cormac Ryan

Work is a crucial part of rehabilitation and there’s a

00:19:32 Cormac Ryan

a really solid body of evidence to demonstrate that work is broadly good for your health.

00:19:39 Cormac Ryan

I appreciate good work is good for your health.

00:19:43 Cormac Ryan

And there's an awful lot of devil in the detail around good work.

00:19:49 Cormac Ryan

But if we go back to

00:19:51 Cormac Ryan

Gordon Waddell and Kim Burton's 2004-2006 work for the DWP, where they were trying to answer this question, is work good for your health?

00:20:04 Cormac Ryan

They were pretty unequivocal.

00:20:06 Cormac Ryan

Again, the devil's in the detail.

00:20:08 Cormac Ryan

And people in

00:20:09 Cormac Ryan

work circumstances where they're under, there are significant psychosocial pressures from bullying to complete lack of control of your time and difficult circumstances.

00:20:27 Cormac Ryan

I don't think it's unreasonable to say that that's probably not very good for your health, but I think that's a million miles away from saying that if someone can go to a workplace where they'll be valued,

00:20:40 Cormac Ryan

and have a good relationship with the people there and get value from that work themselves within a very, very broad range of working activities, that's going to be very, that's going to be broadly good for their health.

00:20:58 Cormac Ryan

I think that's really, for me, it was reading Waddell and Burton's work that made me think how fitting

00:21:08 Cormac Ryan

the Flippin’ Pain messages are for the workplace.

00:21:14 Cormac Ryan

How to an extent, again, this is just my perspective, that we've kind of demonized the workplace.

00:21:24 Cormac Ryan

We have created a scenario where it is laden with threat.

00:21:32 Cormac Ryan

Risk.

00:21:33 Helen Fitzhugh

Risk assessment.

00:21:34 Helen Fitzhugh

Yeah.

00:21:36 Cormac Ryan

Absolutely.

00:21:38 Cormac Ryan

risks that you in your home wouldn't even give a second thought, but we emphasize those risks hugely in the workplace to create, I think, a situation where it's become imbalanced.

00:21:52 Cormac Ryan

One where the threat has been overemphasized very much at the expense

00:22:01 Cormac Ryan

of pushing the positive messages around health.

00:22:04 Cormac Ryan

Think about it.

00:22:05 Cormac Ryan

If you go to a workplace, how many times a poster on the wall will you see something like, you know, don't bend your back or you should sit with everything at 90 degrees?

00:22:16 Cormac Ryan

Whereas how many posters do you see saying, you know, works really good for your health?

00:22:21 Helen Fitzhugh

Yeah.

00:22:22 Cormac Ryan

Yet the evidence that works really good for your health, pretty, very, very robust.

00:22:27 Cormac Ryan

The evidence that sitting with 90 degree angled knees, very ropey.

00:22:32 Cormac Ryan

I'm not saying we shouldn't sit efficiently or we shouldn't move efficiently.

00:22:36 Cormac Ryan

I'm a big lover of moving efficiently, but we shouldn't present it in such a way as it is an extremely threatening thing if you don't do it.

00:22:47 Helen Fitzhugh

Yeah.

00:22:47 Helen Fitzhugh

So it's a really interesting thing in what you're saying, both with this sort of latest angle, but also, you know, the pain and injury disconnect there.

00:22:59 Helen Fitzhugh

This could be quite challenging for people.

00:23:01 Helen Fitzhugh

challenging for people: members of the public, but also people in the workplace who have done these risk assessments and been told that these things are absolutely necessary to protect their firm, for instance.

00:23:14 Helen Fitzhugh

So how do you deal with that when you speak to people about this?

00:23:17 Cormac Ryan

Yeah, no, absolutely.

00:23:19 Cormac Ryan

It is potentially a very difficult subject to discuss.

00:23:28 Cormac Ryan

And it can

00:23:30 Cormac Ryan

If delivered poorly, it can really annoy people, it can frustrate, it can invalidate.

00:23:39 Cormac Ryan

However, if it's done well, I believe it can be extremely validating.

00:23:45 Cormac Ryan

If you will, if you can imagine someone who's got persistent pain in the workplace and they have had a scan and the scan was absolutely clear.

00:23:58 Cormac Ryan

and there's no obvious cause for their pain.

00:24:01 Cormac Ryan

I believe that person feels a great deal of stigma and is the subject of a great deal of stigma associated with it because people are well like, there's nothing wrong with that.

00:24:15 Cormac Ryan

That person's fine.

00:24:16 Cormac Ryan

They're fine.

00:24:17 Cormac Ryan

Why aren't they able to do this work?

00:24:18 Cormac Ryan

Why aren't they able to do X, Y, and Z?

00:24:21 Cormac Ryan

Why should I have to do it for them?

00:24:22 Cormac Ryan

They're really just, you know, they must be.

00:24:25 Cormac Ryan

over egging it.

00:24:27 Cormac Ryan

They must be pretending because there's no obvious condition that they can prove or demonstrate.

00:24:38 Cormac Ryan

Whereas actually the scientific literature shows that you can have terrible, terrible pain with little or no objective signs of injury, that they're completely disconnected.

00:24:52 Cormac Ryan

And pain

00:24:54 Cormac Ryan

can flare up for a variety of biological, psychological and social issues.

00:25:02 Cormac Ryan

Low mood, stress, pain-related anxiety, worry, even things like financial insecurity.

00:25:13 Cormac Ryan

All these things can influence the pain experience.

00:25:17 Cormac Ryan

And so if you understand that,

00:25:20 Cormac Ryan

if your co-workers understand that, if your employer understands that, actually it's probably got very little to do with the back, but rather far more to do with you as a human being having a pain condition, which can flare up and can be variable and needs support and encouragement to

00:25:47 Cormac Ryan

manage it better so they can stay at work.

00:25:49 Cormac Ryan

I think that's the sort of narrative that we're trying to help people to understand.

00:25:55 Cormac Ryan

And what we find is that if you can communicate this well, people do feel validated because beforehand they're like, well, I was beginning to question myself, am I making this up?

00:26:08 Cormac Ryan

Or is this all in my head?

00:26:10 Cormac Ryan

Whereas this really demonstrates that no, it's not in your head.

00:26:14 Cormac Ryan

It's absolutely real.

00:26:16 Cormac Ryan

It's 100% real.

00:26:18 Cormac Ryan

It may not be indicative of a structural pathology, but that does not mean that it's any less real.

00:26:28 Cormac Ryan

And people get that.

00:26:30 Cormac Ryan

And often once they get that, it can be a doorway or a gateway.

00:26:35 Cormac Ryan

to taking a more active approach.

00:26:37 Cormac Ryan

They can be more, it can reduce pain related fear, worry and anxiety and people can be more up for trying more active physical and psychological therapies that they would have avoided, including I think ideas of return to work.

00:26:52 Cormac Ryan

Why on earth would you be keen on returning to work if you were

00:26:59 Cormac Ryan

100% convinced that it was your job that caused your back pain or your shoulder pain in the 1st place.

00:27:06 Cormac Ryan

And it doesn't mean, of course, that intellectually, if you can feel that maybe it wasn't, that you'll immediately jump back into work.

00:27:14 Cormac Ryan

But what it does mean, I think, is that you'll be more open to engaging with the process.

00:27:20 Cormac Ryan

You will see the potential merit of it.

00:27:24 Cormac Ryan

and be more inclined to give it a go.

00:27:26 Cormac Ryan

And I think there's loads and loads of, I like to use some of the scientific studies to kind of tell the story of how we need to give people positive messages at work to reduce the risk of painful conditions.

00:27:45 Cormac Ryan

And also then how we need to big up the benefits of it

00:27:51 Cormac Ryan

to realize those benefits.

00:27:55 Cormac Ryan

I think it's really important that people should be made aware of risks.

00:28:00 Cormac Ryan

But we should only do that if we're absolutely 100% sure that they're genuine risks.

00:28:06 Helen Fitzhugh

That's fascinating.

00:28:07 Helen Fitzhugh

And one of the things that occurred to me while you were talking is that obviously you've got all these really good examples of research studies, but you've also done a lot of work with gathering the views of people with lived experience of chronic pain.

00:28:23 Helen Fitzhugh

And I think it would be really interesting to hear how they take the message and think you should be sharing that with people in workplaces.

00:28:32 Cormac Ryan

Over the course of the campaign, which we've been running for

00:28:36 Cormac Ryan

about seven years now.

00:28:37 Cormac Ryan

I'm going to quickly plug the campaign.

00:28:40 Cormac Ryan

So check it out on Flippinpain.co.uk.

00:28:43 Cormac Ryan

No G.

00:28:46 Cormac Ryan

So that's co-produced with people with lived experience of pain.

00:28:50 Cormac Ryan

So the messages that we've come up with, the materials that we've developed and are on the website, they're very much co-produced with people with lived experience.

00:29:00 Cormac Ryan

And the events we run will often open up with someone with lived experience presenting their

00:29:06 Cormac Ryan

story.

00:29:08 Cormac Ryan

And then at the end, when we do the Q&A sessions, we'll have a person with lived experience on the panel who can field those important questions of how will this land with the general public, my patients or my workforce.

00:29:27 Cormac Ryan

What we've been doing of late is we

00:29:30 Cormac Ryan

We're running an NIHR funded project.

00:29:33 Cormac Ryan

It was a development award.

00:29:36 Helen Fitzhugh

National Institute of Health Research, or health and care research.

00:29:39 Cormac Ryan

Yes.

00:29:39 Cormac Ryan

National Institute of Health Research, their work and health funding stream.

00:29:44 Cormac Ryan

And we got a development award.

00:29:47 Cormac Ryan

The development awards are not strictly to carry out research per se.

00:29:51 Cormac Ryan

They're to carry out preparative work for research.

00:29:56 Cormac Ryan

So it's like to get you ready for putting in a big grant application.

00:30:00 Cormac Ryan

So you can do sort of a lot of the background work that needs to be done, but you can do it well and it gives you time to do it.

00:30:07 Cormac Ryan

So we did work, which obviously you were involved with as well, Helen.

00:30:12 Cormac Ryan

And as part of that, we wanted to get workers experiences, staff,

00:30:20 Cormac Ryan

managers, et cetera, their union representatives, health and safety representatives, occupational health representatives, a whole representative of everyone, I guess, who could be considered a stakeholder within the workplace.

00:30:36 Cormac Ryan

And the remit, I guess, was to say, well, this is the existing Flippin’ Pain campaign.

00:30:42 Cormac Ryan

We believe it's huge value in bringing it into the workplace setting.

00:30:49 Cormac Ryan

Would you agree?

00:30:50 Cormac Ryan

And if you would agree, how would you do it?

00:30:53 Cormac Ryan

How would you adapt?

00:30:54 Cormac Ryan

How might this work in the workplace?

00:30:58 Cormac Ryan

And within the main grant, we wanted to use what they call a realist evaluation approach.

00:31:05 Cormac Ryan

Realist evaluation looks at what works for whom under what circumstances.

00:31:10 Cormac Ryan

It doesn't so much try to look at is something effective, but rather try to understand

00:31:19 Cormac Ryan

how something might work, why it might work, what are the ingredients that bring about the benefit that you might see.

00:31:28 Cormac Ryan

And so in order to move with that, you need to develop what they call an initial programme theory.

00:31:36 Cormac Ryan

Hopefully there's no realist evaluation purists listening to your pod because they're going to realize that we've reached the limit of my knowledge of the difference between programme theories

00:31:49 Cormac Ryan

and theories of change, but ultimately I think the idea is that a programme theory tries to capture more of a how does something work idea.

00:31:59 Cormac Ryan

It tries to make tangible or visible the invisible elements.

00:32:07 Cormac Ryan

of how an intervention might work.

00:32:10 Cormac Ryan

And it tries to contextualize it in terms of what might be the barriers to this working or not, what might be the key ingredients for it to bring about the benefits that we hope it will.

00:32:23 Cormac Ryan

So in order to do that, really,

00:32:26 Cormac Ryan

It needs time to generate a programme theory.

00:32:29 Cormac Ryan

It needs time to immerse yourself in the literature, absolutely, but more so to talk to experts.

00:32:35 Cormac Ryan

And when I say experts, I mean experts of every category, including people with lived experience, because they bring an expertise.

00:32:44 Cormac Ryan

to the table, which is just as valuable, if not more valuable, than any other expert.

00:32:51 Cormac Ryan

So we, as part of this funding programme, created three groups, but there was one central group who are our staff advisory group.

00:32:58 Cormac Ryan

We discussed the campaign.

00:33:01 Cormac Ryan

They basically got all the information we had and then we kind of said, right, well, how do you think this would work?

00:33:06 Cormac Ryan

And with them, we co-produced this initial programme theory.

00:33:12 Cormac Ryan

That was our main group to work with.

00:33:15 Cormac Ryan

Alongside that, we had what we call our internal stakeholder group, but they were predominantly occupational health staff, health and safety staff, HR, et cetera.

00:33:28 Cormac Ryan

So they were a separate group with whom we ran these ideas through with.

00:33:33 Cormac Ryan

And we also had an external advisory group.

00:33:37 Cormac Ryan

These were people from the DWP, from the Department of Health and Social Care.

00:33:42 Cormac Ryan

from the Society of Occupational Medicine who also gave their input into the programme theory.

00:33:49 Cormac Ryan

And after all that, we came and produced a programme theory and we submitted that for publication to the journal Health Expectations.

00:33:58 Cormac Ryan

That was pivotal work.

00:34:01 Cormac Ryan

Ultimately, we feel that absolutely these principles

00:34:05 Cormac Ryan

can apply to the workplace.

00:34:06 Cormac Ryan

And they are important principles to communicate.

00:34:10 Cormac Ryan

And the next part of our journey is to co-create with staff an adapted campaign known as Flippin' Pain in the Workplace, then to implement it over the course of a year and then to evaluate it.

00:34:26 Cormac Ryan

That's the next steps.

00:34:29 Cormac Ryan

And hopefully in the coming four or five years, that's what we'll do.

00:34:33 Helen Fitzhugh

Great, yes, looking forward to it.

00:34:35 Helen Fitzhugh

So given all we've just said in the workplace, what should we do about this?

00:34:40 Cormac Ryan

I think it's about trying to use good communication and good education to reduce unnecessary fears and worries around activities so that we should make it clear in our messaging, our information to staff,

00:35:00 Cormac Ryan

especially from information to occupational health professionals as well, that it's good to be at work.

00:35:08 Cormac Ryan

Work is a safe and healthy place as long as it's within health and safety guidance.

00:35:15 Cormac Ryan

And that we should be really mindful about the language we use.

00:35:19 Cormac Ryan

that doesn't create nocebo effects, that doesn't increase people's fears and worries about doing normal everyday activities to say that they cause persistent pain when the evidence doesn't support that they do.

00:35:34 Cormac Ryan

And I think we should also emphasize to employees the positive health benefits of work and demonstrate the science that goes behind that so that when they're making their decisions,

00:35:49 Cormac Ryan

about how to respond to their pain, whether they should leave work, whether they should stay at work.

00:35:56 Cormac Ryan

They have the right evidence in front of them that will encourage them to make the more evidence-based choices.

00:36:07 Cormac Ryan

Broadly speaking, evidence-based choices are those active choices, those that encourage people to try and stay at work.

00:36:15 Cormac Ryan

And good work

00:36:17 Cormac Ryan

I would argue is accommodating work.

00:36:19 Cormac Ryan

So it's not just targeting it at the individual, but it's also targeting it at their co-workers and their employer so that they create an environment that is more accommodating and supportive and less stigmatized for people with persistent pain.

00:36:40 Helen Fitzhugh

Thank you.

00:36:41 Helen Fitzhugh

That was great speaking with you.

00:36:43 Helen Fitzhugh

And yeah, we look forward to perhaps having a Flippin' Pain Part 2 podcast in the future.

00:36:50 Cormac Ryan

That'd be super, super.

00:36:51 Helen Fitzhugh

Thanks very much.

00:36:52 Cormac Ryan

Love it.

00:36:52 Cormac Ryan

Thanks, Helen.

00:36:57 Helen Fitzhugh

Please do visit www.evolveworkplacewellbeing.org.

00:37:02 Helen Fitzhugh

We look forward to seeing you next time.