Richmond Stace online is known as The Specialist Pain Physio. He regularly contributes to Physio Answers and is responsible for my chronic pain programs adopting mindfulness as a big part of patient education and treatment.
Tell us a bit about yourself and how you got interested in Physiotherapy.
Originally I trained as a nurse and became interested in the different ways that people respond to pain. In particular I observed people as they came round from operations and noted the varied ways in which they coped and described their pain.
I wanted to work in sport and so I then read a degree in sport rehabilitation followed by a further degree physiotherapy. I was uninspired by the approach that seemed so structural and inflexible at the time. Then I attended a lecture by Mick Thacker who introduced the science of pain, the penny dropped and I was hooked into the notion of challenging the status quo by using neuroscience to say, "there's a better way and it is based on science."
Mick set up the pain science masters degree programme at Kings College London and I knew that this was something I had to follow. Those two years were incredible and I have never looked back.
What about schooling and initial con-ed influences?
It was really my time in healthcare that started in 1993 that drove my interest and passion. A friend of mine’s sister suggested a university based course nursing course and that was the first time I had considered health-care as a career. I realised that I did not want to be a registered nurse but was determined to complete the course, which I did. It opened my eyes to the world, that is for sure. The Project 2000 as it was called, exposed me to so many situations that now I am truly grateful for, as all of these sculpted my thinking and approach.
How did you become “The Specialist Pain Physio?”
I believed that tackling pain, and in particular chronic pain, could be done more effectively by challenging the way we think about it. Always using science, logical thinking and drawing upon a range of disciplines such as neuroscience, cognitive sciences, philosophy and art, I felt that a creative approach could be built for each person. With this in mind I set up the clinic and have driven forward with the concept, evolving the ideas as the knowledge base changed and grew. I always seek to update and refresh the approach.
Tell us about your approach and mindfulness
In a nutshell, my approach is comprehensive, meaning that I consider the individual and the different dimensions of pain: physical, cognitive and emotional. When I talk to a patient, I am thinking about the biology of their pain and the influences upon this biology, all of which I view as opportunities for change. Much of the work I do with patients is on a mentoring basis, teaching them about their pain and how they can change. Of course there is treatment but this sits alongside a very proactive programme of activities that develops their knowledge and skills for independent thought and action towards health and happiness.
Mindfulness plays a role as it is such a potent way of developing clarity of thought, reducing the suffering effects of rumination and promoting parasympathetic activity. I teach patients the skills so that they can become skilled at reducing their own suffering by talking them through a range of exercises that they can practice.
You still use manual therapy, whereas some pain science advocates say they are now manual therapist converts… why is it important to some cases?
Hands on has a big role. Most patients expect some hands on work and if used wisely it has great effects. I think that some people worry about the patient becoming passive or dependent but if the methods are explained then this does not happen. I usually teach patients ways of using touch to desensitise and include partners in this when possible.
It is an opportunity for graded exposure -- we should be touched and it be a comfortable or pleasant experience. With hyperalgesia or allodynia, touch is painful and needs to be desensitised. Using the right kind of hands on is a great way to change this, but you need to understand the pain mechanisms, explain to the patient how it works and then use the techniques with skill, patience and full attention. Therapists should be treating patients in a mindful way!
I and some others in the PT Social Media find that it is very possible to make long term changes in quality of life, but only minor to moderate changes in the intensity and frequency of the patient’s pain for true central sensitization. Is this your experience?
Pain is but one experience and we have many others. If we can boot up the brain to get back into other experiences -- multisensory -- then changes can be more sustainable. As much as we are using a range of methods to alter a pain experience, it really only comes from that person. We have to create the right conditions for all the body systems to function in a different way, a different balance. The bottom line is that pain is an output from the brain and so if we can change the habits, behaviours and conditioned responses, we can change the outputs.
What resources would you recommend for those interested in helping more of a chronic pain caseload?
There are some great blogs such as Body in Mind. I regularly put out information via my blogs Facebook and Twitter that are based on my thinking and reading. You can never read enough! The Textbook of Pain is a good start point; Pain Journal from IASP and books by neuroscientists such as Damasio and LeDoux, and others who I greatly respect: Oliver Sacks and VS Ramachandran. I also read New Scientist and Scientific American Mind. You tube is packed with videos but of course you have to sift through them judiciously.
Is there a particular type of patient that causes the “Oh No’s” when you see them on your schedule?
Absolutely not! The more complex the better for me! I am fascinated by the narrative and feel privileged to be listening. All the clues reside in what the patient says and how they say it. We must give the patient ample time to express himself or herself. Columbo style questioning is useful.
I spend most of my days listening to people so that I can work out a tangible way forward for them. I love it. There are no heartsink patients for me.
I believe that pain can and does change. The more that we understand pain and its dimensions, the wider we will think about creating ways of changing people’s experience. We must challenge the backward thinking at every opportunity and continue to groove better approaches! It is an exciting time and it will continue to be exciting, but more importantly, improve people’s lives.
Thanks Richmond for agreeing to the interview, I will most likely post follow ups once I see your initial answers. I think the general Physio population really needs more pain science education in their repetoire for many types of patients, not just the CS ones!
Richmond's Site, Specialist Pain Physio
Keeping it Eclectic...