Healing Outside Clinic Walls: Harnessing the Environment in Pain Care

it just kept confirming this sense that okay, somehow the environment is totally a blind spot in our profession. It's just like we don't think about it

That's Filip Maric, the Founder and Executive Chair of the Environmental Physiotherapy Association, the first international network of over 1200 physiotherapy clinicians, students, academic and professional representatives, seeking to advance environmental awareness and responsibility across physiotherapy research, Practice and education

I think getting people into those environments, they need to and want to spend their time in engaging those that. to be engaged and they find meaningful are all things that we, have talked about as physios for a long time, but for some reason, this idea of outdoors too difficult or too distant, or it just hasn't been incorporated in the same way as, those really fundamental functional tasks

That is Jessica Stanhope. She is a research fellow in the school of public health at the university of Adelaide and chief medical scientist in the rheumatology unit at the queen Elizabeth hospital. Jess holds qualifications in physiotherapy, epidemiology, and public health. If there's one thing, pain has taught us it's that treatment must escape the four walls of our clinics and start focusing on durable changes in the context of people's lives.

I think that we really have to get over as a profession that as you also said in your question, is yeah, but people actually live out there. So why not move more of the treatment out there?

Research is being done that shows the environments that a person lives and functions in can have a significant impact on their health and wellbeing.

and one of the things that we found is that people who have a park within walking distance of their home are less likely to report they're being diagnosed with arthritis. They're less likely to report that they've had pain that's been moderate to very severe in the last four weeks, and less likely to report having pain that had a moderate to extreme impact on their lives the last four weeks.

This episode will help you consider your patient's environments and help them make changes that persist outside the walls of your clinic. Thank you as always for spending some of your precious time on the podcast. I greatly appreciate it. If you feel like you've gotten any value from the podcast, I would love it if you could take time to review the podcast on your podcast provider, so the message can reach more people who need to hear it. Now onto the episode.

This is the Modern Pain Podcast with Mark Kargela.

Filip let's start with you. Cause you're the spearhead who's really gotten this thing off the ground. And it's a pretty impressive website with a lot of really impressive, team members you have there going at the environmental physiotherapy association. But I'd love to hear the story of where it all started.

This whole idea around environmental physiotherapy and what environmental physiotherapy might be actually was somewhat of a tangential outcome, I would say for my PhD studies. So I was doing my PhD between, yeah, 2011 to 2017 under the supervision of Professor David Nichols in New Zealand. And, I was studying something, let's say, on the intersections of ethics and physiotherapy, a somewhat fringe philosophical perspective on ethics, looking at what that perspective might imply in terms of physiotherapy, like critiquing what we have today and what kind of otherwise visions maybe come out of that. as I was working on that, I think one thing that became clear to me was that somehow, The environment, however, we might define that was somewhat of a blind spot and how physiotherapy understands ethics and professional ethics and things like that, it just wasn't really there wasn't mentioned. Professional ethics, generally speaking, are very much on the sort of behavioral codes side and not really like ethical theories in the stronger philosophical sense. And so with that, I I noticed that blind spot, but it wasn't something that like heavily necessarily featured in my PhD. It was just something that was there and it was that in the background of my head for quite a while. It was like, ah, there's something going on there. my PhD, I was really a little bit fed up with academia. I just wanted back into clinical practice and did that for a while. I think for about a year and a half, probably I went back into clinical practice and found myself working in these clinical spaces in a, in a. Somewhat large chain of multidisciplinary clinics and in New Zealand at the time where we had these treatment rooms that classically would have, white walls all around treatment table, a desk, a computer and for what it's worth. Also, no access to natural light. So no windows, nothing of the sort. And I was just thinking, wow, something's up here. And to top that off in one of those spaces. The clinic was actually two minutes away from a really beautiful beach in New Zealand. Just about any beach in New Zealand is beautiful. So, just Google New Zealand and beach and that's where I was close to. And I just thought, okay, it's really weird. Why do we think that, people should come in here from there? And get better in these odd spaces, these unnatural spaces when they could just be outside there going for a lovely walk in the beach whether in the sun or rain. And yeah. And again, somehow, why are we not, why is that not something we're doing something with? so I ended up bringing like plants into my at the time, like clinical spaces. Yeah. Pictures of the outdoors and then people would come in and that would be the first thing they would comment on. It's Oh, wow, look at that picture and how beautiful, that. And it just kept confirming this sense that okay, somehow the environment is totally a blind spot in our profession. It's just like we don't think about it. And then the other thing I suppose was that I'm not sure how to formulate this in a positive way. But if you're Following some of the environmental stuff going on in the world the world is going under, there's a lot of things going wrong. And and that can leave you worrying. If you look into it and and I think I also, I found myself in that dilemma. That's very common to a lot of people that, if you look at those things, You feel this very strong sense of overwhelm because, climate change, global warming, biodiversity loss, et cetera, is like huge issues. And then I'm just one physio sitting in my clinic, and what in the world can I do? It doesn't even make a difference whatever I do. And so the thing I think the place I found myself in was like, okay, so I can't Like what I'm doing alone, just by myself, it doesn't do all that much, but then I can't also become like the president of the world and change everything. It's just not likely for my life's trajectory. And and then I thought, okay, but maybe there's a middle ground here because maybe I can do something in my profession, which has this blind spot, but consists of, let's say around 2 million people worldwide all of those underworld physio, but everyone around as well, and maybe we can do something in their profession, move 2 million people. And if you move 2 million people, maybe that does a difference and moves a few more and, something like that. And so it was on the back of that actually I sat in a kind of cafe with Dave Nichols at one point and we were just like jotting some down some ideas and ended up writing this editorial that we published in 2000, mid 2019 and use the publication of the editorial to start the EPA, which has now been going for a little over five years

Always interesting to hear the stories that bring it to fruition. Jessica, how did your journey yeah, the origin story for sure. How did your journey make your way over to this Jessica in your career? What was the parts of your journey that got you to focus in this kind of aspect of things,

Yeah, so it was never really something I was aware of as a physio in terms of there being an evidence base around even thought to look at it. But with patients, I would, similar to what FIlip was saying, I would go tell them to spend some time outdoors, go and do some gardening, go park in a rehabilitation setting, I'd often take the patients outside. And aims to try and rehabilitate them to a point where they were confident and safe outside rather than often what happens, which walk up and down the hall safely which isn't quite right. So I always had this kind of I guess approach that incorporated it, but without appreciating why in terms of I would now conceptualize it. So about the same time the EPA started, colleague came to me and suggested that we actually do a short opinion piece looking at green space exposure and pain. And their idea was that we have a fair bit of evidence around green space exposure improving mental health. and they're aware of the link between mental health and pain and what was supposed to be a very easy kind of opinion piece and into a much bigger job. Because of course, once we started thinking about that more, there were lots and lots of ways that these were potentially linked, but not a lot of evidence. So, this was all happening around the end of my PhD. that I had a six month research position to get my head around what was there and what these theoretical links were in the last few years, I've been trying to start actually getting some data well, which is, of course, a slow progress process, but we're getting there. And so I became aware of the EPA once we published a paper that was hypothesizing this link exposure And pain outcomes and retweeted it. I became aware of the organization because of that. So it was all happening around the same time.

social media, connecting more lives. It's interesting, I've established some similar relationships just through again, a retweet or something random like that can start something pretty cool. I love the thought you both bring up this like concept of considering the environment, and when we speak with chronic pain patients and, the thing that when we're mentoring clinicians, it's always like we try to treat people in this very sterile white walls, no windowed environment. In some cases, I definitely have practiced in similar settings yet the people that we work with function outside of those four walls where those environmental challenges and different things exist. I'm wondering if maybe both of you can speak to A little bit of how you see maybe a physio maybe having more purposeful consideration of environment in their practice of where the patient functions outside the four walls of their clinic.

As I indicated, I've always tried to incorporate the environment without necessarily knowing why. And it was, In some ways, a bit similar to what FIlip was saying, I was frustrated spending so much time indoors as well. So some of it was actually me appreciating if I had to be inside for three or four hours, the patients who were in there all the time that was a really, probably an unpleasant experience for them. Particularly if they were people who were to what led to their rehabilitation stay, hadn't spent a lot of time outdoors. And so I think we can do a lot more in terms of that rehabilitation side. so about a year or two ago, a colleague I wrote an opinion piece linking this idea around, there's a lot of complaining with COVID and lockdowns and quarantines and those kinds of things, but identifying that for a lot of the patients that we've seen, a little more people in our population, that's what they often experience. Even if they're not in a nursing home or some institutional setting, if they're at home and they are not confident going outside, not able to do it by themselves, then that's what they face all the time. And so I think. It's something that we've all had a bit of a taste of now in terms kind of short term exposure to that idea of being stuck indoors all the time. And so I think really use that experience to people appreciate why that is a problem and particularly thinking about, teaching students, it's a really nice example of, That means. And so I think getting people into those environments, they need to and want to spend their time in engaging those that. to be engaged and they find meaningful are all things that we, have talked about as physios for a long time, but for some reason, this idea of outdoors too difficult or too distant, or it just hasn't been incorporated in the same way as, those really fundamental functional tasks like being able to go to the bathroom and be able to make a cup of coffee and those kinds of things, but it's really important for people to see that. health and well being, that, they do have access to the outdoors, that they do have access to green spaces. And where we can really start thinking about that, but not only just for our patients also thinking about the broader community and making sure that they can access these spaces and get those health benefits as well.

Filip, I'm wondering if you can speak to that a little bit, cause I, I love the idea of being more purposeful with considerations of the environment. And we're going to definitely dig deeper into that green space and pain, cause I know you mentioned there's some good literature coming out on that topic. So we'll get back to that, I'm wondering if you can speak to that a little bit.

I think there, there's one like little bit fundamental thing is like. do we actually mean by the environment, right? What's that term referred to? If I'm like, just to go back to this issue of where they start from, for me, it was a really very like general question to begin with that started this thought for me, which is, well, what does physiotherapy have to do with the environment without necessarily having defined the environment or to specifically in asking that question just yet, right? So in some ways, Thinking of both, if you will, natural environments, but also, human made and also social environments, et cetera, et cetera. So thinking environment in a little bit of a broader way. But of course, in today's world, there's very much also a reason to think about, especially those kind of. What we call natural environments aspects because of all the environmental issues in the world. And so that kind of it has a little bit of a prominent space in what we're talking about, but at the same time, I think it's really worth, especially like in this, in the context of what you're asking, like how to be more purposeful around the environment to think of the environment is even broader category. Right. And so as in general, I think I assume I think it's known quite well that physiotherapists don't engage in like people's life worlds and like they're living environments sufficiently right? We don't visit people in homes and in their homes enough. We don't. Check how people, elderly people cross the road and if it's safe to do so. And, all those things we're, so we're not overly involved in things like universal design and so forth. There's a few of us doing bits and pieces in those kinds of spaces but it's relatively limited for the most part. Somehow a profession is really deeply connected to these particular clinical spaces, right? That we have these. Physiotherapy, clinics, maybe hospitals, and then in those hospitals, the spaces that we use for our treatments. So by and large, like from the start, like we don't have a good sort of relationships to, to the environments that people actually live in. What you said, in the beginning when you asked that question. So I think that's starting point and some kind of like a threshold I think that we really have to get over as a profession that as you also said in your question, is yeah, but people actually live out there. So why not move more of the treatment out there? Right? I think that's a really basic starting point and being more purposeful about the environment also means that, okay, so have your patient in your clinic. every once in a while, but talk to them about the world they live in, like the environment they live in day to day, workplaces the commute spaces and so forth where they spend their leisure time, all of these kinds of things. If the regulatory frameworks around physiotherapy in your country, allow it, go there, do something there with them. Maybe there, I think there are some legal questions in some countries also around this. But, as much as you can either go there or think your way there with your patient and, make things relevant for their lives and the environments they live in. That's one starting point, I think. then, if you think about this kind of ecological things, I think there's like these two sides. For one thing, we could think about how do we make our clinical spaces. Integrate like the environment a little bit more, simple things like plants, indoor plants and things that actually is relevant. And I think over time we'll see, we'll also see more literature coming out on that. We've just, I think had a, I'm not sure if we've published it yet. Yeah, we've had a blog post come out on a physio clinician from Canada who was looking into literature around indoor plants and what that could mean for patients health. It's super simple thing, but some. That the point being we just haven't reflected on it really. Do you have a window like in the hospital when you're in the wind? When you have a window, we know that leads to people standing up more quickly, these kinds of things. So being more purposeful around what is actually the clinical space that I work in and how does it operate, right? But you can also think bigger than. Is that clinical space particularly wasteful? What is the environmental footprint of the clinical space that I'm working in? And are there ways to maybe reduce that? And so slowly, you're looking at different ways to be purposeful around the environment, right? And then, that's, if that's happening in the clinical space, maybe there's also all this stuff going on, like outside your clinical space. where you can think about the environment in even different terms, bigger terms, like what Jess is alluding to with this green space stuff, nature based therapies, health promotion a lot of things in that direction. So I think there's this sort of range of things that we can look at if we're thinking about how to be more purposeful around the environment. It relates to our clinical spaces, our patients lives, but then also, some bigger kind of ecological and sustainability issues, if you will.

You think about the clinical settings that we often operate in, hospitals especially where there's a lot of just sterile, sometimes intimidating things around that patients, and I, again, I know for a good portion of my career, I'd had zero consideration. I was just trying to keep my head above water to feel like I knew what I was doing, but I do think, ingraining this early on in of a physio's training of at least a consideration that this is part of the Context you create in the clinic, right? And our context can really be powerfully, there's a lot of studies on contextual effects and things like that. But I'm wondering if you could speak to maybe a few things, but let's maybe start with the physiotherapy student training. Cause I know there's a big discussion that on your website and I agree. I think we need to. Understand and at least be considering this. And I think it opens up a whole new and FIlip rightfully points out there might be some legal issues in different areas. So obviously make sure you're abiding by all your legal standards in whatever country you're operating in. But to me, it opens up a whole new area where we can really expand our practice into and more. Probably help people where it matters most and it's in their lives. It's not in, of course it's helpful to help people within the four walls of the clinic, but man, if you can help them in a meaningful space, that's meaningful in our life, it seems like it would be much more powerful. I'm wondering if maybe Jessica, you can start with the physiotherapy training where you see that as a necessary part of what we're trying to ingrain in our students.

Can I just jump in with one thing before it just goes there? It's a little bit of a qualification. Some of the stuff that we said before, with our clinical spaces. It was really interesting. There's a colleague a colleague from the Caribbean reacted to this blog post that we recently put out about the indoor plant said that's how our clinics look, they're full of plants indoors and outdoors. They have like big open windows or doors. They're always open to the outside. That's basically how we operate. And so I think we have to like the qualifier here is that Some of the experience that the three of us are talking about are from our specific context. I've worked in Germany, New Zealand, now in Norway Mark here in the US, Jess is in, in Australia. And so I think there's a little, some similarities around, how physiotherapy looks in those places, but I think we have to be conscious of also the fact that, Hey, it will look differently in other countries, in other places around the world that in some cases are way more like ahead of. Our particular context when it comes to, some of these specific things. So I just wanted to flag that as a little bit of a qualifier to the discussion before

Yeah that's a good point. Especially like in the U S where we have a very multicultural, locations where we're seeing people with, who might have different conceptions of what their environmental space should or shouldn't look like. And different things. So it's a good considerations definitely to, to have, as we're working with unique people. Jess, I'm wondering if you can speak to a little bit of what your thoughts are on that whole physiotherapy student training of where we feel like that needs to be at least minimally incorporated are considering as they enter the profession.

I think it's really important and I think it's not too difficult just because if we go back to those fundamentals of what is already And it's conceptualized physio as, and how do we normally do our clinical reasoning, is just about reframing that slightly. So things the ICF framework, which at least some physio programs and the one I do uses as their fundamental framework for clinical reasoning, it has the environment in there. But when I was taught about it, we were only talking about kind of the home environment, the working environment, maybe the social environment. We weren't thinking beyond that, we weren't really thinking about where people spend their leisure time or that kind of bigger impact of the environment on their health and well being. And so I think that's easy tweak When we're thinking about it, just to prompt students think about that when we're talking about things like patient goals with the patient, going, it that you need to do? But what is it that you want to do? And where do you want to do that? And I think that's something reflecting. on how I used to work as a physiotherapist, I wish I'd better because often I think we ask patients what their goals are and we just accept them at face value. But if it's something someone hasn't engaged in for five or 10 years, or they don't think they'll be able to engage in the future, then they might not mention that they want to go and do their gardening that they have done for three years and has been really important to them. So I think building into kind of those prompts around things like subjective assessment and things like that is really important. But I think it also a big part of it is the kind of building. This is being a legitimate part of practice. So we did a survey of professionals in Australia a couple of years ago, and one of the big things that came out as being a challenge was this idea of it. Not necessarily being perceived by patients and clients and even by other health professionals as part of what we're doing. Elements of allied health match it perfectly. And so one of the two big recommendations going forward that came from the people who are involved in the survey themselves, was that we need more research and we need more education both of allied health professionals and of allied health The general public, and I think this is a really lovely way of actually integrating that in a way that's not too difficult to actually get into the program. So it doesn't have to be course or a whole semester on environmental allied health, although that would be wonderful. It's actually just integrating it throughout and getting those prompts along the way, I think is a really great way of. and normalizing it as part of what we do, but should be doing and admittedly what we historically will so, the hospitals, 50, 60, a hundred years ago typically a single story, really great connection with the outdoors. Yeah, it easily will patients outdoors. And that's really shifted. So I think what FIlip was describing in terms of clinics in the Caribbean, although they probably weren't quite as open and things like because of the weather, they, the settings, we used to have them all like that. So it's going back to those basics and the back to those fundamentals that I think is really key And to highlight that is something that has been part of physiotherapy for a really long time. And we just lost sight of it in this touch in the middle.

Filip, where are your thoughts around physiotherapy education as, as far as incorporation of this?

first of all, like from just speaking from a perspective of like our activities in the Environmental Physio Association, we've had this education project international collaboration since early 2020. We started it just about as COVID hit Europe really clearly and maybe started in spite of that. And and I'm really, one thing for one thing, I'm really fascinated by how much waves this has made and how it's gone around the world. We now have over 100 participating physiotherapy education institutions that are working with us to get these topics into physiotherapy training around the world. And for me, that actually means that, like in some way from a personal perspective, I think we've crossed the threshold of a point where it's become clear that, yep, this is simply going to come into physiotherapy education curricula. It just might be the case that some might adopt this a little bit later, some a bit earlier and, and then from the start also, we said, Hey, in doing this, let's just keep it really open and not try and specify you have to do that. And you have to have a special course here, like just was, saying but see what seems to feel right in your respective context, in your program, where in the program do you think there is a small connection you can make to something topically start bringing in some little starting points and then let's see where those are and build from there. And I think that's for me, the segue in terms of content that that what we found is that. The environment actually has something to do with just about every aspect of physiotherapy. Anything you can think of in physiotherapy somehow has something to do with whatever you might think of as the environment. And if that's the case, or given that's the case, You can make these connections explicit in any element of a physiotherapy training program. And that's from anatomy and physiology because, hey, remember we're breathing oxygen and we eat food, which is an environmental thing also, and it's related to our bodies. And, there's some of these connections to all up the way to, for example, in Norway. Part of the law for a physiotherapy education is that in addition to all those like individual health and rehab things, we also have to teach on public health, and so yeah, we also have to teach on social determinants, ecological determinants, sustainable development, sustainability etc. It just goes across the board in the curriculum. How much you put it, where you, where, you know, that might be an open question, but there's possibilities to do a little bit of something just about anywhere. And it's coming.

If you go to the website, there's some teaching prompts and there's some other resources. Well, there's a boatload of resources, actually, if anybody's looking to incorporate this into their curriculum and I know they have some contact abilities too, to the folks at the EPA, that if you want to reach out, I'm, I know they're, they have a ton of resources they can share to, to help you start incorporating it, so definitely reach out, and we'll link it in the show notes as far as the resources and articles and all that good stuff. You touch a little bit upon it, FIlip, with the social determinants of health, that's one big thing that, Definitely impacts in my world where I work with a lot of persistent pain issues, but obviously it creates challenging environments for the people that are navigating some of the challenging issues around social determinants of health. I'm wondering if either of you can discuss where you see these two inner, Intersecting, with what we see clinically with patients and probably not just obviously, I'm obviously biased towards, the persistent pain patients, but whether it's a neurologic patient, a pediatric patient and everything in between, it's going to, there's going to be these components within their care. I'm wondering if you can speak to that intersection

All right. For me, I think I just have to say a little bit. I think I feel in terms of my background, just positioning myself. So I've, when I started working as a physio, I started working at relatively standard sort of everyone's clinic, in a neighborhood in Frankfurt in Germany, a little bit more maybe towards like sports physio, also musculoskeletal rehab in that space. And I eventually also went to do a master's in also that space in New Zealand, but then found a way to go in a slightly different direction. So I am from a muscular background and kind of this fairly classical individual. treatment type of physiotherapy. For me, the possibility that thinking environmental physiotherapy opens up is is along the lines of what also I think a lot of people in our profession are, or more and more people in our profession are talking about now is about how do we move away from this like exclusive focus on the individual towards a little bit this upstream thinking of, How can we somehow, contribute to more upstream levels of either number one in a kind of meso level in the individual's environment, but then also like further up at a kind of population health level at the level of like ecological determinants, social determinants in general, and so on. So for me personally, thinking environment allows to make that connection. Precisely because the environment is everywhere in a person's life, but it's also such a kind of like super category that you might as well just go there, right? Because it's a total, like a kind of connecting thread. And so a, along those lines, I think like social determinants, ecological determinants, there's a number of different terms there. It's very much related to this sort of like thinking and moving upstream and thinking what might our practice be further upstream as physiotherapists. Yeah, I think this is a really like important element of the whole thing.

Jess, where do you see the social determinants intersecting with what you're all up to at the Environmental Physiotherapy Association?

Yeah, so, the kind of environmental determinants and social determinants are quite linked. And I think as Filips described, environmental determinants have to sit above that. So it's another level social determinants. But there is this link between it. So a lot of my work is green space exposure and looking at health outcomes. And in that literature, there's evidence that if you've got green spaces in close proximity to your home, you're more likely to be. integrated within your community. So more social integrated interactions. You're less likely to have violence in your community and kind of those elements influence people's health and well really important. But I think you go back to that thinking of vulnerable people who have to spend a lot of their time indoors and reflecting on COVID. In some parts of the world, that's where we're headed with climate change. So one of the big recommendations around managing climate change is instead of doing too much about reducing climate change, because it's quite difficult, obviously is to ensure that people have secure energy supply, that they conditioning and those kinds of things. But of course, that means we're spending way more of our time indoors, interacting with others in the way. that we normally would. So there's that influence as well. So They're just a couple of examples, of how these things are linked. I guess a more positive, in a way of kind of thinking about another example, though, is have natural disasters, which are obviously terrible, and they can be, have huge impact on people's health and well being, particularly mental health, and have those lasting impacts. But they also bring communities together. So I'm not saying that we need more natural disasters or anything like that, but it's just another way in which those things are linked because they really can consolidate that community and together on things that can reduce their risk and some of that might be things like revegetating around waterways where you can reduce the flood risk or whatever it might be. So I think there's a huge number of connections and that's just a few examples.

Great examples. And, you speak to a little bit of the climate change, in Phoenix, Arizona, where I'm at, we're at 40 degrees Celsius, still this time of year, which we're supposed to be cruising into. Winter but hopefully we'll be cooling off a little bit, but it goes to, and I definitely see this with patients where this is the time of year where everybody's socially isolated. Cause nobody wants to be outside in the temperatures. And when I lived way up North in the U S it was the opposite. It was winter. It was like below zero significantly. So, It's interesting to see some of those challenges that we all face climate wise, as far as like maintaining that social kind of environmental connectedness.

Sorry, it's not just the social on that note, just to jump in there, it's not just the social, right? Exactly what you're describing, whether it's like, if you had these kind of heat waves and the likes that, like we've also had throughout the summer here in Europe. It's not just that people don't have that social connection, but it has actually effect on physical activity as well, which, close a little bit closer to home, maybe to a lot of physios. It, it does have an effect, if you're, if you decide not to go out, that reduces how much you'll be moving around, what kind of moments you'd be doing throughout your day, et cetera, et cetera. So it's very like immediately on the physical also if kind of, if you feel like that's what you need to connect to it as a physical therapist.

Great points. Jess, you mentioned the study on green spaces and pain. Of course, we're going to want to talk about that on this podcast. I'm wondering if you could go in a little bit about what you found. You've spoke to maybe a little bit about. Some of the, what you looked at, but I'd love if you could talk about that paper a little bit. I know it's, I think it's soon to be published if not published.

Yeah, so we've got a couple of papers that will hopefully be out by the end of the year. So one of the things that we're really fortunate to have available to us in Adelaide is a cohort data set that was established in 1999 and their last data collection point was 2015. And there's lots and lots of things that we can do with that in terms of using the satellite imagery and maps of public green spaces and biodiversity maps and things like that we will do down the track. But what we've actually done at this stage is use people's perceived green space. as a measure of their green space. So, about 20, oh, sorry. 2008. They had one of their data collection points, they actually asked people about the features in the neighborhood, and this was broader than green space and lift space and all of those more about the walkability of the area, but they had several questions that did relate to, green space. And one of the things that we found is that people who have a park within walking distance of their home are less likely to report they're being diagnosed with arthritis. They're less likely to report that they've had pain that's been moderate to very severe in the last four weeks, and less likely to report having pain that had a moderate to extreme impact on their lives the last four weeks. So it's still preliminary evidence that there this link and the next stages before we publish will then be unpacking why that might because we do have data on things like mental health and physical activity, social integration and sleep that we can then look at and all of those things can be influenced by green space exposure. So we can then look at, is that the relationship or is there something independent going on? that might be explaining that or a component of that. And I think that this, it really is There'll be different that are more important depending on what else is going lives. So really exciting we're starting to generate that evidence. But we've got some more work to do. But one of the things that we've been really interested in is this aerobiome diversity idea. So there's always microbes around us. And often we think about protecting ourselves from microbes, but there are good microbes around us as well, and microbiome, gut microbiome particularly has had a lot of attention in the last decade or so. Thanks. And one of the ways we can influence that is through exposures, And that can be things that we ingest or that we inhale. And so we were thinking about this in terms of the aerobiome diversity in green spaces. So generally, if you have diversity in the environment in terms of plants and animals and so forth, the aerobiome will have greater diversity. And then when you inhale that or ingest it because it's touch, then that can change your gut microbiome and then influence things like pain and It's difficult to assess in humans. So things like, people's exposure to green space or having indoor plants can give us an indication that we can't really narrow it down in the same way we can in animal models. So we have conducted a math study where we had mice that were three weeks old at the beginning of the experiment, so they'd just been weaned, and then we exposed them to different aerobiotic or diversity levels. So it's really trying to simulate spending time in an urban forest. It's been time in more like a sports field or a less diverse public park or an indoor environment, which is of course where a lot of kids most of their time. And we exposed five weeks before we started looking at their most offensive responses to different thresholds or stimuli. This is an indication of their pain levels. And we then injected the mice. So we did give them a sciatic nerve injury and then match what happened with their pain after that. And what we've demonstrated is that. The mice that had the high diversity exposure, so what we would view as being more that forest environment growing up, had a higher pain threshold than the other two groups, and they recovered much more quickly from their sciatic nerve injury. So day one after the injury, they all decreased their thresholds in a similar way, by day three, The high diversity group had returned to their baseline, whereas the others, they edged towards it, but they diverged again at day 14, which was the end of our experiment. And that's a really important point in terms of giving us some clues around chronic pain. And so these are really encouraging findings. It doesn't appear to be anxiety and stress in the mice because we've looked at those factors as well. So what we're doing at the moment is then look at the spinal cords and the dorsal root ganglia to try and explain what is the link in terms of, well, from that physiological perspective that might be able to explain that and of course looking at the changes in the gut microbiome as well. And what's super exciting about this is. If you have the green spaces that are diverse enough in the right locations, people don't necessarily to change their behavior to benefit. So from a public health perspective, where we don't have a lot of pain prevention approaches, provides us with a unique opportunity. And of course, we've only looked at this in what would be considered early childhood through to early adulthood. But that tells us something about what we can do in childcare centers and schools where kids spend a lot of their time. And so we might not be able to get all the green spaces in the right patches people's homes. We might not be able to get everyone to spend time with their kids in the forest, because we just know that's not going to be possible for a lot of families. If we can get the into those they're already spending their time, then maybe we can reduce the burden of pain. And of course, we're then starting to think about what does this mean clinically once someone already has pain, particularly in adult, where the microbiome changes might harder to achieve. So there's a lot of really exciting opportunities in the future, I think, but I think for me. PhD in public health, so I'm a physiotherapist for public health at heart I think there's massive that we can make in terms of people's environmental exposure and therefore their pain risk even if it is down the track, so those kids having that early explosion affecting them as adults, if an injury, which at some point people are likely to have something going on, so, yeah, super exciting.

Absolutely. That definitely fascinating stuff going on. And I can see, and it makes me excited about the opportunities for future research to, to start exploring these things. It sure makes sense for some of the hyper urbanization where green spaces have gone away. And I know you speak to that a bit on the website and different things. Yeah. FIlip, I'm wondering, cause I want to respect both your time. First off, I want to thank you for it because it's been a great discussion. I've enjoyed it. We could probably talk for about two, three more hours if it was up to me, but I, I know y'all have lives and things outside of here. In the, if we were to look in the future, FIlip, with all the great work you're all doing, what would you like to see as the ideal? Way this is incorporated into, a physiotherapy practice. What do you envision? I know you, it sounds like you've obviously purposeful and you consider it on your own right now, but what would you look to see as like the ideal future scenario is of where this fits in with the big picture?

Yeah. So, I think one thing that probably also needs to be said is that this is what we're doing is not not a development in many ways. It's exclusive to physiotherapy. Thinking about, how the environment is related to health is happening all across the healthcare professions, public health, et cetera, et cetera. And so there are terms and emerging fields that are just about mushrooming at the moment that will be called planetary health, one health, echo health, sustainable health care and the likes. And there's a lot of thinking in all health care professions about what are the implications of those for the health care professions? But also, how can the health care professions contribute to these developments in at a time when we have to when basically it's recognized that we have to think health environment and society in an integrated way and no longer as isolated phenomena, right? So what we're doing is not unique. It's in, in that sense, it's just the uniqueness in what we're doing is maybe that we're thinking from a physio perspective, right? What does this mean for physio and what can we contribute to all of this? So that's one thing, right? So there's a, there's essentially a kind of really global movement and global development roughly in this bigger space of health environment and society. Now, if I think about physiotherapy specifically, for me the it's always the thing that fascinates me about this idea of environmental physiotherapy is that it has the potential to do all sorts of small tweaks to what we're already doing, right? Like we talked about, it's not a big tweak to have a few indoor plants in my clinic. I'm still doing what I'm doing. That's a small tweak, right? But it also has this potential for these bigger and bigger kind of changes Tweaks of, oh, I'm going to go out there and then I'm going to do this. And then suddenly I'm not working with our patients anymore. I'm actually working with urban design and with landscape architecture and God knows what, and then I'm, working in another public health space. And so for me, the potential that lies in there is that yes, it has this potential to, to make. what we're already doing slightly different, slightly better but still what we're doing, but it also has this potential of allowing us to completely delve, dive into new space areas of practice, think about our responsibilities and therefore our practice in a new way, do completely different new things that we haven't done before, but that make total sense. If you start thinking physiotherapy and the environment together. And I think that's where I'm probably most excited about. One of the things that we're, we also only just started doing on our pay web pages to try and in some ways project towards the future. What does this mean for practice? Both in terms of the small tweaks, but also in terms of the bigger stuff. And I think that's really a space that I'm excited developing of what can the new things be that might mean, like in essence, I have to say that all physiotherapy is environmental physiotherapy. because you can't think, whatever we're doing, it's got something to do with the environment. But when you really think that It just starts like opening up these opportunities, I think, and I'm really excited about developing those. I sometimes do that in very like specific and targeted ways and things that we can recognize, but I also have this engagement that I started with my students here at the University UIT, the Arctic University of Norway where in my, in the context of my public health teaching I've introduced something that Initially called physio punk, and now I'm referring to as health punk. I invite students to write fictional stories about a future in which physiotherapists no longer work with individual patients, but work directly on social and environmental issues. And I try to get them to paint those kinds of visions and, ideas and so forth. I'll try and close a little bit on this already in the first cohort that we had do this exam task there was like eight stories that we published in the first sort of physiopunk volume. And those eight stories, there was a lot of stuff that when you read it, you thought this is just outlandish, totally, crazy. And why would you even think that and encourage anyone to think it. The funny thing was. That only a few months after those stories were written about half of the things that were indicated in those stories came to life and to practice. In, in some way or another, like I'll just, I'll give you two examples. There was one student who wrote about how physiotherapists in the future might farm algae for both food, but also for carbon sequestration. So bringing down carbon into the earth. And three months later, I found out that we have a physiotherapist three hours from where I'm sitting. That is farming algae for okay for food for now, But anyway, like it's close. It's there, right? Like it's a physiotherapist doing something completely different that somehow, touches on what we're thinking about. Another student of mine wrote a story about how physiotherapists in the future would go on Arctic expeditions and work on the Arctic ice and so forth. And about four months later, I was invited on an Arctic expedition with our university's icebreaker. To collaborate with some ecological scientists and think about what their work has to do with health and so on. So I think there's an amazing space for us to, to think totally new, totally different about our profession, do entirely new things, but and there with contribute to the health of people in completely new ways, but still contribute to the health of people. Right.

Absolutely. And when it comes to pain, I think the research has been pretty clear, like we need to move outside the four walls of our clinic if we're going to really make a significant impact in pain. And I think you nicely put it it's not just a physiotherapy thing either. This is a We, and I sometimes wonder how much the siloing of our professions into our little neat packages of what we do sometimes limits our ability to have the scope to really make the impact we want. So I think having some of these interdisciplinary groups and things to help us work together and maybe break down some of those silos will be huge. But again, we could talk for hours. I really appreciate you both. I really appreciate all the awesome work you're doing. Those you're listening, make sure you check out the show notes. Cause we'll have links to all the resources, the website and some articles that you can read to, to keep yourself up to it and then maybe incorporate some of these environmental principles into your own practice and into your own community. So thank you both.

Thank you. It's been a great conversation.

for having us.

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This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.