This is the Physical Activity Researcher Podcast, a podcast for researchers of sedentary behavior, physical activity, and sports. Join for a relaxed dialogue about research design, practicalities, and well, anything related to research. Learn from your fellow researchers useful and relevant information that does not fit into formal content and limited space of scientific publications. And here is your host, researcher and entrepreneur, Ollie Tickenen. Welcome everyone. We are going to have a very interesting discussion about pain science, physical activity, and how to do science comes with YouTube. And we have a great guest for this episode. Earlier he was working as a senior physiotherapist. Then he has done his PhD at Macquarie University related assessment tool for a child's concept of pain. Currently he's working as a lecturer in physiotherapy at the University of Technology, Sydney. And he has been active popularizing science, his YouTube video "The Mysterious Science of Pain" has had millions of views, and he is writing a children's book on key pain science concepts. Ladies and gentlemen, please welcome our guest, Dr. Joshua Page. Welcome, Josh. Thanks, Ollie. Thank you for having me. Yeah, great to have you. So you were working earlier as a physiotherapist, but then decided to go for a PhD. Could you tell about the motivations and story behind that? Yeah, sure. So you're going through undergraduate, like before becoming a physiotherapist, I was interested in research and I had a feeling I would do it at some point. And so, yeah, one of my supervisors, I was working clinically in a children's hospital doing like a rotational type job in a public hospital. Yeah, one of my supervisors was doing her PhD and said, "Oh, would you like to do like kind of get a taste test of research, do a masters of research?" And so I did that and I really liked it. And then I had a really great opportunity to do a PhD from there. So throughout that, I was working part-time in different pain clinics, and I gradually kind of did more and more research and then now I'm in the academic position, so teaching and research. Yeah, that's a nice story. And before we go to science of pain, I would like to talk a little bit about your YouTube and science columns. Could you tell for us how did you end up doing some YouTube videos and how was the process? Yeah, so it's a similar thing in terms of what motivated me with my research questions. I was working in a pain clinic setting and seeing complex pain patient one after the other and and running group pain programs with the psychologist and just being really intrigued by the psychology of like what influences our bodily movements and fear and different things like that. And every group pain program, we would tell very similar stories, similar education, the same kind of anecdotes. And I thought it would be great if it could be like a professional could make it. And so I pitched it to the TEDEd team and we did one video on like because I wanted the map in your brain, like your homunculus. I wanted that animated and that was so they made a big thing about phantom limb pain. And then I did another one, the mysterious science of pain, which you mentioned. And yeah, that's just been a really cool process of learning how to engage with experts at other things. Like, I like to think I don't make a horrible PowerPoint presentation. But when you see a communication expert, like someone who has spent years just learning that, they are very, very good at animating. And there was a producer and a director and a narrator and a whole team of editors. And like just seeing everyone play their part in these kinds of projects has really inspired me to be involved more in yeah, this kind of science communication space. Yeah, it's really fascinating. So that's interesting. So you said that you pitched the idea. So it was how did you go? Could you tell from the beginning? How did you find out about this? And how did the process go of them selecting this? Yeah, we actually, I wrote a paper about this with Laura Moseley about the different types of approaches to doing this sort of science communication. I think if you have lots of money up front, you can go and make your own. You could pay people. And we calculated it out. It was about 60,000 Australian dollars to do something like that for a five minute animation and a website and all of those things together. Whereas the like Ted Ed is a not-for-profit and like they basically receive nominations and ideas. And so they have requests on their website and I just went via that. I don't think, yeah, like I think I was very fortunate to get chosen. I just, I don't know, maybe there was no video in that space before or something like that. But yeah, they're brilliant team. And it's similar sort of story with the children's books I'm working on, like working with a publisher and an illustrator and the editors and the graphic designers and all of those different people who are creative professionals and trying to bring the health, clinical knowledge to the masses. And so I suppose there's probably people listening who have great ideas that they love everyone in the world to just know. And it's those kind of ideas that I think if you go to a communication expert in some sort of capacity, it's a really cool journey. And like now we're doing research on those things and it's exciting. So basically you just filled in the request form in the website and you were selected. So how would you say to other researchers who have ideas and what kind of things you think would fit into this education? Yeah, for like their platform has, I mean, if you start watching their videos, you will end up in a rabbit hole and watch the thousands of them. But they have a specific way of pitching it and it's very story based. And so as much as I wanted to hold on to my ideas, ultimately they're the publisher and they own the content. And so that's one of the things you need to think about. Like if you have the money, you can own everything and control the message exactly. Whereas if you're happy to let go a little bit and let people who are not necessarily science background to re kind of work on the script and edit it and things, I was a bit hesitant to do that. But by the end, I really embraced it and I can see the value in like if you're trying to reach a lay audience like a non-scientific audience, you should have non-scientific writers as part of the like collaboration or the people writing. And I think that's probably true for a podcast or anything really is working out. Who can you have that kind of knows the target audience really well? But yeah, I guess like I just also should mention like I think as health professionals, we have so much of a big knowledge base and it often gets, it becomes inaccessible because of jargon and different language. And I think if we can learn to break that down and often that's through clinical practice, like saying the same thing lots of times and explaining it for people who don't speak the same language and those kinds of things. That's when the message becomes crystal clear and you see it over and over again and you're like, hang on, I could explain this in 30 seconds now. And once it gets closer to that point, I think that's when you're closer to pitching an idea to someone. But I'd be happy if anyone's interested, they can email me and happy to think about it together. Yeah, that's nice. And you said that you learned a lot when you were working with these people who were professional in communication. Did you tell what were the most important lessons you learned? Can you put them in words? Yeah, sure. There are so many. The first one that comes to mind is the idea of a story driven lesson. So rather than the main thing being like, I'm teaching you this message, the main thing is the story and it's kind of like a fable or whatever it is. The message comes through slightly subtly and so people love the story and they love the characters, but then they're learning at the same time. And that's the real tricky tension, I think, because there's a risk that you might lose the message completely and people like it for the wrong reasons. But I think if you don't do that, then most people won't even engage with it. It's like a boring TV advertisement. You don't even bother watching it. If it's engaging and tells a story, you're like, oh, I wonder what this is about. And I think that that approach of kind of putting the story first is really, really helpful. And so some of my research I did in my PhD and even now, we're interviewing children and looking at how they think about pain and doing that pre and post an intervention that's based on education is really interesting to see if, like, does their language change? Do they talk about things slightly differently in terms of their tone even? And will they communicate differently with their loved ones, their parents or family members, because of the education? And so I'm really fascinated in that space. It's like the theory, underpinning it, if the nerds out there, is conceptual change theory. And so we're looking at, does someone change the way they think? And ideally, I think that should be somewhat measurable or accessible. And so in my PhD, we build a questionnaire to kind of do that. But yeah, it's a very tricky thing to use a questionnaire as it's not a gold standard, obviously. But it's hopefully a helpful tool. Yeah, and if I go still back to the story thing, so there's probably a lot of ways to tell a story. The painting you can tell from a, you have, like, the hero of the story or the person who happens something and feels, for example, the phantom pain. You could probably tell a story from the, how did researchers come to this conclusion, kind of telling the story of the discovery? What other ideas you have for telling story? And what kind of story you are using in your kid's book? Yeah, sure. So I'll go with the TED Ed video that's had the most views, because that's probably, it's a good starting point. I, to be honest, the most, I think the most successful story aspect of that is the, what the animators did without my involvement at all. So I don't take any credit for this, but they used a, it's not, I wouldn't say it's a dry script, but it wasn't overly exciting or story based. But they created this metaphor of the brain is like a queen. And then, and the body, like, there's like a castle is the nervous system and it's trying to protect different areas and, and there's different parts of the nervous system that function in different ways. And it's all subtle. But as you're listening to the words, which are like about humans, but you're watching the pictures, which are about castles and, and fights and metaphors and shields and things like that, you quickly understand the key message there. And so it's, it's a combination of the audio and the visual that makes that more effective. Yeah. And, and, like, even in, there's a few things that the animator did where they made little subtle references to like pop culture and things. And if you look in the, I had a look in the YouTube comments, although I was warned not to. And there's a few times people have gone, oh, that's from this movie or whatever, that the animator has snuck these things in. And so I think just because these animators are exceptional is obviously one of the reasons that they're very attractive. But from a, from an education point of view, why not tap into that? If there's an audience wanting to hear a message, like, let's give them a helpful one and one that we think can improve society. So then in terms of the children's books, in about, it would have been pretty close to the start of my PhD, like maybe 2016, 2015, even, I had, there's a book called Explain Pain. And that's for adults. And I was working in adult pain clinic. And I just remember the first time I saw a patient and I didn't do any manual therapy, did no hands-on anything, just gave them lots of education. They learnt graded exposure and, and they learnt to self-manage and treat and, and like their long-term outcomes were like exceptionally good. And I just thought, oh, like I had this crisis of, I don't have magic hands and all of that sort of thing. And I, I remember like seeing that anecdotal power of education and then reading some of the data and going wow, okay, it's looking pretty good for adults. It kind of sets the foundation for all these other treatments, like learning self-management strategies. But it's not there for kids. And the, the language is quite complex and, and so I'd love to make a kid's version of that. And so I tried making a book and, and it's just like, oh, pain doesn't mean damage and damage doesn't mean pain. Like pretty simple concept, try and tell it as a story, maybe make it rhyme. I had a few ideas and started putting it together and I was looking at self-publishing. And so this would be like all the dissemination would be on me as the content expert, not as the like designer or any of those other roles. So I'd be having to fill all these different shoes. And I think it went on for a couple of years of like, okay, I'm doing my research, but I'll try and work on this in the background. And then I met with a publisher and I realized how much potential it could have. And so now the books are coming out in the next six months or so. And it's five stories in a box set. And they each focus on one particular learning outcome. And it's about a 10 year old girl going through different adventures and learning different things on each adventure. And it's familiar. It's every day. But at the same time, it's really interesting. And I like, as in the kids who have interviewed, find it really fascinating. Like there's one, one of the books is about virtual reality and going in the classroom. They go inside the human brain. And some of that sort of stuff, like it's funny and it rhymes and it's silly. And it ticks all those boxes. Like the illustrator is just brilliant. So there was a story again. And I think it's just grown so, so much. And to the point where it's driven by the key messages that have come out of qualitative research, we've got these messages. We've simplified them for kids. We've tested them in interviews. And so now we're ready to try them as an intervention. And so I guess what's most exciting for me now is we're looking at going to school systems and providing preventative education about pain. So that stigma comes down so that people don't tease necessarily. Hopefully tease kids as much who when they're struggling with these invisible conditions like pain where it's kind of like, oh, it must be all in your head. I'm like, how can we reduce that? And potentially these books might have a role. So I'm really excited kind of looking five to 10 years down the track of where this could end or could lead to and hopefully keep building. Yeah, it's been a really interesting one. And I guess it all kind of has come back from the learning experience I had by working with other industry experts. Has kind of led to more and more kind of step by step. It's just grown and grown and grown and grown. It hasn't been, I had a great solution straight from the word go. A lot of it is other people's ideas. And I've just got to be a part of it. Yes. Good points. And then I wanted to ask. It scares me. Could I ask one question before you? Yeah. Yeah. Sir, please, please go on. Do you work with children and physical activity? Okay. Then you should listen to us. We wanted to tell you about this whole bell animation that is so cool. And we understood from his funny explanations why humans and polar bears shouldn't sit all day. Fibby and device, it is an accelerator. And I could tell you all the specs. But you just need to know it measures accurately, set until we behavior and physical activity. And is scientifically validated. But most importantly, using it feels like magic. Yeah. Like magic. Ding dong dong. So, learn more at fibbyand.com/kids. Please click it. Because it's important that kids all over the world can learn from polar bear. That's so awesome. Mom, can we have a polar bear as a pet? Please, Mom. Yeah. I think this is super important because, you know, the researchers are doing the work, for example, in physical activity. And then we have the recommendations. It's usually many researchers who are in the working group. And then this message, which is usually targeted to professionals or policy makers, it kind of trickles down to normal people. And then there's word like sedentary behavior. There's like different things which most of the people probably don't understand. How would you, with your experience telling stories, how would you approach physical activity? Like, how would you tell the story? It's a great question. I don't know if I have a great answer, but I can talk about how I would approach it. So, like, for example, we've tried to change, look at how teachers use school curriculums. And in Australia, the way that that happens is different to what my expectation was. I thought that the government or the higher ups in the Ministry of Department of Education would say, "This is what you must teach." And then the teachers would teach that exactly. But what happens is they're given kind of like a guide curriculum or like it might be something about like anxiety and mental health or something, and then or physical activity. And then they're given, there's some resources available, but the teacher then designs the lesson plan. So it might be to create, maybe each group needs to create a poster, to create awareness, or like, how could you reach your family? Like, so they literally give the children the task to develop it. And so by kind of putting the recipients of the message, putting them in the driver's seat effectively is the method there. So like, if I think about the guidelines I'm aware of with physical activity, most of it is like, it's been in some sort of an infographic, but it's often too many numbers, too many words, too much. And so if that was a story, or if it was like, if you think of it as a TV ad or something like that, how could it be compelling enough that people want to engage in the solution, which is, so it's not just conceptual change, you're not trying to say, or sedentary behavior is bad, or don't sit all day, or whatever, you're not only trying to get them to understand that, you're also trying them to then act upon that message. And I think that's the piece of the puzzle where we don't know a whole lot. I've been reading a lot about behavioral economics and there's a whole field of research. Dan Ariele is one particular name who is very, very compelling. And I just love the way he phrases things, but yeah, it's about this idea of going, well, is there like a trigger to get the behavior to start? How can we make it so easy that they do the behavior rather than not do the behavior? And it's all these like simple, like your humans are irrational, and like they don't necessarily know that they're irrational, but it's predictable. And so how do we like kind of capitalize on that? And even like knowingly, like I think about it with myself, I'm like, oh, if I want to exercise the next day, I should have my shoes out ready to go and make it easier to exercise than to not exercise, or whatever it is. And I think those behavioral kind of strategies are unneeded, and we need to know them really, really well before we even try to give the key educational message potentially. But in saying that, potentially for the next generation, we could in part the knowledge now, and then they may generate these behaviors because they understand. So like about 20 years ago in Australia, we started doing more recycling and skin cancers was really bad. And so we use sunscreen and t-shirts and things. And now it's the norm. Like my kids wear hats all the time and they recycle, and all these things, all these behaviors are just inbuilt. And I wonder if it's, is it at the public health level, like the education in schools? Or was there a point at which say like my parents generation were educated and they changed their behavior suddenly? And I think it's a combination and it's probably murky and tricky to tease out. So that's a really long winded answer. Basically, I don't know. But I think it's really an interesting question to tackle, because it's so important that people are physically active. But it's kind of hard to be physically active for the average non-fizzio in the world, even for physios. And it's just about thinking, what are those key kind of steps to get there? And then how can you embed it in a journey or a story that someone wants to be like kind of relate to and be involved with? Yeah, so you said that there should be this kind of tricker to act. And that's probably the difficult one. I think now the communication is better. I think the main main message is in four words. So it's basically sit less, move more. So it kind of tries to activate person, but it doesn't really, I don't know, probably doesn't work for most of the people who are inactive that they would jump in and start moving with that. Yeah, yeah. So in the children's books as an example, I've got one here from the study that we're using. So it's like this cartoon girl, and she goes on an adventure with her uncle. And then in the next book, she's with her cousin and does this and goes on different adventures. And in the last book, it's kind of bringing it all together. And by then the reader has kind of his friends with the main character. Like they really like them and they want to be like them. And so her name is Zoe's Opens. And Zoe has a friend who she's observed, implement an active approach, like graded exposure, kind of building up. He had back pain and dealt with that. And then in the fifth book, it's all about how could like so Zoe's now seven weeks after developing her own action plan? How did she do that? And what does her typical day look like? So it's a success story. And then at the end, immediately following that, it's a blank kind of template ready to fill out for the reader, so that then they're following in the steps. So they've seen not only did Zoe's cousin successfully set a plan and achieve that goal, then Zoe did. And then now it's kind of it's now it's your turn. And we have a whole online platform being built with audio books and worksheets and different things to try and keep reinforcing the learning in different ways, so that the message keeps kind of sinking in. And what we're finding from the pilot testing with clinicians who are going to kind of be the main people using it, I'd imagine, it may go out to the masses and some parents would buy it. But I think the main the tool will mostly be used in a clinical setting where a clinician sits down and says, hey, your homework this week, read the first book or read all five books or whatever it is, depending on the kid. And I think that's the setting where it's like it then supplements the treatments that are given in a clinical setting. And then in terms of prevention, if a teacher then takes the series and then runs with it and makes their own program, but using those learning outcomes and anecdotes from the books and worksheets and things like that. So like the thing that excites me is when there's a shiny new resource, that often is the catalyst for change. Like if I think about there's plenty of great videos and things about how pain doesn't mean damage, but when Ted Ed made the animation, it suddenly reaches millions of people. And I don't take any credit for that. I just think if you can make it so compelling and so easy to watch and it's in HD and it looks brilliant and like the pages are thick and they feel nice and smell good. All of that stuff I think subtly contributes to the longevity of that message. And so like the sit less move more message that you mentioned just then it's like, how do you make that so that the next generation just love that message. Like they've seen a role model like at the Olympics or something who's living that out and or whatever it is, it could be anything. Anyway, I feel like it's going on a complete tangent here, but it's fascinating to think about it. I think it's great and I think that's interesting that you said that telling a success story, because I've heard how the insurances are so that you need to paint the future, that think about what happens and this happens and if you didn't have an insurance, everything goes bad. If you had, everything goes good and then people usually buy the insurance. So I think it's very interesting that how would we in physical activity promote and paint this kind of story is more that people would see that how someone similar to them became something different with probably small changes in behavior. And that that fact that I think it's a really really good point to think about through the success. Yeah. And I think so like if I think about this in research and clinical settings, so researchers need to highlight the burden of disease really, really clear and then also the effectiveness of different treatments that needs to be really compelling as well. And then clinicians could then do things like so for me in the pain programs, we started videoing the gate of like just relaxed walking just walk 20 meters and we film them at the start of a six week program and at the end. And this is a low intensity program there. They're just growing up like 20% each per week in most things. And so by the end of a six week program, like they back off in week two and they gradually build up, they're about double their functional capacity is roughly double. We don't talk about walking fast or anything we just say just relax. And you ask them at the end of six weeks, have you like do you think your walkings any different and keep it really open? And they most of them say, no, nothing's changed really. And it's so interesting because like I mean pain is really complicated and often like depression and things are a part of it. And so their body image is low and they think that no change is possible. And so doing this video and then putting it side by side at the end of a program, it's kind of like one of those teeth whitening commercials, like you can you haven't asked them to walk faster, but they're like really fluid and their shoulders are relaxed and and they're much faster, like significantly faster. They're taking less like longer stride lengths. And we get the whole group to clap them and say you're doing you've done an amazing job. And and it's interesting. It's not until about that point that they can start then setting long-term goals. And so someone in chronic pain is like and this is reasonably high functioning, but challenged by pain. It's it's not until they see in themselves that success story that they're even able to then set the big goal. And I remember there was one lady a couple of years ago, I'm sure she would be happy with me sharing this story. At the end of the program, she said, I've always wanted to climb the Great Wall of China. This was pre COVID. I think it was 2018. And and I've always wanted to go on the Great Wall of China, but I just never thought I'd be able to walk again. And like all these barriers, barriers, barriers, barriers, barriers, like it's a long flight. It's all these things. But by the end of the program, she was like, I'm gonna actually give this a go, like I think I can do it. And everyone in the group's like, Oh yeah, like sure, sure, that sounds nice. Like as in she's not gonna do it. And at the three months follow up, like this is not long after she's been to China. She's walked on the Great Wall. She's showing us all the photos and it was just awesome, like I think. So yeah, her seeing the success, not only learning about it. So like the education is really front and center in this program. She's hearing success stories. She's seeing that science underpinning it. She's understanding, she's trying everything, but still after six weeks still didn't really like wasn't convinced she had changed. But then she saw the before and after. And for her, that was enough of a trigger to then set a big goal. And then it's kind of like, well, nothing's going to stop you now. Like, like she knows that change is possible. And I think often it's like, and probably with physical activity too, people just think like, my job is a seating job. Like I said, in a lecture this morning, we had our new students starting today, I'm like, I'm standing up, you don't need to sit in your bedroom to listen to this lecture, you can stand up to. And I think like we often just put such limits on our behaviors and limits on, well, this is what happened last time, like the last 10,000 times I got out of a chair, it hurt or whatever it is. And we just set these expectations without even being aware of them. And so by thinking critically and outside the box, and working on these kinds of cool outside of the box projects, it allows you to observe like more neutrally observe your before and after and to go, actually, do I need to see it all the time? Or do I need to move every day? Or should I move five times a day? Or like, and you're thinking with less of an anchor point, you're kind of just going, well, broadly, what would be great for all humans? And where can I fit into that? Yeah, and I just think it's really exciting. Like it's a cool thing to be a part of the health professional world. I think we have such a privilege to enter people's stories and see that transform and let them take charge of that journey. Thanks for joining us this week on physical activity research through podcast. If you like the show, make sure you never miss an episode by subscribing or following the show on Twitter. This podcast is made possible by listeners like you. Thank you for your support. If you found value in the show, we would really appreciate rating on Apple podcast or whichever app you're using. Or if you would, in a real old-school way, simply tell a friend about the show, it would be a great help for us. We have a fantastic lineup of guests before coming episodes, so be sure to tune in. Thank Thank you all for your support and have a great day.
