Pain management from a biopsychosocial approach feat. meghan dean

Written By Halle B

In our latest podcast episode, we sat down with Meghan, an experienced pain physiotherapist who works closely with people living with arthritis and persistent pain. What unfolded was a deep, insightful conversation that challenged traditional approaches to pain and offered practical tools for those looking to live well despite it.

Here are the key lessons from our chat with Meghan — a must-read for anyone managing chronic pain, supporting a loved one, or working in the health space.

Pain Isn’t Just About the Joint

Meghan began by shifting the conversation away from joints and degeneration, reminding us that pain is far more complex than we often realise. It’s not just about tissue damage — it’s about how the nervous system processes danger. Factors like sleep quality, emotional stress, past experiences, and even beliefs about pain can influence how pain is felt in the body.

She stressed that two people with the same X-ray may have very different pain experiences depending on their mental health, lifestyle, and level of support.

Movement Is Key — and It’s Safe

A common fear for people with arthritis is that movement might make things worse. Meghan addressed this head-on: movement is safe, and essential.

In fact, gradually loading the joint helps nourish cartilage, strengthen muscles, and desensitise the nervous system. She highlighted the importance of graded exposure — starting where you are, doing what you can, and slowly increasing activity. Avoiding movement entirely out of fear can lead to weakness, more stiffness, and even more pain.

Real Progress Begins With Confidence

Meghan shared a powerful story of one of her clients who, due to fear, had stopped using his painful arm. With reassurance, education, and a simple goal — reaching for a bag of rice — he was able to regain function and reported a 60% improvement in just one session.

This story reflects a key theme in Meghan’s work: success starts with changing your relationship to pain, not just chasing it away.

Flare-Ups Are Normal — and Not Always a Sign of Damage

Pain flare-ups can be alarming, but they’re a natural part of the journey. Meghan explained that flare-ups don’t necessarily mean harm has occurred. Sometimes they’re triggered by overactivity — but often, things like grief, disrupted sleep, or emotional stress are just as influential.

Rather than fearing flare-ups, Meghan encourages people to reflect:

  • What might have contributed?

  • How long did it last?

  • Did it settle with rest?

This type of self-inquiry builds resilience and helps people adjust their activity without falling into fear or avoidance.

Learn to Pace and Push Mindfully

A critical skill in pain management is pacing — finding the balance between doing too little and overdoing it. Meghan advises people to reflect after an activity:

  • Was I able to stay relaxed during movement?

  • Was I holding my breath, clenching, or tensing up?

If you’re pushing through pain but still able to breathe calmly and stay present, that’s usually a safe zone. But when stress responses like gasping, heart racing, or muscle tension set in, it’s likely time to back off.

Understanding this boundary helps people stay active without fuelling nervous system sensitivity.

It Takes the Right Team

Not all health professionals take the same approach to pain — and that matters. Meghan encourages people to ask:

  • Are they asking the right questions?

  • Are they interested in how pain affects your function and beliefs?

  • Are they working with you to create shared goals?

Great care involves curiosity, collaboration, and education — not just prescriptions or passive treatments. When that’s not happening, it may be time to seek a provider better aligned with a modern understanding of pain.

Don’t Forget Sleep and Lifestyle

Pain care doesn’t stop at exercise. Meghan pointed out that lifestyle factors play a huge role in pain intensity and recovery. Poor sleep, inconsistent routines, and stress can all fuel the pain cycle.

She encourages strategies like:

  • Improving sleep hygiene (no screens before bed, consistent routines

  • Managing stress through pacing, journaling, or mindfulness

  • Setting up a supportive environment that fosters rest and movement

These simple changes can significantly reduce pain sensitivity and improve quality of life.

The Bigger Picture: Empowerment Over Fear

More than anything, Meghan wants people to know that living well with pain is possible. It’s about understanding pain, not fearing it — and making changes across movement, mindset, and lifestyle that support long-term health.

Her approach is grounded in evidence, compassion, and practicality — and it empowers people to take charge of their lives, even when pain is present.

Meghan shared some valuable and accessible resources to support those living with joint pain:

Click the links to explore these helpful tools and information.

Missed the episode?
 Catch it on your favourite podcast platform and let Meghan’s insights support your journey to a healthier, more confident relationship with pain.

Full Transcription - 07 Pain Management from a Biopsychosocial Approach:

Danni: We're so excited to have Megan with us today to dive into the fascinating an essential topic of pain management from a biopsychosocial approach. Welcome, Megan. We can't wait to hear your insights.

Meghan: Thank you very much. I'm happy to be here.

Giselle: So talk to us a little bit about pain physiotherapy. What is it?

Meghan: Yeah, it's a really good question. Essentially, the simple answer is, pain physiotherapist is a physiotherapist who's undertaken additional study in pain. Obviously, I didn't start out as a pain physiotherapist. I think the intro was not exactly correct there. I started out, you know, as a young physiotherapist, drove straight into private practice and, and as you mentioned, it was those hard to treat patients that led me to undertake further study. About ten years ago now. So if I could, I might just start with an understanding of pain, as that really underpins any discussion about how to treat and manage pain. And our understanding of pain is something that's really evolved over hundreds of years.

Meghan: So it was around the 1600s that, it was first proposed by René Descartes. That pain was carried along within the nervous system. At that time, it was quite a simple, proposal that when a painful stimulus touched your body, it would be carried via nerve to your spinal cord.

It would then travel up the spinal cord and be received by your brain. So it was a signal, a one way signal, if you will, with the brain as a receiver to that information. Now, not much happened for hundreds of years. And then it was about the 1950s and 1960s with the introduction of new technology and the ability to study the nerves and study the synapses, which are the connections between nerves, that we really started to find out that actually, it's not a one way signal.

It is modified and influenced at every level in the spinal cord and at the level of the brain, of course. So we now know that pain is something that is created and maintained in the nervous system. It has the capacity to be modified. And be influenced by things like brain state, by things like your mood, your sleep. Perhaps the simplest analogy is that pain is like a fire alarm. So like a fire alarm, your pain system is calibrated to alert the body or alert the system of actual or impending danger. So your fire alarm is calibrated to send off a signal when there's smoke or when there's fire.

 

Your nervous system is the same, it's calibrated to let you know when there might be danger to the tissues. But just like a fire alarm, it can have false alarms. It can go off without any, any stimulus at all. In fact, we know that you can experience pain without any injury. So it's become really complicated.

Giselle: So is that when it becomes chronic like chronic pain.

Meghan: Yeah. So the understanding of chronic pain, if we just looked at the I guess the definition to start with a chronic pain is pain persisting beyond about three months. We use that definition as most things most tissues have healed within a three month period, be it bone or muscle or tendon, or ligament. Most things have healed.

So we now say, well, if things have healed, why do they still hurt? And that's when we start to look to there's been some changes. There's been some changes in the way that these nerves talk to each other, or there's been some changes in the way that your brain receives and interprets the signals coming from the body, and then those changes are really what underpin this persistence of pain.

So it's complicated. And, you know, what does it mean to specialize in pain? It means working within a multidisciplinary team, because as a physiotherapist, you only know this part and that is your lens and that is your focus. But then you also need an occupational therapist and you also need a psychologist. And obviously the doctors, the pain specialists are incredibly important in that picture.

Danni: I can imagine Megan to sometimes that'd be difficult, especially transient pain. Like for example, I've got osteoarthritis. And so I'll have like a flare up in like knuckles or something like that. And it could sit there for a couple of months even. Yeah, it goes again. Yeah.

Meghan: Flare ups are incredibly then somewhere else. Yeah.

Danni: Just changes like right now I've got a never had it before on my knees but my knees are playing up. It's like it's just it's crazy.

Meghan: Yeah. And it's incredibly distressing. and sometimes we can hunt around for the answers. Why is this flare up happening now. And we might sort of speak to that a little bit later on, but, certainly a large portion of my job is talking about how can we, first of all, avoid a flare up, you know, what are the contributing factors towards these flare ups? Even getting people to write them down and work out ways that they might, modify what they're doing so that they don't have a flare up. And then we actually do need a flare up plan, you know, what do I do when I have a flare up? And often it's things like, okay, it's okay to step back and maybe do 25% less.

It's okay to have analgesia if you need it, and it's okay to reshuffle your, you know, your what you've asked of yourself for that week in order to allow things to settle down faster. Yeah, yeah, yeah. Interesting.

Giselle: And we know as we age you're more likely to get pain. Right?

Meghan: Yeah, yeah, yeah. 100% correct. It's a bit of an epidemic if we look at the prevalence rates in Australia, it's approximately 1 in 5 Australians over 45 will experience chronic pain. We're talking about sort of moderate to severe pain when I'm saying chronic pain not just those are the mild aches that come and go. But that number swells to about 1 in 4 in our older, age group. So over 85, you know, 1 in 4. So 20, 25% gotta work on the maths. The maths. Yeah. we'll be experiencing chronic pain.

So it really is. It really is an epidemic. Yeah. and to, huge cost to to the healthcare system. I think the figures on the ABS were something along the line of $4.6 billion or so. Yeah. So it's a big, big cost per year. We see pain increase in older age for a number of reasons.

Some of those are because pain is associated with other risk factors. And those risk factors like long term health conditions are also seen in older age, like things like your diabetes, stroke, cardiovascular disease, mental health disorders as well. So unfortunately, there's a two-way relationship between one's mental health and chronic pain. You know, it's easy to understand if you're in pain and you're not able to do the things you want to do, that that's going to have a negative impact on your on your health and mental health.

You know, commonly causing depression or anxiety, but rather unfairly, the presence of those sort of mental health disorders does actually have an impact on your intensity and your experience of pain. So, yeah, it really does get stuck in a bit of a bind, especially when you're talking about things like anxiety.

Giselle: So is it anything, we can do to prevent, like, that pain from happening as we age?

Meghan: Obviously, this is a very this is a big question.

Giselle: It is a big question.

Meghan: Yeah. you're right. Exercising. You know, one of the, you know, when if we look at the most common causes of pain in the elderly or in, in older adults, it really is arthritis is up there in musculoskeletal conditions are up there, osteoarthritis in particular is the biggest, that is the biggest, proportion, that we see.

I think there's about 2 million Australians living with arthritis, osteoarthritis, that is and something like 3.7 million with if we look at the bigger umbrella of all different types of arthritis. So yeah, huge issue, huge cost. You asked about prevention. Well, some of the big risk factors are actually overweight, obesity. So absolutely weight loss is probably one of the biggest ones.

Unfortunately, another risk factor is being a woman, can't do much about that. What other risk factors do we have? We've got, yes. Obviously. Diet, sleep, mental health, staying active, you know, well, all of these things and all of these things then form part of one's, one's plan to, to manage or improve pain as well.

 

Giovanni: So basically looking after yourself and fill in that gap always is a good yeah.

Meghan: Balance balancing life. Keeping social connections. You know if we think about, contribute contributors to, to mental health, it's often isolation. You know, that's another factor faced by a lot of our older clients. So staying socially connected and engaged in the communities can definitely be preventative to the development of pain.

Giovanni: Very interesting. Yeah. So what about looking after yourself. Yeah. Holistically yeah. Yeah.

Danni: It's very interesting the to play though isn't it. Like you know arthritis and all the musculoskeletal stuff that goes on. But the, the role of the nervous system in that. and then when you're looking at things like anxiety, the role of the nervous system in that and the synapses and how all of those things work together.

It's interesting, though, when I hear you talking about, from a lifestyle perspective, like having those connected relationships, getting some exercise, doing those things. And, you know, when you really think about there are some beautiful ways that we can get together in community. Have some exercise, have some social connection, have a laugh, do some things that are good for our bodies.

Getting out in the sunshine all in one hit.

Meghan: Yeah I know it seems so simple doesn't it. But yet it, it can be difficult for a lot of people. And I think our communities aren't built, you know, we don't live in Europe. Communities aren't built that they necessarily support each other. We're spread far and wide. We live in suburbs. We have to drive to visit each other. And we're talking about a population group, where some of them are not driving anymore, you know? So they're very disconnected. So it does become hard to maintain those preventative factors. Yeah.

Giselle: When we're talking about osteoarthritis, what are some of the, myths relating to osteoarthritis that you think's out there.

Meghan: Yeah, I had a good think about this question. And I thought maybe I could best answer it with a bit of story. I'm going to tell you about, a patient of mine, Bob, we'll call him Bob. It wasn't his name, but his name. Bob. He's 80 years old. He was a widower. and he was referred to see me because of, some very severe, right shoulder pain.

Was an arthritic joint, and he was really struggling with it, and he wasn't sleeping. The preceding that, you know, Bob had sort of developed a bit of a grumbly joint and it was a bit stiff, but he was still using it, and he was relatively okay. And then he mentioned it to his GP. His GP sent him for an x ray.

The x ray came back and the GP said to him, look, it's bone on bone, you've got arthritis. and then I'm not sure. I don't think he actually received a lot more information at that point. You know, maybe you can take Panadol Osteo or something along those lines. So Bob goes home and like a lot of people, he's worried, he feels scared and he stops using his shoulder.

He stops using that right arm to carry his groceries. He stops using his arm to reach up to the cupboards or to comb his hair. And this is quite a kind of fit, active 80 year old still driving. But he became very incapacitated. He wasn't able to sleep, and the joint just got more and more painful.

So then hence he after about sort of six months of just going downhill gradually, he was referred to see me at the pain clinic. So, one of the first things we did was sort of examine like what happened in this scenario, in his case is such a typical, typical run of the mill. This they go to the doctor, they get an x ray, and there's this sort of progressive, decline off after diagnosis.

So if we go back to some of the myths or misconceptions or even missteps in treatment, you know, one of the first ones there, really was that, well, the first myth is actually that you need an x-ray to diagnose arthritis. It is a clinical diagnosis. One doesn't need an x ray. So a clinical exam looking for things like painful joint margins or stiffness, morning stiffness, pain is in there.

Definitely. The shape of the joint, the behaviour of the pain. You know, all of these things will give somebody a pretty good guess. So to, to really give you a definitive diagnosis of arthritis. So there's no need to go for a costly x-ray. then there was a really big misstep, on behalf of the, doctor who was overseeing the case in, in using that terminology that I threw out there, “bone on bone” and I'm surprised it still exists out there in the ether.

Giselle: Horrible. It sounds horrible.

Meghan: Exactly. Exactly. The it just evokes in you, this. Yeah. This really unease. And it really does underpin this making patients feel vulnerable so they, they no longer trust their joints. You know, bone on bone. Oh it mustn't be safe. And, and then that sort of feeds into that myth that if I exercise my joints or if I load my joint, it will hasten its decline. And nothing could be further from the truth. And in fact, it is loading a joint that maintains the health of the joint that, you know, maintains the health of the tissues and

Giselle: So use it or loose it.

Meghan: Pretty much pretty much. And it really is important that you're exercising. It is one of the best things we can do for an arthritic joint.

There is a strategy to how we exercise it. And that's the sort of nuances of the health care provider and the physio in how to exercise in such a way that you don't exacerbate your pain, but you still get the benefits, of the exercise therapy on the health of the tissues. But certainly you can see how it's sort of fall and fall and falling down, falling through the cracks, almost.

So Bob came in to see me and first of all, we went we went through all of this information. You know how it's safe to load. And in fact, you joint will be better for it. Your pain and function should improve if we do this carefully. And I said in homework, you know, things like let's start using that to carry light objects.

Let's start reaching just within your comfort zone, but maybe slightly extending out that comfort zone or that safety net over, over some weeks. And when he came back to see me for his second appointment, it was 60% better. So he was he was still in pain. Sure. But it was it was back to where it was right at the start.

Bit grumbly on and off. And he was no longer afraid. He was happy with it as it was. He was confident he could cope with it as it was. And that was it, you know, and it can be it can be that simple. It can be more complicated, I admit, you know, but it just illustrates the importance of that early education and, and that early message and, and the sort of as we said, though, those, those myths that are circulating that actually you should exercise or if you white bear on your arthritic knee, you're going to make it worse or don't run on your arthritic knee.

And these are terrible myths.

Giselle: Yeah. Wow. Interesting.

Danni: So what causes a flare up? Because obviously there's a big difference between osteoarthritis, for example, and rheumatoid arthritis.

Meghan: There is. Yeah.

Danni: And one's an autoimmune disorder and one isn't. So how do we explain that to people too?

Meghan: Some flare ups, through known causes and one of the most known causes, osteoarthritis would be a overactivity. So that means undertaking an amount of, let's say it was gardening or going for a walk. If we're talking about knees. over and above, like, significantly over what you've been doing on average. Generally, when we're talking about exercise, we're trying to get people to stick within, a known amount, a sort of baseline closure and then increase by very small quotas to avoid flare ups.

But occasionally they might go to a wedding and stand up all day. Oh, you know, there's things are arise. So that that's sort of more common, feed into a flare up. Some are a little bit tricky, you know, to do with the disease processes that they can go through periods of time where they're more active. I can't speak to that, you know, fully as not as a rheumatologist.

 

But certainly if you're maintaining healthy lifestyle, if you're sleeping, if you're eating well, if you're out and about, you're doing everything you possibly can. In fact, most people with osteoarthritis actually have quite a stable disease progression. It doesn't progress really rapidly. So those rapid changes in pain that you were describing really are flare ups, insensitivity of the nervous system and more or less frequently sorry. It would be because there's been a rapid change in, in the disease process within the joint. So the other things you look at, you know, why is this nervous system more sensitive? You know, someone hasn't slept for a few days or God forbid, a loved one's passed away or, you know, there might be other. Yeah, there might be some other things going on in this person's life.

Giselle: Going back to, like patients like Bob, how would they see a pain physio? Do they need a referral from a GP, or can they book directly with the clinic?

Meghan: Yeah, for where I work it's a specialist clinic in that you do need a GP to visit there. Yeah. There is some great pain informed physiotherapists in the community and one doesn't need a GP referral necessarily to find them.

Yeah. just a bit of Google searching and, you know, careful reading of people's bios is a good place to start. Yeah, yeah, yeah. Okay. there is so much information out there. You know, they if we look at, myjointpain.org that I, you. So this is a OA support website. So essentially there's tips on managing pain. There's info on OA, how to choose your healthcare provider, how to be your advocate, everything like that.

We've got a Joint Action Podcast which is by a prominent rheumatologist. Again there's a mix of interviews, information, tips and tricks. And the Arthritis Movement was another one. I thought that was a really good resource. That's a collaboration between the two peaks arthritis bodies in New South Wales and in Queensland.

Danni: So again, when you say, OA you are meaning Osteoarthriti.

Meghan: Yes. Yeah. Yeah yeah, yeah. So I mean actually the quality and amount of free information on osteoarthritis and arthritis in general online is incredible. I would say almost more than other pain conditions. which is reflective of the healthcare cost and, and it's very common. Yeah. Yeah. The commonality and, and the amount of research and also where we're really in this preventative space that actually the more people know about this, we might be able to reduce some of those. Those number figures that we were talking about earlie.

Danni: So what about supplements Meghan, I know a lot of people take fish oil and all those kinds of things.

Meghan: Yeah, I think, it's a bit of a minefield. I know that there's more research going on, I think, into things like tumeric and I have to say, it's outside of my scope, to be honest.

I do feel that sometimes loading up on supplements can just be a big waste of money. and that, in fact, looking for just a healthy, balanced diet as prescribed by your, dietitian or GP.

Danni: Go have some salmon.

Meghan: Yeah, exactly. Lots of fresh vegetables. Fruit.

Giovanni: You should go fish yourself. There's some exercise for you to.

Meghan: Yeah. I love it. Yeah, yeah, yeah.

Danni: Gio will go with you.

Meghan: Yeah. it I think it's one of those questions about supplements and diet that the more we know about diet, the more we know it does impact. But because every person is unique, every person's gut biome is unique. We can't be saying this. This is the anti arthritis diet because it might be for someone, but it's not going to be for someone else.

Danni: Its trying what works for you isn’t it.

Meghan: Correct. You know if you have some food and you feel that that continuously or regularly inflames your arthritis, well stop eating it, that might be a trigger for you.

Giovanni: And do you do you work with a nutritionist much too?

Meghan: I have seen in one of my other roles I've worked with a dietician and I was absolutely blown away by her work. So I think there could absolutely be a role for a dietitian or nutritionist, in one's health care team. Yeah.

Giovanni: And that it depends on what type of pain they are experiencing of course, as you mentioned before, it's such a complex and broad. Yeah. Disease I suppose. Is it a disease or something. What did you call it before?

Meghan: Yeah, it's a disease. It's a disease of the joint. So not just the cartilage. I think it's another misconception. It's just a disease of the cartilage. But it's actually a disease involved in the cartilage, in the bone and the capsule and the ligaments. You know, everything's impacted in. Yeah.

Giselle: Can you talk a little bit about pain management plans. Like what they, how to get one who writes them, whats in it.

Meghan: Well any well informed health care professional can write a pain management plan.

I see some really good ones come from GP's. as we've touched on, pain is incredibly complex. so I think the first thing to say is, is this health professional the right person for me? are they asking the right questions? You know, they want to be asking you lots of questions about your pain, about your function, about how you're coping, about your beliefs.

You know, what's working, what's not working, and then coming up with collaborative goals, you know, and if that sort of process isn't happening, then you might not be getting your best possible care. and you might want to look for somebody else. but as I said, I've seen some brilliant plans come from all walks of allied, life.

And, and also your, even your GP's can be a great source of knowledge and information as to what it includes. You look, the majority really, lifestyle modifications. So as we talked about before, weight loss is incredibly important. So a weight loss plan or a weight management plan would be incredibly important. an exercise plan, graded exercise and show that would probably be under the guidance of a physiotherapist or a, appropriately trained exercise physiologist.

and sometimes even your PT’s. we would obviously want to have some sort of sleep, hygiene discussion, you know, how is this person sleeping? Are there any bad habits that have crept in? Are they on their phone in the middle of the night? You know, so developing strategies around that to improve the quality of someone's sleep.

We would also be looking at. What haven’t I covered? Pacing, pacing is a really big one. That discussion that we had earlier, you know, how much to do, how hard to push into pain. We do a lot of sort of reflective, questioning, you know, how quickly does your pain settle down after the event? to ascertain was that the right amount or not?

Essentially it's it's safe to push into pain, but if you're doing it too regularly, you may actually end up making your nervous system more and more sensitized. So you'll go backwards rather than forwards. So there is a bit of a strategy to that. Yeah.

Giovanni: And also how do you understand your own pain tolerance and when, when is it actually okay when you're pushing a little bit too much.

Meghan: yeah. I usually teach that with, I guess, a little bit more questioning. So when you're pushing into pain, is it a pain that you can breathe through that you can relax into whilst you're experiencing the pain or are you starting to kind of show those other signs of distress or stress, like holding a breath or gasping, or your heart's racing or your tensing?

So we're seeing other signs of, of stress coming in. I would say that that's probably too far up the pain, the pain cycle and it's more likely to, result in rebound pain afterwards. So yeah, if you're pushing to a level that you can, you know, still maintain a conversation in and still be calm and relaxed.

Look, we're we're probably in a low risk type situation.

Danni: Well Megan, thank you so much for your time today. It's been so insightful and I'm sure very very helpful.

Giovanni: Absolutely learned so much.

Giselle: Yep.

Meghan: Thank you. Thank you for having me.

Giovanni: Thank you.

Giovanni:
 Thanks for tuning in to this episode of Conversations with G and G. We hope today’s chat offered some fresh insight and support for your caregiving journey.

Giselle:
 If you’re looking for more tools, strategies, or just a bit of encouragement, head over to our website, you’ll find resources to guide you every step of the way.

Danni:
Whether you're just starting out as a caregiver or have been caring for a loved one for years, there’s something there for you.

Giselle:
Don’t forget to subscribe, share this episode with someone who needs it, and join us next month for another real, honest conversation.

Halle B
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