An overview by Erin Keough, pht
I was 25 years old when I packed my bags for my two-month physiotherapy student placement in a Cree community in Northern Quebec. A young aspiring professional, looking to connect with Indigenous populations and better understand the intersectionality of health and wellness.
Originally from Newfoundland, I moved to Tiohtià:ke/Montreal to pursuit a degree in Physical Therapy. I was the only one in my program from east of Quebec, and the only one in my year with Indigenous ancestry. My family being from the Nunatsiavut Government of Labrador, with many of my great aunts and uncles having faced the horrors of residential schools, I wanted to learn more about Indigenous health and how it connected to physiotherapy.
The community that I lived in had a population of about 5000 people. It had a 20-bed hospital with an emergency, dialysis, and physical therapy department. At the time, they had one full-time physiotherapist and two rehab monitors, but it wasn’t enough. The team had a long wait list for physiotherapy services, over 400 people long.
In physiotherapy, we know that untreated conditions and injuries can lead to chronic pain. This is what inspired my end of placement project. The team asked me to try to create a chronic pain group program for the community to help decrease the waitlist and give people back some of their autonomy while they waited for physio – or ultimately, did not need physio services any more.
As a bright-eyed, super-motivated student, I jumped into the project head on. We had just completed a semester long class on chronic pain – I was hoping to use this information to create sessions that people in the community could come to and receive education and exercises to help them through their pain.
It was not before long that I realized our way of implicating healthcare treatments would not work in the community. In our western society, we are taught colonial medical care, which often does not translate to the needs of the Indigenous peoples. Over the course of the 8 weeks, I discussed a lot with people in the community to better understand what they wanted and needed - and if we were able to help. At the end of my placement, I presented to the team and talked about why a group physiotherapy session would not be feasible for the community. Instead, I took the information and created a 30 paged document for the community health division. I explained what chronic pain was, Indigenous populations and chronic pain, how we can treat it, community member reports, and resources from within and around the community.
Below will be snippets of the document. This blog post is not to give concrete information, it is to open the discourse that our current medical system is not designed or aligned to best help our Indigenous populations across Canada. The information collected from this community is only a snapshot of what Indigenous communities may want or need. Every community is different and if Canada truly wants to reconcile, we must listen to what their needs and wants are, partner with them, and allow their elders and knowledge keepers of the communities to be at the forefront of the partnership.
Introduction to Pain
Pain is a complicated, and often debilitating medical condition that can arise at any time in a client’s lifespan. Often pain is a result of an injury or illness that can be resolved. However, sometimes, pain from what started as an acute issue can prolong into a chronic condition. When this occurs, clients report having a decrease in their physical, mental, social, emotional, and spiritual health. But what is pain and how does it arise?
Pain is generically defined as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Wideman, 2022). Unfortunately, this definition is broad and does not encompass the full picture. Scientists for years have tried to understand pain from many different lenses. What is painful to one person may not be painful to another. Some people can have tissue that is extensively damaged, the body does not feel any pain, while others can have no tissue damage and be in intense pain.
From a neurological standpoint, pain can occur when noxious stimuli (heat, mechanical, or chemical) is picked up by the nociceptors in the body. This is then sent to the spinal cord, which brings it to the somatosensory cortex of the brain to process. The input of nociception is not what causes pain, but the way the brain processes the input creates pain, and its level of intensity, as an output. How our brains understand and process this information is completely unique to us and our influential elements that were listed on page 4. Therefore, nociception on its own, may not cause pain and does not explain the full elements of the pain that our clients feel. This means that there is not a one-to-one relationship with pain and noxious stimuli. These types of clients rarely respond well to traditional methods as their pain is multifactorial, and sometimes present without direct cause. Therefore, being able to use divergent thinking and approach this issue from a non-traditional viewpoint is a crucial component of our role as healthcare professionals.
Pain is the most common reason why a person needs to access medical care services (Canadian Pain Society Fact Sheet; Schopflocher et al, 2011). Some of the conditions that are leading causes of pain are back pain, osteoarthritis, and headaches (Sauver et al., 2013), with musculoskeletal disorders, neck pain, and back pain being the leading causes of disability (Wideman, 2022). According to the Canadian pain task force report, as of 2021, nearly eight million people across Canada are affected by chronic pain. When someone has an injury or pain, if it is unable to be corrected, they can develop more issues such as allodynia, hyperalgesia, sensory deficits, and pain spreading to healthy tissue. These side effects also need to be addressed as part of the treatment plan along with the original origin of the pain. Which is why management is multifactorial.
Pain management requires a team of practitioners working together to help manage a client’s pain. This pain has caused our client’s entire life to change, so we have to target many realms of their life besides physical. They often have decreased quality of life from the deficits in their physical, mental, emotional, and spiritual health. One common complication that arises from pain is fear avoidance. Client’s can get stuck in a loop of doing an activity, having pain, and becoming scared of the pain (see figure below). Us practitioners need to be able to understand and help guide our clients out of this cycle. Thus, communication style is so important.
Indigenous Populations and Chronic Pain
Chronic pain is categorized into two sections by the World Health Organization (World Health Organization, 2022). Chronic primary pain either: 1) originates from an acute injury, and even though that injury has now healed, there is still pain, or 2) there is no mechanism of injury at all. Chronic secondary pain linked to pain caused by another condition that the client may have (such as osteoarthritis). Because chronic pain is not straightforward in its presentation, diagnosis, and treatment, it can be often difficult to manage, especially with minority groups (Mittinty, McNeil, Jamieson, 2018). Unfortunately, like many other health conditions, people in vulnerable positions such as older adults, rural communities, Indigenous peoples, low socioeconomic status, low literacy levels, veterans, and racialized communities are impacted more by chronic pain (Newman et al., 2017). Not only are they in a position to be more susceptible to chronic pain, but if they are impacted by chronic pain, they have less resources and funding to pursue treatment. In Canadian Indigenous groups in particular, a lot of them have been impacted (directly or indirectly) by residential school trauma.
The residential school system was created by the Canadian Government to indoctrinate euro-centric colonial ways to Indigenous peoples (Hanson, Gamez, & Manuel, 2020). Children were stolen from their homes, identities taken away, and faced abuse in many forms such as emotional, mental, physical, sexual, and spiritual. The conditions of these schools caused a mass genocide to Indigenous Peoples and their culture. The predicted number is that 24% of Indigenous children died in residential schools and many more were sent home and then passed away from complications (Bryce, 1907). All of our clients are either residential school survivors or first generation from these horrors.
This can cause intergenerational trauma, as those who went to school had to navigate through the horrendous conditions of the residential schools (Smylie, 2001). When they returned home, pieces of their identity and dignity were left behind. From these awful experiences, they may have developed a distrust with the government system, which includes healthcare, so if they were having pain, they may not access care through the hospital settings. Furthermore, it has been observed that Indigenous peoples are more likely to report pain when it is more severe in nature (Elliott et al., 1999; Kramer, Harker, and Wong, 2002). Fenwick (2006) hypothesized that they are more likely to suppress pain as a coping mechanism - which has been done since early ages of colonialism. Therefore, it is important that we as healthcare workers try to understand their pain differently than we may when working with other populations. For example, an Australian researcher found that using a visual analogy scale (VAS) was not representative of the client's pain because the community they were working with did not correspond the facial expressions in the VAS with pain levels (Padianathan, 2000). As these scales and questionnaires are validated for non-Indigenous peoples, they are not culturally specific or sensitive to the positionality and history of Indigenous peoples (Mittinty, McNeil, & Jamieson, 2018).
Communication Methods
When communicating with clients who have chronic pain, we have to create a safe space for our clients to feel comfortable opening up about their pain. Many people who have pain have had it for quite a while and may feel discouraged by not finding solutions in the past. On top of this, multiple studies have shown that colonization has disrupted and erased a lot of Indigenous ways of living and healing through oppression, removing autonomy and decreasing resources (Varcoe et al, 2021; Brownridge et al, 2017; Burnette, 2016) which would impact their trust with the healthcare system. This has been noted in many different cultures around the world. In a study completed in 2015, they found that African Americas were more likely to be stereotyped as becoming addicted to opioids and other pain medication compared to their Caucasian peers, despite being given less opportunity to discuss their pain and prescribed less pain medication (Dickason et al.). They are often afraid that they are being judged and stereotyped before they start to speak of their pain. In comparison to other conditions and diseases, people who have chronic pain have been shown to have the highest disability rates and report the lowest quality of life (Wideman, 2022). Which is why creating a safe space for clients is such a vital part of the chronic pain healing process.
We must forget what we know and what we think we should do with chronic pain from a western medicine perspective. Our first instinct is to take an assessment, finding an outcome measure, and trialing exercise, medication, etc until we find a solution that works. As healthcare professions, we are motivated by a challenge to help. But in chronic pain, when these clients have been living with it for years, it’s not as clear-cut.
“…every time I go to a new practitioner I have to like tell them my whole like life story all over again. And it’s like really exhausting…it’s like I have to be really vulnerable and if they’re not trauma-informed it’s just an awful experience, to be that vulnerable they’re kind of just like seeing things through a certain lens and, yeah, I don’t feel believed or like I’m going to get, like the options they present aren’t going to be like what I’m looking for.” (Wallace)
How do we treat chronic pain in Indigenous communities?
While there are conventional Eurocentric resources that have been developed for chronic pain management, we must proceed with caution when using them. Like previously stated, a lot of the current literature and questionnaires have been validated for a specific population that does not include Indigenous peoples. Furthermore, attempting to adapt these services from a colonialist standpoint to become more culturally competent still creates barriers for people to access services because we are trying to fit them into our western agenda (Jackson et al., 2015; Kwan, 2015).
This is not to say that our way of viewing chronic pain and how to treat it is completely wrong, but that we need to let go of our own ideation of what it should look like and listen to what the community tells us would be beneficial. Some studies conducted here in Canada working with Indigenous women who have lived through intimate partner violence, have found success in using a community-based approach that incorporated their culture (Jackson et al, 2015; Lester-Smith, 2013). Some ideas highlighted in these studies were using traditional meals, stories, ceremonies, and teachings from elders.
A study was conducted by Wallace et al. in 2021 investigating how to improve health equities for those who are socially marginalized and experience chronic pain. They found that there were 5 recurring factors that influenced the participants experiences: location, identity, trauma, discrimination, and ineffective treatment. The Indigenous participants noted that when resources were presented to them that did not reflect their identity or values, it negatively impacted their trust with the healthcare system. So how do we help provide care that is in our own scope of practice?
“For an intervention to be accepted and effective in Indigenous communities, it needs to be safe, respectful, flexible, multilevel, and based on Indigenous worldviews of spirituality, ceremonies, and interconnectedness” Varcoe et al. (2021)
This document/blog post was created to encourage healthcare providers who are not Indigenous to learn more about the basis of chronic pain and how we can understand our clients better. Research suggests that having contextually tailored, trauma informed, culturally-safe care that take a harm reduction approach can be beneficial (Wallace et al. 2021). It is vital as healthcare professionals that we take into consideration that what we learned in our degrees are euro-centric and may not be appropriate. One of the best things that we can do is acknowledge our positionality and active listening to partner with those who want our support.
Resources for the Public
Aboriginal Worldviews and Education - University of Toronto free online course
Canadian Medical Association - Trauma-informed Medical Education
Introduction to trauma-informed rehabilitation with Indigenous clients - Article by Jessica Barudin & Hiba Zafran (2019) https://www.researchgate.net/publication/339513551_Introduction_to_trauma-informed_rehabilitation_with_Indigenous_communities
Indigenous Canada - University of Alberta free online course
Joyce’s Principle
Jordan’s Principle
Reconciliation Through Indigenous Education - University of British Columbia free online course https://www.edx.org/course/reconciliation-through-indigenous-education?pid=304931&awc=3_1665603715_0053a4d95c481a05bc15c98cacba2a11
References
Brownridge, D.A., Taillieu, T., Afifi, T., Chan, K.L., Emery, E., Lavoie, J., & Elgar, F. (2017). Child maltreatment and intimate partner violence among indigenous and non-indigenous Canadians. Journal of Family Violence, 32(6), 607-619. https://doi:10.1007/s10896-016- 9880-5
Bryce, P. H. (1907). Report on the Indian schools of Manitoba and the North-West Territories.
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Burnette, C.E. (2016). Historical oppression and indigenous families: Uncovering potential risk factors for indigenous families touched by violence. Family Relations, 65, 354- 368. http://doi:10.1111/fare.12191
Canadian Pain Task Force Report. (2021). An action plan for pain in Canada. Health Canada. Retrieved from https://www.canada.ca/en/health-canada/corporate/about-health- canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report- 2021.html
Dickason, R.M., Chauhan, V., Mor A., Ibler, E., Kuehnle, S., Mahoney, D., Ambrecht, E., Dalawari, P. (2015). Racial differences in opiate administration for pain relief at an academic emergency department. West Journal of Emergency Medicine, 16(3), 372.
Elliott, B.A, Johnson, K.M., Elliott, T.E., & Day, J.J. (1999). Enhancing cancer pain control among American Indians (ECPCAI): A study of the Ojibwe of Minnesota. Journal of Cancer Education, 14(1), 28-33.
Fenwick, C. (2006). Assessing pain across the cultural gap: Central Australian Indigenous Peoples pain assessment. Contemporary Nurse, 22(2), 218-227.
Hanson, E., Gamez, D., & Manuel, A. (2020, September). The Residential School System. Indigenous Foundations. https://indigenousfoundations.arts.ubc.ca/residential-school- system-2020/
Jackson, E.L., Coleman, J., & Sweet Grass, D. (2015). Threading, stitching, and storytelling: Using CBPR and Blackfoot knowledge and cultural practices to improve domestic violence services for First Nations Women. Journal of Indigenous Social Development, 4, 1-27.
Kramer, B.J., Harker, J.O., & Wong, A.L. (2002). Arthritis beliefs and self-care in an urban American Indian population. Arthritis Rheumatology, 47(6), 588-594.
Lester-Smith, D. (2013). Healing aboriginal family violence through aboriginal story-telling. Alternative: An International Journal of Indigenous Peoples, 9, 309-321. https://doi:10.1177/117718011300900403
Mittinty, M.M., McNeil, D.W., Jamieson, L.M. (2018). Limited evidence to measure the impact of chronic pain on health outcomes of Indigenous people. Journal of Psychosomatic Research, 107, 53-54. https://doi:10.1016/j.jpsychores.2018.02.001.
Newman A, K., Van Dyke, B.P., Torres, C.A., Baxter, J.W., Eyer, J.C., Kapoor, S., & Thorn, B.E. (2017). The relationship of sociodemographic and psychological variable with chronic pain variables in a low-income population. The Journal of the International Association for the Study of Pain, 158(9), 1687-1696. https://doi.org/10.1097/j.pain.0000000000000964
Padianathan, N. (2000). Pain management in the Royal Darwin Hospital emergency department. Presentation to the Scientific meeting of the Australian College for Emergency Medicine, Canberra
Sauver, J.L.,Warner, D.O., Yawn, B.P…. et al. (2013). Why patients visit their doctors: Assessing the most prevalent conditions in a defined American Population. Mayo Clinic Proceedings, 88(1), 56-67. https://doi.org/10.1016/j.mayocp.2012.08.020
Schopflocher, D., Jovey, R., & Taenzer, P. (2011). The Prevalence of Chronic Pain in Canada. Pain Res Manage, 16(6), 445-450.
Varcoe, C., Ford-Gilboe, M., Browne, A.J… et al. (2021). The efficacy of a health promotion intervention for indigenous women: Reclaiming our spirits. Journal of Interpersonal Violence, 36, 13-14. https://doi.10.1177/08862605/88208/8
Wallace, B., Varcoe, C., Holmes, C., Moosa-Mitha, M., Moor, G., Hudspith, M., & Craig, K.D. (2021). Towards health equity for people experiencing chronic pain and social marginalization. International Journal for Equity in Health, 20(53). https://doi.org/10.1186/s12939-021-01394-6
Wideman, T. (2022). Introduction to Chronic Pain. Lecture. McGill University.
World Health Organization. (2022). International Classification of Diseases 11th Revision. Retrieved from: https://icd.who.int/browse11/l-m/en
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