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Wednesday 19 August 2020

A graphic image reading 'My Amazing Body' Pain.
Pain is a normal part of life, but how much do you know about it?

My Amazing Body is a podcast where we explore interesting, unknown and misunderstood parts of your body with help from medical experts and stories from real Queenslanders.

This episode is all about the pain. What is pain, why do we experience it and is it ever useful? We talk with Dr Joseph Kluver, a specialist pain physician, about how pain works and what happens when pain stops being acute and becomes a chronic problem. He explains how he works with patients who have persistent pain and the therapies that can lead to long-term change in their lives. We also talk to Sara Shams, who is a bilateral through-knee amputee, about her experience with phantom limb sensation and pain after she had her amputations.

Episode materials

Audio is great, but some things are best seen as well as heard, or might tempt you to do further reading. These materials provide more information about topics we touch on in the show.

Dr Lorimer Moseley on pain

At 03:55, Dr Kluver mentions a talk by Dr Lorimer Moseley about the experience of pain. You can watch the video of Dr Moseley’s talk below.

Chronic pain in Queensland and Australia

In this episode, we talk about how common chronic or persistent pain conditions are. You can find more information about the prevalence chronic pain in Queensland and Australia at the links below.

Pain Australia – Painful facts

The health of Queenslanders 2018 – Report of the Chief Health officer Queensland

More information about dealing with chronic or persistent pain

If you or someone you know is living with chronic pain, you

Pain Australia

Queensland Health persistent pain resources

Queensland Health persistent pain clinics

Health Direct – chronic pain

Living with your chronic condition: how to manage your health and wellbeing

Limbs 4 Life

Our guest Sara is the member for Queensland on the National Amputee Advisory Council for Limbs 4 Life. Limbs 4 Life is the peak body for amputees in Australia and provides services to thousands of amputees and their care givers. You can find out more the organisation and their programs and services at the Limbs 4 Life website.

Episode transcript

Host: Thanks for joining us for My Amazing Body season 2. It’s been awhile! As you can guess, we’ve been pretty busy handling a pandemic this year. Because of COVID-19, we’ve also had to record our interviews online this year, so sometimes you might hear a bit of noise in the background coming through the mic. We think you’ll agree, though, that the interviews we’ve done with clinicians and Queenslanders for this season are more captivating than ever. Let’s get into the episode.

When was the last time you were in pain? It might have been when you stubbed your toe or knocked your funny bone. Or maybe you live with a chronic pain condition, and pain is a constant in your life. Whenever it was, we can all agree that pain is pretty, well, painful. So, why do we feel it? Where does it come from? And can we make it go away?

Welcome to season 2 of My Amazing Body. We are so excited to bring you another season exploring the interesting, unknown and misunderstood parts of your body. Today, we're learning about pain.

Dr Kluver: Hello, my name is Dr. Joe Kluver. I am a specialist pain medicine physician and the current director of the Metro South Persistent Pain Service attached to the PA hospital.

Host: When it comes to pain, Dr Kluver is an expert. So, we asked him, what is pain?

Dr Kluver: There's lots of different ways that people can define pain. I think that at its simplest form, it's a sense of risk. "My body is in danger. I need to do something about it."

Host: Pain, says Dr Kluver, protects us. It helps keep us safe.

Dr Kluver: If you take the example of putting your hand on a hot plate, pain is the thing that makes you take the hand off the hot plate before you end up requiring a skin graft, hopefully. Pain is, "I'm in danger. Something needs to change."

Host: You'll often feel pain in a part of your body that is sick or injured. But pain is a complex bodily process, involving everything from your nerves, to your brain.

Dr Kluver: The neurology of pain changes a lot depending on how long you have it. With the poor chap who's decided to put his hand on the hot plate, he or she would get little receptors called nociceptors, which are basically damaged indicators in the hands, firing off saying that they're in trouble.

And then that will go down a nerve and eventually enter another nerve, at this level, the spinal cord. Then it will go up to the brain, and it will shoot off in a bunch of different directions. One part will shoot off to something call the smarter sensory cortex, and that's the map that says, "Okay, so there's damage. Where is it? It's in the hand." There's another part which may very well go to the prefrontal cortex, which is, "Okay, my hand's on a hot plate, it's burning. That's why there's a problem." Another part called the anterior cingulate, which will say, "Well, you should probably do something about it."

Host: It turns out, your body learns from pain, and in future, it'll warn you if you're doing something that puts you in danger, like touching a hotplate again.

Dr Kluver: There's almost like a sensory or map, there's an understanding, and then finally, there's a motivational part of pain and they're all kind of intertwined. In acute pain, that's what happened. It explains how, there's very good YouTube video by Professor Lorimer Moseley, who's a pain scientist, who talks about his experience where he got bitten by a snake and didn't particularly hurt, but a few years later, he got scratched by a twig and it hurt like hell, because of that learned response, "Oh my God, I've been bitten by a snake," turns out to be just a twig.

Host: The video Dr Kluver is talking about features Professor Lorimer Moseley speaking at a TEDx event, explaining why things hurt, and what happened to him after he got bitten by that snake. It's a great watch - we've linked to it in our show notes.

Acute pain, or the instant pain that comes on when you've injured yourself, is your body's normal pain response. Even though it's unpleasant, Dr Kluver says it's a really useful part of your body. Some people are born without that pain response, and it's really dangerous for them.

Dr Kluver: So in acute pain, pain is protective for that, and it’s the mechanism that keeps us alive. We know that in some syndromes where children are born without the capacity to feel pain, their life expectancy is quite low because of that.

Host: But it isn't that acute, or instant, pain that Dr Kluver specialises in. He deals in persistent, or chronic, pain. Pain that’s perpetual, meaning it doesn't go away, even if the cause of the pain has healed. This pain isn't useful and it's not protecting us. In fact, it's just making life worse.

Dr Kluver: In chronic pain, however, there's another element that drives this, and this is a process we call central sensitisation. Central sensitisation at its heart is an inflammatory change in the central nervous system, where a lot of our immune cells is little guys called microglia, increase in numbers, particularly around the spinal cord. They then mess with a lot of the mechanisms that would exist, that would usually be able to damp down our pain experience and say, "Okay, we get the message, let's chill out."

When that system breaks, people's experience of pain extends well beyond wherever the initial injury was. It extends to the other side, they become increasingly vulnerable to pain in other parts of the body that were previously unaffected, and a whole other myriad of changes progressively occur. We see the neurology of pain evolve over time, even to the point where then, say for example, with a burned hand, in some people that burn could heal perfectly well, and yet they have persisting pain. Now, the pain is being perpetuated, not by those damage indicators, but nociceptors in the head. But now all the changes that happen downstream, that have taken on a life of their own. This is central sensitisation.

Host: Over 3 million Australians live with chronic pain. In fact, back pain, one of the most common types of chronic pain, is the largest specific cause of disability in Queensland. That's a lot of people, in a lot of discomfort.

Dr Kluver shifted his career to specialise in pain when, as a GP, he saw more and more patients with persistent pain.

Dr Kluver: I was a general practitioner prior to doing this, and I found that I had an interest for the patients where everyone else had kind of given up. Patients with persistent pain are often distressing to the doctor as well, because of that sense of futility, everything we try doesn't work. I decided I would embrace that.

Host: So, what can be done about persistent pain? Dr Kluver says that his work isn't about 'curing' pain, or making it go away. In fact, that's not the aim at all, because it's impossible once that central sensitisation process has kicked in. Instead, he helps patients to live their life without pain getting in their way.

Dr Kluver: I guess I have a few jobs to do. The most obvious job of course, is working out what's wrong medically; giving someone the diagnosis, so to speak. But probably more importantly, it's sitting back and working out, why has this transitioned from an acute process to a chronic process? What is perpetuating this disability and this pain? Then once we identify that, any plan we make is largely centered around addressing those specific perpetuating issues.

Host: Dr Kluver works with his patients to find ways to manage their conditions, which can involve all different types of therapies and treatments. He divides the types of treatments his patients can receive into passive and active treatments, and says the best way to achieve results is to use them in combination.

Dr Kluver: Passive therapy is basically where we do something to the patient, and they don't have to do anything in return. Prescribing a medication or some sort of surgical procedure or intervention, are examples of this. Or here even things like TENS machines, which are little devices that provide very low-grade electrical current over the skin, can sometimes provide pain relief. Or heat packs, are also examples of that. So, passive therapies are therapies that don't involve any buy-in or commitment from the patient and are just really intended to mitigate someone's experience of pain for them.

It's my opinion that for the most part, these therapies don't really provide a dramatic improvement in peoples’ lives with chronic non-cancer pain. Although they have a role, they have a role only then to support what I would call, active therapy.

Host: Active therapies, Dr Kluver says, can provide the most dramatic and ongoing sense of improvement for a patient, but it does require them to put in a bit of the work. This can involve everything from going to counselling to doing exercise programs.

Dr Kluver: That's where the patient has to do all the work. That might be engaging with a psychologist to help work through a lot of the problematic thinking that it can occur with people with persistent pain. Often people are at risk of developing a very catastrophic world view – I guess an example of that would be when someone says, assuming they're not 80, "I've got a spine of an 80 year old, and if I pick up that duffle bag, it's all going to crumble and crack, and then I'll be in a wheelchair." That's an unhelpful catastrophic thought that in all likelihood for the vast majority of people who say it is not true.

Having a psychologist involved to identify these automatic unhelpful thoughts, and then work with people to actually see that they don't have that same sort of default catastrophic mode, is important. Otherwise, it's going to be very hard for people to reengage engage in activities that were previously important to them.

From a physical therapy perspective, which I guess is our other active therapy, these are active things. These are giving people ownership and control and a certain amount of self-efficacy. And so I would argue that that type of therapy is about most importance.

The passive stuff, the drugs, the procedures and injections, the steroids into sore bits, or burning off nerves, or whatever that may be, may actually provide a window for those other mechanisms that kick in. But they're not the end unto themselves.

Host: When Dr Kluver is working with patients, he doesn't just focus on the injury or incident that first caused their pain. This is because he knows that how we experience pain depends on a lot of individual, sometimes lifelong, factors.

Dr Kluver: The other thing of course, that pain physicians and healthcare providers in the area of pain need to do, is work out vulnerabilities people have. If people have awful childhoods with all these sorts of prejudicial events, they're more likely to develop chronic pain. They're more likely to have pain that doesn't respond to usual treatment as well. We need to identify that, we need to work out what we can do to mitigate the consequences of that, and also have an honest conversation with people.

It takes quite a long time to actually unpack all those things with someone. Certainly, everyone is different in regard to the exact things that are contributing to their perpetuating symptoms, the actual diagnosis of the pain condition itself, be that problem with a lumbar disc or a nerve injury, or whatnot, is actually comparatively quite easy to the rest of it.

Host: If you live with persistent pain, chances are that at some point you've been told that it's 'all in your head', by a friend, family member, or maybe even a healthcare professional. We asked Dr Kluver, where does this phrase come from, and is there any truth to it?

Dr Kluver: If it's said in such a way that people take it as, "Oh, your pain is on your head, consequently, it's not real,” then that's dismissive and unhelpful, and I would argue unethical as well. The patient has pain when they say they have pain. The mechanism that's perpetuating it, is a separate conversation to the pain's legitimacy. I think that from that perspective, if someone's saying, "It's all in your head, just stop doing it," then that's not useful.

At the same time, pain is a complex thing. Particularly persistent pain. It's not just this thing that's happening somewhere, in some peripheral part of our body. Pain has to be all in our heads. Without heads, we don't have pain. We've got all these different structures in our brains, which all have this ballet together, which ultimately will result in the sensation of pain.

If someone has got a severe depression, for example, their pain experience will be worse. They will have more pain. The mechanisms that would blunt their pain processing are impaired. If someone has pain from a traumatic incident, and they also have post-traumatic stress disorder from that same incident, their pain will be worse.

So, in that sense, if we're thinking about pain being your head, being that your head's the thing that modulates, evaluates and then perceives pain, it has to be all in your head. That doesn't make it not legitimate.

Host: When it comes to living with persistent pain, one of the major hurdles people face is that their condition isn't visible to others, and they might look perfectly fine on the outside. Dr Kluver says this aspect of pain can be debilitating in itself.

Dr Kluver: I think one of the big things that I see with people with persistent pain, particularly if it is non-obvious, is people look uninjured. Is this issue that people have of particularly of pain flare-ups, where people will say, that'll be a question, "Are you able to mow the lawn?" People say, "Yes." "Oh, so, what's the problem? Well, I can mow the lawn for 45 minutes, but then I spend the next three days stuck in bed with this horrible flare-up."

I think people have trouble reconciling these two things. The joints work, the anatomy works, the muscles are fine, the task can be done. But there's this disproportionate pain flare in the absence of any further injury.

People without persistent pain or people who don't work in this area, I think, have a lot of trouble coming to terms with that. Because at face value, it doesn't make any sense, "Why are you in pain and you haven't been injured?"

Then consequently, many people with persistent pain are left with a choice. "Do I disengage from these activities that I know that I can actually physically do, because the flare-ups are so catastrophic and burn me out? Or do I fight through this and accept the fact that in the act of being able to maintain those typical activities that everyone else can do, I’m then going to be in agony for an extended period of time, that is invisible to the people around me?"

To me, I think that's probably one of the major parts, this sort of almost incongruity with capacity to do tasks and the consequences of doing them.

I think that the other thing that happens too for many people and I've had countless people say this to me, is they start to query whether or not their own pain is real. Again, it doesn't make sense. These flare-ups are just not logical, or there's no reason for me to be in more pain now. Is it all in my head, am I making it up, have I gone crazy?

Host: Some people live with conditions that make them feel pain when there was never an injury to start with. While Dr Kluver says these kinds of conditions, like other forms of persistent pain, are a neurological issue, that doesn't mean they're not real or that the people who suffer them are making their pain up.

Dr Kluver: I think that there's some conditions where this conversation gets a little bit more delicate, and that's where there are conditions where there is no objective evidence of physical harm and then they experience pain. There's a real risk here that people in that situation aren't taken seriously, and I think that's unfair. The classic example is a condition called fibromyalgia, which is a disorder of pain and sensory processing, where basically the volume knob is turned up on high. The brain's capacity to filter out information is impaired, and so consequently people are basically overwhelmed with the sort of input coming up. That pain is all in their head. It's not anywhere else. There's nociceptor firing off. But it's still real, it's still debilitating and still needs to be taken seriously.

Host: Are you enjoying this episode of My Amazing Body? Be sure to rate and review us on the platform you use to listen to podcasts, so other people can find it too!

Are you ready for this episode's mystery body part? See if you can guess the body part from the clues given. We'll reveal the answer at the end of the episode.

What am I? I'm see-through, and I am tough but flexible. You need to keep me clean so I don't get infected. If you engage in onychophagia, I might get dry, ragged, red and painful. Do you know what I am?

So, we've learned that pain is a complex bodily process, that it involves your body tissues, but also your nerves and your brain. It's possible to feel pain when something hurts you, and also to feel persistent pain after an injury has healed. But what about pain that happens when a part of your body isn't actually there anymore?

We spoke with Sara Shams, who is a bilateral through-knee amputee, about phantom limb pain. Phantom limb pain specific type of pain that people with amputations can feel in the limb they've had removed.

Sara: My name is Sara. I am a bilateral through-knee amputee, which was caused by a very rare congenital limb difference at birth, called a tibial hemimelia. I had my amputations at the age of six years old and have been a prosthesis user for over 16 years now.

Host: When Sara was born, the tibia bone and the tibia side of her foot on both legs was missing. This meant she wasn't able to bear weight on her legs. Amputating her lower legs from above the knee gave her the opportunity to use prosthetics.

When someone has a limb amputated, they will often feel sensations and sometimes pain coming from the limb, even though it's no longer there. Sara explains why this can happen, and what it felt like for her.

Sara: So, basically, with phantom limb pain, I suppose once a limb is amputated, your nerves and your brain seems to think that the limb is still there, as well as your spinal cord. So, when there is an amputation, it still sends signals to that area of your brain to say that there is some sort of a pain that's happening, but technically the limb is not there.

I definitely remember feeling the phantom limb sensation. Obviously at the time, I didn't know what that was, but I definitely recall feeling the pain as well as just the, it was just a very different sensation, obviously, compared to normal. I recall when I was younger, I used to say to my mum, "Please itch my leg. It's really, really itchy. I can't undo it." And then she would pretend to each my, I guess, residual limb and that would make it better. So that is definitely one of the memories I have of phantom limb pain, post amputation.

Host: Treating phantom limb pain can take some creativity, because you can't actually treat the body part itself.

Sara: So I recall really simple basic therapies, actually. I was not put on any medications for the pain as a child, but it was a lot of nonpharmacological therapies such as pretending, well not pretending, that's probably not the right word to use, but assuming that the leg was still there, for example, the itching. So, when I did have some sort of a sensation, it was, I guess, dealt with at the time. For example, when, if there's an itch, you scratch the itch.

Host: For some people with an amputation of only one limb, mirror therapy can be used to trick the brain into thinking that you're scratching or soothing the amputated limb itself.

Sara: So, it's a rehabilitation therapy where a mirror is placed between the arm or the leg or the limb that is missing or amputated, and it gives the illusion of normal movement in the affected or amputated limb. So, basically, it sort of works on the brain or works in the regions of the brain that the movement or the pain is stimulated at.

Host: As she completed her therapies and grew older, Sara found that most of her phantom limb pain went away over time.

Sara: It has faded with time, however, I do still have tingling sensations at the site of my amputation. So that's still to do with residual limb nerve pain.

Host: But it's not just phantom limb pain that affects amputees. In fact, Sara says that amputees can be living with a lot of other pain and discomfort, that people who don't have amputations might not even think about as being part of their condition.

Sara: So being a bilateral amputee, lower back pain, first of all, is always present unfortunately. It's basically a way of life.

So, wearing a new leg, your stump has to be accustomed to the socket and make sure the alignment of your knees are correct as well, because that can really affect your gait and walking and the amount of energy that you're using to walk. And the lower back pain is a constant occurrence for an amputee.

Host: Kind of like wearing in a new pair of shoes, Sara says that every new pair or prostheses takes time to get used to.

Sara: As an amputee, I recently acquired some running legs, or blades. And my blades, when I wear my blades, as opposed to my everyday prosthesis, they use a whole different set of muscles once again, muscles that I never even knew that I had existed. So, when I first started learning to run on my running legs, I had to do a different sort of exercise to exercise those particular muscles, because obviously that also led to fatigue and pain, but it's definitely been a great learning experience.

Host: In this case, Sara says the pain was worth it.

Sara: It was the first time that I had ever run in my life on my prosthesis, because as a child, when I was growing up, running legs weren't really, I guess, they weren't as advanced as they are now. So, having the opportunity to run for the first time in my life – it was last year, it was incredible, and I completed the Bridge to Brisbane on my running legs as well. So that was definitely an achievement.

Host: As an adult, Sara manages her pain and discomfort with a team of specialists, using the type of active therapies Dr Kluver was talking about earlier.

Sara: It's a multidisciplinary approach. So, starting from my prosthetist, who builds my prosthetic legs, through to my physiotherapist, who looks after my gait and helps me with exercises for lower back pain and to alleviate lower back pain. And I also do Reformer Pilates, which really helps with building core support and core muscles, the core muscles are the main set of muscles we use to walk on prosthesis.

Host: Sara is the member for Queensland on the National Amputee Advisory Council for Limbs 4 Life. We've linked to the Limbs 4 Life website in our shownotes, where you can learn more about people living with amputations and using prosthetics and hear firsthand stories, like Sara's.

And for people who see Sara on the street and are curious to know more about life as an amputee, phantom limb pain or using prosthetics?

Sara: So one of the main things I would like to, I guess, let people know is, if you have any questions and if you see me walking down the street and you can see that I have prosthetic legs and I am an amputee, please ask. I am more than happy to explain to you what being an amputee means, how my daily life differs from yours, and, I guess, what are the challenges that I face as an amputee as well. So, if you have any specific questions, definitely ask, and I think there's sometimes hesitation around asking these sorts of questions, but I, myself, as an amputee, I'm more than happy to answer such queries. Obviously, it may not be the same for every amputee, but I am definitely happy to raise awareness for our condition.

Host: If you've got acute pain, like a sports injury or a headache, you might be used to popping a pain killer to make the sensation go away. We asked Dr Kluver, how do painkillers, like your garden variety paracetamols, work?

Dr Kluver: I'm really glad you chose paracetamol as the prototypical pain reliever, because we don't know! There's a lot of theories, a lot of things that are suggested. There's a certain group of enzymes which produce things that contribute to inflammation called COX enzyme, C-O-X, there's a thinking that maybe paracetamol blocks one of those. There's a bunch of other theories in regards to various other neurological structures, but 10 people, 10 different answers. It's probably of all the analgesics, the one that's most conventionally used and probably from a mechanistic perspective when the least understood.

I think it's fair to say that the vast majority, if not all the pain relief that you get from paracetamols, because it's working on your brain, not because it's working at the site of injury itself. But beyond that, it's guesswork.

Host: Stronger painkillers, including opioids, can be prescribed for patients with strong pain. These days, use of opiates for ongoing pain is regulated, and for good reason, says Dr Kluver.

Dr Kluver: One of the problems when it comes to opioids is that initially they work. If you give someone a whopping dose of oxycodone at the start, they'll have pain relief from it. The problem there is that is transient, and that people will quickly become tolerant to that effect. Then there's a choice, "Do I take away the drug, do we increase the dose to get that effect once more, do we leave you on this drug that's no longer effective?"

And so people find that they have this progressive increase in their dose over time in order to continue to obtain that same effect that they initially had. As that dose goes up though, there's other quite toxic effects of these drugs that starts to show their heads. There's a condition or a syndrome called opioids induced hyperalgesia, which is translated to ‘higher dose of opioids make pain worse’. That’s separate to the fact that someone's becoming tolerant and losing the effect of the drug over time. They then in the background, have this progressive worsening of their pain through to a similar mechanism that we see in central sensitisation.

Then after that, there's this issue that opiates are toxic to other parts of the body as well. If you give someone opiates for a long period of time, they're far more likely to develop osteoporosis. They lose muscle mass, then lose circulating testosterone levels. Then finally, if you then combine it with other drugs or if people have a higher dose, or if they have other medical vulnerabilities such as sleep apnoea, they can die.

Host: Hundreds of Australians die from accidentally overdosing on opioid medications each year.

Dr Kluver: People overdose and die on opiates often, and it's usually because it's a part of a cocktail of other drugs. But nevertheless, opioid overdoses are very, very dangerous. So we're left with this drug that creates the impression of effect that people remember because it's quite profound in the improvement pain people get initially. But then the improvement goes away and then people have to then chase that same effect moving forward while they suffer all these other toxic effects in the background.

The final point I'd like to make is that not all opiates are created equal. Some medications out there in the general the population or wherever they may be, are far more likely to contribute to this problem than other opiates.

The newer opiates, the current thinking is that, although we still need to be very careful and these problems can still be an issue, there are probably far less prominent issues than our old-school drugs, like morphine and fentanyl.

Host: And what about other types of pain therapies you might see on the internet or hear about from a friend? Particularly if you do live with a persistent pain condition, you might have seen a lot of ads for superfoods or new devices promising to cure you pain for good. We asked Dr Kluver, should people be wary of these kinds of claims?

Dr Kluver: Oh, it makes me angry. There's this almost cannibalistic element to it, in my view.

If we genuinely think it's going to help people, then I can't really fault the motive, but I'm not convinced that's what's happening. I think that on one hand, it contributes to the sense of futility that people get. You know, "I tried this, I tried this, they said this will work and it didn't. I did this, I did this." There's also, I've seen many people inject tens of thousands of dollars into that sort of stuff, and so there's another harm there.

But I think it also contributes to this concept of passivity. This whole thought of, the problem can be fixed by me lying back and having something done to me. ‘Bob's super snake oil with unicorn dust’ is inherently a passive thing. "I'm going to sit back and I'm going to smell the unicorn dust, and that will sort all my problems out."

It really disempowers people, in my view, to actually taking active control of their healthcare, so it's all still just in a bottle. I think on balance, from my perspective, that's probably a greater harm than the financial one, because it runs completely contrary to what I say.

Host: To end our episode, we asked Dr Kluver to bust an old-school pain myth. Is it true that women have a higher pain threshold than men?

Dr Kluver: As far as the awareness of the sensation of pain, a lot of the research where they get fancy machines to represent the exact amount of heat or pressure, or whatnot. We find that women actually say, "No, I'm now in pain," earlier than men. So as far as that awareness of tissue injury, the evidence says that women tend to be a slightly on the lower side.

But there's lots of other individual variability things that extends well beyond gender there. Even people's mental health, people's awareness of what's going on, distraction, all these things, or just good old-fashioned individual variability. To have such a sweeping comment, I think is problematic. As far as pain tolerance goes, how much pain they'll put up with before they say, "Stop it."

Host: Dr Kluver says he finds his job helping Queenslanders understand and manage their pain extremely rewarding and encourages other doctors and allied health professionals to look into specialising in pain.

Dr Kluver: I think the best part of my job is the feeling you get after – and this happens reasonably often – after knowing a patient for a long period of time, having this battle, there's been ups and downs where we've worked through so many different things.

Being at the spot where they'll just shake my hand, never to be seen again, with a smile on their face. That sense of the kind of like this shared goal that we both work towards, with everyone being on the same page. After a period of time, we got there. I think that's the best part of my job. And when people turn and say, "Yep, the pain is just as bad as it was before. But look my life's still a three-dimensional, look at these wonderful things. Here's the pictures of us going on holiday in Greece."

I think that's probably my favourite part. I think that the other thing I really love is the group of people I work with. We can have these really complex and quite traumatic situations when we're seeing patients talking about their lives. The way we can all sit down together and problem solve and work out what useful things we can do and then coordinate amongst ourselves. I think that makes the job, in a sense, actually, quite a lot of fun. Because you can say, "Okay, this is a terrible situation. Let's all put our heads together and actually find a way to help this person have less terrible life."

Often, particularly if the patients are keen to engage, we can achieve that.

Host: Thank you for joining us for this episode of My Amazing Body. Did you guess this episode's mystery body part? The see-through part of your body that might get damaged if you do onychophagy, or nail biting, is your cuticle! Congratulations if you figured it out.

My Amazing Body is brought to you by Queensland Health. Many thanks to Dr Kluver and the Metro South Hospital and Health Services Team for lending their expertise to this episode, and to Sara Shams and the team at Limbs 4 Life, for sharing your story and information about living with amputations. And thank you to my podcast colleagues - our producers Lauren and Jessica, Carol our audio technician and Helen on sound effects and music.

Last updated: 19 August 2020