James McAuley

I used to always say that you can tell and this sounds really bad, but you can tell somebody who's a psychologically informed physiotherapist because you like them.

Tim Austin

Welcome to a pain podcast. My name's Tim Austin and I'm the chair of the Pain group of the Australian Physio Association. Firstly, all of us here today we'd like to acknowledge the Turrbal and Jagera peoples of the Meanjin as the original owners and custodians of the lands on which we are here today, recording and we pay our respects to elders past, present and emerging.

I'm joined by three wonderful people. First of all, we have Dr. Anne Daly, who is a specialist pain physiotherapist, one of the first to receive that award. She is a clinician but she also works as clinical lead in Victoria with TAC and WorkSafe professor James McAuley, who works at NURA, the Centre for Pain Impact. And also Dr. Lester Jones, who works in Singapore at the Singapore Institute of Technology as a senior lecturer.

Welcome. Welcome to the three of you.

James, Lester, Anne

Thank you. Thanks Tim.

Tim 

We've titled this What is Psychologically Informed Practice and you each have spoken a lot on this topic. And also as some of you clinicians. So I thought we might start by saying what is psychologically informed practice. And I didn't mention James, you are a psychologist. Yeah. So why don't we start with you. What is psychologically informed practice?

James 

You go with me first. It's a really, really good question because there's no really clear definition of that. So I'm well, I'm first of all, I'm not a clinician, so I'm a psychologist, a small B, I'm a researcher. But since I've been working all my professional life and my research career with physios and I think psychological form practices the kind of physio that I would send my mum to see, I would feel safe sending my mum to somebody who cared about her and treated her with respect and dignity and felt very well.

James 

My mum felt very comfortable dealing with her and telling her about her life story and etc. etc. about what's concerning her, etc.. So I think on a very low level that is what I would consider to be psychologically informed physiotherapy. I used to always say that you can tell and this sounds really bad, but you can tell somebody who's a psychologically informed physiotherapist because you like them and you like going to see them.

James 

And it turns out that those skills are actually really teachable. So those are psychological skills that can be taught to physios, to how to communicate in a way that somebody feels respected and empathic and that you're empathic, etc., etc.. So that's what I would say, psychologically informed, physio is.

Tim 

Is some of those soft skills that we used to used to call those. Lester you also come from a psychology background and then into physiotherapy. What's psychologically informed practice to you?

Lester Jones

So probably take a little bit more of a specific definition for psychologically informed practice. So I like to think of it as the adoption of psychological principles and strategies into a non psychology discipline. And I think that for me the important thing is being able to adopt the principles with and also adopt the, the theory, the measurement, the ability to adjust the strategies that comes with the psychology discipline. I think adding those things together I think is helpful.

Tim 

And for you Anne.

Anne Daly

And what I would say first is why are we talking about psychologically informed practice? And to me it's part of the maturation of our profession and this acceptance that the by a psychosocial context of an individual is really important in terms of determining where you're going to go to with the care you provide to that person. And if you understand the importance of that by a psychosocial context, we need to be as psychologically informed as we are by a medically informed and socially informed.

Anne 

So I think that's where I've come to it from progression through my clinical career. And I understand it to be, for me, mostly using cognitive behavioural principles, that I've taken upon myself to learn, but also sought supervision from psychologists to make sure I'm doing it in a way that's really useful and safe.

Tim 

So we've really got this theme of pain being a bio psycho social construction of our nervous systems. Then we need to be incorporating some of those different skills potentially. So if we look at some of those sort of psychosocial variables from the research, James, what do we see? What what variables classically come up as being relevant in people's pain experiences?

James 

Well, I would say the three, probably the three main psychological areas, but these are really from the cognitive behavioural or cognitive aspects. Really they would be catastrophizing probably fear avoidance and maybe more recently self-efficacy. And I heard Lester say this morning that people tend to use off efficacy a little bit too broadly, and I think that's probably very true. But I would say those are probably the three main constructs. There are others, there are pain, beliefs, attitudes, etc. and also which I haven't really talked a lot about before, but distress as well. But that can often be a reaction to having a long term pain condition or a pain condition. It also can be a trigger for it as well.

But those cognitive constructs, I think all those cognitive influences, I guess I've been seen in the past at least to be barriers to recovery. So they stop people recovering. And I think that there are interventions then which target those and try to help people to recover better. I'm not sure that's always successful, but that's the intention and that's why I think we're talking about psychologically informed physiotherapy.

Tim 

And probably also relevant to really specify that each of those things aren't just risk factors for disability, but also increased pain experience, very direct correlations, connections between catastrophic thinking and intensity levels.

James 

So I think you're obviously right, there is a direct correlation between whether or not that's causal is a whole other question. I think that the type of people who catastrophize the type of people who are fear avoidant are also the people who have worse pain and worse disability. Whether or not those things cause worse pain, disability is a whole other question.

We know the type of people who do badly. We we can identify those people, but we don't know what really what causes those. So I think there's a whole different set of techniques and, and research methods that we need to investigate that. So I know it seemed a little bit fuzzy whenever I said this is what I think psychologically informed physiotherapy is, is just be nice to your client.

But I did that deliberately, I think because that is really what I see. I'm not sure that some of these other constructs are as important to change as we think they are. I think that the literature is a little bit incomplete when it comes to that.

Tim 

And there's also literature around those soft skills that the very nature of the consultation, the nature of the connection between the clinician and the patient makes a difference to outcomes. Yeah. So Anne in the in the clinic, how do you assess for some of these things?

Anne 

Well, I let the person that's come to see me, which is usually someone who has quite complex pain, I let them tell me their story and that can take a bit of time actually. But I learned so much from that story. I stopped them and asked questions and check in whether I've got the right understanding of what it is that they're telling me.

That's sort of our starting point and I always check in with them. If by the time we start to get to our physical examination, have I asked them everything that's really important to them to tell me on that day? I also ask them, of course, for their permission before I would do anything involving a physical examination, touching them, you know, anything along those lines.

I also use a case formulation model very much related to the work Michael Nicholas has done, but really bring into that that person brought with them along with their experience of pain, what came before the pain. And I guess with my experiences in compensable health care, a lot of what happened around the time of that person's injury and those ideas around it being such an unjust situation that the person may have done absolutely nothing but is in this situation because of fault of somebody else.

Or, you know, those those types of aspects, so really important to understand what they bring with them, which could be strengths as well, very much related to their strengths.

Tim 

As you were describing that, I think I felt a little bit like James's mother and I could be Anne’s patient.

James 

I was thinking that, I could send my mum to see Anne.

Tim 

I mean, what you've just so wonderfully described succinctly, is the patient at the centre.

Anne 

Absolutely.

Tim 

Patient stories is is at the centre.

Anne 

Absolutely. And you know, I've been doing this work for a long time now. I've never seen two people with the same story every single person is different and we have to acknowledge that and address that in the way that we're working alongside that person.

Tim 

Lester a lot of your research work. A lot of what you write on your involvement with various professional organisations has been around a lot of those aspects where what the patient brings as being unique to them can present significant challenges. We're talking here about trauma and trauma in all of its forms. Could you just share with us what is trauma in this clinical context that we often read about in trauma informed care?

Lester 

Yeah, I think that's a great question, Tim, and I think it's important to recognise we're not talking about tissue trauma here. We're really talking about response of a person's nervous system to overwhelming stress that persists and the events could be something catastrophic, like a natural disaster or a car accident could be related to experiences of abuse or acts of war and violent conflict.

Lester 

So I think that the events are quite variable. But again, it's not the magnitude of the event that's important. It's actually how responsive the person system is to that that experience. And so I think that, again, when we're thinking about trauma in terms of this context where we're talking about pain, I think it's relating to how a person's system might be more reactive to triggers that might be associated with sensory or cognitive or emotional aspects of pain.

James 

Can I ask Lester a question, if you don't mind? What do you do about that? Those don't seem to be something you can do anything about traumas.

Lester 
Yeah, no, I think that increasingly we're finding that the best way to manage trauma is to offer safe contexts for recovery. And I guess that that's important, that way of reducing the threat. But I think it's also important that we're starting to add additional safety into the person's nervous system. So Stephen Porges, who's polyvagal theory creator, he has lots of goodwill, hints around this and he talks about trying to give as many safety cues to the person's nervous. System as possible.

So it's not just about reducing threat, it's actually about creating safe contexts, and that includes relational contexts with the therapist. So therefore, you know, again, we send people to Anne.

Anne 

Thank you, Lester.

Tim 

James, I can see your research brain going there as you as you hear that you've been involved in research around psychological factors in pain for a long time now in terms of treatment paradigms, you've been involved in exploring modification of lots of different variables, cognitive variables, particularly in education, without being too broad. What do we see? What does that research into, into changing the psychological variables tell us?

James 

Yeah, I guess one of the main paradigms that's driven research and clinical practice in the last ten years I guess is the start back approach. That's that stratification, risk stratification and treatment. The original trial was published by Jonathan Hill in the early two thousand and tens. I think it was the late two thousand and whatevers, and that made a big splash and it's driven the research agenda since then.

But if you look at the actual results of the trial, they found a very, very small effect on disability, nothing on pain, and that is that people were stratified. So I just remind you about that. People were stratified into high risk, medium or low risk. And the high risk patients were treated by a psychologist. Since then, the study the RCT has been replicated, tried to be replicated in several settings around the world.

The most recent was a big study called Target in the States that randomise about two and a half thousand people with acute low back pain who were assessed as high risk off a poor outcome. And those patients were referred to physiotherapists who'd been trained by psychologists to deliver psychologically informed physiotherapy and the people who were referred to get that receive that type of treatment versus usual care standard physiotherapy weren't any better.

There was the same amount of transition to chronic low back pain. There was some problems with the trial in that not everybody who was supposed to receive psychologically informed physiotherapy didn't actually get it. They didn't actually turn up. And sometimes so there are some problems with some problems the trial. But I did a whole series of sensitive analysis and I think it's pretty good evidence to me that actually trying to address psychological barriers to recovery is really tricky.

And I don't think that we've got that nut cracked yet. From a research perspective that's not taking out from anything someone's doing in clinical practice. But from a research perspective, I don't think we've got that cracked yet, some of the stuff that we're doing has taken a I would regard it. I'd argue that it's a bit of a step further by combining that.

Was it principles from neuroscience, physiotherapy and psychology melding that together. And I think we've come up with something which I think looks like it's very promising. But yeah, I think it's, as I said, I'd psychologically inform physiotherapy something that from the research perspective I don't think has been cracked just yet.

Tim 

And in the compensable space, there's been a few studies that have looked at just outcomes of returned to work as a key one. And certainly some of those have specifically identified psychological risk factors. Yeah, and barriers and psychosocial too what do we see in that space?

Anne 

I mean, it's a complex area and so we know from the wise study that people did particularly well when they were accepting of a psychological involvement early on after their injury. To me, one of the issues was that about 50% of the participants refused to go further because they didn't think that seeing a psychologist in the first weeks after their injury was valid.

The thing that concern me more about that was that was in a health care setting and I would have thought acceptability would have been highest there. So my interest is that physiotherapists are very well placed in that early post-accident setting to deliver what an injured person would consider to be a valid treatment. When we add in that psychologically informed component to it, then to me, provided that's high quality we’re sort of melding the best of both worlds, we've been doing that.

At WorkSafe in Victoria using APA titled Pain Physios to work with injured workers who've been identified early in their claim as having a high risk of a poor return to work outcome. And we've had that's been running for a while and we've recently had that evaluated by Esquire at Monash University and the outcomes are outstanding. It's not a randomised controlled trial observational, but it's with real life injured workers and a workforce that we have access to.

And what we've found is that the outcomes that are changing basically every outcome we measured changed substantially pain, intensity, pain, interference in sleep and pain interference in general activity. The PSECQ and we use the PHQ four as a screener for depression and anxiety and that changed significantly as well. And when we also looked at a global rating of change statement from the injured workers within 6 hours of this intervention, they were saying that they were between better and much better.

It's really incredible outcomes from a six hour intervention that was pretty targeted and worked alongside their usual community based physiotherapy.

James 

Do you mind again if I ask a question? Is that okay? Sorry, because I'm dying to get your knowledge on this one. So the strongest predictor that we've ever found of a poor outcome for someone with acute low back pain is whether or not the injuries compensable, whether they it's a compensable injury, stronger than pain intensity, stronger than disability, stronger than any psychological variable. Why is that?

Anne 

There's a couple of things that I would say here, and that is I'd like us to go back and have another look at some of that research, because there's a lot of research where having a compensable injury is actually an exclusion criteria, which I have to say drives me insane. It really does. And so when we look at work, which is specifically with people with compensable injuries, we're not saying that big a difference to people who don't have a compensable injury.

So another piece of research we've done with Epoc, the electronic persistent pain outcomes collaboration, we've looked at outcomes from pain management interventions for compensable and non compensable patients and the differences in outcomes are nowhere near as big as anybody would be thinking that they are so interesting. It's fabulous. And in the research that we've done with Epoc, we've really examined every bias that we might have related to Oh, if you're taking this much opioid, you won't have a good outcome.

Sorry, that didn't actually work out exactly as we thought it would. You know, if you score this high in in depression, then you're not going to have a good outcome. It's an interesting piece of research because it's so rich with with real person stories. But the important thing is that when we compared the outcomes to those who don't have a compensable injury, there's some difference.

You have about one in ten more people fitting into not a spectacular outcome compared to your non compensable population. I do think the whole thing around perceptions of injustice and the fact that the compensable systems can be very difficult to navigate as an injured person and perhaps a person with low health literacy. We hear good stories about it all the time, which other people don't, where people have had a great experience of their compensation claim.

But of course there's a lot of times where it doesn't work out very well. So the system itself can be, I think, you know, we've heard traumatising, definitely bruising for quite a few people who come into it, but not all.

James 

Thank you. Lester. You've done a lot of, again, your work in socially disadvantaged populations and you could argue that as a social construct, compensable is really challenging for people. It increases their stress levels. They're confused, How do we go about dealing with some of these things in a clinical setting?

Lester 

You know, this is where I think one of the things we need to really embrace a bit more as physiotherapist is this social contributors the social aspects of the biopsychosocial model. I think that we haven't done that very well. I think the three things which you know and again and sort of raised one of them the sense of justice or a sense of injustice or the sense of not belonging or the sense of not having autonomy.

Are three things that are really nicely written about as being influential. And I think that, again, once we start looking for those things in an individual, I think that they're really easy to identify where things can be going wrong, but actually remedying them can be much more difficult. And I think that part of that is that, again, I think the important thing with the biopsychosocial conceptualisation is we're talking about a very interactive, integrated process of of these domains.

And so it's very hard to sort of just pick one out, okay, we're going to deal with catastrophizing or we're going to deal with this person's injustice and expect things to fall into place. I think that's often realistic. I mean, I have a mantra that all pain is complex, but sometimes that presents simply. And I think that, again, one of the things is once you at once, you sort of are thinking about the biopsychosocial model as this interactive process.

It does make it challenging. And sometimes the the answers are with the client themselves. I think that so a lot of the complexity are often they're the best people to sort of try and work through their story, but often they that needs to be flagged to them that that part of the story is important. I think that's probably the key.

Tim 

The future of research. You mentioned the social aspects of pain has not been researched as much is quite clear that over the last hundred years the biomedical aspects have been explored significantly and in the last 20 to 30 years, perhaps 40 years, the psychological and the social, which arguably may well have the biggest impact on people's pain and disability, lags behind.

So that's probably what I'd like to see happen as future. And what do you what would you like to see researched more in the future?

Anne 

So I guess, you know, from my background where I really like to see real world examples of things and being able to measure change in that. I'm very interested in outcome measurement and experience measurement. And so to me, if we're talking specifically about psychologically informed practice, I think we need more research where physiotherapists, well-trained physiotherapists are delivering the intervention.

Because I was looking at this recently and you know, we're building up that evidence base, but some of it we're still it's still the evidence of psychologists actually doing the research or doing the intervention. So we need to make sure we're building up our base with with physios who are doing the intervention, the researching that.

Tim 

Such as stress modex from Michele Sterling.

Anne 

Yeah, absolutely. Yes. It's a perfect example. And there's others. Kim Bernell work out of Melbourne has also addressed a lot of these things as well. I hope that we can publish our work using the title Pain Physios. But another thing that's really important to me is that I love that we have specialist pain physios now. I love that we have titled Pain Physios.

I think we're an amazing tribe within the physiotherapy profession. But when I look at the clients of WorkSafe and the TAC, they're saying the ground routes, community based physios and so trying to get uplift within that group who are often inexperienced, rushed, you know, seeing really complex situations all the time. That's one of the areas where I'd like to say if we can help with sort of transferring those skills to that group.

And that's a project I'm involved with with the TAC at the moment where we used a co-design process with about 80 TAC clients telling us what they didn't like about there management within TAC and what they want they felt they wanted more from. And then we also used a group of pain experts, physios, psychologists, GP's and pain medicine specialists, and we've designed a digital platform that helps the physios to collect outcome measures and to score them and interpret it for them.

But not only to do that, to then go, Oh look, this person scored high on this component of the outcome measure their only in the first few weeks after their injury. Here's a bit of information, advice and resources as to what you can do with them. Oh, they've scored really high on anxiety. You might not feel comfortable with that, but here's some some sort of lead in conversations that a psychologist has written for you to try.

And then as time goes on at six and 12 weeks, that the information, the resources change to actually match the fact that nothing stays still, things can improve, but some things can deteriorate as well.

Tim 

Interestingly, the recent low back pain standards gave some suggested starters and yet might be arguable whether they're appropriate. But one of the very few ones to actually make some suggestions about what to do about these things.

Anne 

Yeah, and look that's what you know, I've been involved in the Whiplash guidelines recently as well. And to me there's nothing more depressing than reading a guideline that just says, No, no, not enough evidence. We need those clinical. How do we actually put this into our clinical practices? So that's what we've worked really hard on in this pilot. So that's live at the moment.

We're collecting the data. We're asking the physios, What did you think about the resources and guidance that we gave you? But we're also asking the patients, what did you think about the outcome measures? Did you think that was okay? A physio was asking you that? Was that too much of a burden for you to complete? And hopefully at the end of it we'll narrow that down, work out what outcome measure was actually the most appropriate for them and take this wider.

Tim 

James your your future, like your you're leading a research group and have done for many years. What would you like to see researched? Or maybe you could share with us some of your plans potentially?

James 

Yeah. I'm going to take that opportunity to do exactly that. Thank you, Tim. Ben Wand a very close collaborator of mine. He's a physiotherapist. We did our years together in the UK and he's super clever and he developed this intervention called graded Sensory motor retraining. He hates the name, so if anyone has got a can come up with a better name.

Great. I don't have such a hate hatred for it. So I'm calling it that. He developed this intervention a few years ago when we went to the NHMRC and got some money from them to test the intervention in a trial. And the intervention really is pretty straightforward. It's over 12 weeks and essentially we talk to them and essentially persuade them that pain is much more complex than what's just going on on their back, that the information that's coming from their back into their brain is processed in a different way so that it's not accurate.

And we can show them that by doing tactile tests on the back, we can show them that they're not very good at locating touch on their back, for example, or any sensations on their back. And we can train that and then things get better over time. We get them to think about rehearsing movements they might find provocative, etc., etc. as a graded intervention.

Yeah, it is. Got elements of great exposure in it as well. So we tested out and found that it was effective, was published in JAMA last year. At the same time, another trial was published in JAMA Psychiatry, pain reprocessing therapy developed by an American team, and they really concentrated more on from a psychological perspective, persuading people again or explaining to people that the brain was much more important than they had in their experience of pain that they may have thought in the past.

So they again tested that and again, they found very nice effects. Everybody knows about cognitive functional therapy and the trial that was just published, Mark Hancock's trial, that was just published. Again, they found good effects. Now, there's always problems with all of these trials are not none of them are perfect, but they're suggesting that we're on the cusp of a completely new way of thinking about managing low back pain and a successful way.

The interesting thing about each one of these trials from completely separate groups, each one of them found effects that the short term that was sustained over one year and in fact in pain reprocessing therapy and greater sensory motor retraining, about half the people had no disability at 12 months, none. So I think this is an exceptionally exciting time.

Graded sensory motor retraining, the therapy that I'm most closely associated with. It's not mine. I just did the test of it. It's not mine. That's what I'm most closely associated with. We've got we want to know what to do next, right? Because what I don't want to do this was done in a Gatton era and it was done by a group of physios and exercise physiologist.

They were the clinicians, six clinicians. So what we don't want to do is immediately just roll out and start training people because this has happened all over physio for many years. So the next step for us is to develop with with the Noy Group from South Australia, some training packages and then test whether or not we can implement that successfully and the clinicians are happy to take it on and patients have similar effects that we originally found.

So that's what I want to do, that's what I am doing. And then taking that approach, applying it to neck pain, applying it to which we got funding for all this phantom limb pain to complex regional pain syndrome. Yeah, So there's a whole series of studies that we're doing at the moment. And if I could just take one second to say if anyone's interested doing a PhD on any of these projects, please get in contact with me. Thanks, Dave.

Tim 

And finally, Lester, what would you like to see?

Lester 

Well, let me finish with a bit of a global idea, and I think that there's been a lot of research and a lot of research money spent on trying to identify what's the transition from an acute pain to chronic pain story. And I think that we need to sort of stop looking for that and start to engage with what was happening with the person even before their pain started. And I'd really like to see much more research on that front.

Tim 

I'd like to see some research on that clinical encounter of how we communicate with patients, real research based around what is putting the patient at the centre.

Anne 

Yes.

Tim 

Well, thank you very much. That time went way too quickly.

Anne 

It did.

Tim 

But we must finish. So thank you again to Lester too, Anne to James. We hope you've enjoyed this podcast on Psychologically Informed Practice. Thanks very much.

Anne, Lester, James

Thank you. Thank you. Thanks Tim.