Soph
It is our absolute pleasure to welcome Jane Bradshaw with us this evening. Now, Jane is a senior physiotherapist with over 40 years of experience across gerontology, chronic pain and rehabilitation. She works at the Be Pain Smart Clinic at Royal North Shore Hospital and she supports patients with chronic pain, spinal cord injury and traumatic brain injury. She holds a master’s in health care service management and researches kindness, listening and connection in complex care. Her work also explores meaningful activities in pain therapy, human flourishing, using Seligman’s PERMA model, and identity changes following disability. Jane lives in the Blue Mountains and enjoys kayaking, hiking, and spending time with loved ones when she has her free time. Thank you so much for joining us, Jane. It's lovely to have you.

Jane
Thank you for inviting me.

Matt
Yeah, it's great to have you on, Jane. Well, 40 years, you've probably a lot of stories to tell.

Jane
You want to hear a story? My claim to fame.

Matt
Oh, sure. Let’s hear a story.

Jane
So I was working in North Queensland when I was, like, 23, and they were filming that thriller with Nicole Kidman and Sam Neill. Dead Calm. Have you watched it?

Matt
I will now.

Jane
It must have been rather stressful for Sam Neill, because he needed some therapy. And I was working in private practice. So actually, I didn't know who was. It was rather funny, really, but yeah. So that's my that's my claim to fame, I think. Plus, I used to work in London and it was the practice that used to service the people who lived in Buckingham Palace. So, you know, if the King or Queen were really crook they used to come and see us. I didn't treat any of the royal family, but I did treat some interesting people when I was there.

Soph
So amazing. And yeah, I can only imagine what an interesting experience that would have been. But I guess, Jane, for those who are listening, given that you've had, you know, so many years working across physiotherapy and obviously a lot of really rich experience. Do you mind sharing a little bit about what got you into physio in the first place? You know, what was it that actually drew you to the profession to start with?

Jane
Well, actually, I think it was probably a bit of lucky circumstance because I was in high school, mum sent me for careers advice and physio came out at the top. So that was it, really. And in those days, it was a diploma. So it was three years and it was mostly lots of clinical work, right from the get-go. And it was quite old fashioned, my training and very, quite strict. We were called by our surnames. So, you know, Miss Heritage, that was my maiden name. And, but anyway, they churned us out as lovely physios and after that, I came straight to Australia because I wanted to travel. That was kind of a bit frowned upon by my principal of the school. But I've definitely had an amazing, brilliant career and continue to do so in Australia.

Matt
Right. And you've stayed.

Jane
I think it was because my mother was Australian, I have an Australian passport. So I think it's in my blood. So yeah, definitely stayed. And I've had fantastic experiences working in different types of areas of physiotherapy, including chronic pain the last 15 years or so. It was a really great time to start working in chronic pain because APA was embracing pain management. I went to a lecture by Lorimer Moseley in Sydney, and I was puzzled about the complexity of chronic pain, and he seemed to have some of the answers. And he was talking about this virtual physiotherapy thing where people imagined movements, and I thought it was amazing.

Soph
Amazing. And do you mind me asking a little bit more about, I guess, what does your day to day look like now? Because it sounds quite different to maybe what you would, or an even probably what a lot of physios out there listening, probably do on a day to day. So what would a typical day at work look like for you? What sort of presentations or conditions are you seeing? What, you know, what comes across your desk?

So fortunately, we had some extra funding in the New South Wales government. Allegedly the minister used to chat to her neighbour who had chronic pain over the fence and maybe that influenced the funding of New South Wales Health. So, there was lots of allied health jobs going. I'd done a little bit of work at Nepean chronic pain service. So my first job was at Nepean Hospital and then also at Westmead Hospital and followed by some private practice work in Penrith.

My most recent role has been Be Pain Smart, which initially was at Royal Rehab, which is in Sydney, and it was a pilot project for treating people with spinal injury and/or traumatic brain injury because there was a real gap in services within public health. So, I work very closely alongside a clinical psychologist, Doctor Regina Schulz. Currently we work in a multidisciplinary team. And the novel way of working is that we have the patient in the same room as the three professions, the pain specialist, the psychologist and the physio. So the patient doesn't have to repeat their story three times. And I think this is extremely helpful for someone who has a TBI in particular and has cognitive and memory issues. And often people feel very overwhelmed when they come to hospital. So I think it's a great model.

Soph
Absolutely. And I mean, you've sort of, highlighted your journey quite well there, Jane, in terms of how you've, you know, moved across different areas and worked for quite a while now in the chronic pain space. And I'm interested, you know, particularly with your role now, in the neuro space and with TBI. How has that been for you in terms of, I guess, how those maybe more traditional pain management skills then translate into that neuro setting? Has there been anything that's been maybe a bit more of a challenge or different or ways in which you have to adapt things?

Jane
Sure. Well, particularly with people with traumatic brain injury and/or spinal cord injury, and sometimes they have both. I think one has to be very optimistic and hopeful as a therapist, as a physiotherapist, and the person with profound disability and chronic pain, often has been to many other services to try and get help. Maybe they're looking for a cure and often they have lost hope. So when they come to our service, I think it's really important to give them a sense of empowerment and paint a brighter future that they can live a quality of life despite having chronic pain and also we don't promise cures, but definitely in my experience, people can improve the, reduce the severity of their pain.

I also think it's, really important for, in my practice, to develop a therapeutic, good therapeutic alliance. People with traumatic brain injury, in particular, they often have high levels of anxiety and often feel overwhelmed in social situations and perhaps even going out of the house. So a really calm manner is really important. Something else is really important is being aware of cognitive memory issues. So we often do a lot of repetition in our work with this patient cohort. We perhaps spend a couple of sessions going over the same issue, whether it’s activity pacing or sleep hygiene or managing your emotions. So I think as a therapist, one needs to have a lot of patience, which I hope I have in my practice.

Yeah, and I think, kind of an appreciation of the loss of identity is really important, which I've been studying, the concept of human flourishing, which is a really interesting part of positive psychology. It's been studied over 30, 40 years by Martin Seligman, who has written books about flourishing in in the normal population and people with disabilities and in our research, we've looked at how human flourishing is important after traumatic brain injury. So loss of identity after disability is really important. And perhaps it's not something that's addressed in our pain assessments. It's really important to ask people about perhaps the grief and loss they experienced since they had the injury. How they’re going with the adjustment process, what is meaning and purpose for the person and their family?

There's a lovely term called ikigai, which is from Japanese, and it means reason to get out of bed in the morning. So I bring that to my work and also I ask them more about positive emotions. So, human flourishing as a framework stands for positive emotion, P, engagement, which is all about an experience of living, living in the flow and doing activities that you lose sense of time. So for some people, it might be working in the garden doing artwork. And that's a really important experience for people to experience, to flourish.

And then the R is all about relationships. So with family and friends, and from our research, I think that the relationships that we have in our community, our family, society, helps the person with an injury to maintain a sense of self throughout the journey of recovery. And then I've mentioned meaning and that stands for M that's the acronym is PERMA. People have different reasons for going throughout their day, whether it's their values, their family, whether it's spiritual reasons or religious reasons. And I think that's really important in our complex patient population to have that type of conversation.

So the A is about achievement. So that's all about setting goals, which is really important in pain management. And achieving tasks or having that sense of achievement even. And as we know as physios, we always have to set realistic goals. Smart goals.

Soph
Thank you for sharing that, Jane, because I've not actually come across the PERMA model before, but I think hearing you articulate the different components, I think it really speaks to a lot of what is sort of embedded within our pain management approaches, but maybe just not in that distinct frame. And I think there's so much value in exploring these things with people. How do you see physio, in particular, as being positioned to, I guess, explore some of these things or consider these things with people that we're working with?

Jane
From my experience, I believe that physios are really great at forming therapeutic alliances. We have the honour of touching people, you know, like, that is, a very special, like, relationship that we have, you know, just even if we, obviously we're not doing eight hours of massage a day anymore. I think in the old days, but just, you know, that touching the person and working with them very closely creates a therapeutic relationship and providing emotional support to the person and providing empathy for the journey that they've been on through having a disability and acknowledging that chronic pain is real and that their struggles are real. So I think, physio is uniquely placed to have those conversations with patients. And often we find that, in our practice, that people open up to us. It’s definitely a unique position.

Matt
I really like the PERMA model. It sounds like it's focusing on someone's quality of life and what gives them meaning. I mean, M is part of that meaning. How do you guide someone to it or I guess in an assessment, are you asking specific questions? Are you going to pick those up?

Jane
Yeah, I think I can pick them up because often we want to know what gives someone joy. I think that's really important. You know, often we say what's your day like, what kind of activities do you go through each day? I want to know how the pain affects the activities of daily living. And then often I ask people, you know, how do you feel when you're doing that activity? Are there any activities that bring you joy during your week? And I think that focus on positive emotions is really important. And there's lots of evidence that people who are more optimistic and joyful have a better quality of life. And our biomedical model is quite focused on how depressed or how anxious someone is or how much pain they're in. So I think having a knowledge of, you know, positive psychology is really important just for the balance when we're working with people.

Soph
Absolutely. I think you've you've touched on that really nicely. And it's interesting, a few of our interviews that Matt and I have done with other guests, the idea of, psychologically informed practice is sort of come up a few times. And, you know, we've sort of discussed it as being this sort of emerging space that we're sort of shifting towards as a profession. And it sounds like particularly in your work and in your research, it sounds very much like that is, sort of, something that becomes quite important when we're thinking about physios’ roles with people. How has it been for you? Because, you know, I imagine over the years of practice that you would have seen almost, you know, from start to now how that has evolved over time. What's been your experience, your observations of how that side of physio practice has emerged over time?

Jane
Well, I'm very relieved because I was the type of physio that I didn't see much point in doing a 10-metre walk test and counting the steps and you know, the time and everything. Like, it didn't seem to have much meaning for the patient or for myself, and I was more interested in the experience that they went through. So I always thought there was something missing with chronic pain management because the traditional approaches of just massage and manual therapy and exercise didn't really work at all. There was great need to address mental health for our clients and I was very happy to be, over the last 15 years or so, to be working with psychologists and develop my practice of psychologically informed care.

Most patients, as people, need to be validated and listened to and treated as a person, and not just as a sore knee or a sore shoulder. I mean, it's pretty obvious, but I think it's definitely worth stating. And it's a very optimistic way, I think, of working with our patients.

Soph
It's really interesting as well that your research and your frameworks that you use are sort of oriented around the idea of flourishing, because I think particularly in terms of the ways we think about mental health, that has really interesting implications. You know, flourishing can happen with or without mental illness. And it's not necessarily about labelling people as being anxious or depressed. It's actually just how you as a human being, experiencing life right now and appreciating there's a whole range of different experiences that people might have of distress and wellbeing. And I think that that's a really lovely way of thinking about it. I think it really opens up that understanding to people's experiences beyond just you know, labels or trying to pigeonhole people. So it's fantastic to hear you talk about that.

Jane
Yeah, and also, someone might have periods of anxiety and depression and suffer from chronic pain, but they also may have periods where they feel happy, and they feel content. They have meaning, meaning in life. They get joy from the little things they do. So it's been very interesting to learn about how the framework is used in other patient populations as a way of helping people live healthier lives with more sense of wellbeing.

Matt
It seems like, I guess your central focus is on the person. And part of that is, the emotional support. And part of that is, the emotional support that you're providing and particularly in that PERMA model, How would you see that as being made essential rather than a nice-to-have? I feel if I was very time poor it’s like, okay, I've got half an hour, you've come in with, you know, an ACL or in your case, like, a stroke. I just need to focus on impairments. How do we kind of shift that thinking to, you know, it's not a nice-to-have, it's, you know, essential to look after the emotional.

Jane
I think in healthcare systems it needs to be embedded in healthcare systems. I think it's too much to expect clinicians to deliver, be all things to all people and deliver emotional support, regardless of the clinical setting. That's why, in the paper that I wrote as part of my master's, we made some recommendations about the culture of our health setting needs to be addressed. Definitely In pain management, we need time. I also did some narrative group supervision training. Which was following on my master's and my research, and that was around the narrative approach in groups with physiotherapists. And that was very well received in terms of helping people have a safe space to talk about the issues that they were facing at work. And the other thing I really liked that came out of my paper was, and with qualitative research, it's so amazing because you find things you don't expect. So in groups, in group therapy, both in the hydrotherapy pool, the participants we interviewed were in the hydrotherapy pool for, not just pain, but, you know, recovering from knee surgery or hip surgery. And also in the pain management groups that they felt a sense of emotional support from others going through the same issues. One lady talked about kindness, observing kindness when the staff were looking after someone who she perceived as being more needy than her and more disabled than her. What I get from that study is that patients do notice how we interact with people. I think that's essential. But most important, and I have worked in a variety of different cultures in my career, I think workplace culture is really important, and it's something that when you have it in a good workplace culture, you know it. And when you're not, you know it as well. So it's kind of invisible. And I think it's based on the leadership, and also the relationships with other staff members. In an ideal world, we'd all have a, you know, good workplace culture, but sometimes it's hard to find.

Soph
It's tricky, isn't it? And we don't always have complete control. You know, we have a degree of control, obviously, as clinicians over our own practice and what we do on an individual basis. But we're always working within a context, within certain circumstances. And some of those things we may not always have control over. I know we've spoken with other guests who have highlighted things like, the challenges with not having enough time in appointments, for example, to be able to explore some of these things or some of those other pressures. And it, certainly, it does make it quite difficult. One thing that I was keen to ask you about, Jane, because you've obviously you've worked across a lot of different settings and sort of jumped from the pain management space into a more niche pain management within the neurological space, which in itself is interesting. But you've also started to venture from a career point of view more into the research side of things as well. And I think that that's something that we often don't get the chance to hear much about. I think a lot of people listening, you know, might be interested in how that general journey or experience of mixing research with clinical practice has been for you. Do you mind sharing a little bit about how you found that as a physio, kind of, you know, working as a clinician researcher?

Jane
I started my masters 2018, I think, and I hadn't studied for many, many years formally. So that was a big learning stage of my life. But I found it really, really satisfying. I had some great supervisors. I did my masters through the University of Tasmania. I found it very rewarding and I think it's been great being able to do just the last few years in terms of working part time and also doing some research with people with traumatic brain injuries. So I think I've been really lucky being able to combine both. And I think it's very exciting, doing research and discovering something new. So I would encourage everybody to think about research, talk to someone who they know is a researcher, and see if it's for them.

Matt
I wanted to ask a question around using these skills in a setting that's more common because you are in a very unique, position.

Jane
I'm really lucky. I've got an hour for each patient and that time, and I'm not sure how people manage to do pain management, you know, giving advice, motivational interviewing, when they have much less time. I think it might be impossible. You need the time.

Soph
One of the things we're kind of keen to get a bit more on from people is, I guess, how pain management principles might apply across maybe different settings than your typical pain management, you know, musc settings.

Jane
So I can give you a really good example. So I have a case study that someone I worked with, he was C6 complete, spinal cord injury, 15-20 years, middle aged. During Covid, because obviously he was scared of getting Covid, he just stayed at home and was bedbound and he had a lot of pain. And I was seeing him on telehealth. When I started the service, we only really started doing therapy consistently about two years ago. And when I first met this client, I wasn't sure if we could make a difference, but he was someone who loved art. I think he used his mouth for doing artwork He enjoyed socialising. My approach was very, very simple in terms of setting a goal of getting out of bed. And where would you want to go if he got to get out of bed? He’d go to the cafe by the river. We met every two weeks. He started achieving his goals. I'm not sure that he had quite severe neuropathic pain. The pain was the same, but he was improving his quality of life.

Even someone with severe neuropathic pain that we think, oh, you know we're not sure if we can change anything. I think it's an area of practice that is really, really interesting. I think that there's many things that physios can do in terms of looking at wellbeing or flourishing and asking that person, if you have maybe a little bit less pain and improve mood, what would you like to do? What would bring you joy? So that was someone I could, perhaps even 20 years ago, I wouldn't have thought I could have achieved much in terms of helping someone with profound disabilities.

The other thing that's a bit taboo is sexual function with people post-TBI and spinal injury. And I did a understanding sexuality after injury course through Royal Rehab. And I would really encourage people to do a course like that because it helps perhaps us have more confidence about asking about sexual function, because that is really important side of people, of life, for everybody. And, just because people have a disability doesn't mean they can't have an enjoyable sex life.

Soph
I think it's interesting you mentioned that, though, Jane, around the importance of sexual function and relationships and the implications of that. And I know that you were maybe speaking a little bit more specifically to, you know, disabled groups in that particular setting. But I actually think it's something that I know for myself reflecting on that, and probably a lot of people listening, that it's actually something that comes up more often than we might think in physio. I still remember my first year of practice. I was, you know, working at a pretty typical musc, sports, private practice. And, I had the spunkiest 82- or 83-year-old woman that I was seeing after a hip replacement. And I remember she walked in to her first appointment, first time I met her, and we started chatting and I asked her, you know, she was like two weeks post-op, and I was like, you know, how’s your hip going? And she's like, yeah, look, it's going alright. One question for you, though, when can I have sex next? When can I get back to that? And I remember at the time being so taken aback because I was still so fresh, like, no one had told me that this is something to expect, but I think it speaks really nicely to what you were talking about before, and that, as physios, I think we're really privileged in that we get to have quite, you know, trusting and often close relationships with our patients. Not to say that this particular patient that I would close at that point, she was just very forthcoming.

Jane
Yeah, I agree and I think, the more conversations you have about sexual function and I think the less embarrassed one as a physiotherapist is, so, you know, desensitising oneself, is a good way of looking at it.

Matt
Maybe we’re more embarrassed than the clients, to be honest.

Jane
Maybe. After I did the course, I asked everybody, but all my patients, but maybe a bit less now.

Soph
I mean, it's important, I think, and it speaks to that, you know, I of course, like, sex may or may not be, you know, at the top of people's priority list in terms of their values and what gives them meaning. But for a lot of people, it is quite an important thing. And I don't think we necessarily ask enough about it. Myself, I think it's definitely one of those areas that if we're thinking about the PERMA model, for example, and the sorts of things we could be considering amidst that, I think it's definitely something to think about. You know, I think there's so much we could ask you about Jane and, you know, short of holding you hostage all night, as we keep chatting, you know, I'm conscious of our time here, but thinking about pain management and I guess the value of people potentially learning more about pain, thinking about the people who might be listening, they might be working across different settings. Maybe they're in private practice, maybe they're in women's health, maybe they're in the hospital setting. You know, we could have people from all over.

Jane
Yeah.

Soph
Do you have any advice or insights for people who might maybe be interested in learning a little bit more about pain management as to, I guess, how it might help them or, yeah, I guess anything that you would suggest to them as a point on their journey?

Jane
There are a lot of resources. My journey has been, you know, picking up pain courses, doing through the Noi group, working with Lorimer Moseley and David Butler. They were amazing, very enthusiastic. I teach people mindfulness and meditation, and I think that's something that, as physios, we are very well placed to teach and there's many courses you could do. For education, if you go to the ACI website, there is a clinician training for patients with traumatic brain injury and chronic pain and it's free. So I'll just do a quick plug for that.

Matt
I mean this highlights your wealth of knowledge and your wisdom. And it shows that you really care about the population you work with and, that you really see people as, not just their impairments, but they're actually people who are suffering and they should have quality of life. And I've really taken a lot of things away from tonight. And I want to thank you for sharing all your wisdom. I mean, we can talk for hours I’m sure.

Jane
Thank you.

Matt
But I also want to thank the listeners, because this is why we do the podcast. So, for the listeners, so they can really know more about pain and, really how to help people suffering from chronic pain as well. So feel free to check out additional episodes, by following Physios on the Mic on your preferred podcast platform. Thanks for tuning in and we'll catch you next time on Pain in Practice.