Soph
Today on the podcast we have Andrew Gorrie joining us. Andrew is a physiotherapist who's dedicated his career to supporting young people living with chronic and complex pain. After graduating from the University of Sydney in 2012, he joined the Sydney Children's Hospital network, where he's worked ever since. Since 2016, Andrew has been the pain physiotherapist in the interdisciplinary, Chronic and Complex Pain team at Sydney Children's, with a few secondments along the way. His work extends beyond clinical care. He's contributed to research projects exploring issues like attrition from pediatric pain services, caregiver burden and somatosensory testing in children with chronic pain. And more recently, he completed a Master of Health Management and Leadership at UNSW in 2023, further strengthening his expertise in leading and shaping healthcare for young people. Thank you so much for joining us, Andrew.

Andrew
No worries. I'm very happy to be here.

Matt
Yeah, I'm very excited. Very excited. What a rap sheet, if that's what you call it. But I want to know, how you got into physio in the first place, and paediatrics especially. Physio in the first place. I was an undergrad at USyd. And I did encounter some physios as a teenager with a few injuries. So I, like everyone, just knew about sports physios and thought that's what I was signing myself up for. Went to uni, didn't understand why I was learning half the subjects we did. Years into it I still thought we just were sports physios and luckily got a student placement in paediatrics, which I loved. And then even more luckily got my new grad allocation, which at the time was very luck based, like a bit of a lottery. And I got the Children's Hospital at Westmead as my new grad year.

So that's how I found myself into physio and paeds, and then really, you know, luck got me there and then managed to get a few more contracts. And then by 2016, the next job that came up was pain, and I found my way there, too. So just by chance, really, and really enjoyed the path to get there, but also have loved working in the caseload and I mean, I've been there a while, so I, I must have loved it because I didn't fail.

Andrew
Yeah, you’d hope so.

Soph
You're still there. And it's interesting hearing you say that, because I think it's been a theme across a couple of the interviews that we've done already, where we've really heard about this, I guess, people realising the diversity of what physio is. I think a lot of people have that experience of, you know, going into physio, and thinking, oh yeah, like I'm going to work with a sports team. And of course some do that, but that, that real, like, I guess, diversity and range of opportunity that exists once you get into it, I think is something that has come out in a few of these conversations.

We know that you went, you know, into paeds pretty well straight away, and that has always been an area of passion. But, I also know that you've sort of had a range of experiences within that sort of niche paeds setting as well. Do you mind maybe sharing a little bit more about some of those more, I guess, specialty areas almost within what you've been doing?

Andrew
So I've been at, predominantly at Sydney Children's Hospital in Randwick. So across the Children's Hospital at Westmead as well. That makes up the Sydney Children's Hospital network. So very limited secondments from there, like, as a new grad for example, into adults. So that's my only adults experience is the first-year secondments. In the specialist hospitals, you go through the sort of rotations, the sort of core rotations, respiratory, orthopaedics, rehabilitation. Within those caseloads, you deal with some pretty complex cases, both children with complex disabilities presenting into those other specialty areas.

But also, I suppose, other caseloads as well, you know, sort of, with increasing psychosocial complexity, I would say, which is sort of, for example, inpatients that might be presenting with chronic pain or functional neurological disorders. And that was probably my introduction into that sort of a caseload. As I moved into more senior roles, which if I can remember back, I think was 2016, a lot of the specialty roles are part time. So you sort of jigsaw puzzle together full-time work. I think that's pretty common through lots of hospitals.

So all in paediatrics that I was doing chronic pain, palliative care was attached, sort of came with that role at the time, orthopaedics, including some sort of niche areas of orthopaedics, like structural talipes, for example, and spinal bifida. At the same time, I do a really rare caseload called epidermolysis bullosa that most people have never heard of.

That was the main caseloads I did, I guess, in a more senior role for quite a number of years. And then some of those caseload, had more allocated staffing. So they sort of got broken up across, well, to more people so that there's sort of less people in each caseload. I generally feel like I've probably seen the vast majority of things of paediatric presentations in specialist children's hospitals, so, in the pain world, we see all of them. I get asked things like, what's the respiratory management for this? And, you know, I have this neurological condition or this genetic condition. I'm having this intervention, I'm having Botox, I'm having AFOs. I'm having all sorts of different things.

Musculoskeletal was probably the big, nice obvious one, which I did quite a bit over in orthopaedics. I'm pretty lucky. I've enjoyed all the caseloads, but they also certainly build on each other and help what I continue to do. And help me in the pain caseload. So yeah, I can go on and on about all the different caseloads. I don't know if you want any more detail about any of them in particular.

Matt
Well, you kind of stole my next question, but it sounds like you're a man of many hats. Do you ever consider them distinct hats or, you know, you kind of morph it into one? You can't divorce one kind of knowledge and expertise in a clinical area from another one.

Andrew
The general skills, like communication, which, you learn from all your caseloads, and you learn from all the people you work with in those caseloads, I’d probably say. For example, you got your general caseloads, like orthopaedics, where I think everything else I do, I can use some of my orthopaedic knowledge. And then children from other caseloads will present in orthopaedics, and then I'm bringing that knowledge back. So it does go both ways.

Communication is different in different caseloads. People have different, it's probably fair to say, strengths of communication. In different caseloads, the way they communicate to patients and families just to other team members, and I try and bring the best from everything, or at least bring what works for the person in front of me. Perhaps that's a better way of thinking about it. Because I think people in different settings respond to different things. So I do feel like I'm better in each case that I do, I think, because of my experience in the other caseloads.

Soph
It sounds like there's certainly a lot that you're able to then, I guess, draw from and explore. And I mean, we've spoken a bit about the range and breadth of different sort of exposure in areas you've worked in. Reflecting on your current role, and I guess what a typical day to day looks like for you now, what are the sorts of, I guess, presentations and conditions that you see predominantly at the moment?

Andrew
So I work in the pain team Monday to Wednesday, and we're a predominantly outpatient service. So the inpatient service, the acute pain service, is a bit more medical and nursing where they have a little bit of allied health involvement. But my role in the pain team is predominantly outpatient. We’re a specialist service. So a lot of the children who come to see us will have been through other specialty areas. I probably, a few times as we talk, mentioned ‘like’ the adult pain world, or ‘as opposed to’ the adult pain world, although you guys can jump in because I'm guessing what happens in those areas. But, like the adult pain world, they've been through some other specialists.

Matt
Yes.

Andrew
Before they get to see us. We see a range of things. We see children with very complex medical backgrounds. We see children who have very limited complexity in their medical backgrounds. And, you know, this pain episode is their first major interaction with the hospital. So that's, you know, a big range there with how they can present in that regard. We see people who have had a traumatic event occur, like, for example, a physical trauma that's resulted in a structural injury, or a need for surgery. And then the pain has persisted. And we are seeing them down the track. We see people who have impairment from pain beyond what you might expect or at least severe impact on their lives that, above what you might expect from a specific structural cause, I'd say that's part of our bread and butter, and the other part of our bread and butter is people with no identified structural cause, and yet they have chronic pain.

And that's when our team becomes the specialist service for them. I suppose the other big one is we do see a lot of CRPS as well. A lot of the other children I've just mentioned, they’ve probably had pain for at least three months, despite that sort of classic definition of chronic pain. But we also see people with CRPS and we really like to see them as early as possible. We find we prevent a lot of the secondary issues and, you know, exacerbation of symptoms if we see them early.

So that's another sort of range we see, too. We see the CRPS children quite early. And then we see the chronic pain, the children with chronic pain, we see them, you know, months if not years into their concern. Well, it changes the way they're going to interact with us and it also changes the way we're going to approach their presentation, too.

Soph
Absolutely.

Matt
You use the word ‘we’ and ‘team’ quite a lot. Could you describe or give us a bit of a picture of kind of how you guys would operate as a team? Because I know some, I guess, teams would operate and, physio, go see that person, then the doctor and then psychologists or whatever. Some teams do them all together at the same time. What does it kind of look like for you?

Andrew
Yeah, ‘we’. I'm probably hoping to present, I guess, a picture of what occurs internationally, if not at least nationally, with complex pain teams in specialist services. It is a team approach. The best evidence is for a team approach. So it's nice, you know, we like to think, and I certainly like to think, that I'm part of an evidence-based approach to paediatric chronic pain. We call ourselves interdisciplinary. And you can spend a while talking about that. I think it's helpful, for the people working in teams, to know the differences between transdisciplinary, multidisciplinary, and interdisciplinary. We consider ourselves interdisciplinary, which, you know, I'll make a mistake in trying to quote the exact definition that we each bring our specialist skills to the team. We perform a full assessment, where we each contribute to the assessment, and then we discuss the presentations but with shared goals. So our team meets, comes up with shared goals, sometimes debates to get to shared goals. But works to the shared goals based on the child and family's goals, too.

But we put that all together, from our own specialties. And that's what we have to work on. That's what the evidence is for. And also from experience, that's what works. If we're working towards the same goals, then, we can provide our discipline specific expertise to the problem. I'm lucky, I'm part of a pretty comprehensive team. There's slight differences in paediatric pain teams that I'm familiar with around the place. We’re medically led like, I think most hospital services. So we have pain specialists, who specialise in paediatrics. We have, specialty nurses. We have, physio, clinical psychology. We have social work, we have occupational therapy, and we have child-life therapy. And I'll get in a lot of trouble if I've forgotten anyone. But I think that's our team.

Matt
We’ll splice them in when you remember.

Andrew
Yeah, yeah, yeah. Just edit it back in later.

Soph
I think, no need to stress about being concerned about the definition. I think you nailed it. The interdisciplinary/transdisciplinary definition stuff for context was a big part of my early PhD work. So it's something I’m familiar with. I’m sitting there very intently listening. But yeah, you nailed it. And for those of you that might be listening that's kind of interested, Andrew describes the interdisciplinary team quite beautifully. You know, everyone's bringing their own professional skillset and working together.

Transdisciplinary teams, I think we don't. I mean, we talk about them, but I don't think we're really seeing them that often in practice yet. I think they're very much still an emerging, sort of, sphere. And that's where we're really getting teams of professionals, who bring those unique skillsets. But in practice, in terms of the actual role or job that they would be doing within that team, there's so much, I guess, role sharing or, like, task sharing and people kind of share those skills and learn from each other and coordinate to the extent that you might see a clinician in that team and you suddenly, you can't really tell what profession they're coming from based on what they do with you, because there's that much sort of overlap and skill sharing and that's where I think it's an interesting space, because I think in theory it's something I think that has a lot of value, but I personally don't know of that many examples of seeing it happen in practice, particularly if we’re talking in pain. I think we still very much stick in that interdisciplinary sort of model. I'm interested if either of you are aware of anything or we've seen examples of that in practice.

Matt
Yeah, I mean, I would like to say that, within where I work, the skills are common. The core skills are common. So, strategies, you know, like pacing or helping someone work out with planning, or thought match or what have you, that could be delivered by anybody. Because they're core skills and any clinician should be able to deliver them. I mean, yes, there are professional boundaries, like, I can't say, you know, you should take this medicine and it should be this dose at this time. That's definitely not my role. But those core skills, I do see that in practice that everyone's capable of delivering those effectively.

Soph
Yeah.

Andrew
We're quite used to transdisciplinary in the paediatric world more generally. So I think for paediatric people, that they come across transdisciplinary more often. But it's not what we label pain, paediatric pain services. I'm not aware of anyone doing that. But I completely agree with Matt, where the core components of pain, a huge amount of it can be delivered by a sole person, not necessarily from any specific discipline.

And I'm a big believer in, and I don't think I'm special in this regard, that education about pain is the most important thing. Children and their families have to understand what the health profession knows about pain, why we think they have pain, and why we think they should do all these really difficult things to get better. That can come from anyone, there's, you know, from all the disciplines I mentioned before, people can do a great job of that. I think physios are well placed to do a very good job of it. If you think about the biopsychosocial model of pain, children and parents want to hear the validation about the physical, the biological, structural, they want to make sure you’ve assessed that. They want to understand how the central nervous system is a biological thing. And I also find where there's often reluctance to engage in psychological therapy, which we know is so important for pain, I've actually often found that people are quite receptive of hearing that from the physio, sort of like, instead of saying I'm the physio and everything I say is the most important thing for you, it's the physio acknowledging, helping them identify that there's other contributors to their pain and, I feel like I often open the door for other members of my team to sort of jump in. So I think physio’s well place to do it.

Soph
Yeah, for sure. I think we see that a lot actually, because I've been reflecting on, like, my own experiences in the community as well. You know, we know that even from a mental health perspective, a huge, you know, even talking adults at this point, I work predominantly with adults, but there is a huge barrier to accessing mental health care a lot of the time, regardless of whether we're talking about pain or even just sort of, I guess, general mental health.

And I would agree with you, I think there's this really nice bridge that physios can often, you know, act as, because people are generally a little more comfortable coming to see us for physical health that doesn't necessarily carry the same level of stigma. And because we are afforded that time to spend with people, too, we often do develop relationships, and that can be that trust to then sort of talk about it and sort of, yeah, I guess open those opportunities up. So I think we see that in, you know, I guess the community setting and in private practice and in adults, too.

But yeah, it's really great to hear that. And I think something that you've touched on already a few times is sort of the, I guess, the knowledge and the skills that we pick up in that pain space. And you've obviously had, you know, a fairly extensive and broad exposure to develop these skills. But, I'm interested when we're talking about, I guess, chronic pain specifically or not even just chronic pain, but pain in general, I guess, reflecting on how your journey has evolved. How did you go about sort of developing your knowledge and your skills in that area? Were there particular sort of courses or, sort of ways of seeking out information or experiences that really helped develop that for you?

Andrew
It's a good question. I have to think back. I feel like I have to think back to when I started. And just finishing up on transdisciplinary, too. As Matt said, we pick up a lot from our teams. We're very blessed in a large team, like in a specialist team. So I sort of I'm always reluctant to sort of, you know, tell people working in more isolation as a physio what they should be doing. I just hope if I have any insight, it's to, you know, this is how I got to where I am and this is what I believe, having worked in a team but your practice will be dictated by your setting and your experience. Because I learned a lot from my team, that's, you know, sort of what makes me think of that point. I feel like I've been blessed my experience. I probably have seen a lot of children with pain and seeing them and their families, but if I talk to the physio down the street who just sees, you know, probably everyone they say, see he has pain too, just from lots of different reasons. And, I feel like they probably have read a lot of what I've read, and I probably, maybe all I know more than them is what my team has taught me. But our physio knowledge might be quite similar, but it's the sort of more broad bringing in those other domains.

Sorry, back to the actual question. I think I've had a range. So, I worked with a very experienced pain specialist at the start of my career. I certainly picked up a lot from him. Even though I worked with him and chatted to him all the time, when he gave presentations, I really liked the way he put forward information. Very evidence based. I'm dreadful with all the neuroscience. It goes in one ear.. I go, oh, good, that's why we do what we do. And then I, you know, remember why we do. And I ask, don't give me an anatomy quiz. I won't do very well.

But, he explained it, you know, and I really liked the way he explained it, from existing evidence, which, that was a great source. And, you know, he to summarise papers for me really, but like, put them in nice slides and things like functional MRI is showing the danger, memory and emotional responses that are increased in chronic pain. If you learn nothing else, you just take that away. And I explain that to children and their families, and that's a good start.

There's some good textbooks I've read. The Moseley and David Butler pain books were great, especially earlier on in my career. I've never found one video that perfectly suits the patient in front of me, but there's certainly some great videos and resources that I've learned from and also used in my discussion with children and their parents. My team shares research and we have a nice research unit that sort of we do that together. But I personally try and be as evidence based as possible. It’s funny, we talk about what's evidence based and when I have done a bit of work on some papers, you try and find sources and, you try and trace it back to the actual really solid evidence for what we're doing. And it really makes you question how evidence based is it. And that's part of how I try and learn. I'd say that's hopefully the right summary of how I've put it all together.

Soph
I think it's a great overview, and there's definitely some great resources in there. But I think what you touched on there with the evidence-based practice is a really important point because I think, again, I apologise because this is linking into my PhD work. So my brain's just like, yeah, this is great, like, I really gelling what you're saying. We use the term evidence based. But like you said often when we then just check some of those assumptions and biases, we might have, we realise that maybe the evidence we have isn't actually is as sound as we think it is. And I think in pain particularly, we often are making assumptions about the evidence base, on very particular populations. Like, we know that there are huge groups of people for example, who aren't really represented in the research. And so, you know, we're often making big, you know, I guess, generalisations, despite only sort of testing things in certain groups. And that can, yeah, be a challenge. It's a good call to, I guess, remain a bit critical and question and to, I guess, challenge some of those assumptions that we might have.

Andrew
There's definitely no evidence-based formula that addresses everyone in front of you. And just like I said, the video resources, they'll never be one uniform resource that actually perfectly captures the person in front of you. And just as there's no evidence that perfectly includes everyone or is, you know, their preferences as well, not just the actual clinical presentation, but their personal preferences. I think, Sophie, where you said there's gaps, I think come to paediatrics and see how many more gaps there are.

Soph
Yeah.

Andrew
So just because of the availability of participants in studies and the willingness to sort of be part of a study, for your child, really. But I think that's where we sort of really do do it, child- and family-tailored therapy, you know, like, there are studies on that are sort of, I know, they'd like to do one on resources, and how well does that address the concern of the person? And can you just send them that and are they fixed? And I think that's certainly at the sort of pointy end of more complex presentations. You really need skilled clinicians who are sort of putting it all together. And the evidence does not answer the question, it’s your interpretation of the evidence and your clinical reasoning with the person in front of you, I feel like that's how you hopefully get the best results.

Matt
How do you approach some of the unique challenges in the paediatric setting? But what comes to my mind is, okay, I can deliver pain education, I can do these treatments x, y, z. It's like, oh, I've got parents. I need to get them on board. How does that go for you?

Andrew
You are treating the child and their family, you know, whether it's parents or carers or grandparents or whoever happens to be the main carers of the child. Siblings sometimes, not too much. It gets a little bit complex when you’ve got too many people running around. You have the family unit. So the chronic pain is a pretty horrible thing. And, you know, we're certainly, you know, almost always seeing them because of the effect it's having on the child, but it's also almost always having a large effect on the family, too. We talk about the biopsychosocial model. We talk about things that contribute to a pain experience. And social is in there. So, things that the outside world are doing are going to be helpful and unhelpful for pain experiences, really.

I was a co-author in a study on parental burden, actually, carer burden, and it was very interesting. There were parts of being a parent of a child with pain that were found to be to be strengthened in their relationship as well. I'll jump around a bit here because it is a bit complex but you're educating the child and the parents about why we're trying to make all these recommendations to what we think you need to do to help you achieve your goals. Despite the fact that your child has pain and despite the fact that your child is upset with their pain, and despite the fact that you're probably upset that your child is upset with their pain. Education, we need everyone on board. When things are difficult, that can be the part of the challenge to educate the parents, but then they're also part of the solution. They're hopefully helping the child move forwards, too.

Often the child and parent are not in the same place. One might be further forwards in their, you know, whether you say willingness to change or whichever sort of wording you want to use, getting on board with a pain rehabilitation program, but we like them both to be moving together.

As I mentioned before, we have a social worker in our team, so they will often do a bit more of the parent education, whereas in our team, the rest of the team really, but the clinical psychologist might do some of the more child work. And the social worker meets with the parents more. But as I said, it's the goal to have everyone moving forwards in the same direction. I don't know if you're necessarily alluding to this as you asked the question, Matt, but the people sometimes say, like, you know, all this pain neuroscience, it's complicated. I do occasionally hear from adult clinicians, ‘I struggle to explain it to the adults. So how do you explain it to the kids? We deal more with teenagers, really, but we do get a couple of, sort, of four, five, six, seven, eight year olds. And we certainly adapt to the age of who's in front of us.

When you're explaining to your adult about chronic pain, the complex world that is chronic pain, I would imagine you're trying to use quite simple language. I feel like my brain works quite simply so it's easy for me. I translate it for myself, and then I translate it to someone else. The education tailored to the child is probably the right level for the parent anyway. Not because the parent isn't intelligent, but just because that's all we can really take in anyway. So, I feel like that's an asset. I try and do the education to the child with the parent sitting right next to them and encouraging them both to ask questions, hoping that I'm conveying it in the way that's appropriate for both of them. Because I think that's the other big sort of paediatric thing, that might be different for some adult clinicians.

Soph
Absolutely. Andrew, I'm interested because certainly that was you sort of, you know, touched on it there. My thought was, you know, how do we adapt to this? Because, you know, even when communicating it quite simply, I think there is often a lot of nuance in, I guess, even at a practical level with some of the strategies we're trying to communicate. And, an example that I think of is around pacing, for example, and helping someone to have a bit of a framework for pacing and appropriate sort of self-monitoring during activity to know how are things traveling? Do I need to slow down? Do I need to stop? And I guess, I could imagine that, particularly if you're talking about younger children, that might be challenging for a few reasons. I guess, do you have any go-to, sort of, strategies for sort of explaining that or helping children in particular to pace their activities in terms of ways they can kind of conceptualise these ideas. Or do you find that you sort of rely a little bit more on, I guess, external support from the parents to kind of come in and take breaks, you know, sort of help impose breaks as needed? Like, what do you find works in practice from your experiences?

Andrew
I love pacing, I find it very funny because we're normally, doing the opposite of that, aren’t we. We always try to get people to do more.

Soph
Physios are not great at it.

Andrew
Yeah, yeah, exactly, physios are not great at it. I have a few thoughts on your question. My team, the OT, is great at pacing. She's really good. Our child-life therapist is really good. I force myself to try to be good at pacing. When we're talking about pacing, I'm always thinking about boom or bust cycle. In all clinical areas of paediatrics, not just pain, we’re typically relying on a motivated child who wants to be out with their friends and sporty. We rely on a lot of sort of natural recovery and motivation, in all the caseloads I do to, sort of, help them get where they want to get. And I think that's true of a lot of the children I see that in the pain world.

I would imagine compared to the adult world, it's just a different motivations in a child compared to an adult. The other funny thing I find about children with chronic pain is we talked about patient-centred goals, and certainly we want them to be engaging in, you know, is it soccer or is it violin or is it going to the shops with their friends? But we also need them going to school, or at least completing education. So I always have that in the back of my mind where we talk about patient-centred goals, it’s not always the child's goal to go back to school. It often is, they often like parts of school, like socialising with their friends, or some of them love learning.

Like, everyone loves different things, but we are trying to balance the things they want to do with the things they just sort of have to do. And, you know, usually the parents are more on board with getting them to school. Again, not always, like, different people have different motivations, but, I think that's where pacing is very interesting because, I say this as the classic example of boom or bust, but it's not the most common presentation we see, that the child who is, sort of, playing soccer on Saturday morning and then falls in for the other team that was playing after them, and then fills in for their brother's team that afternoon or the next day, and probably got man of the match in their award, despite the fact that they've got sort of a niggling chronic pain. And then they spend Sunday on the couch, and then it's hard to get to school on Monday, and it's hard to get to school on Tuesday, and it's hard to get to school on Wednesday. And if maybe they get to school on Thursday and Friday and then they've sort of recovered by Saturday and they're playing two or three games again. And that's just, for me, that's the classic boom or bust cycle.

And that's where it comes back to, there are things we have to do in life, like, you know, we have to work, and children have to go to go to school or be educated in whatever form they choose to do. But, they have to get an education. That's hard to motivate the child because then we go into our metaphors about, you know, how do we pace, why do we pace? And one of the metaphors we use is you've got your energy bucket. Today we're going to take from the bucket, but we don't want to take from tomorrow's bucket. We're only using today's bucket, and we want to wake up refreshed tomorrow to have tomorrow's energy. That's a metaphor. Other people use spoons in a very similar metaphor. I don't spend a lot of time on these metaphors. I'm very lucky. My team's a bit smarter than me on this in this regard.

But that is the classic picture. And for me, pacing is more about, I guess, balancing things you really want to do and things you're maybe not so motivated to do, but we sort of have to do. And that's, I think, that's the challenge with pacing in the paediatric world. Yeah, I mean, I think that's a bit similar in the adult world.

Matt
I mean, I don't really know someone who loves to do laundry or loves to vacuum, but that can be part of someone's goals. You know, they just must get done. So how are you going to approach that? And how would you pace that out? Probably the clients that I see aren’t going to school, I guess, but they are either going to work or want to go to work. Or, you know, they have a family that they need to continue to provide for.

Andrew
Yeah. And I guess as Sophie said, are the parents helping with the pacing, like, good luck. You can try, but, it's very hard, like, tell any child not to do this thing they love when they're feeling up to it on the day. There’s some means of doing that, but it's not very easy to do that. We talk a lot in my team about being self-directed. And you know, a four year old’s not going to be self-directed.

Matt
They think they are.

Andrew
Yeah, when they're too young, they're not going to be self-directed. But, from maybe, perhaps a younger age than you'd expect. We're talking about self-direction with support, you know. You have to take the education on board. You have to understand, like I said before, why we're getting you to do these really typical things.

We talk about your goals to you so that you want to, you know, have some motivation, but it's the child's pain and they're ultimately the ones who are going to have to make decisions that get them where they want, where they need to get to.

Matt
Absolutely. It's been really great having these conversations. I feel like we could chat for ages. But I'm very conscious of your time and, I don't want to monopolise you any further than we already have. But I guess before we finish up, if you were to reflect on maybe our conversation that we've already had and try to, I guess, identify maybe the one key insight or the one takeaway that you'd hope that anyone listening might take away. What would you want that to be?

Andrew
I mean, we talked about transdisciplinary before and, the hospital pain services are often interdisciplinary. You know, depending on the audience and who's interested, like, the question would be, are you doing transdisciplinary care and, you may well be. Something I didn't quite mention and again, I'll get in trouble if I don't mention it.

We talk a lot in our team about, you know, part of what we're doing is by validating the pain, or acknowledging that it's there. But despite having the pain, we're still going to move towards our goals. In doing that, what we try and do as a team is we're bringing our attention from the pain. We know it's there. We're bringing our attention from it to other, more enjoyable activities. I suspect a lot of, you know, private physios or whatever setting, but physios working in isolation are probably doing things like that and they're probably taking biopsychosocial histories and they're probably offering intervention up until a point, and then they're probably hitting a threshold where they're saying, perhaps, you know, this isn't going where I want it to, perhaps it’s more complex than I can manage on my own. Am I engaging, you know, am I working with a GP and making suggestions around clinical psychology, or am I referring to a specialist pain service? I don't know if it’s the take-home message, but that's something I just think of.

I mentioned before, like, I don't like to tell other people what's appropriate in their setting. I hope you learn from different people. And, you know, I can tell you what works for me in my setting. And then you've got your own practice, and then it's about thinking, how do you, you know, with complex presentations of children with pain, what can you offer? What can other people offer? And when do you, sort of, make that decision to speak to someone else or refer to someone else?

Soph
It's a good, sort of, point to reflect on. You know, what are your own skills and competency and what does your context afford you? And making sure that we're doing everything we can to support the patient, whether that's with us directly or connecting them with others who can help. So I think it's a great take-home to finish on.

Matt
Totally. Andrew, thank you so much for sharing your vast wisdom when it comes to paediatrics and chronic pain.

Andrew
My pleasure, guys. Thank you.

Matt
For the listeners who are keen to hear more, you can check out additional episodes by following Physios on the Mic on your preferred podcast platform. Thanks everyone for listening. And we'll catch you next time on Pain in Practice.