Soph
Welcome back, everyone. And we are very, very excited to have with us for this episode, Doctor Peter Roberts. Peter is a specialist Musculoskeletal Titled Pain and Sports Physiotherapist with quite a few decades of experience now. How many years are we up to now, Pete?

Pete
We're up to 51.

Soph
Just a couple. Just a couple of years of experience. Peter has had a lot of experience over these decades. He's worked across a lot of diverse settings, starting his early career with, and working under Jeff Maitland as an early grad and then going on to work in sports, supporting athletes at lots of different levels from local cricket, netball teams, all the way up to working for national netball teams, as well as the track and field at the Sydney 2000 Olympics.

He then went on to develop a passion for helping those who were a bit stuck in their recovery, and proceeded to delve into the space of persistent pain, founding the Paragon Pain program in 1999 alongside two psychologists. And he's been very active in the educational space and supporting the profession, having taught as a guest lecturer in the undergraduate and postgraduate physio programs at the University of South Australia since 1980, and he currently lectures to physios in complex pain management in the Master of Advanced Clinical Physiotherapy Musculoskeletal program.

He wrote and delivers the Advanced Clinical Pain course, which is soon to be the Pain Level 2 course for the APA and is an active member and volunteer with Pain Revolution, where I was very privileged to have him as my Pain Rev mentor. So I struggle to fit a succinct bio in there because you've been very, very, very busy. Many hats there. But, thank you so much for joining us.

Pete
Pleasure. I'm really excited to be part of this podcast, and hopefully I can influence other people on their journeys to really get on their bikes and enjoy it and go forward in curiosity. I'd have to say that I was thinking about the podcast and thinking about what sort of things have driven me, is curiosity. I really want to know more. I want to understand what's going on. And I was very curious about people, you know, they're very complex. And I guess as my career's evolved, I've got more and more interested in people and their stories, the complexity of the individual, and discovered that the individual is key in how we go about things.

You know, we're struggling to show through RCTs, you know, what really works best, although we're getting closer. You know, there's more studies now targeting down to individual, if you like, packages to match the individual's needs. And the tools they need and it's still complex. It’s hard. And so we're still not getting the great data that we were hoping to get, but we're getting much closer. I guess Peter O’Sullivan is leading the way recently with his CFT three-year outcomes, but also Lorimer Moseley’s had several projects that have been demonstrating some good shifts. And it's really lovely to see. And it's just, adding more magic to our toolkit. So I'm really glad that these guys are out there, really putting their feet forward, they’re both passionate and driven and I’m really pleased to be part of Loz’s Pain Revolution. The culture there is something I can't describe and I feel very privileged to be there in that group.

Soph
Amazing.

Matt
Wow. Awesome. Thanks, mate.

Pete
But, you know, I think the other big thing is don't stop learning as a physio. I've done every course that I feel is relevant, every year, every conference. I love to learn, to hear, and there's always gems that you could take home with you. And part of it's the gems of catching up with people and sharing ideas. I really loved mentoring you, Soph, because you're so passionate, and the danger was that I was quite passionate as well. So we tended to go pretty laterally at times, which was fun, you know, but you always go back to the centre, don’t you, and that's the enjoyable part about teaching and collaborating, it's, you know, the more you give the more rewards you get, really, and I do like that part of that.

Soph
Absolutely. And I think, you know, because, I mean, we know each other pretty well, Pete, and we've already spoken about, you know, really, I guess, the complexity of individual people, and I know that, particularly Matt, who's not really met you before or had the opportunity to meet, I know he was really keen to hear a little bit more about, I guess, your journey. So, Matt, what jumps out at you? You know, what do you want to know about Pete?

Matt
I feel like you are all over the place, kind of thing, you know, you talk about starting in sports, which is, I feel like that's every physio as they start out, it's like, I want to be that sports physio, so, you know.

Pete
Yeah.

Matt
That’s where I’ll start. And then you move on to more pain programs and understanding more complex pain issues as well. Maybe we'll start simple. And what kind of drew you into physiotherapy? Because a man of your skills, I feel like you could have done anything, really.

Pete
Thank you. Look, it's a bit of a journey, really. The fascinating part is, as a young boy, an 11 year old, I fell off a super stack, and it was about three metres high. And I really hurt myself. I still remember that. I couldn't move for about a week, and I was on a farm, and I sort of had a chronic-y back from then on. You know, I really never understood it until quite a few years later. That led me to be interested in the body, I think. And then my grandmother had quite severe rheumatoid arthritis, and I remember the physio. And by that time we’d moved over to the city, because I was at college. The physio used to come in and the physio was like a godsend to her. It was her only hope of movement and relief. I thought, wow, you know, that's a really special job that physio is doing. And that really motivated me to get into physio.

Initially I struggled to get it in because actually I don't have a mathematical brain. I got the ancient history prize, but I was always bottom in the class in maths. And in my days you had to do science pathway. Everyone did, you know? Maths 1. Maths 2. Chemistry. Physics. And, none of them were very strong for me, so I had to repeat Year 12 to get into physio. You know, it's been a really wonderful journey. I mean, part of that, too, was that I was quite a high-performing athlete myself. I was playing quite a high-level tennis, I was running cross-country competition. You know, I was playing a lot of sports. I love sport.

Matt
Right.

Pete
And so I was intensely interested in sport. So that's where that started. And I think my interest in sport was from a scientific basis. And I wanted to understand more. It’s that curiosity coming through. And then when I finished the physio degree, I was really lucky in that, in my day you could actually, if you were with the public hospital system, the Queen Liz, they would actually sponsor you to do the advanced manipulative physiotherapy course. There wasn’t a sports course in those days, it was all about manipulation. Geoff Maitland had led us into the world of moving from masseurs into, you know, this whole clinical reasoning approach.

So, you know, that was just such a wonderful time. It was just clinical reasoning. All those principles are still all there today. They’re the core of how we reason and unpack people. And, you know, he would always prove what he'd done. Did it work? Did it change? Proving, negating all the time is exactly what it’s all about and that led me to that world, so at that same time I was still having a very heavy sporting career and looking after state netball and local youth district cricket teams and, you know, really involved in that. But when I was at Geoff’s practice, he had a very high, manipulative, hands-on approach, which I did as well. I was manipulating probably, up to eight to 10 times a day. He’d usually have about 20 patients in his practice.

But I found there was a group that just weren’t responding. And so I said to Geoff one day, do you mind if I keep these patients’ stats? I’d just like to unpack them. And I gathered about a hundred of them over about six months and they had some very common themes. They all had their problem more than three months. There was usually some sort of trauma, psychological stress going on. And that led me on that other pathway of trying to understand this group. And because actually they end up being the main ones that you have on your list because the sports ones all get better. You know, you just got to get them in a good program. They’re going to recover. You know, they’re driven, they’ve got great immune systems. They’re usually motivated. And then there's the chronic-y ones. And then, you know, there's that psychosocial domain that seems to be high, they’re usually stressed, depressed, lost their identity. And so, you know, you're in that world of chronic pain again. It sort of started from there, really.

And, you know, sports careers are not good for families. You end up being an athlete before and after, and during. And so, I did sort of make a conscious decision to move into a more family-orientated pathway because, you know, you just can’t have a family being in an athlete world, very well. So that was motivating me a lot to move out of that. I mean, I would have loved to have done a lot more international sports, like, or even other Olympics. But it's a big ask. And if you are, you've got to follow the Olympic team that you're assigned to, you know, and go right with them.

So that led me away from that. But you know, I did do a lot of things in that. I was running basic and advanced taping courses. I actually went over to India before their Commonwealth games and we taught the Indian physios how to do taping techniques. And I was teaching that at UniSA as well. So it was part of already that skillset I had. So yeah it was quite good. And I used to run taping workshops for the physio students at my practice and the school, would send them down to do it because they didn’t teach it at the schools. I really loved all that and I’d get other physios heavily involved. And, you know, it was quite good.

My practice was quite big. I had up to ten physios there at one stage. But we had a very strong commitment to having a year apprenticeship for physios or mentorship where they’d have to sit in with a physio every week they’re be on a three-month assisted, sort of, building their skills pathway. And we never had any trouble getting physios and they were really good physios. They knew who was offering good training and good opportunities. So we were always lucky in that way.

Soph
Pete, is it okay if I come back to something you mentioned before when you were, sort of, starting earlier on and you were working in that sport setting and noticing these people who were just stuck because I feel like that's an experience that I think most physios who are listening, and I know myself have had that experience of sort of coming out with all these skills from uni and going, right, I'm ready to help solve the problems of the world and then feeling like you, you know, you’re just hitting a wall sometimes and you sort of realise this, maybe there's more to this than what I thought and I need to, you know, upskill or I need to seek out more information so I can better support people. And I mean, the landscape now is very different when we're talking about pain science and pain management, because, you know, you already mentioned Lorimer, among, you know, many other researchers at the moment. There's a lot more resources in education now around pain, but I'm interested in what that was like for you early on, because I can only imagine that there was a lot less in the pain space available at that time. How did you go on that journey and what was your learning and exploring pain more, what did that look like for you?

Pete
You're absolutely right, Soph. There was very little out there. I remember I had an awakening when I went to when national, I think, APS conference and there was a guy there, I think it was Philip Siddall and another guy did an article about this whole thing of central sensitisation. And it was like it suddenly made sense. There is another mechanism. And so in those days, it was only nociceptive and neuropathic, and nociplastic, we know, is a new entity relatively. But because there are these people who are often sensitive you know, and they're often protected, and there was always psychosocial stressors in there. That was a big awakening for me. And that's when we started really working on the pain program idea.

It was a really funny story that started me on that. What’d happened was, I had this lady who came to me with all this spasm in her back. And she was locked up, and I had a bit of a reputation, this is about the 1980s, I reckon, I had a reputation for being good with my hands. And I manipulated her and she straightened up. And she could touch her toes. ‘Oh, it's wonderful’. And I gave her a few little things and she came back about a month later, the same. So I went through that. Asked what’s going, ‘Oh no, no, nothing. I can’t work out what's going on’. Anyway, did the same.

Yep. Great. Two weeks later she's back again. And I could just detect there was all this stress in her body. People in those days were really scared of psychologists. They really saw it as ‘it’s in my head’. ‘Look, you've got all this tension in your body, I think we need someone help us try and lower this and psychologists are experts.’ And she bought that idea. And so I referred her to this lady who I’d come across who is Maria Polymeneas, actually, you know, and she was the one who I helped to co-found the pain program with. But to cut a long story short, she went to see Maria and I didn’t see her again. I thought, ‘oh, I wonder what happened?’ So I rang Maria and I said, ‘oh, I was very curious how you go on with this lady?’ She said, ‘it was simple. I just told her it was okay to have an affair with her minister and to leave her husband.

And so, you know, that was the whole problem. But, you know, sometimes people won’t open up to you. So you definitely need your colleagues to, you know, help you sort of unpack these things. And, you know, time and time again, I do find that. You find you’ll unpack stuff, the psychologist will say, ‘how did you find that out?’ And the psychologist says, ‘I didn't realise they were hurting themselves like that.’ So you know, having that interdisciplinary team really struck home at that time and that you need your colleagues collaborating because we do tend to work in islands and, always look for opportunity to reach out and have a chat. You get so many surprises and so many helps. And it makes your career so much more enjoyable when you’re collaborating with others.

Matt
Well, that's certainly a story. I think that tops all the stories I've heard before. You mentioned starting a pain program. I guess, what was your criteria? What were the things that you found that was essential that people must know, to help manage their pain when making a pain program?

Pete
It's a really good question, and I'm thinking about that. You know, I was always curious about, you know, what really concerned people most and it surprises me what they did want to know. And the way that I came across that was, when people came into the program, usually sit them down in this group. And we’d say, ‘why are you all here today?’ And we’d do a brainstorm on the whiteboard, you know, of all the reasons they were there. But you know, most of the time they didn't mention pain. It was usually, ‘my life’s shit’, ‘I hate this, it’s ruined my marriage’. ‘I can’t work.’ ‘I’ve lost my identity’. You know, they don’t talk about agony and pain. And I was really fascinated by that But, you know, they sort of seemed to open up because they felt everyone in the room was on the same page, you know, and they didn't even think about the pain issue. It's just how much of the rest of their life had suffered.

And that was a real eye opener for me to really get on my bike about, I need to understand people a lot more. And in that space, I did a motivational interviewing course, and that was one of the best things I've ever done in my career, because it taught me how to have conversations that allowed them to own and have permission to take control. And it's such a powerful gift, you know, and I actually went on to run some motivational interviewing courses with psychologists for a few years there as well. I haven't pursued that because it's not my dream to be doing that. I'd rather be teaching physios about chronic pain, but it taught me so much about that relationship building. And it's something I do a little segment on in the advanced pain course, you know, because I think all physios, you can call it motivational interviewing or interviewing skills, help them own, and if you like, take control of things, discover how can I go forward, get my life back.

Soph
I agree, it's such an important skill for us to have. And to be honest, I'm kind of a bit amazed that it isn't the foundation of a lot of our communication skills even now, because I know for me, when, you know, I did a NMI course a few years ago and I had a similar experience. I found it so drastically altering to the way in which I sort of approach practice, and the way that I thought about even just the structure of the consultant, almost, how can I get my own agenda and my own ego out of the way so we can actually get to the person who's in front of me, which, you know, sounds strange to say, but, you know, we don't realise how much we tend to centre ourselves as clinicians a lot of the time, unless we’re consciously thinking about it. So yeah, I would agree with you totally. I'm really interested actually, Pete, though, you know, you had this journey, this transition, you know, from doing a lot of sports work early on and then moving into this sort of complex, persistent pain space. And I know you drew comparisons earlier about how, you know, many sporting patients do tend to recover and get better and, you know, maybe are a bit of a different presentation. But I'm interested with all that you've learnt going down that journey of venturing into the pain space, when you reflect back on the sporting context and sort of some of those, you know, sort of athletic populations, are there aspects of the pain science and pain management that you still feel, you know, really critical that you sort of still use in that sporting context or that you see as being really important, even though it's maybe not traditional pain management sort of setting?

Pete
Absolutely. And so, I still see quite a few elite sportsmen, I’m treating a couple of state-grade, state-one squash players at the moment. And, I've seen a lot of runners, because I was running courses for physios and some physios still refer me complex running injuries. But also my name is still out there a bit. So I'm often in the back lane, assessing running and/or squash or tennis. So I do have a big interest there.

I mean, you know, in my lecturing and teaching at uni, it was on rehab of movement, movement and analysis and training. That started from Shirley Simon. I thought she was gold when I first met her because she didn't actually start by looking at people from the objective movement base, she started looking from how they moved. ‘Well, it hurts when I get out of a chair.’ ‘How do you do that?’ And then she’d just change it. ‘Oh, that's better.’ And, you know, she would go to that level.

So with athletes, I go to that space a lot. Where does it hurt and how did you do that? And, you know, it's often breaking it down with video analysis, but also getting into the detail underpinning that flexibility. There's also a big group with chronic, recurrent pain. There’s one squash player in particular recently I had. He's had a bit of a chronic-y body all his life. He's quite an anxious, stressed sort of personality. And he developed this really funny pain that didn't make sense. It was sort of going from his elbow up to his shoulder. You know, but he's trying to hit a high smash, which he said he always stuffs up. So we started unpacking that and he had some sensitivity with pin prick. I actually got him to do the Recognise program. And he was really low for a squash player. That was really unusual. Like, he was only getting 60% recognition on the Recognise. And then I put him in the mirror with the other arm, doing a smash, and it brought on his elbow-to-shoulder pain in the other arm. So, you know, that was really exciting, you know, and he liked the label, ‘oh, this is a dysynchiria phenomena’, you know, like, he liked the diagnostic label. But he turned it around within two weeks. You know, he did mirror training. He realised it was in his system so he did the Recognise, we did some sensory acuity training, and he got rid of it and he's now playing number one, state one. But the year before that he'd be down at two or three levels because of this confidence issue with his arm and elbow.

I got another squash player like that as well who was going to give up when he was in state four with a chronic knee, groin, ankle and sort of wandering pains. And again, he's a really smart personality, he’s an actuary which is all into stats and detail, managing super funds and stuff like that. And he's actually a huge advocate for me. He’s so good now, he’s in state one as well. And he's in his late 40s but still winning. He's a very good patient. He's very obsessive, you know. So anything you give him is good, but you got to be careful because he’s a typical boom-buster so you’re constantly talking about the sweet zone and pacing, but he's onto it. You give him the detail, he’ll do it.

So I really enjoy those because, you know, they have a lot of energy and the motivation’s big, and the results are good, you know, if you get them on page. I mean, that's the lovely part about practice. In a way, it's funny with people, they’ll often talk about, ‘oh, I can’t do the housework or I can’t do my gardening’. So I’ll say, ‘let's turn this into a gym’, and so, build a bit of a gym program and it sort of shifts the context, like, you know, if you can get fit in this gym you’ve already got at home you’re ready for anything. You’re fit for purpose. And that’s Loz’s model a bit, you know, fit for purpose. Find the things that are relevant and meaningful that you value, so, and then, you know, you’re into it.

Matt
With your examples that you've given, it sounds like you were helping them explore the biopsychosocial model without kind of making that more explicit to them, to get that on board. Is that right?

Pete
Yeah, it is. It’s interesting, the big thing is to be listening and being present and silence is actually helpful for them to contemplate. Because it's saying, I want to, sort of, sit with you on this, and I'm curious about what else you’re thinking. The guy who had the elbow pain had long-term anxiety and, had seen a psychiatrist. And, I never delved into that because I could tell he was very private about that. I sort of knew just from things that had been said. He’s now opened up right all up about it and will often, when he comes in with another injury or whatever, we'll talk about, you know, what sort of stress he was under, how did that affect his performance on the day. And he's got really good at body scanning and breathing and using techniques on the game time, you know, particularly if he's got a really hassling, challenging player that he’s trying to work with.

But you're right, Matt. There's always psychosocial domains and it's actually making sure you're working in their comfortable space. You know, that's the thing. And I think, you know just using simple language. Oh, how did you feel about that or did that affect you in any other way? When you're under that pressure, what happened? You remind me of a lady who I've seen a few times on and off, and she recently just had a flare-up of her back and couldn’t move. She’s my art teacher, actually. I mean, it's a masterclass art class, and I was at the art class with her on the day and she was really struggling with my back. ‘Can you do anything?’ She’d, sort of, sent me a text that she would be struggling, so I took some tape with me, just in case. You know, initially she thought, ‘I bend down to do up my shoe laces, and I think I’ve strained a disc.’ I said, ‘you were just bending to do up your shoe laces, and you know how much stress that drives?’ ‘I guess it's not a lot. I do it all the time, don’t I’. I said, ‘yeah, well, what else was going on?’ She said it was like a light bulb. ‘I had all these student exams and there's a lot of stress’ and we went through that. But she's a lady that's had like an autoimmune, chronic pain-type thing. And we talked about her immune system and stress and, you know, she sort of suddenly let go of it all in a way like, oh, I'll be okay.

So, you know, pain can really push people into this protected worry, stress zone. And then that becomes overwhelming to the stage they can hardly move. Yeah, I'm very much into this world of how can you boost your immune system, you know, I see, a lot of people, I talk about the bioplasticity of that and how chronic pain, although you might have some genetic or gender, predisposing factors, you can work your genes around if you get active enough and fit enough and enjoy life and do things you love doing socially.

Soph
It's such a interesting area, you know, delving into the, you know, the research around epigenetics and the nervous-immune-endocrine ensemble and all of the, you know, really dense sort of pain neurobiology research that's coming out. It's so fascinating. I do have one question for you, and I am very conscious as I ask it, that it has potential to be slightly controversial. You talked a lot about your early career and how, you know, you really started in that hands-on, manipulative sort of therapy space. And I think the thing that's been fascinating for me is to see all of these discussions sort of emerging on, you know, some on LinkedIn and professional channels and social media. And it seems like there's these two camps you've got, you know, pro manual therapy and then you've got, you know, your pain therapists. And if you look at what you're seeing online, you think that it's such a stark divide between pro and anti manual therapy. And I'm interested in your take on that because I think, my suspicion is, there's probably a lot more nuance in the middle there. But I'm interested in your experience, and from the years that you've worked across a range of spaces, how do you see manual therapy these days and how it sort of fits within or alongside pain management? Have your views changed and evolved?

Pete
Look, I think it's back to the individual's preferences and what they like. Some people’s physicality is the dominant thing and they want to be manually made to feel nice. You know, to feel you've given them some instant relief. So I think manual is always there. It's part of who we are, really, you know, and psychologists often say, we can put hands on people, I can’t, you know, and it's such a gift because people do like to be touched in pain. It's soothing, it's relaxing and, you know, but there are lots of situations where manual therapy can unravel frozen shoulders that have become stiff in their later stages. You know, the evidence for early stage isn't there, but certainly in later stages. And we see it over and over again, particularly in protected states.

Look, I think it's that people are making such a dance about ‘them and us’. I think it's always ‘them and all’, ‘us and all’. One of the things I do with every patient that comes in, I spend a fair bit of time around their expectations and understandings as my starting point. I'm surprised how many people say, look, I just want some good exercises. I've got a few people who come in, can you just do some hands-on, I don't need to know about anything else. Fine.

I think you have to be adapting to that individual's view of what they see. Frequently, though, if I see this more than that and where there's a recovery, I’m into, nearly everyone can recover. Unless there’s a disease or an autoimmune condition, some, you know, serious inflammatory disorder, 90% of people can recover. I'm always looking for the pegs that put that in their toolkit that leads them to recovery, you know. So I love the Peter More UK 12 tools. And I love the Pain Health website, and I love the Pain Revolution pain facts. I love Peter O’Sullivan’s stuff. I tend to send them wherever their problem, if you like, seems to add a bit of nit. And, you know, the Explain Pain books are great, it’s got lots of stuff. It's a bit complex, but you can really pick out some good stuff in there. And, you know, the pacing and goal setting on the Pain Health WA website is treatment. If you do it like this, you pace it and grade it up, you’ll get better. There are lots of, I guess, gems of information you can give people. And it's also picking the right amount. Some people just need a little bit, other people need a lot. You know, so you've got to be prepared to work with people's hunger and interest, you know, for that information.

Matt
How do you get around or encourage someone who feels like, I guess, talking to a patient is not necessarily therapy or treatment? I know you did highlight that it is treatment. How do you convince a therapist or maybe help a therapist understand that, you know, we need to be talking to our patients and using, I guess, the psychologically informed kind of speech.

Pete
I think a few. It's like building a friendship, you know, it's around listening, building trust, understanding the inner workings of that person where they really feel like he understands me. I had one today who just felt she didn't sync with the psychologist, like, ‘she doesn't get me’. And she was really upset about, she felt guilty that she didn't get the psychologist. And I said, ‘well, you know, it's like friend ships. Are there some people you just don't get? It's quite okay. There are plenty out there for you, you know, like you've had in your life.’ A friendship is 80% of the treatment, I believe. You know, the treatment is about being heard, being understood, and then I can do this.

I'll tell you another story. I had a guy out at tennis. I play competitive tennis. And, this guy, a young guy, was playing one of the top players. He was running everywhere, and it just looked like an injury ready to happen. Because he was so fit he could chase everything down. But he wasn't such a good player technically. Anyway, he went over on a crack and he was on the ground. So I happened to be there. And his lateral lower fibula was swelling up quite rapidly. And so, you know, it was really sore. And I did some tests and I said, ‘this looks like your fibula’, I checked out the lateral ligament, and it was it was highly tender compared to the fibula. So, I taped him up, and we helped him, ‘look, I think you need to go to the local sports clinic, see a doctor, decide whether you need a scan, whether you might need crutches for a few days, you know, just make sure the fracture’s aligned and, you know, because, they’re all quite different’. I said, ‘look, it's not your main weight-bearing bone, so you’re sort of safe’, you know, and some people don't have a fibula, so I wanted to reassure him that this isn’t too bad but, you know, we want you to keep an eye on it and manage it. Anyway, I rang him two days later. I said, ‘oh, did you go to a sports clinic?’ He said, ‘oh, no, I decided I didn't need the sports clinic.’ And he said, ‘I mean, I'm slowly getting better and, you know, like you said, it's probably take a couple of weeks.’ And, you know, he said, ‘I'm pretty happy, the swelling’s still there, it’s quite tender to the touch, but I did the same taping technique you did and it seems to be really helpful.’ Then he said, ‘I’m limping around and getting better.’ I said, ‘okay.’ That's the other extreme of someone who’s just totally taking ownership and, you know, I can manage this and I'm safe, and, you know, he was always going to do well. He's a resilient, sort of adaptable personality.

So, you know, I think as physios, back to your question, Matt, you know, I think we still get to do our job. Assess, look, give your opinion, because in that first assessment, you can't always tell what people are going to do. You know, how they’re going to go, you know. He was someone who ended up doing really well. And you get somebody else who's home to bed for three days. But he was always probably in that group that was going to do well because he's active, he's driven, good at decision making and probably a bit risky, but some would say. But that's how he was playing it.

Matt
Yeah, wow, I feel like a common theme for you and it's something admirable, you always want to connect with people. You said friendship’s like 80% of the treatment, almost like all your research and everything is just the icing on the cake that you've done. I often think, if I can know more, then I can explain better or I can do better, but perhaps I need to take a step back and, like, who's this person right in front of me? What did I need right now? And a wholesome approach.

Pete
Yeah. Good point. It is such a challenge, in what do they need right now? And how do you unpack that? I think you can unpack that. I often get to the end and I say, 'well, what do you take away for today? You know, what do you think happened?’ I'm actually a bit disappointed sometimes because, you know, I thought I was offering a bit more than that, but, you know, I wouldn't say that to them, but, then they come back and they've reflected a bit and they've taken on a lot more. And I came back with one lady who I wasn't sure how much she’d taken on, and she'd written three pages, she'd been to all these places, she’d written down everything, ‘I feel so much more owning this now.’ She’d had a lot of other physio and hadn't done well. You know, there’s personality factor there as well. So we’re still in this juggle. It is complex.

And, you know, it gets more complex when you have other, stronger psychosocial factors like personality disorders, post-traumatic stress. There's so much juggling with their highs and lows with those issues. It's such a perseverance sort of pathway because it can be like this all the way, but eventually it seems to gradually wind back. And they get it, you know, and they take ownership. They’re on their personal journey often with their pain journey, sort of, if you like, dancing with that, often in a negative way, so, you know, be patient and, you know, something I always do at the end of my sessions is, often say to them, ‘when would you like to go back again?’ And they look a bit floored. ‘When do you think I should come back?’ I say, ‘well, I'm really flexible about it. What do you think you need?’ Because I want them to own that idea of ‘I'm managing this.’ ‘I’m in control.’ And I’m also testing that hypothesis, are they ready to own it? If they're not sure I’ll say, ‘look, I'd like to give you two weeks of playing with these ideas and see what you do with it.’ Sometimes they’re going to come back a bit earlier. So often I’ll get them back in a bit earlier after the first session, because I want to make sure they've taken on the concepts and, you know, if we need to fine tune things a bit better. But it varies a lot. Depends on lots of things.

Soph
I think one very, very clear message I'm getting from everything that you've said, Pete, is just how important it is that we can actually sit with and connect with the person in front of us, but importantly, really tailor what we do and the tools we use to their person and their presentation and their needs and their goals. Because there isn't a one size fits all, and it's about us giving them the space so we can explore that together and go, well, what is going to work for this person and what can we pull on? And I think that's just such an amazing place to come at physio from. I think, you know, that's such a powerful thing. You spoke about, I guess, asking patients of their takeaways from a session and, you know, what have you learned in this session and what are you taking away from this session? I'm going to take a page from your book, Pete, except I'm going to flip it a little bit. And I'd like to ask you, what are your takeaways from the session? If people who are listening, you know, if you were going to give them, you know, one or two key things to walk away with, or maybe one bit of advice from the conversation we've had today, what would you like people to take away from today's session?

Pete
Take kindness to every patient. Kindness is really a joy and I’ve come across a few people with that, work on that motto, kindness, and it's actually magic. And you hear patients talking highly about physios and you know that technically they're not very strong, but they just love them and they'll do anything for them, you know? So kindness is a real gift. And it just rewards you back every time. It makes your practice and life lovely, really. So, with that first. And curiosity. Be curious about everything, because it means that you're giving them complete control of conversations and leading them to ownership of their problem. And that's very rewarding when they do take ownership. I mean, I love it when people say, ‘I don't think I need to go back for a month, I think I've got the tools.’ It's like, yay!

But, I mean, the problem for a lot of physio practices is the business model and there's real conflict there for them because, you know, you do need to get turnover and return visits. And I get that. You can still do your stuff in shorter sessions. But it's harder work. And I think more frustrating work because you're not able to form such connected relationships and shared therapeutic relationship as much as because, you know, even if you've got a 20-minute consult, I know some practices work on 15, but 20 minutes is still five minutes in and out to stay on time and you've got 15. Thirty minutes is also hard in these complex ones. In South Australia, you can get restricted consults where you can get an hour. Use it every time. It makes your work so much more enjoyable. And if you can become a specialist physio, it's a joy. I have an hour with every patient, and often with follow-ups, I’ll have hour consults, you know. On the whole I see a lot of complex patients within four to six times over six months, but I'm usually involved with a physio practice doing gym or an exercise physiologist, so I’ve usually got a psychologist, we’re touching bases, we're using shared goals with the other practitioners and particularly, a lot of their program is goal orientated, you know, with finding sweet zones, and pacing and grading and developing the whole package.

You know, it's a tough world for physio practices now because the overall expenditures have hugely gone up. The physio returns from compensable bodies and from the general public has not gone to the same degree. So I do feel for them. But if you want to really fly as an individual practitioner, do the specialist training core program. You might have a field you love. It brings in that time, and I guess, control over your income which I think is really special.

I mean, we've got the advanced clinical pain courses coming out next year so, you know, there's got to be opportunity there if people who are wanting to hear what I do. But I work closely with a guy called Alastair Flett. He's a really fantastic practitioner as well, and specialist physio. And, look, there are so many good specialist physios out there. You know, there’s the whole pain specialty cohort now There's heaps of really good musculoskeletal and sports physios, women's health physios. They’re the main groups I work with, and I'm sure there's others in neurological and thoracic and other areas as well.

Matt
Pete, thank you for giving us your wisdom and sharing your time. It's very much appreciated.

Pete
Thank you, Matt.

Matt
And we also do need to thank our listeners as well. Thank you, listeners, we hope you've got a lot out of this. I know I have today as well. And you can also check out our additional episodes by following Physios on the Mic on your preferred podcasting platform. So thanks for tuning in. And we'll catch you next time on Pain in Practice.

Soph
Thank you.