Jared Powell (00:11):
Welcome to the shoulder physio podcast, a podcast dedicated to exploring meaningful topics in musculoskeletal healthcare. I'm your host, Jared Powell, before we begin, the primary purpose of this podcast is to educate and inform the views expressed in this podcast by myself and any guests are information only do not constitute professional advice and general in nature. If you act on the basis of any podcast episode, you should obtain specific advice from a qualified health professional before proceeding
Jared Powell (00:46):
Today's guest is Peter O. Sullivan. Peter is a renowned researcher, clinician, and thought leader within musculoskeletal physiotherapy. Peter is based out of Perth in Western Australia, where he is a professor of musculoskeletal physiotherapy at CA university. I wanted to get Peter on the show to speak of his evolution in thought and beliefs, as it pertains to low back pain. Peter has publicly pivoted from a biomedical quantitative heavy research approach to a more bio psychosocial qualitative approach. Over the past 15 years, I asked what catalyzed this intellectual shift and what were some key lessons he learned along the way. This is a must listen conversation to hear from one of the true giants in the musculoskeletal physiotherapy landscape. This conversation was originally recorded in December, 2021 for my YouTube show on the shoulders of giants. Before we get into the nitty gritty of the conversation and for your information for the first time in two years, I'm running my one day shoulder workshop in Sydney and Melbourne in may and June, 2022. Tickets are limited to 30 participants for each event. The course offers a complete distillation of the evidence base for shoulder pain. Man management equipping you with up to date, knowledge, techniques, and clinical reasoning skills that are clinically actionable. If this is something you are interested in, check the show notes for more information without any further delay. I bring to you my conversation with Peter O. Sullivan. Hello and welcome. So I am privileged today to be joined by professor Peter O. Sullivan. Hi Peter, and thank you very much for coming on the show.
Peter O'Sullivan (02:29):
It's a pleasure. Thanks for inviting me.
Jared Powell (02:32):
No absolute the, the privilege is all mine. So, so firstly, Peter, it's an absolute, real thrill to talk to you today. I I've mentioned you a moment ago, but I've read all your work sounds nerdy. I know, but I've been really heavily influenced by it. Without trying to embarrass you too much with too many grandiose statements, you have really influenced a, a generation of therapists for the better. And I would just like to, to take this opportunity to say thank you for your work. And you've made a real difference.
Peter O'Sullivan (02:58):
Well, I probably have to preface that by saying that it's not just my work. I am so privileged to work with an amazing group of people researchers, clinicians both here locally and, you know, nationally, internationally who have huge part of that journey. So you know, I'm just part of a team of people who have, you know, have been part of this journey. So it's so important to recognize that.
Jared Powell (03:24):
Yeah. Yeah. Good. That's a good point. We're gonna get to some of your publications in a minute with some, some really special co-authors as well. So I'll just, yeah, I'll sort of just briefly introduce you. So everyone knows who you are, Peter, but your professor of musculo physiotherapy over in Perth at cur uni, you're a specialist Al physio as well, and you you've authored hundreds of papers. I don't know the exact number. You probably don't either. And , and the papers are that have made a real impact and they've been, they've made people think and they've made people reflect and they've challenged. Dogma are especially my biases when I first started reading them 10 years ago. And we're gonna get to this in a minute. So, so your papers have, have been influential to a wide range of people and they've not been, and again with your co-authors, they've been varied in terms of their approach. And that's gonna be a really important conversation a little bit little later on importantly, Peter, you you're a clinician as well. You're still practicing. So that's a real key ingredient too. Yeah. So, so what's your normal week look like at the moment Peter
Peter O'Sullivan (04:28):
? So my normal week is I spend I'm three days in the practice. My, my caseload is people with disabled, you know, who disabled with persistent pain and it could be of any pain area. So foot ankle, knee, hip, back, neck, shoulder, widespread, chronic headaches, migraines, it's chronic pain. So that's where I spend a proportion. So half my week, essentially with patience and and I, I love it. It's, , it is such a privileged position to be in, I think. And I'm so grateful for that. I've learned so much from those interactions and do every day essentially. And then the other half my week is mainly research, but also partly involved in education in our postgrad program. And so that would involve a number of, you know, research projects, supervision of PhDs and the like postdocs.
Jared Powell (05:37):
So has it, has it, have you made a deliberate effort to sort of maintain your clinician status?
Peter O'Sullivan (05:43):
Yeah, yeah, actually during my PhD I worked part-time clinically and my PhD was a clinical PhD and ever since then, I've only ever had a part-time position at the university. So my whole academic career has been on a 0.5 position. And that's been a, probably one of the key things for my career development. I think in that there's this kind of interplay between, I mean, working as a clinician has allowed me to ask clinical questions that we can then explore in a research environment. I also see clinical practices, the perfect end of one experiment, which has got all the biases of being N of one. But it also gives you a, an in depth understanding of the individual. And we often lose the individual when we do big, big data assessments, the individual gets lost and we start talking about mean differences and we don't see the complex multidimensional profile of people who come to see us, which is essentially every person we see.
Peter O'Sullivan (06:47):
And I think that gets washed out in a lot of research. And so we talk about these kind of very general understandings of pain, but it doesn't tell us about the individual. And you probably see in that journey you talk through my research journey that we've really embedded ourselves in the qualitative space in the last number of years and potentially, oh, I mean that, that, that kind of resonates with me as a clinician, cuz that is the story that I hear every day in clinical practice. And you know, in my view, that's where we have to go in research is be embedded and engage with the people with the lived experience cuz that's where we'll learn the most
Jared Powell (07:27):
Beautiful. So you lead us perfectly into the next question or to the next, so I'm just gonna talk here for a bit, Peter. No, nobody wants from me, but I need you just set it up and then yeah, go for it. And then we're gonna hear from you. So I've, I've had a I've I've gone through your back catalog, Peter, and this is a, this is your life. All right. And I arrive, I've arrived at an early paper in the 1990s, 1997, which was called, I think you were the lead author of this one altered patterns of abdominal muscle activation in patients with chronic low back pain. So this is 24 years ago. And then we go to the early two thousands, we've got a paper titled lumber, repositioning deficit in specifics in specific low back pain population, 2005 diagnosis and classification of chronic low back pain disorders, maladaptive movement, and motor control impairments as underlying mechanism now skipped through two, 2012. So seven years between that 2005 paper and then in 2000, well you wrote a paper in the BJ sermon editorial, which, which I read in maybe my first year of practice, Peter, you, you killed me mate. You absolutely. You ruined everything for me. So thank you. It, it was,
Jared Powell (08:33):
It was called it's time for change with the management of nonspecific low back pain. And we're gonna speak about that one in a minute, but it was a really good paper. 2013, you started publishing on cognitive functional therapy and that was with JP Canero as a lead author, 2015 with Sam Buley as lead author. You had a qualitative study on patient perspectives in cognitive functional therapy, 2018. I think your landmark paper actually was your cognitive functional therapy and integrated behavioral approach, which is a
Peter O'Sullivan (09:03):
I'd agree with that.
Jared Powell (09:04):
I reference that. Good. Yeah. Let's talk about that one in a minute. And then, and then you've got your one with Jeremy in terms of, is it time to reframe non traumatic? Yeah. Another landmark paper, sit up straight time to a, and then more recently a paper about police with JP. Yeah. And Sam. So apologies for just regurgitating all your work. Not at all, but I think it's helpful for others. So let's talk about this progression. So started out quantitative heavy research, looking at impairments, looking at motor control, looking at posture and, and then somewhere around 20 10, 20 12 from the outside, something happened now what happened?
Peter O'Sullivan (09:41):
So yes . So if you kind of frame my my journey as a young, you know, as, as a training physiotherapist, I had this enormous sense of frustration that what I was being taught had over evidence base. You know, we had a, I, I trained in Dunedin in New Zealand and we had this little library, it was a little room with publications of the spine and the Australian journal physiotherapy. That was it like that was it for research and nothing else. And then we were trolling out all this stuff, which had zero evidence behind it and that deeply concerned me. But in, in that sense that my entire mindset around managing pain or understanding pain was purely structural and biomechanical. That was it. And and that really took me into my PhD journey or post-grad, and then into the PhD Chi PhD journey, looking at, you know, a specific group of people with spondylolysis and the whole idea it was right, right around that time with the emergence.
Peter O'Sullivan (10:48):
So, you know, stability and local muscles, global muscles. So I just got sucked into that void, I think, but also around that time, was this some emergence of, you know, pain science. So max dustman who you may or may not know of was a really pioneer in that space who was at curtain. And we had some extraordinary conversations about, you know, like these worlds, his, his world was neuroscience. And my world was people with back pain who had these impairments and structural biomechanical impairments. And I was addressing them and these people were getting better, cuz that was my lens. And then, you know, post PhD, it all just kind of started to unravel. So I can remember when Dans he was my P first PhD experiments really. And we were started looking at, you know, what these people were pain were doing and it wasn't do.
Peter O'Sullivan (11:44):
We weren't seeing what we thought we would see. And I think that's been a lot of my journey is you ask a question of data and you look at the data and it tells you something different and you have to stop, reflect, reframe and go, what is this telling me? And I think that's been my clinical journey as well of like we come at it with these beliefs. We are so belief orientated as human beings, I reckon. And that ability to sit back and self reflect. And probably the other thing that was pivotal was around the mid nineties. I made a decision to completely change how practice. So get out of this short treatment session and spend an hour with a new patient half an hour with a follow up. And that was pivotal for me to have time to listen, to reflect, to question, to explore to play, to be creative.
Peter O'Sullivan (12:39):
That was a critical moment in my career where I'm going, I don't, I can't work in this paradigm treating symptoms. It deeply unsettled me. I felt like I was treating symptoms and not getting to the underlying basis of what was going on. It didn't have time. I was working on autopilot was horrible. That deeply unsettled me as a thinking person and as a reflective person. And I think those parallel journeys and, and then the evolving understanding of pain, I think pain research was really at its infancy. When I graduated, it's exploded of then updating my under of reflecting that in clinical practice and going back and asking these hard questions and looking at the data and going, what does it tell us? So that whole process really upended my entire belief system. essentially to go actually, the things that I was believing that I believed just weren't evidence based and I had to, then I had to go, well, what I'm doing I can't do anymore.
Peter O'Sullivan (13:37):
So either I walk away from it or I do something different and I'm so grateful, I didn't walk away that I actually had the, you know, presence in mind to go. These people desperately need help. So walking away from a difficult problem, doesn't solve a problem, actually going deeper into reflecting on my own practice, my own belief, my own behaviors, how I interact or how I support these people is the key. And, you know, understanding that I trained in manual therapy spent hours learning to really to manipulate any, you know, parts of the body. And I, I can do that, but I, I just saw, I see that as such a small part of the whole picture now, like I spent hours learning those skills and the skills that are fundamental I see in clinical practice are not those skills patient handling is really important, but that's part of communication.
Peter O'Sullivan (14:34):
I think mm-hmm so did you have, so that's a, that's kind of, it's an iterative journey that just has so many layers and it's been influenced by lots of people as well. Yeah. You know, people who really questioned me hard who have like attacked my beliefs. Yeah. That's been a painful process, but, but I've, I've gone. I suppose. I've been fortunate to go back and really question myself and then allow myself to go, I need to leave that behind. And so the ti the 2012 paper was kind of like my coming out paper, really. I mold, I mold on that paper for quite some time and contacted Karen car and said, I feel like I need to publish this I need to kind of set my records. Right. Cause I, you hadn't mentioned other papers, like clinical instability, you know, that was my belief system that these behaviors that we were seeing patients were a, a fundamental deficit in this stability of the spine.
Peter O'Sullivan (15:32):
And it was all just about that. And I, I, like, I just had to kind of throw that cloak away and go, you know, what, that's how I saw the world, but this is now how I see the world. And this is how I think we have to move forward. And of course that didn't sit well with quite a few of my colleagues. Yeah. But, but to me it was, is kind of like a re reset, I think, in terms of where I was heading both clinically and, and a, and from a research perspective.
Jared Powell (15:59):
Yeah. That's well, that's that, so, so around about that 2012 paper, so you were sitting on that for a few years. I imagine intellectually you
Peter O'Sullivan (16:07):
Were definitely. Yeah. How would I write this? How would I frame it? Yeah. And I kind of felt like I've been tagged with this. Yeah. But you were into, you know, stability, you're published on this stuff and I'm like, I had to come out and go, look, I get it. That's where it was at, but that is not what I'm thinking. And the reasons people got better were probably completely different reasons to what I thought, you know, you know, why a human being changes. It's probably got a lot more to do with fundamental beliefs and their perception of threat. And probably what we were doing is reframing in a way that de threaten them. And look, you could argue, you could take lots of different ways of doing that. I don't think it was the best way or evidence-based way. And so I had to reset that for myself
Jared Powell (16:53):
And then so publishing that. What was your, so how was it received sort of broadly at the time? Were you MOED? Were you criticized? Yeah.
Peter O'Sullivan (17:01):
Yeah, totally. Yeah. Yeah. I think there are a lot of people thought I'd gone to the dark zone. Yeah. Like lots of people, I felt like I'd betrayed my training in my profession and, you know, I was, it was not received well at all by a number of people. Yeah. And others, I congratulate me for having the guts to do it. And I, I didn't really see that as particularly brave. I saw as kind of redemptive for me more than anything. nice.
Jared Powell (17:28):
Peter O'Sullivan (17:29):
Was definitely, it was like, oh, relief. It was like, I just threw off that piece of clothing that really had I'd out. I'd outgrown yeah. It didn't suit my fashion at the time.
Jared Powell (17:44):
Yeah. Well, yeah. And so, so on that, right. So, so 10 years ago seems like in the grand scheme, not that long ago, but in evidence based practice in physiotherapy, I think if it's quite a long time ago actually mm-hmm. And so, so when that, when that paper came out, did you, so you were already practicing differently at that point?
Peter O'Sullivan (18:04):
I imagine. Yes, definitely. Oh yeah, absolutely. So that was more a landmark academic point to go, well, I, I need to sit my next direction clear here, cuz I've evolved way beyond where I was at. People were like going, they were talking to me like I was back 10, 15 years ago. I'm like, that's not me anymore. I don't sit in that space anymore. So yeah, no, I, well, and truly moved by that time that, that was more like a sign post to go actually, just to let you know yeah. Cause I was getting all these emails about, you know, this work that I was like, that's not where I'm at anymore. So I, this was like, Hey, read this. This is where I'm at now.
Jared Powell (18:42):
But isn't that amazing? The, the evolution of, of not just your beliefs, but, but the research as well. And I think it's, it's missing from a lot of practice and I'm not having a gold at anyone or anything, but this reflective mindset in regards to evidence. And you mentioned five, 10 minutes ago that you had two choices, you could either keep doing or leave what you were doing. I
Peter O'Sullivan (19:05):
Couldn't, I couldn't keep doing
Jared Powell (19:05):
It down a different pathway.
Peter O'Sullivan (19:07):
Jared Powell (19:07):
There's a third option. You just keep doing what, what you're doing ignorant. No, I couldn't at all.
Peter O'Sullivan (19:11):
Yeah, couldn't do it. No. And did you just, I'm a bit, that's me. I'm not, I'm a value based human being. So I just can't do. I don't believe in, I can't. I mean, you know, I, I nearly failed electrotherapy in my undergraduate training. I hated it. I didn't believe in it. I thought it was. I'm like, I, I just can't subscribe to stuff I don't believe in. And that's probably been to my disadvantage advantage over my life. It is who I am. Yeah.
Jared Powell (19:38):
You you're that guy. I love it.
Peter O'Sullivan (19:40):
I am that guy. And, and you know, I, I kind of reflect on the, where we've come as a profession, we kind of got ourselves we're historically locked into this, you know, short consult. You paid, you're paid for the session. Not for time. It's ridiculous. Like that is driving really poor practice that constrains people to not having time to think and evolve. I think it's a disaster for us as a profession. And I bailed out of that early and that was critical for me in my row if I reckon, how
Jared Powell (20:12):
Peter O'Sullivan (20:13):
But I reckon that said, I just did it.
Jared Powell (20:15):
Yeah. You just went.
Peter O'Sullivan (20:17):
I just said, look, if no one's come and see me. That's okay. But, but I'm here and I'm gonna spend an hour with patients and I'm gonna charge them for that time. Yeah. And if they want to come, that's cool. If they don't. That's cool. And I never ever my entire have I been without a significant wait list of people wanting to come because these people want to tell this story and no one gives them time.
Jared Powell (20:42):
Yeah. Yeah. Look, okay. Look, we're gonna, I'm gonna come back to that in, in a second. I just wanna, I wanna, so, so just on your evolution again, you, you know, there are many, many people in the world who just look at your early work, right. And then are completely ignorant to any evolution of your thought or any evolution of your, of your thinking. Well,
Peter O'Sullivan (21:02):
It probably makes it feel more comfortable. Yeah,
Jared Powell (21:04):
Totally. So do you think that's what under lies at all? It's this, it's how they sense of their world. Some
Peter O'Sullivan (21:11):
Totally look, we know that's what, that's what human beings do. Right. We, cherry picked stuff that fits our world view and we ignore stuff that doesn't because it unsettles us. Yeah. Cause we are fundamentally belief driven. Yeah.
Jared Powell (21:23):
Yeah. Yeah. And there's parallels with, with patience there as well, I guess, parallel
Peter O'Sullivan (21:28):
Climate change and vaccines and politics, and God knows what
Jared Powell (21:32):
I'm with you that's
Peter O'Sullivan (21:34):
Jared Powell (21:35):
That's conversation for next week. Can we go from your 2012 paper, Peter to cognitive functional therapy now I don't expect you to, to give the full synopsis of it, but what, what led to that it's it's
Peter O'Sullivan (21:48):
That was the hardest paper I've ever written.
Jared Powell (21:51):
Peter O'Sullivan (21:52):
Okay. That paper took three years. I I've never spent that much time. Yeah. Writing paper. And I think what was so hard about it, I think intuitively I worked the way I work to write that down was really difficult to articulate how I, how I intuitively work with patients was an incredibly difficult thing to do. And, and it was greatly helped by the team of people who were involved co-authors on that paper to kind of sculpt it, weave it. And I wanted to be a paper that was accessible for for clinicians that they could read it and go, that makes sense, but also to be heavily embedded in the patient narrative. So we had those cases in there as well to talk about the multidimensional complexity of pain and how we can't subgroup people. It doesn't work. We tried, it doesn't work.
Peter O'Sullivan (22:44):
We tested, it doesn't work. Everyone is their own individual, but to consider patients these different domains that are important for, for everybody and consider them within a multidimensional framework. So that then there's kind of two parts of that paper. One is the individual, the multidi dimensional nature of pain, which is bio psychosocial people go, oh, he's just into psychosocial. That's. I mean, like, you know, I tell, send people for MRI scans, I recommend surgery. That's about triage and understanding the drivers of pain. But for the, for, and so I see a mix of that in my own clinical practice, but it is truly about the multidimensional nature of pain. And then the second part of that paper is what do you do about, so there's like, what is the problem? And how do we, you know, how, how do I cons or how do we conceptualize how we manage it? And you know, to be, to be completely clear here, this is just a, a, a one lens of like looking through my world as a physiotherapist with all my imperfections and biases and weaknesses and vulnerabilities to go, how do I make sense of this world through my lens to take a patient with disabling back pain on this journey to deal with that complexity. That's essentially the paper.
Jared Powell (24:01):
Yeah. Well, very well, very well said. And it focuses on, on load back pain.
Peter O'Sullivan (24:07):
Yeah. But that, yeah, and we had to do that really because we were setting up a number of trials and we wanted to use the paper as a template to say, this is the intervention, this is our lens, this is the intervention. So that it was a reference paper for those trials. So that was part of deliberate. And then you know, it's really a template for looking at, at pain as I understand it.
Jared Powell (24:35):
Absolutely. And, and how how's that one been received, Peter? Was it better than your 2012 coming out or was it a little bit mixed as well?
Peter O'Sullivan (24:42):
Look, we, we it was, it was not except, well, we tried a few different avenues to get it published and there are some yeah, some journals didn't wanna touch it. Yeah. PTJ kindly touched it and it's, I think it's their lead paper. Yeah. and so look, I don't know. I kind of feel like we live in the ecosystems now. I, I, I, that's the thing that worries me about social media is like people talk, you know, you see this, you know, it's like you are, is that self confirmatory bias that we are so prone to. Mm. Yeah, look, I, I think probably there was a sense that you know, we were trying to brand something to me, it was much more to say, you know, we had to call it something and, and I see this huge gap within pain, the pain at the moment, we've got, you know, the biomedical and the psych psych over here. And there's this missing piece in the middle that the lived experience for the individual or like the embodiment and pain. And I think that's where this work sits somewhere is a gap between psychology and physiotherapy. And it's not trying to be a psychologist, it works with psychologists, but it fills a space that I think has not been adequately met in current practice.
Jared Powell (26:00):
So, so before we go into the, to the qual and the phenomenology stuff, what do you, what role do you see for quantitative research going forward? I still think you feel like it's valuable.
Peter O'Sullivan (26:10):
Yeah, totally. It does. Like, you know, we've been fortunate to be part of a cohort study group here and that's like big, you know, data sets of like tracking the development of pain and, you know, 1300 young kids from the age of 14 and they're now into their mid that's. That's been really helpful. Yeah. To go. What is the, you know, what's the big picture story of this group. Mm-Hmm, , you know, this is an emergent problem. This doesn't look like injury. This looks like some other, some chronic health disorder that emerges looks like asthma. So from a, just a broad picture, understanding of health to realize that this is like a complex multidimensional health disorder that emerges often and early in life, that sets a trajectory for life gives you a different understanding of the problem. I think that's really helpful to kind of look at it from a big picture and zoom into the individual. And we've been lucky to have been able to do that with access to that data set. So that quantity stuff tells you something in general terms that the qualitative stuff tells you about the individual. And you need both perspectives.
Jared Powell (27:20):
Peter O'Sullivan (27:22):
From a general how perspective or public health perspectives you need both.
Jared Powell (27:25):
Yeah. It's, it's, it's bringing all of that together, which can be troubling for a clinician. And I've experienced this myself, you know, it's, this is what, this is what that RCT says, right? Yeah. This is ineffective versus that or not, or whatever, but this person is here, so yeah. How do we reconcile that, Peter? It it's challenging for a lot of new graduates.
Peter O'Sullivan (27:47):
Yeah. Look, I, I, I see that, I, I kind of feel a bit concerned about what I see through social media, cuz I feel like there are these wars that are set up, which are really unhelpful. I genuinely think we have to come back. And I, that's why I love the likes of you know, Julietta Belton and her initiatives and looking at the patient perspective, cuz I think we're missing the patient in the middle of this. It's like, it's about our agenda. You know, it's like I'm into this and I'm into that. And this is where I, this is my skill. And I think this is better than that. It's like, honestly guys, we are talking about human beings suffering here and you are talking about your thing. That's just deeply insensitive in my mind to the people who are sitting in our community who are disabled and distressed and are suffering.
Peter O'Sullivan (28:35):
I, I just go, we need to come back to that as our reference point. Yeah. And stop these ridiculous arguments about minutia. It's crazy. So out like we have to be armed with knowledge and that knowledge and understand that knowledge is updating all the time. Yeah. It's all the time updating. And we have to be alert to be updated all the time, but we also have to be respectful for the individual. We have to understand what the literature says and there are some really cool, you know, I, I love the paper that Ivan ledge around best practice. Like that's a cool template to measure our practice by. And then the follow up to that was patient centered care, which I think's a really cool papering around. How do you deliver that practice? That's a really safe space. I reckon for a clinician it's not about, you should do this. You should do that. It's about the person sits in the, at all of that. And the person is the key and their agenda is the key. We come to this question with our agenda and that's not right. You know, we can impart our knowledge and perfect as it is. But at the end of the day, that's a dance when you're working with a patient and that distressed and you know, they're disabled and they're lost talking stuff at them. Doesn't help them.
Jared Powell (29:50):
Yeah. A lot of mansplaining going on. I, I remember a quote from you Peter many years ago. And again, this speaks to me stalking you over the years over internet. And I think you said something about helping a, a person in pain is like putting together a puzzle. They bring the pieces you help them put.
Peter O'Sullivan (30:08):
Yeah, that's right. I do see that. Yeah. I do see that. And
Jared Powell (30:11):
Is that, how is that a nice
Peter O'Sullivan (30:13):
Metaphor way? I love, I, I see it like that. So literally people come in to see me, you know, I had classic case, you know, this week of a lady came in, you know, just incredibly distressed and she's going the co I, my back, my back seized up a few months ago with COVID J it's a COVID J yeah. Like it was a COVID jab has to be really distressed. Right. And as it unraveled, the, it was all this stuff happening in this person's life. Like really tough stuff happening in this person's life. And the Ko jet might have just triggered something. might have let a match in a very dry forest with a rushing wind that turned into a forest fire. But a, I don't think it, you know, the COVID jab was the least of the issue in that sense. So I, I kind of, I, you know, that whole, you know, space for that lady was distress and she was frightened and she was lost and didn't know what to do.
Peter O'Sullivan (31:18):
It was on all these drugs. She couldn't think straight, she was, you know, threatened to lose at work. You know, that's the world I live in. Yeah. That's the space that I deal with. And it's like, you know, at the end of the day, at the end of the session, we could kind of reflect on how the nature of her pain and where she was gonna go was not just about the COVID jab, but I wasn't in a lecture on that at the get go. And my interest for her were her interest. She wanted pain control, you know, she wanted to get back to doing the stuff she loved. She wanted to be able to go to work and not be stressed. That's her, that were her goals. They became my goals in terms of how I cared for her. That's how we have to see this thing, I think. Mm.
Jared Powell (32:00):
And do you, that conversation or that particular case you just mentioned, it sounds, it sounds difficult. It sounds challenging. It sounds like there's hard conversations, right?
Peter O'Sullivan (32:11):
There's she had four panic attacks in that session. She was lying on my bed. She goes, I have to get up panicking. I go you're okay. It's okay. Just how did you
Jared Powell (32:20):
Peter O'Sullivan (32:20):
That? Breathe. Just breathe. It's okay. I get, this is stressful for you. I get that. You're frightened. Yeah. But just hang in with me. Just breathe. It's okay. At the end of the session, she said, I feel like I could go to sleep. Yeah. But I held her there. I held her there and go, you're safe. And like, if you understand fear, and that's why Sam Besley's work. And I look, I have to credit some wonderful people who have taken me on their journey. Like these PhDs colleagues of mine have taken me on journeys that they've led that have taken me through these awesome spaces. Like Sam's qualitative journey of understanding pain related fear. It's such a helpful body
Jared Powell (33:02):
Peter O'Sullivan (33:02):
Yeah. Such a and it's, it's resonates with Sam as a human being, you know, she's deeply interested in the individual mm-hmm but that's given, it's so helpful to then arm you to go what I'm seeing in this patient. It's fear. Yeah. Like I'm going, what are you feeling? I'm terrified. She's says she's terrified of lying on the ground. Like lying on the back. That's the nature of fear. It's irrational.
Jared Powell (33:25):
Yeah. And then, so
Peter O'Sullivan (33:26):
Yeah, it's tough. But I reckon that massively reflects us. Like we have a discomfort as seeing people distressed. We have a discomfort as seeing people in pain. That's on us as an individual. Am I comfortable with distress? Well, I have to be in my job. You know, like yesterday, I don't know. Six of my patients would've used tissues. That's a normal day for me. It's normal. It's good. It's healthy. It's, it's a normal experience of people who are suffering with pain. Yeah. I'm okay with that. We are not trained to deal with that stuff. As physios. We find it difficult. We shut it down. We ignore it because that's on us.
Jared Powell (34:07):
Yeah. And I, I reckon for the first seven years of my career, it still happens. My, when times get tough. What do we fall back on? We fall back on these fixing movement impairments. We fall back on a bit of manual therapy, which I'm not demonizing.
Peter O'Sullivan (34:22):
No, me neither. Look, I use manual therapy. Yeah. Cause it's, again, it's the patient's agenda. Yeah. But I'm really clear about what it means. Yeah. And I'm really clear about its place.
Jared Powell (34:31):
Yeah. And so you feel like our role is more of perhaps a coach of support, of empathy, of bringing knowledge to the table because there is a rich my,
Peter O'Sullivan (34:42):
Yeah. Like, look, I, I, yeah, a lot of things. And I think I captured, we captured that in in the, the CFT paper around the skill. Like it's a broad skill. I think that's so cool. Like we have to be really skilled in communication. We have to have a deep understanding of human behavior. We have to be at a trio for, for specific pathology. We have to have skills around coaching. We have to have handling skills. You know, we have to be able to be adaptable in the way we train people and skilled trainers of movement and build. I mean, essentially the, what we are doing is fundamentally, I think de threatening people, building self-efficacy shifting, people's understanding of their world. And that's, that's hard for clinicians. It's bloody hard for a patient with a lived experience. so, so there are two behavior change. Things that we think have to happen with, with a clinician. One is for us. And the other is to, we need to do it ourselves to take our patients on that journey. And that's what we are seeing at the moment through train our training programs with PA with physios is like, they're telling us this is that they're, that's an intervention in themselves. And some people find that easy. Some it's really tough and some won't ever go there.
Jared Powell (36:02):
This is why I think physios like
Peter O'Sullivan (36:03):
Our patients like our
Jared Powell (36:05):
Patients. Yeah. And who blame them. So this is why I think Peter physios are the polymaths of healthcare. And I got a little into a little bit of trouble for saying that, but we have to be aware of everything right. From the cells. Think so. Yeah. And I'm not trying to denounce any other profession. All healthcare professions should probably be like that. But, but we also have to appreciate how complex it can be as a job. Right?
Peter O'Sullivan (36:28):
Yeah. That's it is.
Jared Powell (36:30):
Yeah's what it is. So we have to support each other in new graduates, especially totally
Peter O'Sullivan (36:34):
Jared Powell (36:35):
Yeah. I don't,
Peter O'Sullivan (36:36):
I'm not undermine them. Yeah. Totally agree.
Jared Powell (36:39):
Do you feel like we are getting any better in terms of on average and this is your opinion. I'm not asking for evidence here in terms of, of appreciating the multidimensionality of pain and incorporating and equals one and all these sorts of things in on average in clinical practice, perhaps in Australia,
Peter O'Sullivan (36:55):
I think we give it lip service, but I think fun. We're not skilled. I think we don't have a skill workforce to deal with that. Yeah. I don't think we skill our undergrad and look, I can't talk for, you know, I have to be careful here cuz you know, I think, I, I think, I think there is a shift in a lot of the teaching programs. I definitely think that, but I, the skill set required, that's pretty tough. You know, I've kind of gone through my journey, acquiring skills. So I've got about it. I, I kind of wish that someone at the beginning of my journey had gone look, mate, if you wanna spend your time and energy do it in this way, would've saved me a lot of heartache, but that probably wouldn't, you know, then my journey, my journey would look different to that.
Peter O'Sullivan (37:37):
And I'm not, I don't read anything that I've done from that angle, but yeah, I think we need to really be like I think dealing with particularly like if you think of our health challenges at the moment there's noncommunicable communicable diseases, the pain is a massive issue. It's a huge source of disability. We are not managing it well in our communities. We're not funding it properly. We don't have, we're not porting the resources into it that need to be that constrains bad practice as I see it. And we are not upskilling people to feel confident in dealing with it. And that's what we understand from the qualitative studies. So yeah, we have to, we have to real I think a multi-prong approach of like one develop evidence. So we just can't be doing. That's got no evidence. That that's part of what we are interested in and, and look at it to say, you know, can we, we talk about self-management right.
Peter O'Sullivan (38:34):
Self-Management doesn't happen. Self-Management is coached, it's evolved. That's a really hard gig for someone who's locked into opioid dependency and outta work and whatever to shift them towards self-management and massive goal, we put it's in the guidelines, but how do you do it? Yeah. What does it no real well, there's no framework behind that. And it's like the, the reviews go, you know address psychological and physical barriers to recovery. Well, what does that look like? How do you do that? And you know, I, I feel like we have this huge opportunity to upskill which to me is kind of like, that'll be the second part of journey I, as I see it that's kind of like my next chapter I reckon.
Jared Powell (39:20):
Yeah. Awesome. Yep.
Peter O'Sullivan (39:22):
My last chapter, maybe ,
Jared Powell (39:26):
I'm not no Peter, you much, many more chapters to go. Can it, so that that's, that's sort of gets us to just briefly yours and Jeremy's paper, right. And terms of this, how we are trying to reframe how we care for people with persistent Mulet pain. And it's a beautiful paper. It's just, it's hard to see it. And from my perspective, and this is, I'm not having to go on anyone or anything here, it's just, and this was what you were saying before. We're just not set up clinic wise to be able to Institute a lot of these things. Are we, because there's pressures from bosses, there's pressures from this and that massive
Peter O'Sullivan (39:59):
Issue. So massive issue. So I look at it this way. You don't go to a psychologist for 20 minutes, do you? No.
Jared Powell (40:06):
Peter O'Sullivan (40:07):
Jared Powell (40:08):
Peter O'Sullivan (40:09):
They don't work like that. I don't work like that. I can't work like that. Now 20 minutes is okay to screen and it brain ankle for someone who's highly coping, give them some advice. So you know, I, my view on how we should be stretching practice is screen for complexity early. Yeah. And then, you know, drive people down two paths. So for those who have got simple problems, don't overtreat them cuz you over medicalize them. They don't need it. Reassure them, set them up for success, cuz that's all they need reassuring education success for those who are vulnerable, we need to capture them early. Cuz we know they emerge early. And most of these people present with the recurrence of an underlying problem. When happens in their life, usually is what happens. And we, our systems are not designed to deal with that.
Peter O'Sullivan (41:01):
So Ivan Lynn did this led this study in ed, looking at people in non traumatic pain, heaps of them coming into ed with back pain, neck pain, and they're scanned and given opioids and sent on their way. Like these people are crying for help. They're frightened and what are we doing? They're frightening them more, you know, like that's nuts. So, you know, in my mind we need to be able to screen people. Everyone should be screening. Their patients, identify those who have got, you know, who've got complex and then either not hold them, either refer them to people who are skilled to deal with that complexity or upskill yourself to deal with it yourself. And you know, to my way of looking at it, you don't wanna spend an hour with every sprained ankle cuz that's or a, you know, cast strain or whatever, cuz that's just not fair on those people to pay for that. But that idea of actually structuring funding around complexity to me just makes a whole lot of sense. That would change our landscape if we could do that.
Jared Powell (41:59):
Yeah. Yeah. Well I I'm with you there. Well, so what are you I'm conscious of your time here, Peter? What are you, what are you working on at the moment? Is there anything we need to, we need to keep it here out.
Peter O'Sullivan (42:09):
Where do we go well with we've run this big trial in Australia, which is we're called the restore trial. It's a two center trial between Perham and Sydney and ironically it's the only CFT trial that's been conducted in Australia. And people go, why does that happen? Well, you know, I, I, there's a perception that if I treat my patients as, or I don't treat any patients and collect their data, never doesn't happen cuz that's got huge inherent biases. Mm. But this trial was really it's fully funded in a, in H I C trial where we trained a group of practitioners toward to competency. So it wasn't like you just go and do a program and go out like we, we trained competency. So you couldn't be involved in the trial and this, you were delivering what we perceived to be CFT.
Peter O'Sullivan (42:58):
So that's, that's, we've got a PhD student Phoebe Simpson who's working in that space, looking at the journey for the physios, which is a really cool space and she'll be publishing that work next year. And then we are looking at both economic and clinical outcome for these people and they people who are really disabled. So we took in, you know, a lot of physio trials exclude people with psych comorbidities. I mean, that's, that's other people we need to help . So it's crazy. You know, they exclude people over 65 there's whole group of people at a later age who are desperate for help. So it was a very inclusive trial. It was compared to usual care cuz we wanted to look at the economics, the outcome and the economics of that. So that's a really important study for our group to go and we will learn a lot from it, like all research, you know, it's and I think, you know, it's embedding something that's completely cont countercultural with in the health system.
Peter O'Sullivan (43:56):
Like a lot of what we do is completely countercultural to people's understanding of pain. And I don't know if you read the back facts paper, but that paper which was published in BJ saying, which also has like gone like wildfire collected the beliefs, like basically collected the beliefs of about 80 P people, chronic low back pain. There were all these common misconceptions and then talked about the facts. That's a huge challenge for us. So, you know, that's an area that we're working on. We're also JPS involved in applying CFT to people with NEA who have been told they need an ear replacement. There are other implementation studies in the UK and Denmark utilizing that model we're involved in a a study, a a co care model. These, the other thing that was particularly interested in that physio shouldn't be in silo that we need to be working closely with other health care practitioners to deal with really tough patients.
Peter O'Sullivan (44:55):
So Rob Schutzer, who's part of our group clin site, super guy and he's leading some work looking at how CT dovetails with pain, psychology to kind of integrate care as a model here. And then we're kind of looking at how that works in the GP space as well. So yeah, there are heaps of projects. , that's just, that's just touching a small fraction of it. So kind of two streams of work, well number of streams of work, but yeah, yeah. Peripheral like peripheral pain how the, this model works for, that sits in that space as well as in the, in the pain back pain space where I see this going, you know, de depending and look, this is updating all the time. You know, it's not this, this is not a constrained intervention. I, I, I learn every day in practice. So, you know, that's the beautiful part about learning.
Jared Powell (45:50):
Did, did your just quickly did clinical experience of seeing patients contribute to your
Peter O'Sullivan (45:56):
Jared Powell (45:57):
Massively evolution? Yep. So
Peter O'Sullivan (45:59):
My complete abject failure as a clinician, my complete inability to affect any meaningful change whatsoever in my patients made me deeply unsettled and highly reflective people who came back or were lucky to come back to go, yeah, really screwed me up. You know, what you did just blew me ups like what the hell is going on here? And that's where I think that's, I, I think I've been fortunate that the patients know, know I deeply care for them that they've been good enough to come back and go, mate, you're up. Like that has been so helpful in my clinical journey. That's
Jared Powell (46:40):
A great report. And,
Peter O'Sullivan (46:41):
And it, and it is still helpful in my clinical journey. I don't get it right all the time at all. Like, you know, we've got a tough gig managing, helping people at pain. It's a tough problem of this stuff emerges from deep, early life trauma that sets the trajectory. That's a highly vulnerable group of people, you know, simple therapeutic modalities are gonna do nothing to that. That's a much deeper issue that we have to support people with. I'm not promising fixes for those people cuz I don't, I have them.
Jared Powell (47:15):
So I think that's the message. Honestly, from today, Peter it's it's clinical practice is hard. People are complicated as they should be. Right. But learn, reflect, grow, evolve from these experiences, keep reading, be radically open minded, critically appraised to all these sorts of things. And perhaps one day will be adequate. Right?
Peter O'Sullivan (47:35):
Well I think the other, the other thing that goes with that is we have to be way kinder to each other. Yeah. And not bashing each other up. We have to be supporting each other. We have to be kind to each other. There's a lot of lack kindness out there in the social world, social media world. It's just ego driven. It's not nice. I hate it. That downs me as well. And I feel like it's driving people away for important conversations.
Jared Powell (48:01):
Peter O'Sullivan (48:01):
With you. It's not right and wrong. It's it's about, and I just go back to hang on at, let's go back to the patient. It's their agenda and let support. I mean, I, I get saddened by hearing young physios going, you know, I don't see a future in this job. Yeah. I, I, that saddened me, but I go, well, that's a product of partly training. Partly the way the system is operating the constraints of current practice to survive, force you into these doing that you probably don't wanna. I be doing that you don't believe in. You know, that I've been fortunate. That's not, I could ended up there. I would've gone and done something else. And I nearly did. I nearly did. I nearly left at the early stage in my career. I nearly did, but I'm so grateful. I didn't. Cause I love my job.
Jared Powell (48:46):
Yeah. Good. It's
Peter O'Sullivan (48:47):
I, I wanna just finish with that. I got this card yesterday day. This is the golden moments for me in my work. Dear Peter, there are no words for me to express the amount of thanks and gratitude for you. You have given me my life, me hope and happiness and ESTs of my life again. Thank you for being a compass to help me get on my right track. Like that's the gold that makes me love my job. And that's a person who was outta work, who was on a shitload of opioids who was disabled and distressed. And now is back at work. She's off all the drugs. She's got a pathway for a future. She still has some pain, but it is not, it's not dictating her life like that is just the loveliest experience as it's a such a privilege to take a person on that journey and look, not everyone gets to walk that path. But if, if in my small time on this planet, I can help facilitate a shift in how we care for people. I'm happy with that.
Jared Powell (49:50):
Beautiful. All right. I'm gonna finish off with what book are you reading right now? These are weird questions.
Peter O'Sullivan (49:56):
That was interesting. Like I I just recently read John Suzuki's the legacy. Oh cool. It's a very cool book. It's very short, but it's kind of a, a reflection on our responsibility to care for our planet. A very beautiful book and it's resonates deeply with me. I feel very unsettled with our, our political landscape at the moment and how we're operating. And to me, I don't see a lot of discussion around that, around that, but you know, care for ourselves care for each other care for our planet as part of our ecosystem.
Jared Powell (50:30):
Peter, that's a perfect, that's a perfect end point. That's absolutely poetic. I thank you so much for your time mate. Like I said, this is, this is really, you know, 10, 15 years been a physio and you've been probably the biggest influence on my career. I know I can speak for a lot of my colleagues as well. I'm not trying to inflate your ego here, Peter, but I'm just trying to say thank you. So thank you very much for your time.
Peter O'Sullivan (50:52):
Yeah, look, thank you. And I think one of the things that we don't, we don't often know, we don't really know how our work sits on people. So to hear that it has influenced you in a positive way is wonderful. Cuz that's we spend, we agonize and spend hours doing this stuff off to try and how we message something and we don't always get it. Right. So if it, if it falls well and sits well on people, that's great. So that's what it was, you know, then it's done what we hoped it would do. So thank you.
Jared Powell (51:21):
No, you're welcome. Thank you for listening to this episode of old physio podcast with Peter O. Sullivan. If you want more information about today's episode, check out our show notes at www.shoulderphysio.com. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you. Soon. The shoulder physio podcast would like to acknowledge that this episode was recorded from the lands of the Yugambah people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning and working from every day I pay my respects to is passed, present and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.