Jared Powell:
Hello everybody. We've got a very special guest today. In very funny circumstances, we have Professor Peter O'Sullivan. Peter, welcome back to the show. Yeah, thanks mate. Nice to be with you, Pete. We're, we're all ready to do a big webinar presentation today. We've got our wires crossed, so we're gonna adapt as all good human beings do, and record a, a quick podcast conversation. Pete, last time we had a chat, I have to check, but it was probably three or four years ago, and we talked about your fascinating change and evolution going from like the spine biomechanics, man. Yeah. Which you were renowned as being to, to modern day Pete, the, you know, the champion of the patient's voice and bio-psychosocial care and, and cognitive functional therapy. Sort of, I wanna signpost that for people to go back and listen to. But today, Pete, I want to chat about your more recent work, which is the restore trial, which is your new academy that you've set up evolve. Do you mind just giving everyone a little bit of an update actually as to what you've been been doing over the last few years?
Peter O'Sullivan:
Yeah, yeah. So probably been in the trenches a little bit. Really , so like up until, you know, probably eight years ago, we'd had a number of small trials that have tested cognitive functional therapy as a model of care for people with chronic low back pain. And what do we know about chronic low back pain? It's a leading cause of disability in the world. It's extraordinarily hard to affect long-term changes. And if you look at the systematic reviews for pretty much anything, the long-term, the benefits of treatment often, you know, fade out at six months and usually there's nothing at 12 months and there's almost no three year follow-ups because there's no benefit at 12 months. So why would you follow someone up for three years? So it's a kind of bleak space if you look at evidence for treatment. So we'd had these two trials that were demonstrated 12 month benefits.
Peter O'Sullivan:
So one was Miria O'Keeffe's trial, which in a really tough group of patients that was demonstrated, you know, moderate effects out to 12 months. Full reductions in disability shorten furs trial, which compared to manual therapy and, you know, exercise demonstrating three years effects as well for reductions in disability. So, you know, issues around dropout and critique around different aspects of the trial. So we, Peter Kent applied for funding for a large multicenter trial. So that was based in Sydney and Perth, and it was against usual care. So that was the restore trial that was published in The Lancet in 23, which is a, you know, a really cool kind of acknowledgement of the rigor behind that research. It was multicenter, it was in practice. We trained a large number of clinicians, 18 clinicians. They were all nested in primary care. So it was kind of as much of a close to a pragmatic implementation trial as we could.
Peter O'Sullivan:
We didn't constrain what the control arm had, they could have whatever care they wanted or were offered. The other thing that was unique to this trial is that because we were training 18 clinicians, we had to create a training program. What often happens in a clinical trial is you have a clinician that comes and they do a workshop. They go, oh yeah, no worries. We'll go and deliver. But what we, what we know from most, most psychosocial interventions, and one of our now postdocs, Phoebe Simpson, did a scoping review looking at psychosocial interventions or biopsychosocial interventions for back pain, is that very rarely do these interventions trained to a competency standard, and very rarely is the fidelity of the treatment assessed during the trial. So you don't even know what people have done. So what we did differently in this trial was we trained people to a competency standard.
Peter O'Sullivan:
We said, these are the things that we need people to deliver if they're delivering CFT. And so that was around interview technique around behavioral examination around, you know, the key clinical reasoning communica person centered communication and delivering the intervention. So we took people through a training program, which we developed, which train knowledge and then skills, and then we directly mentored them while they treated people with chronic low back pain. So real world stuff. And then we gave them feedback and got them to self-reflect and watch their videos, and we gave them feedback on the competency checklist. And then over a period of six months, we got everyone to a competency standard, and then they went into the trial. That's quite unusual in a clinical trial that that's done. So it was a rigorous training program. We can talk about, you know, is this, what a, what's that look like that made this trial quite unique and that we knew that people were delivering the intervention they've been trained for.
Peter O'Sullivan:
We tested it against fidelity checking, and they delivered it. The results of the trial demonstrated large and sustained effects for everything we tested, essentially. So reductions in disability, reductions in pain, reductions in fear, increased confidence or self-efficacy, reductions in pain catastrophizing, and it saved a lot of money. So the, the economic benefit was fi over $5,000 per person across a year. That means the training program to train one person is paid for by one patient. That's it. Like, you know, people go, oh, it's too rigorous, and, you know, it's too expensive. It's like one patient pays for that program. Now, across your career, I don't know how many people you, and that was across one year, we've now got, which should be published in the next fortnight, the three year follow-up data, which shows that this is now maintained out to three years. So those effects are out to three years.
Peter O'Sullivan:
So what happens beyond that, of course, is, you know, we don't, we won't know, but it's highly likely that if you've changed someone's pain tra trajectory and disability trajectory out to three years, that's likely to be enduring. So that that's massive. Yeah, it's cool. It's super exciting. Yeah. And we are now doing further trials as well testing this in different countries, you know, different care systems, different populations of people, but that was a tough ca that was a tough population. We explicitly had a very open inclusion criteria. We wanted people who were tough, who had failed care, basically. So they were predominantly in the higher middle risk group. If you think of a start back screening tool, we had very few low risk cases, and we know they, those are the people who are hardest to treat. Subsequently Mark Hancock published a moderation paper showing the people who benefited most from this were the most disabled people and the, the people we're failing in our health system. So there's lots of really cool work coming from this that tells us there's something that's changing in these people for the long term. Yeah,
Jared Powell:
I want to get into that. Can you first, how would you describe CFT to a lay person? What are the key principles of CFT that you would want somebody to understand?
Peter O'Sullivan:
So, great, great question. So, and we get asked this often. Number one, it's person centered care. What does that mean? It means we are interested in, you know, what's going on for you, the impact that pain has in your life. And we are interested in what your goals are. So it's personalized care. It, it is considered the whole person. So that means we are interested in all aspects of your life and your understanding of your pain and your fears and concerns, your social situation. That's critical. There are three pillars of CFT, and this is aligned to what patients ask for. Patients predominantly say, there are two things I want. I want to understand what's happening in my, what's going on. That's like, number one, what, what's this whole thing about like making sense? So making sense is a pillar of CFT, of like, how do I make sense of this problem?
Peter O'Sullivan:
It's personalized. So we lean into the person's story at their experiences and what we observe in their examination to help them make sense of what's going on for them. We often describe that as people come to us with a, as a jigsaw puzzle, but they, they don't know what it looks like. They've got all the pieces there, but they don't know what it looks like. And we just help to kind of lay out the pieces in a way that makes sense to them. And often patients go to us, they literally say, that makes sense. The first time this has made sense to me because we are doing it through the lens of their own experience.
Jared Powell:
. The
Peter O'Sullivan:
Second pillar we call exposure with control, which is fundamentally well. So the second thing patients ask for is they ask often for three things. And we, we, every patient who we see, we go tell us your short-term goals and your long-term goals. Very often a short-term goal is, I want some pain relief or control over pain. And a long-term goal is I want my life back Now. Life back might mean get back to work, play with my kids, have confidence to get back to the gym, to do the stuff I love. It might be, you know, to be able to sit in a chair and go to the movies, like, go out for dinner with my friends, ride a bike. You know, like it's all the stuff that makes us who we are, the things that we value. And so the, the key element around the, the exposure with control part is pain controllability.
Peter O'Sullivan:
And often, you know, what we see with from a lot of our research is that people with back pain become massively overprotective. So, you know, when you have pain in the body, you over guard and you protect it. You start avoiding stuff, you start changing the way you move, you end up tensing up muscles. It might be consciously or subconsciously. So we help them unravel that process of like learning trust back in the body, learning to relax the body, re-engage with movement, build confidence back in the body, and then generalize that to the stuff they love. So that process of kind of building self-efficacy, building confidence, often breaking these rules that a people governed by which we give people this crazy information of like sit tall, bracey core lift with a straight back, which actually leaves people very trapped in this kind of, these rules that don't serve them well, that kind of create abnormal overprotection and tension in the body, which is probably no prognosis, we think.
Peter O'Sullivan:
So that's kinda like the second pillar is like, build confidence back in the body with pain control to get back to the stuff you love. And the third pillar is around lifestyle change. So get people re-engaging in regular physical activity, get them sleeping, build strategies around sleep, which we know is really important. And kind of dialing the nervous system down. Stress coping strategies around body relaxation, re-engaging socially. You know, we may lean into issues around healthy diet and all of those kinds of factors as well, but we know though lifestyle factors are really important not for everybody, and that's why it's personalized. So we don't give a, you know, a blanket, you gotta do all this stuff. We go, Hey, tell me about the pattern of your pain and what the things that are that are drivers for it, and let's work out a way, a bespoke strategy where you can target those things in a way that makes sense for you in a way that fits within your life and is aligned to your goal. So that's kind of, you know, an an overview capture of what CFT looks like, which is fundamentally aligned to the guidelines. It's aligned to what p patients ask for. So it's person centered and, and it kind of makes sense and it's, it is got evidence.
Jared Powell:
Yeah. It's, it's got the most robust evidence out of really anything for non-specific low back pain. I've got, I've got about a thousand questions. I'm gonna try and remain coherent here. I mean, CFT as you describe it, it sounds complete opposite of like the find it and fix it kind of mentality that we've had in physical therapy for since its inception. I imagine. How do you deal with the tension of a culture that still promotes this, find it and fix it solution in a profession that's still, still, it still pervades the profession, let's be honest. Yeah. How do you deal with all of that in your, 'cause you still work clinically. How do you deal with that in clinic?
Peter O'Sullivan:
Yeah, so if you look at my journey, Jared, and I think we to touched into that in the last podcast, but that's where I came from. I trained as a manual therapist. I trained to identify impairments and treat impairments. But what we know with, you know, people whose pain becomes chronic and persistent is that doesn't work. We know we can create short-term pain relief, but it doesn't change pain trajectory. So, you know, the kind of the palliative approaches around manual therapy, which are probably, they're very driven around treat the signs and symptoms, not the underlying drivers. And I, I realized pretty early in my career that that was not something I was fundamentally comfortable with. Now that's not to say that we can't provide pain relief for someone who's suffering, but the long-term journey is the key. And in my mind, you know, someone's suffering and I can create pain relief for them.
Peter O'Sullivan:
That's totally cool. But the long journey is the key. If those, that person keeps coming back with the same problem day after day, great for business, crap for Kia. So we need something different, right? And so I'm not, I don't kind of sit in this world as you mustn't put your hands on people. I'm much more pragmatic to go, what can I do to pro to provide the best care for this person at this point in time and in their journey to get back to the stuff that is important for them. That's the key in my mind. I'll give, let me give you an example of a young woman I saw yesterday, 22. And she'd written a letter to me saying, look, I've seen numerous physios and chiros. I've had scans done to my back. I'm in, it's impacting my mental and my physical health.
Peter O'Sullivan:
I don't know what to do. Please, can you help me? She told a story of having literally a dozen people she had gone to see who had given her corrective advice around body posture, needling, massage, manual therapy, manipulation. She had done it all, but she didn't know why she hurt . And she's going, I'm like, what do you think she's going? The hardest part is everyone's told me something different and I'm so confused. Every clinician I've seen has told me it's something different. And it's almost all of it is around something is at fault with your body. And I said to her, what do you believe is going on? You live with this day in day, you are the expert. She goes, what I've noticed is I'm way worse when I'm stressed. I'm like, oh, tell me about that. Well, I've had all these stresses. So all of her social stuff comes out around the stresses in her life.
Peter O'Sullivan:
So how do you respond to stress? I tense up. I can feel it. I tense up. I don't sleep so well. I become agitated. So what's your relation to this pain? I can feel this tension in my body. I can't dissipate it. So what are you trying to dissipate it? Well, I've been given all these corrective exercises and what do you notice? Well, it just makes it worse. I'm like, okay, so let's explore what you're doing. That's a great example of where the fix, it just hasn't worked for this young lady. It's now impacting on her mental health. She can't do the stuff she loves. She can't work in the job she wants. She's 22. She values physical activity and she's frightened to do things now with her body. So her body has become a threat to her. She's lost confidence in it and the things that she's been told aren't working for her.
Peter O'Sullivan:
So for people like that, that's a 22-year-old, right? That's a whole life ahead of her. If we don't help this young lady, where will she end up? Someone will probably operate on her. Someone might offer injections. She hasn't gone down the pharmacology route. But the kind of rolling stone, you know, trajectory of chronic pain is that we just do more and more stuff to it. Instead of fundamentally going, Hey, let's look at what the factors are here. Let's look at what's important to you and let's take you on a journey and let's give you the tools to be in charge of your body so that you know how to manage it and respond to your own flare up so you're not dependent on me. And that is just such a joy as a clinician to kind of empower people to be in charge of their health rather than be dependent on me for quick fixes that we know don't deliver for people like this young woman.
Jared Powell:
Yeah, I mean, I can regale you with stories that I'm sure you can with me how many times I've seen that in the past. It's depressing actually, when you think about it. People have this misconception, I would say, Pete, that CFT is pain education. And I know that's completely wrong. Yeah. So can you please explore how, you know, common physical therapy interventions such as exercise therapy, manual therapy, advice, education, all of these things that we're trained in. How do you incorporate these pillars of physical therapy into CFT? And it's not just you are talking to somebody for an hour.
Peter O'Sullivan:
Yeah, yeah. Great. So all of our qualitative research is when we ask patients, what do you think this is? Which is, that's the perfect way to do it. It's like, you know, we have an idea of what we think we are doing, but actually if you say to a patient, what was it that you got from this? What was most important? They often say it's the first time that things made sense to them. It was not generic. They weren't given a booklet. It's like they could see how all the pieces and the puzzle fitted together of their own experiences, which are often confusing and contradictory. So there's a, that's a key dimension around personalized understanding of what's going on. The second part they say is, you've coached me. There's a lot. Therapeutic alliance is critical. Trust, trust in the clinician, but you showed me, you built trust back in my body to do the things that I'm frightened of doing that I've avoided that are valuable to my life.
Peter O'Sullivan:
So that's about the doing. So I would say the talking bit is to build therapeutic alliance and identify the barriers for the patient as well as the person's strengths that you can lean into. The doing bit is the golden bit. And what it's what we call behavioral learning. And that is so for this young woman. And she's like, I can't, I can't bend, I can't lift when I, and I sit for a period of time. So I'm like, okay, show me all those things. And you know, sure enough, during the session, every pain was ramping up when she was doing it. And I'm like, huh, I'm noticing, do you think you're breathing when you're doing that? No, I'm not. What are you thinking of? I'm focused on my back. So, okay, let's change this. Let's just try something different. Let's get you to relax your body, start breathing, f change your focus, shift your attention, now do it.
Peter O'Sullivan:
And she's like, whoa, that doesn't hurt. What does that tell you? So what we call reflective behavioral learning, and that is your deepest learning is your experience. So if you have, if you have a belief that you can't sit for a period of time or bending and lifting will do you harm or ramp your pain, it's your experience and you give that person a completely different experience and then you, you can unpack it and go, huh? So when you relax and move and do the same thing, it doesn't hurt you and you can do more of it. What does that tell you? It tells me it's safe. It tells me that my rules that are govern me and not been helpful. It tells me that I've got this new opportunity to engage with things that I love. So that's the behavioral stuff. Now, in terms of hands-on, we use hands-on a lot to facilitate.
Peter O'Sullivan:
She didn't know where she was in space. I can paid her and go stick my thumb in her back. She goes, UCH, that's seven outta 10. I'm like, what am I touching? I'm like, I don't know. Touch it yourself. What does it feel like? Oh, it feels like a knot. Okay, what's a knot do you think? Oh maybe a knot. It's a bone. No, no, it's not a bone. It's probably a muscle, right? So clench your fist, it's like, oh, that's hard. Relax it. Oh, that's soft. Touch your back again. She goes, I didn't know. I was so tense. So we used touch to train, to teach, to give people insight. And it's like, hey, check in with your breath. Where's your breath? It's like, oh, you know, it's up here. It's really shallow. Hey, what happens if you bring it down here? Oh, that's hard.
Peter O'Sullivan:
I don't know how to do that. Like, let's try it. And like, ah. So I notice now when I'm stressed, I breathe up here and really shallow when I breathe down here, it's like, makes me feel calm. Huh. So does that influence your pain? Yeah, relaxes my back. Oh, that's interesting. 'cause You were telling me the tension's, the driver. So you can see how we incorporate the patient's story, their own beliefs, their own experiences, the role of touch and behavioral learning to create this deep kind of understanding of what's going on, making sense and building confidence back in the body of like. She came in going, I have no control over my pain. Walked out going, I've got this new understanding of my pain. I feel like I'm in control of it. I'm gonna go to the gym today and do stuff I haven't done for the last three years. 'cause I was frightened every time it did to hurt me. And that starts a journey. Love
Jared Powell:
That. Beautiful. I'm gonna continue that train of thought when that that person wants to go to the gym. 'cause I, I wanna bring this down, you know, to the very fundamental level for a clinician. 'cause They, they wanna know what they should and shouldn't do in this situation. Yeah. Will, will you write that person a gym program? Pete? Well will you say go see a pt,
Peter O'Sullivan:
A gym program? She had a gym program she was doing, which she loved. I'm like, what's gym program? So I'm like, how would you write your gym program? Like, you know, like, so I'm like letting her direct it. I'm like, what are the things you love to do in the gym? Love lifting weights. Cool. So where would you start? Okay, do this and this. So she's like, can I do that? I'm like, start right. What would be a a weight that you could start that's light. You can gradually build up. And she's going, I'm so excited. I'm like, what else can you do in the gym? Oh, I love cardio. Like what? She goes, well what about the row machine? I'm like, yeah, great. Like, you know, repeat a bending something she's avoided. Now we might, if someone's really sensitized and really fearful, we might start that journey a lot slower. You know, it is like, baby steps lead to big steps. So we might start that really slowly and build it up, but for others it's like, let's go . Yeah, it was a let's go person. . Yeah.
Jared Powell:
We love those people. We love, we love all people. But yeah, they're often a little bit easier. But the challenging,
Peter O'Sullivan:
So just on that question, some people need really clear guidance and others have a lot of internal self-efficacy themselves. And we are just, we are just leaning into it. And as long as they don't get caught in a boom bust cycle where they just go and smash themselves, flare up and they come back and go, well that was a waste of my time. You know, all that's told me is that I shouldn't be doing this thing. We want to set people up for success, not for failure. Yeah,
Jared Powell:
I love that. That sort of breeds a dimension of self-efficacy. Is is mastery in small wins, right? Setting people up for success.
Peter O'Sullivan:
Absolutely. Yep.
Jared Powell:
So you gotta get
Peter O'Sullivan:
Those. And the magic layer ups is the other most important thing. And we saw that, we've seen that in our case work and within the restore trial, everyone gets a management, a pain flareup plan. Because pain flareups are almost inevitable for people with chronic conditions. Be it asthma, be it, you know, like whatever. Back pain is exactly the same. And mastery of flareups is the other thing our patients have told us is really important of like, yeah, I've had a flare up, I don't panic now I know what's going on. I reengage with the same thing used. I used to panic, protect, avoid, you know, lie in bed disaster. Like, you know, now I know what's going on, I realize it's safe. I've got tools to reengage and movement and I get better quicker. That's
Jared Powell:
So important. That's so important because flares, flares are, in my opinion, a different, there's often a different response in a patient because they can come to you with 12 months history of back pain, whatever, two years they feel better. But then within 12 months there's a flare. Does that mean everything's just been for nothing?
Peter O'Sullivan:
Yeah. And often they do. They'll think, oh my god, you know, I've just lost everything and I'm back to square one. Where we actually say to them, Hey, it's like the flu. You're gonna get it like at some point and you'll feel like crap. The key thing is, you know, it's gonna get better and look for the things that trigger it. So what we know from, you know, the things that would trigger a flare up when you're stressed, when you're run down, when you're not engaging in physical activity, you know, like it's usually general health stuff that predicts a flare up being more sedentary, you know, flat mood. That's the stuff that triggers a flare up. It's not because you've done harm to your body or injured yourself. It's usually a minor event with a stressed human being. Yeah.
Jared Powell:
That's super important to get across. Pete, can I ask you a challenging question? Perhaps? I know you like these questions, so it's not, it's not a gotcha moment, but what, what do you do when somebody isn't responding to, to CFT? You know, how often does this occur for you and how do you sort of manage that?
Peter O'Sullivan:
Yeah, great question. And I suppose the, there are a number of things that spring to mind here, and I, I lean back to our research on this as well. So within the restore trial, about 70% of people, or 75% of people, I think achieved a clinically important change for reductions in disability, which is really impressive. That was out to 12 months. What that tells us though is around 25 to 30% of people haven't achieved that. And the moderation analysis we looked at, whether it's people with high levels of pain, people with high levels of disability or distress or catastrophizing or fear, and those things didn't predict outcome. So that left us a little bit, oops, the things that normally are predictive of poor outcome, we didn't sh we didn't identify in that moderation analysis. So that kind of helps us lean back into the qualitative work where we go.
Peter O'Sullivan:
We asked people who are non-responders to go, what are you thinking? There are a few things that come up and then we ask clinicians as well. There are a few things that come up. Number one is, as a clinician you've gotta reassess, have I missed something? You know, have I missed some underlying pathology? So don't, you know, it's not just about the patient not engaging, fundamentally go back and reassess, make sure you've not missed something. That's number one really important. Number two is what's happening in the person's world. And what we've seen is people who've got a lot of social stress in their life, and I, I get to see these people that are caring for someone with Alzheimer's or major mental health problems and the, you know, the under enormous stress and they don't have much social support. They might have a lot of financial stress.
Peter O'Sullivan:
There's just loss of happening in their life that makes recovery so much harder. That's where we just gotta, you know, really support those per that person in the journey to kind of build some stress coping strategies around their life. There are other people that we see who are absolutely fundamentally believe they're broken. They've had an MRI scan, they've seen a surgeon. The surgeon says, look, your back's screwed. You know, you need a, you need to have your disc fused or a, a replacement. And that becomes an absolute fixation. And fundamentally, if you believe you are screwed, it's really hard to get better. And, you know, we will lean into as much of the behavioral learning to try and dis-confirm that belief. But for some people it's inevitably go down that path of getting a fusion or whatever. This is not a panacea, it's a journey.
Peter O'Sullivan:
And some people just don't have the internal resources to walk that journey. And, and that's just the reality of what we're dealing with because there are so many counter pressures in our society through social media, through peer networks, through our health system that makes CFTA really hard gig because number one, we don't fund it adequately time for clinicians. Number two, we don't upskill clinicians. And the narrative or the discourse around back pain means that most people think back pain means your back's like a machine. There's something broken, it needs to be fixed. And that's a really hard shift for some people. So they're the kinds of big ones that we would see and and probably the other group of people who have had significant early life trauma. You know, they carry a really often a, not all but a number carry a really big burden. You know, we know influencers, their whole health trajectory. So that's probably the other group that we would see. Yeah,
Jared Powell:
Yeah. There's some really sort of serious things in there that like, it would be sort of remiss of us to think that, you know, we can fix everyone. Right. What is on their own journey And there are so many influential contributing factors within that.
Peter O'Sullivan:
Yeah. And I think the other thing that taps into Jared as well is like, you know, often as a young physio, we were taught it's all about pain. It's not about pain. It's like, it's about what's important to the patient, right? And the patient comes in and says, look, I want my life back. And that we see that like, I want my quality of life, I want confidence in my body to do A, B and c and DI can cope with pain, but I can't cope with not having my life. If we start fixating on the pain, then we are not aligning our care to the patient. So we've gotta ask them about what's important for them and make that our priority of our care. So, you know, when we ask people down the track, you know, how are you going, I'm, I'm great. What does that look like? Yeah, I still get pain, but it doesn't bother me. It doesn't define me. It doesn't limit me. It kind of reminds me to care for my health. That's a great place to be. This idea that you've gotta be pain-free is not about being human. And I don't think that's a helpful expectation to create in any human being because it's not about being human. Yeah. Like is part of life. It's about defines you and how it impacts you. That's what's important. Yeah.
Jared Powell:
It's the antithesis to being human is to have no pain. You know, the rise of ai. They might not have pain. Yeah. But they probably will if they develop some sort of experience in the Yeah. Like, you know, first person experience. Right. Just
Peter O'Sullivan:
On that pain has probably been one of my biggest teachers in my own life. And often patients say that to you, say that to us. It's kind of like, and this has opened all kinds of doors. I would've never opened if I didn't have go on this journey. We hear that is kind of like, that journey kinda enriches all kinds of aspects of a person's life. 'cause It kind of, it helps them engage with like a, a broader sense of health, I think, which is beyond the back.
Jared Powell:
I have a few more questions if you've got time, Pete. Yeah,
Peter O'Sullivan:
No worries. All
Jared Powell:
Good. I'll go to, I'm interested in mechanisms and causal explanations, et cetera, et cetera. How do you think, I, I don't know if you've nested a mediation analysis in the, in the response
Peter O'Sullivan:
Yeah, we have. Well, fingers crossed it should. You
Jared Powell:
Don't reveal too much if you don't want to, but could you hypothesize? Yeah. Cool. How, how does it, how and why does CFT work for you? Yeah,
Peter O'Sullivan:
Great. So that's a big question we've asked. We've asked this in a few different studies. So single case experimental designs allows you to ask what changes when relative to someone's symptoms. What we've seen in our work, it's, it's kind of like a complex system where everything changes at once. , you know, we often go, it's like, oh you gotta change this to change that. We don't see that in a lot of our work. We see that the person walks out with a change mindset. They walk out with renewed confidence, they walk out less frightened, they walk out with a, with a different belief around their body and different behaviors around the way they move. It's like this cluster of factors seems to shift all at the same time. Now for some people it looks like one thing needs to change before another. But a lot of people, it all happens at the same time.
Peter O'Sullivan:
So what are the things that we know are important for recovery? And I reckon this is a really cool kind of thing as a clinician to keep nested in your head. It is like, what does it take for this person to get better? That's kind of where I would go. Well what we know is that if you build this self-efficacy, they function more, right? What's that mean? Confidence in the body. Confidence to reengage in valued activities, confidence to go to work, confidence to bend up and pick up your kids or play with your kids. That's really important, right? So is my intervention, building confidence in that person to reengage in stuff they love. So self-efficacy, really important. Pain catastrophizing. So, so it's a really unhelpful 'cause it's got a kind of, it's a bit stigmatized, the the language. But fundamentally like what are you thinking?
Peter O'Sullivan:
Like your thoughts around your back is like, I'm screwed, I'm damaged, I can't do this, I'll never get better. Like those thoughts we can screen and like an arb bro screening tool, you know, belief that it's for life belief I can engage in physical activity, that kind of stuff. So when we see that drop people's pain drops. And so that's around your thoughts and your disability drops as well. The other one is around pain related fear. And this is specific to, you know, the populations that we see who are frightened and there's lots of sources of fear. And, and Sam Buns Lee's work has looked at this around people frightened because the information they've been told frightened because they've been told their back's worn out, frightened because they've got a back of a 60-year-old and they're 30 frightened because they've got torn discs or they've got arthritis or whatever.
Peter O'Sullivan:
So we create a lot of fear in people. Or it could be fear of loss, fear of movement, fear of doing damage, fear of the future. So when fear reduces pain, reduces disability reduces as well. So, and the other one that we've seen is a reduction in pain itself. So when you have less pain, you are more likely to engage in physical activity. So that's not really commonly explored in the chronic pain space. 'cause There's almost a belief you can't change pain. Pain is very modifiable. And it's something we explicitly target in CFT. So the fundamental things for a reduction in disability are reduction in pain are building, increase in self-efficacy, reduction in pain, catastrophizing and pain related fear. Those things explain a lot. Then we've had a series of studies that have looked at movement itself. And what we've seen is speed of movement looks really important.
Peter O'Sullivan:
So if you ask someone to bend over and pick something up often, and when someone's frightened or in pain and not confident, they move really slow. As they get quicker. That correlates with a reduction in pain catastrophize and an increase in self-efficacy kind of makes sense. You'd see the same in the shoulder. Someone's like, oh, doing this versus they do this and they're like, whoa, what's changed? Like speed of movement. It could be the range of movement hasn't changed. Speed of movement's changed. So we see some really interesting kind of behavioral links to kind of being less protective is how we would interpret that. You know, with doms, you've got gone to the gym, you have real, you just move slow. What that reflects is probably a whole bunch of things around your thoughts and the levels of sensitivity. Again, you know, increased confidence to move. So they're all the kind of things that we are seeing that relate to improvements. And that's consistent across the pain literature. We know those things across, not our literature, the pain literature. If those things improve, people get better. It's almost like retrofitting your interventions to target the things that have to change. And
Jared Powell:
A hundred percent
Peter O'Sullivan:
We have a hundred percent done that. And within CFT we explicitly target all of those mediators that we know are important and we see that they underpin the treatment. Yeah,
Jared Powell:
A hundred percent. We have a, a paper under review right now about why mechanisms matter. And it matters because that's where you target your treatment, right? Hundred percent. And I, everybody might have slightly different, everyone needs to just like change this one thing. You can certainly have person-centered care there, but like, we need to be aware of the causal influence of the things we're wanting to target. And if we're targeting strength when it's bloody self-efficacy, that's the, that's the mediator, then we're getting nowhere and this is where we've been for half a century. So I think that's super important.
Peter O'Sullivan:
Yeah. Really important.
Jared Powell:
Can I ask about the trainability of clinicians Yeah. To do CFT? Yeah. And because as a, as an early career physio, I could imagine that it might seem a little bit daunting to like, to have all these hard conversations with people about pain and stress and sleep Yeah. And all these things, right? Like clinicians receptive. Do they learn quickly? Do they implement it well? I know you've mentioned fidelity a few times. How's that whole thing?
Peter O'Sullivan:
Yeah. Such an interest. We are really interested in the space because that, I was involved with the paper around the modern pain clinician. Like what, what are the skills that it is kinda like, instead of thinking, oh, what does a physio do? It's like, what do patients need? You know, what do people with chronic pain need? Because in a sense, what we've done in our, in our care systems is we've, we've kind of just attached professions to a problem. Instead of saying, what are, what are the skills you need to address this problem? If that makes sense. Well, how I see it is kind of the patient's sitting in the middle and we've got psychologists over here and physios over here and pain physicians here, and a GP here. And we are kind of like all doing our bit. The patients are going, my needs aren't met.
Peter O'Sullivan:
Like fundamentally, we had to listen to the patients. And there's a beautiful paper that Helen Slater led called Listen to Me, learn from Me, which was what do patients with chronic pain want from us as clinicians? And that's a super cool paper to go have I, am I delivering that to the people that I care for? So, you know, it can be daunting. And I, I think fundamentally there are a few things that are daunting around pain. Back pain holds a special place for people to become frightened, right? Like we are frightened of it. Patients are frightened of it. So our own belief systems are really important. And we don't like people seeing people suffer. And people with pain often show a lot of distress and a lot of protective behaviors. And we will often lurch back from that because we don't want to hurt them.
Peter O'Sullivan:
'Cause We think ourselves harm and hurt at the same thing. What we saw in the training program was a lot of the time is we were building the confidence in the clinicians to lean into and engage in behavior change where they were like, oh, I don't wanna do that. Oh, the patient said, oh, this is making my pain worse so I'll back off. So we give people a lot of subliminal avoidance, protective messages all the time and the way we nonverbals as well as verbals, right? So that's a lot of what we coach people with. The other area is that we hear is people are like, well, I'm not a psychologist so I feel deeply uncomfortable asking people about what's happening in the world. And we would say, have you got friends? Have you got a family? What do you see if, if you know that your friend and your family are having a hard day?
Peter O'Sullivan:
Do you, do you ignore it? Well, maybe you do, but that's not cool. Would you say, Hey, it looks like you're having a really tough time. What's going on for you? Now that doesn't mean you fix it, but what we know is showing empathy, deep listening, a validation of a person is in itself therapeutic. We just that, so the interview, we kind of break our assessment. Like we go, oh, we interview, we assess, we treat, that's crap. We intervening with the person. The moment you lay your eyes on them, the moment you shake hands with them, the moment you ask them to tell their story and you go, Hey, that sounds really tough for you. How's that working for you? Or, that sounds like you've been through a really hard journey. Often they'll break down a cry. How's this impacting on your life? Now how you respond to that, you just go, Hey, that's super normal.
Peter O'Sullivan:
It's really normal when you're in pain and you're distressed, you can't do the stuff in your life that it gets you down, that it makes you worried. So that's not a mental health problem. That's a normal response to pain when it disrupts your life. So that's another key point of the training. Now probably the short answer is not every physiotherapist may feel they're ready and willing to engage in that journey, and that's their choice. But let me tell you, you go, this happens in sport. It's like, it's a human experience. If you're not comfortable with people's emotions, you should probably think of a different job because it's just the nature of pain. And my view is we need to upskill people to be comfortable with those conversations, to validate that, to sit with people's discomfort, not to fix it, to be alert to when we need to refer to someone who, who might need to see a psychologist for additional care. That's important. That's a critical role as anyone treating pain that's irrespective of profession. Like, it doesn't matter what profession you're in, they're just fundamental communication skills that number one patient's value that we know improve clinical outcomes. They reduce your risk of being sued. They encourage your patients to come back and engage with us and trust us. It's good for your business. Like there's no downside in it. Yeah.
Jared Powell:
Beautiful. I've got one more somewhat deep question. Feel free to pass on this. As an empathetic and caring clinician, how do you avoid taking like too much on Yeah. Mentally when helping people with severe disability? We know burnout's a big problem in physiotherapy. Yes. It's, you know, where where people too, right? So you, I reckon you hear all these stories and they're very affecting. How do you manage it? Yeah,
Peter O'Sullivan:
So I, it's a really great question, Jared. And it's something that we are very alert to because we work with, you know, people who come with a lot of a big burden. We know that's a big deal. I think there are a few things that are really important. Number one, I'm, I reckon as a manual therapist, I carried a way bigger burden 'cause I was trying to fix people. Mm-Hmm . I'm not doing that in my job anymore. That takes so much pressure off me as a clinician. I'm really coaching people and, and that's their choice if they want to go down that journey and I will adapt to their needs and they're trying to support them in their goals as much as possible. But I can't carry that for them. That's probably number one. Number two is we need clinical, clinical communities that support each other.
Peter O'Sullivan:
And what we've heard is that the hardest gig is to work in a silo where you don't have good collegial support. So having those social networks we know are important for human beings and we need them in our clinical communities. And that's part of what our dream is for the Evolved Pain Care Academy, is to connect clinical communities across the world so that we can coup support each other. The third part is around my own self-care. So what do I do? Like I'm up every morning and I would do like an exercise routine yoga, like, you know, strength work, whatever. That's a non-negotiable for me. I do it every day. I've got a dog. I walk my dog every day. I, I hang out, work in the garden, I go mountain biking. That being in nature and being active is part of my own therapeutic journey.
Peter O'Sullivan:
Also, I think just that ability to self-reflect to, to talk to someone that's around that social support, but also just having really good stress management, your own stress management strategies. But the collegial bit's really important around that. And I think, you know, often we, we train up physios, we just chuck them out into the ethos when no one like psychologists don't do that, right? Yeah. The psychologists, they have ongoing support and they go through mentoring. And that's the other thing that we are doing on the Evolve platform is looking at supporting and mentoring people because we are not skilled. You can't be skilled. I wasn't skilled when I graduated. I'm still learning every day when I work with patients. It's an ongoing journey. So we've gotta do a better job of supporting and nurturing and and empowering our own people so that they realize this is not straightforward. It's extraordinarily rewarding work, I think. Mm-Hmm . It's the most rewarding thing I do in my job. You know, see the transformational change in people, but it comes with a, it comes with a burden and we need health systems to support this, that pay for time. That's another, yeah. Massive issue. Underfunding not enough time. And then we're, it's like saying go and see the psychologist for, for 10, 20 minute sessions. No psychologists will do that. Why would we expect someone with chronic pain to be managed in a 20 minute session? It is nuts. Absolutely nuts.
Jared Powell:
Yeah. , don't get me started on that. I, I remember as a new grad Pete, I, you know, talking about supportive new grads and early career clinicians, I straight into private practice, 60 to 80 patients per week, 20 minute consults. I did it for two years and I nearly destroyed myself. And then I went overseas and have had to find myself and blah, blah, blah, blah, blah. Yeah. And that's not, that's not sustained. That's not healthy. That's the worst thing you could do. Yeah.
Peter O'Sullivan:
And I feel so sad. I, I saw a post saying that most physio, well there's a huge drop out of physios out of our profession. And it really saddens me actually, you know, people go, if you had your choice again, what would you do? I I just love my work. Right? I made a decision and I had a similar experience to you where I literally nearly got out of physio. 'cause I'm like, I can't keep doing this job. It's not sustainable for me as a human being. You know, it's not, it's not healthy for me. I made a decision in 96 to completely change our work. So a new an hour for a new patient, half an hour for a follow up. I've never changed that. Probably one of the most other most important learning decisions in my career of the sustainability. Now the problem is health systems don't fund our time. Well, some do, but a lot of them don't. And we've kind of got ourselves trapped in these short consults, treating signs and symptoms. 'cause You don't have time to do anything else. It's a really big problem for us. Yeah.
Jared Powell:
Can you speak to us briefly about your Evolve Academy please? Yeah.
Peter O'Sullivan:
So once the Restore trial came out, we had literally thousands of people contact us to go, Hey, how can we learn about this? And I'm literally invited, you run workshops all over the place. It's not good for my health. It's not good for the sustainability of the planet. So I'm like, yep, that's not cool. So what we've done is we, as a team, we decided we would, we wanted to do a few things. Number one, we wanted to make access to knowledge equitable. What does that mean? It means that we know the burden of back pain is really high in low income countries and middle income countries, but they can't access knowledge. So one of our goals was how can we create free resources and how can we create equitable access to training so that people in low income countries can access it at a level that's affordable for them.
Peter O'Sullivan:
And fundamentally, we are hoping that people in high income countries will support their colleagues in low income countries. That's kind of like our mission. So we set up an a social enterprise, which is fundamentally non-profit. So all any profit goes back into supporting the mission. That's the Evolve Pain. Carere Academy. There's a portal for patients. 'cause We want free knowledge for patients because we want clinicians to send patients to go, this is what the evidence tells us. It's trustworthy, it's evidence informed, and it's in a language hopefully 'cause it's co-written with people with pain that makes sense to you. So that's the free portal. We've got free open free knowledge as well, like as a short workshop for anyone. Young graduates, new like students, people who are just want interest so they can dip in and get their toes and go, what's this all about?
Peter O'Sullivan:
And then we have tiered learning, which is about like a, it's literally like a three day workshop, which we call a knowledge workshop. Real patients, real encounters, talking through the journey of recovery of patients. Two really different patients. One where the journey was so hard and the other one where it was a little bit easier. And then the follow up tiers are around developing skills and then mentoring. So essentially we realize that people will want different exposure to this work, and we are giving them access to various levels of exposure. Some people want work in, in pains and pain clinics where, or they're dealing with a lot of people, chronic pain and they really want the upskilling journey. Then we want to support them with that. So, you know, fundamentally that's where we're at at the moment. We've self-funded it. We put in a lot of work and time and, and hours and like everything we do, it's evidence informed.
Peter O'Sullivan:
So we've tested this already in a couple of implementation studies. One in Scotland, one in Denmark are taking people through the journey using the online resources and they love it and it works. So it is been road tested. So it's not like we are just chucking something out that we think's a good idea. It's, is had extraordinary amount of work behind it. And we are using this now in all our subsequent trials to support clinician training, but we rely on feedback. Right. So yeah, we, we are interested how this also adapts to people in low income countries. Do we need to change the messaging? We always like patient feedback, clinician feedback. We want it. So if any of your listeners go on it and they go, oh no, that's crap. We don't like that, this would be more helpful. Tell us . That's how we learn.
Jared Powell:
Tell yeah. Tell you nicely. Don't, don't troll Pete. Yeah.
Peter O'Sullivan:
You know, fundamentally we learn from like, I think all of us learn from constructive feedback.
Jared Powell:
Absolutely. I I still think that constructive criticism is like the biggest driver of progress and change. Right. It's, we we're nowhere without it. Yeah,
Peter O'Sullivan:
A hundred percent.
Jared Powell:
Can I finish with some rapid fire questions? Yeah. And also a couple of funny questions from listeners. They wanted to ask you. Favorite book of all time? Favorite, favorite book of all time? Oh. If you have one or one you're currently reading or, or a genre that interests you.
Peter O'Sullivan:
Oh, look, I, I really love Isabella Inde, so I've read a lot of her books and that kind of, this beautiful exploration of the human experience and history and that's the kind of stuff I really, it's the, it is the human experience, the lived people's journey. I'm drawn to that. That's, that would be kind of like the novel kind of book that I would enjoy. Cool.
Jared Powell:
Is that fiction? Non-Fiction?
Peter O'Sullivan:
Yeah, it's fiction. Cool.
Jared Powell:
Coffee order or hot beverage order.
Peter O'Sullivan:
Oh. So I actually have my own little Italian coffee machine, and part of my ritual in the morning after I've done my workout is I, I will make a coffee. It's a flat white.
Jared Powell:
Beautiful. Me too. Isn't that the best way to start a day? A bit of movement. The smell of coffee. Yeah.
Peter O'Sullivan:
I grind the beans. I've, it, I've had this thing for 20 years. It's like the, you know, it's like the, the old Ford that just keeps going
Jared Powell:
. Yeah. But you know it inside and out, right? It's, it's part of you good favorite food if you were to have a favorite food?
Peter O'Sullivan:
Hmm. Great question. Look, I love fresh food, so probably I've got this great dish that, so I like cooking as well, so it's kind of, that's my other kind of, you know, download time is when I cook, so it's a really cool recipe. Macadamian coriander, a pesto with white fish on a sweet potato beans and red onions, .
Jared Powell:
It's great. I'll come visit you when I'm, lemme
Peter O'Sullivan:
Know and I'll cook it for you.
Jared Powell:
Absolutely, mate. And you pair that with a bottle of white. Do you, are you a wine man or,
Peter O'Sullivan:
Yeah, I do like, I do like a little bit of wine you know, maybe a bottle a week sort of thing. Well, not a whole bottle, but share a bottle with people I care for.
Jared Powell:
Yeah, yeah. Good on you. Good dogs or cats or both?
Peter O'Sullivan:
Yeah, so we have a cat and a dog. My dog is this beautiful white German Shepherd who I, I was very resistant about getting a dog. My wife wanted a dog. She grew up on a farm. She goes, we need a dog. I'm like, I'm like, don't have time for a dog. I love that dog. You thought about self care. She is just the most beautiful thing in my life. We walk every day together, like for an hour a day. It's sort of my meditative downtime, you know, like literally come in the door, run, jump on the bed, you know, like, that's my dog. She's beautiful. The cat cat wakes me up about four in the morning, scratching my face, wanting some food. ,
Jared Powell:
Textbook cat, cat behavior
Peter O'Sullivan:
Over your face. The dog will never do that. love, but it's a different relationship. And you'll never call your child by the cat's name, but you, well, the dog's name . It's, it's a special relationship. ,
Jared Powell:
My youngest son is called Rex and there's a lot of dogs out there called Rex and I can see that resemblance there. People want to know your haircare routine, , because you have a ridiculous head of hair and of your vintage, no offense or what do you do?
Peter O'Sullivan:
I do. You know, a really funny thing is, I think we posted the Restore trial and someone made a comment, you can't trust anyone with a perm like that. . it must be the Irish gene. So am I here. Turned wildly curly in my early youth and has remained that way. My daughter has the same hair, but it'll a bit longer. I have the easiest hair care routine. It's called Wet and Shake, . .
Jared Powell:
I need to steal one of those curls and put it in my head, Pete, as a bald man and maybe it'll grow a, a garden in there, . Alright, that's all, that's all from the the rapid fire questions. Where can people find you? Are you still on the socials? I know you're trying to do a bit more Insta. Where can we find you?
Peter O'Sullivan:
My X is a bit of an evil place, but I still, I'm still intermittently on that LinkedIn where, you know, part of the evolve is got a social network on Instagram and LinkedIn, and so we're trying to push things more towards that rather than being my personal, but I, I still do engage just because it's a, it's a nice way to kind of share knowledge to people who might be interested in it. People around the world tell us they value it, so that's why we do it. Awesome.
Jared Powell:
And you've got though the Evolve website. Yeah, if you wanna find Pete's publications, I'll link a few, but I, I'm assuming you've got a Google Scholar or research. Yeah,
Peter O'Sullivan:
That's right. Yeah, yeah. Perfect. And the other thing on the just on the evolve is we've put up all the open access papers on the Evolve website, so people who wanna dig deeper around all the work that we've done and other work that we think is really important. We've got, it's, it's all in that within the free resources for clinicians on the website. Awesome.
Jared Powell:
Okay. Peter O. Sullivan, thank you very much.
Peter O'Sullivan:
Good on you mate. Lovely to chat.
Jared Powell:
Thank you for listening to this episode of of the Shoulder Physio podcast with Professor Peter O'Sullivan. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rate in your 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 Ang 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 elders past, 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.
