Episode 1

* please note this transcript is auto-generated and may not be 100% accurate*

“What it highlights is that coaching people to better health is a great way of caring for people rather than creating a dependence on them to come back and see us again and again”.

Welcome to the ‘Empowered Beyond Pain’ podcast, proudly brought to you by Body Logic Physiotherapy. I’m Kevin Wernli, a physiotherapist and Ph.D. researcher, and I’m joined by world-leading physiotherapy specialists* and clinical researchers Professor Peter O’Sullivan and Dr. JP Caneiro as co-hosts. 

We’re based in Perth, Western Australia, and through this weekly podcast, we aim to make sense of science and bring evidence to your eardrums, to empower you to better health, and empower clinicians to provide the best care for people in pain

Each episode is full of practical tips and insights to help increase your understanding, and shift your behaviours to nudge you down the road to growth.

Welcome to the first-ever episode of Empowered Beyond Pain. We’re absolutely thrilled to have you here. In this inaugural episode of season 1, we chat, from a distance of course during the Coronavirus pandemic, with Professor Peter O’Sullivan from Curtin University and Body Logic Physiotherapy. 

The conversation is mainly related to Frequently Asked Questions about Telehealth (Also known as, online video consultations). We talk about things like how online physio helps without putting hands-on people, avoiding unnecessary surgery, as well as the mechanisms behind how people improve and get out of pain. After the conversation, I summarise my take-home messages, and we introduce the ‘to try today’ segment which is designed to help you turn information into action. 

This episode is proudly brought to you by Body Logic Physiotherapy, where the goal is simple, to empower you to better health. If you’d like to know more about how telehealth works, visit www.bodylogic.physio, and click on the Telehealth button. This conversation was also recorded a few weeks ago, and things may have changed by the time you’re listening to this, so keep an eye on the website to stay up to date. We hope you enjoy the conversation and remember to ask… Is there more to pain than damage?

With the whole coronavirus pandemic happening lots of practices are moving towards telehealth rehabilitation and it’s been some interesting research. For example, a systematic review showed that telehealth was as effective as face-to-face consultations for the management of musculoskeletal pain and injuries. Alan, can you kind of talk to how people get better or how telehealth was proven to be just as effective as your in-person face-to-face consultations?

(Alan) It’s interesting and it doesn’t come as a great surprise to me because I think what we’re learning more and more about musculoskeletal pain – is the things that are really important around pain for people is to have a clear understanding of what’s going on for them. Educating them, but also learning tools to get back in control of their pain, and to regain function is imperative. 

So, these are the traditional tools of – 

• hands-on pushing it 
• massage
• manipulation
• kneeling.

It’s also developing an understanding of building confidence and having strategies of getting back to function again. These are things that we can do, just in this format. The way we’re doing it now and the beauty of video consulting particularly, is that we can easily demonstrate to people. I can get up with and demonstrate movement and set a program up, but I can also look at how you’re doing it too. 

So, it’s got this capacity to both communicate and to watch and to modify behaviour, and set up a program. That is what we would do in a normal consultation. The disconnect in terms of you’ve been face to face with me putting my hands on you. It’s not the key thing that influences whether a person gets better or not. It’s much more around – do you understand what’s going on? have you got a clear plan? Have you got strategies that you can implement to make changes to get you back to living again? These are things you can do easily through telehealth. 

Australian government deems physiotherapy as an essential service but you and the directors at Bodylogic physio have decided to only have online consultations. Can you tell me about that decision?

I think it’s wonderful the Australian government sees physiotherapy as essential because we have such an important role in the community in terms of helping people manage pain, but also other aspects of physiotherapy like healthy neurological and respiratory. Obviously our area is pain, which probably represents the bulk of physiotherapists in the private sector.

We took a view that we had a social responsibility to care for our patients the best way we could. To us, there was a growing risk that we ourselves, as well as people coming into our practice, could be carriers of coronavirus without our knowledge. Because of that, we were seeing more and more highly anxious patients coming in looking at us as if we could be carriers. We felt it was actually untenable to provide a high level of care with the view that we were keeping our clients safe. 

We decided last week that we would move to telehealth and the reason for that is essentially the fact that we felt we could deliver the same high levels of care, through a safe environment. It was safe for the patients. Safe for us. And provided the care that they needed in the comfort of their home. It wasn’t a hard decision in that sense, because we felt like it was the best way we could be here for both our community as well as our staff. 

The practice, you know, if you ask the general population what physiotherapy is I feel like the consensus would be that physios assess and treat pain and injuries and that provides some sort of hands-on treatment. Some massage and manipulations with some dry needling, but it sounds like with physiotherapy at least bodylogic has kind of changed a little bit. I suppose the existing model of physiotherapy and perhaps what modern physiotherapy kind of looks like. 

It’s a great question and I think probably one of the things that frustrate me most is when if I’m with a group of people and they go “So what do you do for a job” and I say I’m a Physio. It drives me crazy because I think there is that perception out in the community that physiotherapists only provide short-term pain relief.

Because they’ven saw this or that and don’t know what we do and the fact we’ve you know, evolved a lot. I think certainly our research has. I often practice that it takes a bit longer to change but certainly the research work that we’ve been involved in highlights that hands-on therapies provide pain relief in the short term. And they tend to be purely that it’s short term pain relief, but what we’re interested in is providing a level of care or a certain type of care that empowers the person to self-manage their problem. And reduce their reliance on us to provide care to them. 

In a sense, we’re working as hard as we can to get people not to rely on their care, which may seem like a very bad business model. But it’s a wonderful health model because it puts people in charge of their health and this builds their confidence. It gives them the tools to manage flare-ups if they get a pain flare. It gives them the confidence to engage with movement and activity and to go to work, even if they may have some pain.

Because they know they’re not harming themselves. It also equips them when they can’t contact us that they have the tools to cope with their pain in a better way. I think, you know when we kind of see these different ways of looking at physiotherapy, the idea is that physiotherapy is about hands-on therapy and providing short-term pain relief. We know from all the guidelines that it’s an option but it’s not the whole care package. It’s an option you can add that into your care package, but it isn’t the whole care package. 

The care package is giving people a clear understanding of their pain. Sure, if you’re identifying anything serious, you can refer them through to a doctor. But we can give them strategies to manage their problem that often involves exercise. It may involve relaxation. But whatever it involves, it gets them back to living again. And addressing other lifestyle factors such as sleep, managing stress, and regular physical activity. We can also help with recommending what you eat. Those kinds of things that we know are very important in terms of your general health and both mental and physical health. 

I think we’re dealing with a population at the moment who’s fearful and they have enormous stress. Often, they’re stuck in their homes. I really feel for people in our community who maybe have underlying health issues or in the ADA older age group who are feeling quite isolated in their homes.

To us, telehealth is an amazing opportunity to support those people in that community. By the sounds of it, it’s not just our local community, but it’s wider than that across the country and around the world. You sort of mentioned it being a bad business model, but what I know you know from my perspective is if it helps me get better and you taught me how I can better and get better and stay better. I’d probably tell everyone about it. Or if someone asks me about pain, I’d kind of share that news as well as “it’s tongue-in-cheek the bad business book”.

I believe good care of human beings is a wonderful business model and the best care you can give someone. It’s the best way. Then you can have people coming back to see you. Not the same people, but the friends and the family and of those people in the neighborhood. That’s the best model of care.

What sort of advice would you give to people in the community that are a bit stuck at the moment and are dealing with uncertain circumstances? Well, yeah look, I’m ahead of my day-to-day of doing telehealth sessions I’ve had people of all ages I’ve had a quite a young chap and I’ve had many older people. All of them, I think, would be feeling a bit uncertain. People can’t go to the gym anymore, so they are having to reframe what exercise looks for them. 

We’ve had opportunities to discuss what other kinds of exercise they can do to build up a program for them and that’s good for their health. I’ve had another chap who’s had a pain exacerbation and so I’ve been able to give him simple strategies for him around managing his pain on his own and getting moving again, building his confidence so he can get back into activities as soon as possible. 

I have other people who are over 70 who are restricted to their homes. I wonder when I build up an exercise program for them what they can do in their living room. Then I address issues around their mobility and their strength and their balance. As well as their fitness, we can be creative around what we do with almost no equipment. Just using body weight in a chair and using imagination, using dance. There are so many ways in which you can build movement back into people’s lives in a creative way that is linked to their goals and includes the things they love. 

If people wanted to find out more or set up a consultation with someone like yourself or anyone else what should they do? 

It’s a great question. I think probably the thing I would people ask first is what can you provide me through telehealth? I think that taps into fundamentally what people are after and what they understand with their pain. If you’re hearing that someone’s saying “look we can listen to your story, and we can assist you. We can set up and we can map out your goals we can build strategies to get you back in control of your life.

We’ll get you doing the stuff you love. Build confidence. And give you resources that can help you understand how pain works.

If you’re going for a consultation, we can teach you how to self-massage. We don’t need to provide basic therapies that don’t align with your needs. With what evidence we have, I’d be asking some questions first. Before you set up that consultation and they’d be around what that model would look like for you. I think that’s the fundamental question of how the model works for the patient. 

Is there anything else that you wanted to talk to the public about telehealth?

I think we’ve had so much change in that community within a very short period. We’ve been talking about doing telehealth for years now but we haven’t had the time to do it. Now we’ve been forced to do it so that’s something that we’ve done literally what was going to be a two-year plan we’ve done in a week. I think what a crisis like this does, it forces us to change and adapt. 

The other thing that I think is important is that a lot of our community will be feeling abandoned at the moment. They might have been on a wait-list for a knee replacement or a hip replacement. Or an arthroscope or a tendon repair. Or other forms of surgery like for spinal or other body parts. I think the one message that I would give to that aspect about community is that there is so much that high-quality physiotherapy care can offer those people. 

We’ve seen it in the GLaad program with people. Managing weights can be a significant pain reduction and can help them reduce their medication and get themselves active. We’ve seen it with numerous trials now around this approach without hands-on therapy. 

You can coach someone to understand their pain and to get back to living again. That can have huge benefits in terms of reducing their levels of pain and disability. There are lots of opportunities that I think of that can come from this crisis, where people may feel like they’re being denied one level of care here. That’s more into surgical interventions, but actually, there’s a whole other level of care they can access. 

We know now that the government has agreed to support telehealth for chronic musculoskeletal disorders with medicare rebates. And we know the health funds are also coming on board to support that. Its a profession I think they have an amazing opportunity to reach a group of people we may not have had otherwise because they’re looking for a different kind of care that they haven’t had access to.  

The cool thing is we’re not limited by geography. We can provide this level of care to a wider community to geographical areas where people may not have been able to get access to us before because of transportation barriers.

I think what you’re sort of saying about people having a different option- I read a study that was done from an undergrad program where they put people on to have knee replacements and they gave them an exercise in education and a weight loss program. Now that can be done through telehealth and a year later your follow-up. Well, seventy-five percent didn’t end up having a knee replacement because they got to a stage where they improved so much from the education side they didn’t need to. In two years it was 66 percent that still hadn’t had the knee replacement. This highlights a huge opportunity for people to have alternative care.

Absolutely, and I had a guy just last week who we saw for the first time. He needs a total replacement but I’ve set him up with the program instead since his surgery was canceled. He came in just as a checkout review, but this guy is going to do just fine. He’s fearful not protected through the program, but I’m reviewing his program later this week. He’s avoided what I would say is unnecessary surgery. 

I think what we do know at the moment is there’s a lot of unnecessary elective surgery, that’s not acute surgery like fractures or acute medical problems. A lot of people are being scanned and then they get told based on, you know, a rotator cuff tear or some other joint changes that they need a joint replacement. We know that it be a knee hip shoulder or rotator cuff tears. We then test them for meniscal tears in the knee. Physiotherapy can help to solve them. 

Educating people and giving them the tools to get back in control of their health has a massive benefit for those people both in terms of symptomatic reduction. And also getting them back to living again and functioning and caring for their general health. 

I think those are the messages that we want to spread. This is not a fix. It’s not a cure. But a lot of time surgery isn’t either. This is a way in which we can support people who would feel may be abandoned at the moment. It is a huge opportunity for us to work together and to find the best care fit out there. 

You’re a professor at Curtin University doing research there but for the people that don’t know what’s EFT is can you briefly discuss? 

It’s called cognitive functional therapy and it’s an approach of management for people with disabling muscle problems. There have been many studies that have looked at the application and this approach for the lower back, but we’re also applying this to other body regions like the hip and the knee. Essentially the basis is an approach similar to the things that we talked about. 

It’s around understanding people’s stories and understanding their beliefs, as well as their fears, their worries, and concerns about their pain. By exploring how they use their body concerning the pain often what we see when a person has this pain for some time, the tissue becomes very sensitive. They’ve also become very protective and guard their body and they start not using it normally.

When this happens I can help with ongoing sensitivity protective guarding. So, the cognitive functional approach is to get people to understand the pain and gradually get them back to restoring their levels of function. Then we kind of take on the protective, like the hand brake of the system, by not protecting the body. And that takes time.

 It’s a graduated process of restoration of movement, learning to relax the body to get back strength and mobility and function. And of course, the confidence back to the body so they can get back to living.

That takes about a three-month process of gradually coaching someone through that journey and can take anywhere between five and what some of our motivated patients do – up to ten sessions over three months. 

Several studies look at people with disabling back pain and demonstrate larger benefits in terms of pain reduction, particularly improvements in function. Certainly up to six months and functional improvements for several years. I think what it highlights is that coaching people for better health is a great way of caring for people, rather than creating a dependence on them to come back and see us again.