Welcome back to the Healing Pain Podcast with Mary Grant, PT, BPhysio, MMT, MISCP
We’re discussing how to combine two evidence-based and effective methods for the treatment of chronic pain, which are Cognitive Functional Therapy and Acceptance and Commitment Therapy. My expert guest is Mary Grant. Mary is a Senior Physiotherapist at the Rheumatic and Musculoskeletal Disease Unit at Our Lady’s Hospice in Ireland where she’s developed extensive skills in musculoskeletal rehabilitation with a particular emphasis on arthritis and persistent pain problems.
She’s a guest lecturer at the University of College Dublin in the physiotherapy program where she trains student physiotherapists on the assessment and treatment of arthritis and has been involved in the development of a new program with Arthritis Ireland. In addition to her physiotherapy degree, Mary has also earned a Master’s of Manual Therapy and has a keen interest in combining pain neuroscience education, Cognitive Functional Therapy, and Acceptance and Commitment Therapy for the treatment of chronic pain.
In this episode, you’ll learn about the similarities, differences, and complementary approaches of Cognitive Functional Therapy and Acceptance and Commitment Therapy, how they help people with persistent pain, and how physiotherapists can go about employing these methods and techniques in clinical practice. If you’re interested in learning more about Acceptance and Commitment Therapy and how you can combine it with other pain neuroscience education or Cognitive Functional Therapy, make sure to check out my latest book, Radical Relief: A Guide to Overcome Chronic Pain. It is available on Amazon. Inside, you’ll learn all about ACT or Acceptance and Commitment Therapy and how you can combine it with pain neuroscience education. Let’s get ready and let’s meet Mary Grant and learn about combining Cognitive Functional Therapy with Acceptance and Commitment Therapy.
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Combining Cognitive Functional Therapy and Acceptance and Commitment Therapy with Mary Grant, PT, BPhysio, MMT, MISCP
Mary, thanks for joining me. I’m excited to talk to you.
Joe, thanks for having me. I’m excited too.
Mary, you’re one of the few therapists I know that are doing great work with generalizing a couple of different approaches regarding pain and that’s pain education or pain neuroscience education, Cognitive Functional Therapy, and Acceptance and Commitment Therapy. I love this and I want to see more professionals start to implement this knowledge and weave it all together because they’re all important. They’re all effective in either small or large ways, but the challenge is getting people to bring this all together. Your story is important because it is a story of someone who has been on exploration to learn more about pain, which all of us are on as professionals. People with pain are on that same explanation, same journey, that same path as well. You’ve been practicing since 1990. Start a little bit way back then, so to speak, and then bring us to where you are now.
I qualified in 1990. Starting off with a lot of young physios and did lots of different rotations around general hospitals and I enjoyed all of that. We certainly wanted to do MSK, which is hard to get into and specialize in. I was lucky enough to get a job in a rheumatology specialist unit at that stage. I started doing lots of different MSK courses. I still work there. There are lots of patients presenting with complex persistent pain. It’s fascinating but challenging work at the same time.
I was trying to find the best way or the best combination of ways to work with these patients. Manual therapy was the holy grail at the time and muscle imbalance. Those courses were out as well. Pain neuroscience was coming online as well. I did all of those courses, lots of physios at that stage. In 2010, I did a Master’s in manual therapy and I thought at that time, “This is the pinnacle of learning in MSK.” Surely, I’ll have all of the answers now after I’ve done all this and I’ll know exactly how to treat complex persistent pain.
Your career mirrors mine a lot. We both graduated in the ‘90s. Back then, there was a strong emphasis on manual therapy and exercise as well. Slowly, the mid ‘90s started to creep in some of the pain education. It did start slowly. Pain neuroscience education is this big thing, but all of us remember when there were little bits and pieces of it. Many of us are putting those pieces together even before those frameworks and the research was out there.
There wasn’t a way of how you put it all together. You would be doing your manual therapy to somebody and then somehow, you’re trying to throw in the pain. There would be some specific exercise you’re putting in there too that was hard that nobody could do. A lot of it didn’t make any sense. We’ve tried to put it together, it seemed to me anyway.
The manual therapy degree wasn’t the icing on the cake for you.
It wasn’t.
When did you start studying or how did you come about Cognitive Functional Therapy?
A couple of years after doing the Master’s in manual therapy, I’m trying hard to develop the magic hands and work hard on that, but I was getting fed up and disillusioned. Honestly, seeing Peter O’Sullivan’s work on Cognitive Functional Therapy out there. I went to a workshop in London in 2014 and it was amazing. It was a real revelation at the time. It was the best workshop I’ve been to. There are lots of other physios like us that have a similar experience, having done lots of different courses and trying to find answers, and how best to manage complex persistent pain. It was a nice coming together of people.
I want you to define what Cognitive Functional Therapy is for us. Before that, did you start to venture into that CFT space? Of course, it’s new and evidence-based. Was that because you found out pain education, like manual therapy wasn’t what you thought it was?
There’s fantastic science behind it, but it seems like you have to give the patient all this information and they were supposed to take it on. Suddenly, everything would make sense and they’d be able to do what they wanted. It didn’t work like that. The CFT, what was good about that was it was more about working with the person where they are in their journey and such. It’s not spewing all this information at them but going, “Let’s make sense of your pain problem together. You probably have all the pieces of the puzzle. Can we try and put those pieces together in a way that makes sense to you?”
It’s helping the patient build that story of what happened around their pain versus pain education is kind of, “I’m going to deliver this information. Here’s all the info. With that, you’ll change.”
That’s a big difference. That’s like this outpatient thing, “I understand this pain doesn’t mean harm or doesn’t equal harm, but my pain is different. My pain is not like the other person’s pain in the group that you’re talking to about pain.” It didn’t make sense. You have to make it individually and that was what was different about CFT. It was that a person and what was going on with them at the time that they developed the pain problem. What might be still going on that’s keeping that pain problem going? I felt it’s different that way.
What you’re saying is reflected in literature. Pain education is one small part of a cognitive behavior on a lifestyle approach to helping people with pain. Manual therapy is not the holy grail. We have to learn how to use it effectively and efficiently, but it’s a smaller part of that bigger process that people will go through regarding pain. Let’s dive into Cognitive Functional Therapy a little bit. As a treatment model, it’s still being built out by Peter O’Sullivan and JP Caneiro, another wonderful physiotherapist who I admire and follow their work. In your own words, because I know you’ve been through some training, define for us what Cognitive Functional Therapy is.
I haven’t done any formal training in CFT. I’ve been to quite a few brilliant workshops, but there is some research underway that formal training wouldn’t tell us. I’m not an expert. CFT is a framework where you can apply biopsychosocial model and it’s truly patient-centered. You advise this patient in an individualized way. It’s underpinned by open communication, which helps to build trust and a good therapeutic alliance that’s at the center of us. It’s about looking at what movements or activities the patient avoids, fears or the ones they find difficult for their pain within all of that. You look at those as behavior experiments. You’re looking for things that you can pull out of how they move or what they think about how they’re moving, and you may give them a different way of doing it.
A lot of it centers around lower back pain.
They use that model and they’re expanding it out in the research way as well in other areas of the body too. It is something that I certainly use with all of my patients. I try to use that approach with all of my patients. The research is mainly on low back pain. JP Caneiro, he’s working on OA, in general, doing quite a bit of work in that space. It is expanding all the time.
I’ve had both JP and Peter on the show. You’re right. It started with chronic lower back pain and they’ve moved over into knee osteoarthritis, which is useful and beneficial. I’m curious, you use CFT in practice. You’ve done some workshops on it. You follow up on the research. Am I hearing that CFT was a game-changer for you? If it was, how come you still brought ACT into your treatment?
There are a lot of similarities between CFT and ACT. With CFT, you’re explicitly targeting pain control during exposure to the nominated task that the patient says is difficult for them. The whole idea is you’re challenging what they call negative and inaccurate cognitions and modifying how the person physically performs the task using body relaxation, body control, and extinction of safe behaviors. That’s the hook, that’s the way in with the patient.
The problem is if you have a patient with pain that moves well and they don’t have any of those movement behaviors or safety behaviors that you can change. There isn’t a hook that you could grab on to. We’re struggling with those patients and there are plenty of them. There’s also the patient where you do work through those movement behaviors and they successfully integrate the new ways of moving, but they’re still bothered by pain. They’re saying, “I could see that I’m moving better, but the pain is still annoying me. It’s there all the time.” What do you do to help that person?
I started noticing the psychological flexibility we mentioned in social media and as well in the RCT and CFT. They found that psychological flexibility was particularly important in determining responders. It’s like, “I’ve heard of that before. I’ve seen it somewhere else.” There were a few podcasts around like yours, Joe, and another good one from Australia, The Knowledge Exchange Podcast. They were talking about ACT. This seemed like it might work well at CFT. Because I work in a rheumatology specialist unit, we still have lots of patients that are limited in terms of how they can move. Being that maybe something like ACT would be useful for someone who has got impairments that they can’t necessarily change. That made me think, “Maybe this would be something that could add to CFT.” CFT is fantastic and it’s the best framework I’ve come across. Maybe this was something that we must add.
What I like about that is you took something that’s evidence-based. You learned about it. You implement it into practice. It worked with some people, but it didn’t work with others. You broke that down into three parts. We should highlight those briefly. CFT, in essence, helps people and targets people who have movement dysfunction and they’re relying on safety behaviors to move.
Fear is driving that behavior. Pain has caused them to change their behavior. Beliefs about pain have caused them to change their behavior. I suppose that’s at the hub of it, in a way. This is what I understand about it anyway. You’re looking for these maladaptive beliefs and you’re trying to change those beliefs through changing their behavior.
You found that worked with some people and some people, you would change the way they moved. You’ve worked on their beliefs, but yet the pain persisted. There are some people who came in with what we call maladaptive beliefs but had no movement dysfunction. You were thinking, “What do I do now?”
I didn’t have a way in then. I didn’t seem to have an option to offer those people.
ACT was another tool and another way to start to help people whose pain neuroscience education or Cognitive Functional Therapy may not have been going deep enough with them.
That’s fair to say that that’s the case.
Tell us what this looks like. Another journey begins with you into ACT. It’s a journey we’re on together, so to speak. What did you notice as you started taking ACT and implementing it into your practice?
The first thing that hit me in the face was my own strong bias or professional identity towards needing to reduce pain. I wasn’t aware of that. That was such a strong bias. It kept coming up all the time in the earlier days of learning about ACT. In the CFT, I’ve moved from doing manual therapy to the patients to relieve pain. I changed from doing that to working with the patients to find their own ways to reduce pain.
I have made a big shift in how I work with patients, but my main goal was still pain reduction. That’s not wrong, bad or anything. It is how physio is viewed, generally, by physios, other healthcare professionals, and the general public. Physios have to ease your aches and pains. That’s what we do. When you’re discussing with patients or asking patients how they’re doing, there’s always this subtext like, “Is it working? Is your pain gone?” Often, that isn’t possible. It’s often not possible for persistent pain. We know that.
What I thought I found with ACT is it expands the options available to be on helping people to live well with pain. I thought I was doing that, but I wasn’t. I was still trying to get rid of the pain. I can even think back to the sessions with patients where I would be doing all the movement adaptations and distinguishing all the safe behaviors. I’d be going, “How does this feel? How does that feel?” If the patient wasn’t saying better, the pain is less or the pain is gone, I’m sweating. That was a big shock that I thought about what I was doing. I wasn’t even aware of what I was doing.
That can weigh heavy on us as professionals if we take on that role of someone who has the ability to solve everyone’s pain or if we believe, talking about maladaptive or false beliefs of approaching our career and approaching our patients with, “Yes. I have the ability to wave my magic wand and take your pain away.”
I had moved from trying to get the magic hands, but I was still trying to do magic in another way, I suppose.
You had magic hands?
I never got the magic hands. I tried hard, but it never happens.
Touch can be a magical thing for people. If we approach it with this certain approach, “I’m going to work my magic, so to speak,” that can be quite challenging. I’m curious. As you know, when you come into my ACT training program in the first week, I’m talking quite clearly about adopting a stance that is not about pain relief. It doesn’t mean that an ACT approach does not alleviate pain. Many times, it does. There’s a group of people or patients where we’re not quite sure what’s going to happen. We start with that stance of pain relief first. Did you find that existed within the pain neuroscience education and Cognitive Functional Therapy world? Did you find those two approaches were pain relief first, where ACT is pain relief might happen but it’s not a priority?
I found that difficult. I found that confrontation at the start as you know and everyone in the Facebook group knows because I kept going on and on. That’s my main goal with every patient from the start. I struggled with the idea of maybe stepping back from that as a goal. A lot of the patients when they’re coming, they’re desperate to have pain relief naturally enough. Because of the particular unit that I work in, they’ve been through maybe 4, 5 or maybe 10 different approaches already and they’ve failed those and that’s weighing on them and then you’re the last hope for them. What they see is they have to get rid of the pain to go on living and be able to live.
Depending on the professional who comes into the program, their background, their experience or previous training, some people are locked in horns with pain relief. It’s hard for them to let that go. When I first started learning mindfulness and acceptance-based approaches, and I’ve looked at all of them at this point, I had to spend some time reflecting back on my own work, on things that I believe, or on things I’ve said to people. Was that appropriate? Could I have delivered it differently? How do I now start to move forward from this?
Some people can get it fast. If you’ve been through that biomedical training, manual therapy, pain neuroscience education, where we’re going to reconceptualize and change all this, it can be tough for people. I appreciate you talking about it. What you’ve experienced, many other people haven’t. To this day, they still go into the clinic every day and they struggle with this. We know burnout is high amongst professionals who treat pain.
If you’re trying to eliminate pain and it’s not happening and you’re going home at night, you’re stressed about yourself or you feel like, “How can I continue to serve people deeper?” I recommend you explore that. How can you serve people deeper? Serve it from an acceptance-based perspective versus one of a complete reconceptualization perspective which is different. It’s night and day in a lot of ways. They can coincide. They can run what I call colinear. What I tend to see people doing is pain education in the beginning, maybe the first 1 or 2, maybe 3 sessions, and it’s still there throughout but moving more toward that Acceptance and Commitment Therapy approach with regards to treatment. Tell us how does ACT helps people live with chronic pain better?
Living well with pain is a difficult concept for all of us, patients and clinicians. It doesn’t sound right living well with pain. It’s a tough one. The first step is to acknowledge the patient’s journey and what they’ve tried already to get rid of pain and how this has worked or maybe not works for them. What I love about ACT is using metaphors like storytelling to try and maybe help the patient to see that maybe there are other ways around this. Maybe it’s okay to drop the whole trying to control the pain or get rid of the pain agenda. That can be hard for people because that’s what they want to do. You have to go carefully with that with people.
The next thing is once you’ve passed that suggestion out there, controlling the pain is not maybe the most beneficial way to go or maybe they’re ready to try something new and that’s where clarifying values are for them as humans. What they care about most and who they care about most in their lives. That’s the next big thing that can help them to go on the path towards going back to what they want to do or be. It’s different.
Where do you find yourself bringing values in now that you have trained in ACT? If you look at the lectures, some approaches put them first before anything. Some other protocols put them last once they’ve been trained, some of the psychological flexibility skills. Where do you find values coming up in your conversations with patients in your evaluation?
Usually quickly, if not the first session, maybe the second one. It’s something that is done in CFT to an extent as well. They use the concept of meaningful activities and getting back to meaningful activities, which is quite similar but maybe values are a bit broader, in a way. It’s more of a compass rather than goals. Meaningful activities are important and can be part of values. Let’s say you have someone who wants to be able to play football with their kids and they’re struggling to do that and that might be part of the value of being a good parent for that person. Playing football is too much at this point in time.
You can also be a good parent by maybe reading a book with your kids or doing their homework with them. You can still work on their values with them but still work towards maybe doing other stuff. They are still being guided by their values, which is important. You can get bogged down and the, “I can’t do this thing now whenever I want to and that means I’m crap. Therefore, I’m not going to do anything. I’m depressed.” It’s awful. The beauty of ACT is looking at all of the ways or maybe the steps towards the thing that’s guided by your values, which is a much bigger thing and it’s always there. You can choose to live by that or you can choose to maybe sit on the couch or go to bed because you’re feeling crappy. You can maybe decide, “I’m going to sit with my kid and we’re going to do some reading together.” That’s values-driven.
I like that you mentioned the meaningful activity part of Cognitive Functional Therapy. It’s super important and ACT has values. I haven’t looked at those two like you have and I’m like, “Meaningful activities are important. Values are important.” I find that value turbocharges the meaningful activities, so to speak. Sometimes people are like, “I’d like to do meaningful activities, but I’m still in pain.” Some way, the value circumvents that or gets around it in what I call a sneaky way.
They don’t even know what you mean when you ask them. What are you missing? What do you want to get back to? They’re not even able to say what that is because they’ve been immersed in the whole awfulness of the pain for long and it’s hard for them. They can’t even say what it is. It’s been so long since they’ve been able to do things that they enjoy or are interested in. They don’t even know anymore. That value is a piece. Giving time to it is a nice way of allowing them to think, “I’m not a person with pain. I can be a person who’s interested in things or wants to do other stuff. Not even the doing, but not be a person with pain.” Your world gets small.
I’ve never thought of it or looked at it like that. What you’re saying is it’s hard for them to contact meaningful activity because pain, in essence, has stripped the meaning from their lives, which points to experiential avoidance. You’re trying to have people contact meaningful activity, but they’re in experiential avoidance and fused with what’s happening that they have a hard time accessing that. Values can be a way to bring them back around. Describe to me how you work with thoughts and emotions, which are an important part of any approach to pain. How has ACT helped you with the thought and emotions part of persistent pain?
Going back to CFT. CFT is fantastic. They do address things like thoughts and emotions. I don’t think there’s a way of explicitly working with thoughts and emotions in CFT and there is in ACT. You choose to help people to notice what their thoughts are and how those thoughts are affecting them so that you can explore how their mind is affecting them in terms of their pain with them, which is interesting. The first step is trying to focus on present moment awareness. They can try and notice what their thoughts and emotions are in the present moments when they’re doing something that’s maybe scary, painful or both. That is interesting. Often, patients don’t have an awareness that thoughts and emotions can affect how they behave, how they move, or how it affects the pain. The pain itself generates thoughts and emotions and vice versa. Maybe it’s new in some ways to me as well.
Before learning about ACT, I would ask people what they were thinking about a feared task. I’d see that they were struggling with something and I’d be saying, “What are your thoughts?” They might say, “I’m afraid that this is going to damage my knees.” I would try to reframe that thought or refute that thought. Instead of stepping back from it a bit, let them step back from it a bit and allow the thought to be there but still go ahead and do the task that we were working on. That’s been a whole new way of working with thoughts for me with this pain. The way I was doing it is by trying to refute or reframe thoughts is probably quite invalidating and I didn’t realize that it was.
In my head, I almost wanted to say to patients, “Stop thinking that thought. That’s a silly thought. It’s not real. It’s not a fact. It’s a thought.” Now I don’t think that’s the right way to go. That would probably be quite upsetting for people as well to have you say that. I’m trying to deal with high proficiency because high proficiency is common in people who are struggling with persistent pain. Thoughts are a big part of that. You’re thinking about it all the time.
I used to ask patients, “How much time do you spend thinking about your pain?” They might say, “All the time.” I’d say, “How is that working for you? Do you think that’s a good thing to be doing?” I’m always with the suggestion that you could stop doing thinking that. I used to write that down as well as my homework like, “Stop thinking about the pain.” As if you could do that. As if that was possible. I love the fact that in ACT there are two cognitive diffusions. When you have thought that are intrusive, that keeps coming up all the time, you can show the patient that this is another way of dealing with these thoughts. This may help. You don’t have to push them away. You don’t have to block them out. You don’t have to stop thinking about it. It isn’t going to work. You can try this instead.
If people go back to the episode I did with Lilian Dindo, she’s a psychologist who uses ACT in one-day workshops. She and I talked about this exact topic. We talked about it briefly. She said, “If you start using traditional Cognitive Behavioral Therapy, helping people reframe their thoughts and you start using ACT, you’ll find that there’s a group of people that don’t like to have their thoughts refuted. They know that these thoughts are quite persistent.” They’re like, “I appreciate your help. I appreciate you helping me reframe or challenge these thoughts but just so you know, these thoughts have been here a long time.”
It’s almost like, “What else do you have? What else is in your bag of tricks?” “Here’s cognitive diffusion.” Those thoughts are not going to go away. All of us, even if we reflect on our personal experience throughout life, not about chronic pain, about things you use. Everyone reading at home, think about what type of thoughts do you have about yourself that have probably been there since you were young that constantly come up? They may not come up every day, but they come up during certain situations, around certain people, around certain times of the year. Have those thoughts gone away? The answer is no. There are effective and evidence-based ways to relate differently to those thoughts so they don’t negatively impact your pain.
You can allow the thought to be there, but you can still move along in accordance with your values. That’s powerful. I found it helpful myself in my own life as well.
Tell me about that. Where have you started using some of these skills in your own life and how have you found them to be beneficial? I’ll tell you from personal experience. When I first learned ACT, I was excited to use it with patients but I couldn’t believe how it changed me.
To give an example. I suppose it’s maybe a little bit superficial but it’s probably not either. I do powerlifting as a sport. Whenever I have to do a max lift in training or on the platform in the competition, it’s scary. I’d have the whole heartbeat thing, hardly able to breathe, nausea, hands are all sweaty and everything. Even as I’m talking about it, I’m starting to get a bit of that. I used to try and push all that away. I’d have my headphones on. I try to pretend I was somewhere else. If it was a competition, I’d pretend I was anywhere else but there. I try to remove myself.
Learning about ACT, I was thinking, “I’m sure all of these techniques would help me with my whole squash fear or lifting heavy fear,” which is a bit of a pain when you are supposed to lift heavy. It did. Even the whole noticing the thoughts, noticing what I was afraid of and voicing that thought to myself and then letting them be there, connected to breathing, noticing other things around me as well, that whole present moment awareness. Whereas before, I would be trying to block things out and I wouldn’t execute the lift properly or I might miss a command in the competition and I do a stupid mistake. I realized that wasn’t working. It takes practice because I’m still practicing it. It certainly works better for me. Being present was better and being able to notice the thoughts and call out the thoughts, the familiar thoughts that come up when I was afraid.
Every person who’s trained in ACT has a story that relates to themselves and sometimes they are things related to exercise. Sometimes there are other types of examples that are a little bit deeper for people. To effectively promote and use ACT, you have to learn it. It’s a process of understanding what’s happening, that shift that happens that regards to acceptance or willingness, as we like to say. You apply that so you learn it didactically, then you apply it to your own life and you continually apply it throughout your life.
We all may have episodes of life that become challenging, but we’d like to stiff-arm and push away from us and not have. We’re going to be confronted by many different types of challenging things in life, some of them involving both physical and emotional pain. If we’re even making that distinction anymore, I don’t think we are. How do I use this with people? How do I help people with it? In your example, you mentioned fear. Fear came up. When you reflect on what you’ve learned about ACT and then what you’ve learned about Cognitive Functional Therapy, which relates to fear and fear avoidance, do you see a distinction between those two or how the approaches are distinct?
Both ACT and CFT targets fear related to pain. If you look at Vlaeyen’s fear-avoidance model, CFT works to extinguish fear. ACT takes the stance that maybe we don’t need to extinguish fear in order to recover. Maybe it’s not always possible to fully extinguish fear. That’s true having experienced that myself. I don’t think it is possible to extinguish fear. You can still do what you want to do but have the fear there. You do have to acknowledge that it’s there. Know about what it feels like in your body because there’s the effect of fear on the body. Being aware of that, instead of trying to block it out, that’s a big difference between ACT and CFT. I don’t think it is possible to extinguish fear, especially when it’s related to something like pain. Pain has a horrible way of cropping back up again and then the fear comes back quickly. They’re like first cousins.
That’s a good way to look at it. Some of the newer psychological research points to the idea that it’s difficult to what we call extinguish fear. It’s almost like we can take a fire extinguisher and spray some powder on it and the flame goes away. If you’ve ever had chronic pain, it can be difficult to extinguish those thoughts and beliefs and even the fear about things that may cause you pain. That makes sense because we know that pain is about prediction. The mind is predicting what’s going to happen in an effort to protect yourself based on your personal learning history. We talked about this, the three Ps, protection, prediction, and your personal learning history, and how those three come together.
I truly believe that it’s almost impossible to extinguish that fear once someone has it. That doesn’t mean that we can’t change the environment and place new memories on top of that fear that makes it less impactful for us, which is what ACT does. We help people relate differently. Through that relating, we develop new memories, not overriding, not extinguishing the old ones, they’re still there. There’s no delete button in the nervous system. We’re helping people relate differently. With that, they create new memories and hopefully, different behaviors they can adapt and move forward with different types of activities, which starts to bring us to exposure. I do think that’s our specialty as a physiotherapist.
What’s different with exposure and ACT is you’re exposing people to the pain, not exposing people without pain. That’s how I would have used exposure. Before ACT, I would have used exposure in a way of, “Let’s go as far as it’s comfortable for you today,” kind of way. Even with CFT, in fairness, I don’t think that Peter O’Sullivan would necessarily do that. He’s fearless around pain. The CFT approach would encourage that. ACT gives you a bit more permission to do that. You’re exposing the person to what pain is like and that’s what they’re learning. It’s okay to feel pain and do this thing. It is saying that pain is not the same as harm all the time. It’s experiencing that and everything that comes with it and not just the physical sensations but the thoughts and the emotions as well as part of that.
I asked a patient, “Can you lift your arm up?” She’s like, “It can go this far but that’s it.” What happens then? What she meant is that it can go this far without pain, but can you go further and what happens? She could go further and it wasn’t maybe as bad as she thought it was going to be. There was pain but she could do it. I only met this lady. It was her first session. It was interesting for her that she’s like, “You’re giving me permission to go past the pain?” That seemed to be quite new for her whereas before, the other interaction she would have been, “Stop at the pain. Don’t go any further.” She was saying, “I can go further with the pain?” It was different.
It helps us relate differently to patients when we’re exposing them to things that are potentially unpleasant, uncomfortable, painful, whatever word you want to use. It can probably all be used interchangeably. As people learn ACT, they realize, “I was hesitant to take someone far enough and expose them to pain in a way that would help them change their relationship to.” We can talk about pain and theory. If you start to play with pain and bump up against it and brush up against it a little bit, over time, it will probably change or you’ll change.
You have to do it.
If you lift weights twice a week, you’re going to build muscle. Here’s how you do it. You do three sets of ten at 75% maximum capacity with two-minute breaks in between, and then you make sure you have protein. We can talk about that all day long. You have to take action to do it. Pain is the same way.
You have to be a bit fearless.
We’ve talked a lot about pain neuroscience education. We’ve talked about Cognitive Functional Therapy. We talked about Acceptance and Commitment Therapy. You studied all three and you’re weaving those all together, which is rare. I want to commend you for doing all that because it’s not necessarily easy to take those theories and blend all three together. It takes a special individual to blend things. It’s a lot easier to say, “I’m going to go deep on one thing and this is what I do. I’m only going to do this.” You’ve started that blend. My question for you is, as a physiotherapist, why is it a radical idea to think that physiotherapists are using the mind and mental training skills for the treatment of chronic pain?
It goes back to what we were saying at the start, that whole professional identity bit that we do things to people to take away the pain. A patient comes in, they lie on the couch. We do whatever we’re doing with our hands. We might stick some needles in them, give them a token exercise at the end. I don’t think anyone does that anymore. It’s a bad physio, in a way, but that would have been how I was trained back in the day before we had all of this information.
I still think that’s what the general public expects and is often what referrers expect as well. They’ll say, “I’ll send you to the physio for some exercise and I’m sure that’s going to help your widespread persisting pain, your fibromyalgia.” It’s not that simple. You can’t exercise that away. A person might already be quite fit and still have widespread pain. That’s not deep enough. Physios as well, I suppose, we are a bit fearful about asking about thoughts and emotions. That’s something that CFT does challenge quite a bit as well. In some of the research done by the CFT group, there’s some good work on that and the vicinities I’m going to work on are looking at why physios are maybe afraid to ask those feelings, emotions and all of that kind of thing. We certainly didn’t have anywhere to go with that.
As a physio, we found out places to go with that information. There are valid ways to ask about it. Not that we’re trying to be psychologists or anything, we’re not. If someone has an anxiety disorder, I would refer to thoughts. We can still work with thoughts and feelings about pain. That’s definitely in our wheelhouse. It’s how we’ve been seen all this time that we do things to people to alleviate the pain. We don’t ask about those questions. We don’t work that way. It’s a mindset thing, generally, I suppose. That’s a bit of a vague answer.
It fits well with where we are as a profession and it also gives people an idea of where we need to go as we move forward both in research but more importantly, in clinical practice and public awareness, which I want to talk about more and more. My entire show is public awareness. How do we engage the public and refers who have beliefs about what we do? How do we engage them with, “Here’s what we really do,” that helps people with pain? Exercise and physical activity is a part of that and the research proves that along with the psychological component. Putting the brain and body together or putting the mind and body together, that’s what we do as a profession. That’s key because the best research points to that direction. Mary, it’s been great chatting with you. Thank you for joining us. Please tell everyone how they can learn more about you.
I’m not that active on social media so much anymore. I am on Twitter. My Twitter handle is @MaryMG40. I’m contactable there if anybody wants to. Thanks, Joe. I enjoyed this. Thank you for having me.
Make sure to share this episode with your colleagues who are combining pain neuroscience education, Cognitive Functional Therapy and Acceptance and Commitment Therapy. They’re out there. Mary and I know a bunch of them. They’ll benefit from this conversation and learn first about those three interventions, how they’re different, how they can be complementary, and how you can use it in clinical practice.
Important Links:
- Rheumatic and Musculoskeletal Disease Unit at Our Lady’s Hospice
- Arthritis Ireland
- Radical Relief: A Guide to Overcome Chronic Pain
- JP Caneiro – past episode
- Peter O’Sullivan – past episode
- The Knowledge Exchange Podcast
- Lilian Dindo – past episode
- @MaryMG40 – Twitter
About Mary Grant, PT, BPhysio, MMT, MISCP
Mary graduated from University College Dublin with a BSC Honours degree in Physiotherapy in 1990. She began her career gaining valuable experience in several of the teaching hospitals in Dublin completing rotations in Respiratory care, Neurology, Orthopaedics and Rheumatology. She has worked as a senior physiotherapist at the Rheumatic and Musculoskeletal Diseases Unit at Our Lady’s Hospice and Care Services since 1997, where she has developed extensive skills in musculoskeletal rehabilitation with expertise in treatment of arthritis and persistent pain problems such as fibromyalgia . She is a guest lecturer on a yearly basis on physiotherapy assessment and treatment of arthritis for UCD physiotherapy students. She has also been involved in development of a new programme with Arthritis Ireland to support pregnancy in arthritis. In 2007, Mary completed a Graduate Certificate in Orthopaedic Manual Therapy at Curtin University in Perth, Western Australia. She went on to complete a Masters of Manual Therapy with Distinction at the University of Western Australia in 2010 . Mary has a keen interest in pain neuroscience and the treatment of complex persistent pain problems such as chronic neck and back pain. She attends yearly workshops in Cognitive Functional Therapy with Peter O’Sullivan and uses this evidence based approach to develop individualised programmes which are genuinely patient centred. Mary has recently completed a post graduate course on the use of Acceptance and Commitment Therapy in the management of persistent pain with Joe Tatta at the Integrative Pain Science Institute. This qualification adds another dimension to her work in helping patients move beyond pain so they can reclaim a full and active life. Mary enjoys strength training and competes in powerlifting.
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