Welcome back to the Healing Pain Podcast with Alexa Knuth, SPT

We’re going to talk about psychological aspects of pain rehabilitation that physical therapists perceive as important. When we’re talking about research, a new topic or providing new information, oftentimes I’m talking to a pain researcher. It may be someone with a PhD or someone who is actively engaged in investigating different aspects of pain from a lifestyle and a biopsychosocial perspective.

In this episode, I’m introducing you to Alexa Knuth, who is a student physical therapist. Alexa is a student at Robert Gordon University in Aberdeen, Scotland. She is in the last year of her program and she is excited to start a career. Even before she started her career, she had already started to delve into the evidence and contribute to the evidence base by writing a paper called Psychological Aspects of Rehabilitation as Perceived by Physical Therapists. You can all access that. It was published in 2018. I came across it and thought it was important to share with all of you so we’re going to be talking about that on the show.

Alexa also has an interest in working with and applying psychological techniques to a specific patient population, which is those who are looking to self-manage inflammatory arthritis like rheumatoid arthritis. There are lots of great applications for this work here. We’ll talk about that in this episode as well. Overall, we’ll talk about the important psychological techniques people can use for self-management and which physical therapists perceive are the most important.

As you know, psychologically-based care or psychologically-informed physical therapy is something we often discuss on this show. We teach courses on that at the Integrative Pain Science Institute. You can go over and check out our courses as well as the newly released Psychologically-Informed Pain Practitioner Certification. That’s a complete certification that discusses the different multimodal approaches that you can use with regard to cognitive and behavioral interventions as well as whole health interventions for treating people with chronic pain. Without further ado, let’s begin and meet Alexa Knuth.

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The Top Psychological Components Of Pain Rehabilitation With Alexa Knuth, SPT

Alexa, welcome to the show. It’s great to have you here. I’m excited to speak with you.

It’s very great being here.

We’re going to talk about a paper that you published in 2018 with regard to the psychological aspects of rehabilitation as perceived by a physical therapist. Everyone can find that paper in the Journal of Physical Fitness, Medicine & Treatment in Sports. Before we begin, tell everyone about you, where you are now and the unique education that you’ve pursued.

I am in the final year of my PhD program or DPT program. I go to school at Robert Gordon University in Scotland. I finished up my data collection. I’m doing my PhD on trying to co-develop a self-management intervention for patients living with inflammatory arthritis. I moved back to the states and am finishing my program remotely. I hope to begin a future career as a physical therapist at the end of 2022 in America.

You mentioned you were going to Robert Gordon University in Scotland. That program is unique in the way it is set up. Can you explain the difference between that program and maybe a DPT program we might find in the United States?

Robert Gordon University has a CAPTE-accredited program. It’s nice that I was able to go abroad, have that amazing life experience and work in the UK for a few years, go to school, be able to transition back into America and become a physical therapist. It is similar in the way that it was supposed to be three years of education as the DPT programs here but everything with the pandemic got pushed back a little bit.

The reason why I wanted to go to this program, in particular, is that they’re very research-heavy. I have a large interest in doing research and I want to continue that. In order to get my DPT or PhD there, I would have to go through the entire PhD dissertation process, conduct a study and things of that nature.

In the US, you’ll receive a DPT but in Europe, it’s considered a PhD.

That’s correct.

That’s interesting. I love that format. I wish more DPT programs had that because more professionals would pursue research as you did with your paper there.

I’ve done research. I went to SIUE, which is Southern Illinois University in Edwardsville. I did my undergrad and Master’s there as well. They have an amazing undergraduate research program where I got integrated into it right away and kept doing research until now.

Let’s dive into this paper that you published. As you know, the reason why we’re interested in that is, on this show, we talk a lot about psychosocial factors. PTs are in a unique position to implement the psychosocial with the physical and yet there are some questions about, “Does this fit into our scope of practice? What should we be doing? What works? What doesn’t work? What’s acceptable?” That paper is called Psychological Aspects of Rehabilitation as Perceived by Physical Therapists. Tell us what the aim of that study was.

The aim was to try to understand from a physical therapist’s perspective what they believe to be the most important psychological and social factors that impact our daily practice. I was interested in knowing from a physical therapist’s point of view like, “What do you see most often? What do you find to be the successful and unsuccessful coping behaviors of patients? What was your training like? What was your education like? Do you feel confident in being able to address these problems that we see in everyday practice?” That’s what I was curious to find out.

That’s why I was so interested in the paper because you did cover a lot of important topics in one paper, which is wonderful. PTs do encounter a lot of different psychological and mental health challenges within their patients and practice. What did your survey find?

My survey found that the top three things that were most encountered and taken into consideration were that most of the people who answered the survey were outpatient and home health. It was very much geared to musculoskeletal conditions as well. I want to point that out before we continue any further because that does show the population that we are talking about. The big things for musculoskeletal conditions were stress and anxiety, depression, as well as problems with pain management.

Thanks for clarifying the point on the survey data. Was the survey done in Europe or the United States of America?

It was done in America. I did this as part of my Master’s thesis when I was at SIUE. The way we went about it is I initially emailed all 50 of the APTA organizations in every state. Multiple states got back to me and I had 95 physical therapists answer the survey completely. This is data from that.

Those are the psychological conditions that are encountered by PTs. What are the interventions that you’ve found that PTs are using most? You have quite an extensive list in the paper.

I took this survey from a paper done in the UK looking at athletic trainers and the psychological conditions that were found there. I talked to him, got his permission and then edited it to fit what the physical therapist would see. These were the psychological interventions I had listed. What came up to be the most was creating variety within the rehab exercises using short-term goals, encouraging positive self-thoughts, effective communication skills and reducing stress and anxiety.

It makes sense because that’s in line with the conditions that are often encountered. What were the other top two?

The top one was creating variety within different rehab exercises and using short-term goals.

As a whole, our profession does short-term and long-term goal setting very well. You also looked at the perceptions of what physical therapists thought about successful copers and those that were unsuccessful. Can you give us some feedback on what you found there?

The results showed that patients that were adherent to their rehabilitation program, had a positive attitude and were motivated within the rehabilitation process were the ones that were likely to cope more successfully than patients that didn’t comply or adhere to their treatment program. They were dealing with excessive stress and anxiety and weren’t motivated to complete the rehabilitation program.

Stress and anxiety are a real through-line throughout your paper.

It makes sense too because anytime you get some injury and it affects your life, there is going to be some unknown about what’s going to be next or what the rehabilitation process is going to be like. As I’ve found through clinical education and my experience with patients, it is a lot about having to educate people like, “This is the rehab process. This is what to expect.”

It’s about trying to teach people what to expect from this rehabilitative process and in the future. It’s helping to create variety and keep people’s interest in it a little bit more and keep them motivated because physical therapists from this study were saying that compliance to the rehabilitation helps and it does help them get better. In that way, they can move on with their lives and get back to doing the things they love, their hobbies and their everyday lives especially if they suffer an injury that puts them out of work.

The world was a very different place than when I was doing this study. With COVID and everything, it’s so much easier to do things remotely but at the time, it wasn’t. If you suffered an injury that took you out of work and you didn’t have the infrastructure or it wasn’t as common to work from home, that’s a pretty big deal. It affects somebody’s life.

You’ve been through school now where you’re coming to the end of the school year you’re training. How does your education align with what you found in the paper? What were the similarities and the potential differences that you noticed?

My education was a little bit different than what my study had found. One of the things about my study is the people that had been working as physical therapists had been working for a long time. The average age was about 50 years old or so. Things have changed quite a bit within the research field, the educational systems and what is taught. I can’t speak for what their education was. The things that they were taught were outside of the scope of that study in particular. The things that we are taught now were very much in the sense of this biopsychosocial model looking at the wider determinants of health.

We did cover things on how to communicate effectively with patients. We also talked about pain and this cyclical relationship and how all of these wider determinants can affect a person’s general psychological state from the day-to-day to their long-term psychological state as well as how social factors can impact somebody’s stress and anxiety.

Low back pain is a very common condition that we would see or treat within a musculoskeletal outpatient clinic and how people can get stuck in this loop of this chronic back pain. We also talked about things like behavior change, exercise psychology and adherence. We learned that some skills treat those things like motivational interviewing and goal setting. They are making their way into the education system.

There are some of those that I didn’t notice in the paper. I was a little surprised but it’s from 2018. It’s still a relevant paper as far as time goes but things may have changed since then. Bring us up to speed and talk to us about your current PhD work and what the focus there is.

I’m co-developing alongside patients as well as healthcare practitioners a self-management intervention for patients living with inflammatory arthritis. The way that we developed it was through a series of online workshops and this iterative process of what your needs are and what you want to focus more on in the clinic. It is because, with the healthcare system, you don’t have so much time with patients.

What we realized was there was this gap in the clinic that if you only have 30 minutes to talk to somebody, there are only so many things that we can treat but there’s this wider scope of needs of patients that also need to be addressed as well. As you were saying, we as physical therapists and even other healthcare professionals are in this opportunity position where we can address these. How do we address it? You don’t have enough time in the clinic to talk about all of these things. If you had an hour and a half, that would be amazing but the system doesn’t allow for something like that.

The great thing about these interventions and group work that you can do is you can get a large community of people. There’s a lot of debate within the research field that we can’t make it all on an individual base and needs to be a larger group. Where do you draw the parameters around the population you want to work with?

It’s based on people with similar needs and conditions even if they’re not the exact same condition like inflammatory arthritis. It’s an umbrella term for rheumatoid arthritis, psoriatic arthritis and spondyloarthropathies. There are all different things that can fall on it. It is taking those groups and being like, “What needs are mostly the same? What can we address in this intervention that can talk about more than just the pain and fatigue? What about work issues that are related to that? What about helping them to communicate with their parents, their family and their healthcare practitioners and addressing those wider determinants?”

You brought up some important points there because when you read the research especially in the psychoeducation realm around pain and pain education, most of those interventions are usually between 60 and 120 minutes long with either a patient one-on-one or in a group setting. What you’re starting to point toward here is that it’s great and works well in a research setting. How do we more efficiently deliver essential education to people who need it? You’re starting to look at different phenotypes of people who could benefit all from the same information.

It’s trying to figure out what we can put within this intervention that talks about everything and then the individual needs that might be needed to address more in a clinic on a one-on-one basis.

You’re stretching outside the normal realm of a single intervention such as exercise, which is what most PTs are taught. What are the other key educational factors people need to cope effectively with their condition?

Specifically for a chronic condition and even more specifically for inflammatory arthritis some of the big things that we were talking about were pain and flare management. Those are the two big ones but what we also need to talk about are these lifestyle things. You have your rehabilitative exercises but what about just exercise in general?

Given a specific population, especially for inflammatory arthritis, they need something a little bit easier on their joints so they can’t be doing a bunch of HIIT classes. It’s going to be too hard on them. What about the group exercise classes? How do you point them to community resources that can help them engage? What about walking groups and talking about diet and sleep hygiene? That’s hugely going to impact how they feel.

One of the things that somebody pointed out to me when I was doing this research in these workshops was that it is great to affect emotional wellbeing in these lifestyle factors. However, I can’t do any of that unless these big symptoms of pain and fatigue are addressed. In a clinic, those are going to be our priorities because when we do our assessments, we are looking at your physical symptoms, what you do for work or what your home life is like. We do ask those things but we have to prioritize because we only have so much time. This was a great way of being like, “We can address those in a clinic but this is how we can address these other things and meet those needs for you.”

The interventions that you’ve developed sound very education-based or whole health education-based. How long are the visit’s duration? What’s the intensity of the visit?

We’re still developing it. A lot came out of this so I’m still analyzing all of the data we collected throughout these workshops. By the end of it, I should be able to make a recommendation for how long this should be. It’s dependent on the clinic and what the clinic’s capacity is. Every clinic is going to be different. Some things are going to be better than others. It would be great to be able to deliver all of this in a linear fashion but if you don’t have the capacity for it, you have to be able to prioritize what are the other things that we want.

After your research and almost completing a program, what do you see is the role of the physical therapist with regard to psychological and psychosocial interventions? There are still some questions based on some research and clinical data that it doesn’t fit into our practice or physical therapists have to be highly supervised for this to work for them. What are your thoughts on that?

What I am coming to terms with and discovering is it’s very much on a needs basis of the patient population you’re working with. Every population is going to be a little bit different but once you have an understanding of that condition, how it presents in a clinic and then how it impacts their work if there is even an impact on their work, on how it impacts their social life and how it impacts their day-to-day psychological health then you can start targeting it.

That was one of my biggest frustrations when I was coming to terms with this. I was hoping for a cheat sheet that’s like, “If you see this then everybody is going to present this way. These are the techniques that you can use and it’s going to fix it.” That was not the case at all. It’s very much on a needs basis. It will look different in every population. Even within that population, it’s going to look different to every person.

Let’s say you take a CBT course on chronic pain and they teach you some of the basic CBT techniques for helping people cope. What you’re saying is that’s great and that’s a foundation but how you apply that will change based on if you’re working with a population that has chronic low back pain, inflammatory arthritis or women with pelvic health conditions that there’s a need there to modify the intervention specific for the population.

It can be even more so just the individual. It’s a great tool to have in your tool belt. For CBT, I can’t speak to that because I don’t know that one super well. What I have noticed with other ones that I am a little bit more familiar with, like relaxation, is being able to individualize that to the person. Everybody is going to want a little something different.

That’s what’s not taught in a general course. It’s very difficult to teach. When you’re teaching to a broader group, it’s hard to contextualize it just for the patient in front of you, which then starts to complicate some of the research studies with regard to outcomes. Those are all great points. Alexa, it has been great speaking with you. I’m excited about your work and congratulations. Hopefully, by the time this comes out, you’ll be very close to graduation. Let people know how they can follow you on your work.

You can follow me on my LinkedIn page.

I want to thank Alexa for being here. If you’d like to reach out, you can find her on LinkedIn as Alexa Knuth. If you know any physical therapists or other practitioners interested in learning about the psychological aspects of rehabilitation, make sure to share this with them on social media. It can be on Facebook, LinkedIn, Twitter or anywhere people are talking about psychosocial aspects of care. Thanks for being here. We’ll see you in the next episode.

Important Links

• Alexa Knuth – LinkedIn
• Psychological Aspects of Rehabilitation as Perceived by Physical Therapists – Article
• Integrative Pain Science Institute

About Alexa Knuth, SPT

I am currently a physical therapy student at Robert Gordon University in Aberdeen, Scotland in the last year of my program. I am keen to begin my career following completion of my board exams.