Welcome back to the Healing Pain Podcast with Dr. JP Caneiro, PT, PhD

It’s great to be with you sharing the latest information on pain science and the care of chronic pain. On this episode, our expert guest is Dr. JP Caneiro. JP holds a PhD in Musculoskeletal Physiotherapy. He’s part of an international team of clinicians and researchers that developed a behavioral intervention named Cognitive Functional Therapy. JP holds a research position at Curtin University where he runs a multicenter trial for low back pain as well as lectures in the Master’s of Physiotherapy program. Clinically, JP focuses on the management of complex pain working at Body Logic Physiotherapy in Perth, Australia. He’s also an associate editor for the British Journal of Sports Medicine and for two educational websites. The first one being called BodyInMind.org and the second, Pain-Ed.com.

In addition to the great information that JP will share on this episode, he’s also generously providing you with four free downloads that you have to get your hands on because they’re so good. They’re so important whether you’re a practitioner treating someone in pain, or you’re someone who has had pain and you’re looking for answers on how to alleviate it and return to a more active life. The first handout is called A New Way of Thinking About Pain. This is a good infographic that includes phrases to help people reframe what pain is so they no longer think that they’re being damaged or that they’re being harmed by the pain.

The second is an infographic about the Cognitive Functional Therapy framework. You can look at this and follow along with that framework as JP and I talk about his great work on this episode. The last two are the important studies that JP has been involved in the past few years with regards to chronic low back pain and Cognitive Functional Therapy. The first paper is called Cognitive Functional Therapy. It came from a 2018 Journal of Physical Therapy. The second paper which is published in 2018 Scandinavian Journal of Pain is called The Implicit Association Between Back Posture and Safety of Bending and Lifting in People Without Pain. JP was part of that study, a pivotal study with regards to a lot of the work that we’ve talked about on this episode.

To download these free four gifts that JP has generously provided, all you have to do is text the word, 132Download, to the number 44-222. If you’re on your computer, you can open up a new browser, and you can type in the URL, www.IntegrativePainScienceInstitute.com/132Download. All these handouts will be available for free. If you’ve been following this podcast, some of the work that we’ve been putting out over the last couple of years, you may have noticed that all the content that used to have under DrJoeTatta.com has now been moved to one place. It’s all located on the IntegrativePainScienceInstitute.com website. This is going to be our new home, it’s a place where you can go for all the free podcasts, all the free blogs, and all the free gifts and giveaways. Lastly, the practitioner training and continuing education courses. I’ve organized it so it’s in all one place for you and it’s easy to access. Let’s meet JP and he’s going to share what he discovered during his Ph.D. studies and how he has been able to translate this important knowledge into clinical practice. JP is a brilliant clinician. He’s easy to talk to. You’ll find that his passion for helping people with their pain really shines through. I know you’re going to enjoy and you’re going to learn a lot on this episode as I did. Sit back and relax, let’s meet JP.

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How To Overcome Pain-Related Fear And Low Back Pain with Dr. JP Caneiro, PT, PhD

JP, welcome to the podcast. It’s great to have you here.

Joe, it’s great to be here.

I interviewed Peter O’Sullivan on the show. People loved his work. I was talking to him. I was like, “Do you have anyone on your team who could talk about similar topics?” He was like, “You have to talk to JP.” I reached out to you. I want to thank you for joining us on the podcast and shared some great information that you have about pain and back pain specifically. You are a physiotherapist practicing in Australia. Can you tell us about your journey into the world of physio and then further into your Ph.D. work when it comes to pain?

Thank you so much for having me. It’s a pleasure to be here. My journey started back in Brazil. I’m originally from the southern region of Brazil. I did my undergrad and finished in 2002. I went on to do a Master’s of Biomechanics. I had an opportunity then to do a Ph.D. I felt I wasn’t very mature clinically then. A good friend of mine told me to move to Australia to do Master’s. We moved in here, learned the language for the first year. The second year, we jumped into the Master’s. That was quite transformative especially around the time of 2005, 2006 when you had this almost divide between the specificity, core stability, and this more multidimensional approach. That suited my personality and my biases as a clinician.

I delved into the world of clinical work. I was very fortunate early on in my career to start working alongside Peter O’Sullivan. We’d been working together for years clinically. I finally engaged in my Ph.D. journey, which was a wonderful opportunity. Basically what led me to that journey was this need to understand better about what people are thinking especially I saw a group of people that become quite disabled because they’d become quite fearful of their bodies or fearful of engaging in activities that they valued because of pain or because they have beliefs that they may cause harm to themselves. Trying to understand where that information came from, can we change that? What is the process of changing those beliefs and their behaviors that using an integration that you alluded to, which is cognitive functional therapy?

That specific population that you’re interested in that you have studied in your Ph.D. work, can you describe that population to us a little bit?

Steven Linton a couple of years ago published a paper and he quoted saying, “About 50% of people with back pain have some level of pain-related fear.” People that have fear is highly associated with higher levels of disability, pain intensity, work absenteeism, people moving away from social and physical participation. There’s this engagement from valued life activities. There are different things that drive that fear. Some people fear the feelings that they have in their body. Some people fear the potential consequences of having that problem. Some people are fearful of feeling pain. That population can become quite vulnerable and disengaged from their life in general. That becomes quite interesting to try to help this group of patients.

One of the key papers in your Ph.D. work is a paper published in 2018 in the Scandinavian Journal of Pain and the title of that paper is Evaluation of Implicit Associations Between Back Posture and Safety of Bending and Lifting in People Without Pain. I recommend everyone download it and read it. It’s a great paper. It was a pivotal piece of your work and has a lot of clinicians have approached the paint going forward. Can you tell us what the aim of the study was?

Probably a little bit of a background in that study was that the study that led us to that particular paper was a study in a group of people with pain in a variety of levels of fear, specifically the fear of bending and lifting with a round back. We got a bunch of people that have consistent back pain and we asked them a specific question of how fearful are you of bending and lifting with a round back. Some people said they’re not fearful at all. Some people said they’re quite fearful. We looked at implicit evaluation using a similar measurement to the paper that you mentioned, which is the implicit association task, but we also look at physiological threat responses. That paper was looking at two people present this phobic response, the defensive response when they are looking at images that are considered to be threatening. What that paper demonstrated to us was that people would self-report they are not fearful or they’re highly fearful.

When you look at the results of the implicit association task, it was telling you that everyone had an implicit bias towards bending and lifting with a round back as being dangerous. That poses the question that is this only related to people with pain or is this a societal belief? I’ll explain a little bit about the implicit association test. It’s quite interesting. Who developed this test is a group of psychology researchers at Harvard. They have a project called Project Implicit, which is quite interesting as a member of society to go and do some of these tests on that website because it challenges your thinking.

Basically, it’s a reaction time task almost like sorting out tasks. People are presented with an image or a word in the center of the screen and two categories at the top. For our study, we’ll be having someone bending and lifting with a round back, for instance. At the top, you have straight back and round back. Your job is to allocate the image to one of those sides. The image will be presented under a second. You have to be quick at saying they should go to the left or to the right. That same picture will be presented with safe and danger. When you have a single category, it’s pretty easy. We made things a bit complicated where we put safe and round back and straight back and danger. You have to allocate that image. If you see safe and run back together, you may not be as quick to associate the image with that side as you would if you saw safe and straight back. Our hypothesis was people that were more fearful would be slower to make that association.

What we found is that across the board, everyone was quicker to associate round back bending and lifting with danger. We needed to have a look at people without pain. That’s what led us to ask the question in the paper that you mentioned about the people that don’t have any pain, do they have this implicit bias towards bending and lifting with a round back has been dangerous or is this something that pertains to the group of people with pain? What we saw again is that some people will say that they self-report they’re fearful or the people will self-report they couldn’t care less about bending and lifting with a round back. At the end, on average, the group was demonstrating this implicit bias.

Our understanding of that data was that we’ve probably tapped into societal beliefs. The way these tests work is we’re trying to get as close as possible to what would be subconscious. We can say in the academic environment that we measure subconscious beliefs. We’re trying to get as close as possible because we’re trying to get people not to have time to access their conscious memory. Probably what we are doing is when they demonstrate to you images and words that are quickly available in your mind, it’s easier for you to associate. If you look around everywhere you go in terms of health and occupational safety, all the images are about the straight back being safe, round back having a big cross.

If you ask any grandmother and any mother around the neighborhood, everyone will tell you that round back is a bad thing for you. There is this belief around posture. We are probably tapping into the information that is most readily available in our society. There is this idea that the back is easy to harm and hard to heal. We looked at this population and implicitly they’re making the same associations. That creates what we think is this strong schema that you might be going on about your life and everything is fine. You experience pain.

Once you’ve experienced pain, your brain is probably going to tap into that schema and go, “I have back pain. What should I do?” I shouldn’t bend because that’s what my implicit schema is telling me. You go and talk to your friend, your neighbor and healthcare professionals. They reinforce the schema and what we think potentially happens. The speculation on our data is that you have this update of the schema that goes from bending in the back is dangerous to protect the back from now on, especially if your pain is related to bending. You bend forward and you think you’re on your back. That reinforces that schema and you get caught up in that idea. Ideation has a behavioral response. They may get people trapped in it.

I have a couple of new questions that I didn’t have prepared but as you spoke, I had some lights going off. The first thing is to clarify for everyone that your research starts to point toward the fact that both people with pain and people without pain believe that bending with a round back is potentially dangerous.

We believe that we’re capturing that the message. It is a message that is out there in society.

My second question is as physios in the Western world, we probably would all agree with you that this is a prevalent problem and these beliefs exist and are sometimes reinforced by sometimes people who have well intentions. It’s not just people who aren’t up on the latest research. Do these same implicit beliefs exist potentially in a third world country where education hasn’t potentially penetrated as deeply?

That’s one of the things that we raise in our study as one of the limitations. We’re looking at this Western society population. We are almost like asking people in different countries to look at the same question. The same friend who came over to Australia with me, he’s looking at potentially investigating that in Brazil. We also had some conversations with other people in different parts of the world to look at that. One of the things that we know is that different cultures have different perceptions of pain. Some of them look at pain from a spiritual perspective or they don’t allocate a body part to their pain. They see pain as almost like a proxy of their health to an extent so that would be interesting to see. Potentially we may not see it because they don’t have access to that or that information is not so strongly provided to them. I’d love to have a better answer to that question. We’ll have to wait for more research.

It’s interesting now with the internet, I wonder how much it affects cultures around the world almost instantaneously. Where before the internet, the information didn’t travel as fast. I don’t know if it was your particular study or one of the studies prior, you mentioned a physiologic response. You also mentioned that if someone has these implicit beliefs that it causes them to think about protection. What are the physiologic changes that may be associated when someone feels like they have to protect their back?

If I look at the defensive responses that I’m making my comments upon, if we backtrack a little, a physiological threat response comes from research in psychology where they look at people with a phobia. For instance, someone with a spider phobia, they would have a physiological response of heightened heart rate, elevated autonomic response with skin conductance levels, and a stronger eyeblink reflex. If they look at an image that is threatening versus an image that has a neutral valence such as ice cream, their blink to the threatening image will be much stronger.

We captured that framework of assessing physiological responses. Instead of presenting people with a picture of a spider, we put a picture of someone lifting with a round back. Our hypothesis was that if you’re fearful, you may present a similar response. We didn’t find that looking at the image was enough to elicit that defensive response. That makes sense with the current understanding of the role of fear, for instance, where fear exists, self-reported emotion. It’s more cognitive and emotionally driven. A defensive response may come as a consequence of you being exposed to the actual tasks.

When we look at that particular group of patients, they did not present that response. We believe that’s because they haven’t been exposed. There was another study that came from a group in Germany led by Julia Glombiewski. She looked at back EMG and skin conductance response. They run a very similar paradigm. In the end, after showing the images, they told the participants that they had to perform the tasks. They never did perform it, but they thought they had to perform it. By thinking that, they had an increased muscle activity in their back and they had an increased autonomic response.

It reinforces this idea that if you are about to be exposed, they think you’re under the spotlight to do something you don’t want to do, that may drive them that defensive response. To answer your question, we will have to take the next step, which is to get people to perform a threatening task and look at how they respond. That was part of my Ph.D. where I asked people to do the three tasks, which was picking up a pen off the floor however they wanted. I asked them to touch their toes and stay as close as possible to their toes for a few seconds. They’re keeping their knees straight so they’re almost forced to bend their back. I asked him to lift a box, which is about ten kilos. That data has not been published yet. What I have in that instance is what is the expectation of pain in performing those tasks? What is the actual experience or performing the tasks but also EMG and kinematics of the back? That may give us some insight in terms of back protection when they exposed to a threatening task.

In the cases of the participants in my study, it wasn’t only threatening, but it was also pain-provocative. There’ll be some data. They will have to hang around to see the results. We’re currently analyzing the data. If I think clinically, when we ask people if they say they’re fearful of picking something off the floor, the common response for someone with back pain is that they tend to brace themselves or they slow down their movements. They hold this point extension or they try not to bend it. They could prop their hand on their knees. They hold their breath or they may not flex their trunk at all. They may do a deep squat to pick up something off the floor. Although this may sound like a generalization, there are quite a few studies demonstrating that people with back pain, especially people that are more fearful present a slower guarded movement when they have to do a pick and lifting tasks. That’s how we see this protective response.

It’s a protection in a way almost makes me think of tightness or contraction. Your patient or your client may be in that type of either one, more global posture or two, if you look at the muscle physiology on maybe a segment by segment analysis, you may find that which is why people have I difficulty starting to move or engaging with movement because of the fear or the belief they have that they are going to injure themselves.

A lot of times that response of tension, protection and slowing down is quite an automatic response and often a neutral response. Many people don’t even realize it. Ironically many people do that. In doing that, they get themselves caught up in a cycle of discomfort and even breaking that, although they’re quite fearful that many people can provide some symptom relief.

That’s why I love that you mentioned they flashed the pictures fast. It doesn’t give you a chance to think about it, which so many people with pain are doing things and they are not thinking about what’s happening. A lot of this is subconscious, which is interesting. A lot of ways you’re trying to overlay some new learning into their pain neuro matrix to help to recondition that, which is interesting. There are some studies that are very popular, famous studies on cadaver models where they looked at bending and flexing of the back, intradiscal pressure, spinal loads and compression forces. People got very excited about a lot of those studies. How do your research and data start to inform some of those studies?

We tried to allude to some of those studies in the discussion of this paper where if you look at some of those studies, a lot of them are very models. They’d been reproduced in humans basically doing modeling. There are no significant differences between what would be like stoop lifting versus squat lifting. There is a lot of inconsistencies in those messages. At the end of the day, if you have an idea of how much forces you’re putting through a body part, it doesn’t tell you if that is related to pain or not. Studies that have tried to intervene in changing someone’s posture, ergonomic interventions to try and reduce the presence of pain or disability or even prevent the occurrence of that, they haven’t been that successful. It’s almost like we’re looking at one piece of the puzzle. For some people, they may not be capable of performing such tasks because they’re not conditioned to it or because they are being exposed to it for the first time or they’ve been exposed to it for a prolonged period of time.

For other people, that makes no difference. Several other factors may play a role in pain onset or persistence. When the way we think this study form is to say, “People are thinking this way, at a cognizant level but also at an implicit level.” That’s the easiest memory to associate is that rounding your back is dangerous. We are not trying with this study to say that everyone should bend their back. Everyone should round their back. That’s not the argument. The argument is saying like it makes sense that this information is not there and therefore it makes sense that when we see patients in the clinic, there are some of these responses that we’ve seen they are not irrational. They are common sense responses because they’re basically doing what they think is right. It’s like following the rules. Isn’t it?

That’s common sense, there’s a whole model called the common sense model of self-regulation. It provides a lot of evidence to support everything you’re saying and further supports your research. We have your research about some of this information regarding danger and safety. We have some of the older information about pure biomechanics, compression and loading. What’s the research telling us with regard to should a physio discuss or educate about proper lifting techniques and body mechanics as part of a pain rehabilitation program for chronic low back pain?

I wouldn’t be able to tell you a study that tells me what is proper lifting. What I can tell you even with the qualitative data we got from this particular study that we are talking about in the Scandinavian general claim where we asked people about what do they think is proper lifting. I could basically copy their responses and put them in a textbook. It’s exactly the same. You’ve got to use your knees. You’ve got to keep your back straight. That is based on this idea that the spine has so many bends. The disc is quite vulnerable. You should protect it. There is this fear of using your back. There’s something about the back that people become quite fearful. Maybe it’s because it protects your spinal cord.

If someone is involved in a job that they have to do a lot of lifting like manual labor, you’ve got to do the heavy lifting. You’ve got to condition yourself to be able to do that. One of the things that we know is that if you aren’t involved in such job like cumulative loading can be related to pain. It’s usually not the only factor. If I’m sitting on my bottom for the whole day and then all of a sudden I get a very physical job, I’ve got to condition myself to do it. What is the best way of doing it? It’s usually the way that you feel most natural. They can distribute the load across your body. I’ll probably wouldn’t be telling someone that you’ve got to keep a straight back because I have no evidence to say that. If it’s natural for that person to easily go down to the floor and lift something, great. How you do that? You use your hips. You use your back. You feel that you’re strong across your body. Usually, when we try to prevent a body part from loading up and using it, it’s usually the body part that you use them up because you load it up.

When I reflect back, I’d been practicing since 1996. I’ve been practicing longer than a lot of people probably reading this. When I run into PTs, I was a competitive gymnast around my entire life. I’ve watched people bend and twist and put their spines under tremendous load. I got into PT school. I remember very clearly in my orthopedics class, they’re educating us on the exact things that a lot of your research is moving people away from now. In my mind, it makes no sense to me because I like to put my back through. I’ve seen many people put their backs through it in that specific sport. I’m not saying that’s a model. I do think it makes you think what are we teaching people?

I watched gymnast injure themselves, but I also watched them probably recover faster than the normal population because they would pretty much re-engage in healthy movement again in a way that was progressive. I have a clear picture in my mind of a physical therapist who came to me for chronic back pain years ago. I started using Pilates exercises in treating people with back pain like way back in 1999. People thought I was crazy because a lot of Pilates exercises involve deep flection of the spine. Everyone is like, “This is bad for disc patients.”

This particular PT came in who was a McKenzie-trained therapist, a wonderful therapist but her spine literally was stuck in neutral and would not move in either direction. It took me weeks to start to help her move one physically. A lot of this is decreasing people’s fear of healthy movements. A lot of information you have is so valuable obviously for patients as well as practitioners. Let’s talk about some of the simple lessons that we can teach people. You gave us some great downloads to some of these images. People can download them for free. Let’s talk about the stabling thoughts and beliefs that people have. For instance, my scan or my MRI means that I can improve.

That’s probably another thing that holds us back as a profession. This idea that scans will drive disability and that scans dictate what we should be doing. It’s a pretty recipe-type approach. We have some overwhelming evidence now that scans change with age and how much they will change will depend on people’s genetics, epigenetics, the stresses that they put their bodies through over the years, the relationship between that and disability and pain, the future is pretty minimal.

If you have a pretty, unhappy, overwhelmed, unhealthy person, that’s a greater predictor of pain in the future, than your extra scan. That is something that we are commonly informed by our patients that, “I’ve got the scans so therefore I can do these things.” Giving the message that the spine is resilient and that loading your spine strengthens your spine. It strengthens your ability to use your spine and condition your body to do the things that you want to do. They add greater value to your journey than your scan. It’s a pretty limited view if we are just looking at the scan.

It’s changing people’s beliefs and going, “I can do these things despite my scan.” I got to be mindful here. If you look in every examination, we’ll get a patient who will go through a 3R system and we go, “Are there any red flags? Are there any signs of specific pathology here?” Depending on the specific pathology, they’re quite adaptable. They’re quite modifiable. They can improve some of the things like if you can have a stress fracture. You have to respect the healing processes of that. It doesn’t mean you should brace your body and not move for three months.

You have a gradual progression of loading and some of the things like disc bulges and disc protrusions. It’s quite different having that versus heavy disc protrusion with nerve compression and progressive neurological loss. They are very different pathways. In both, even if you have a pathology such as nerve compression, providing the idea that these things have a good natural history, so you’re providing a positive message. We’ve got to monitor this. These things are not getting worse and you’re coping well will continue to progress. It will gradually load you and get you back to do the things that you want to, which is very different than say, it’s all doom and gloom and that will dictate our treatment.

Peter’s work, when I look at it, the Cognitive Functional Therapy, cognitive-functional approach to pain and most of his work is around back pain. I’m excited to see that he’s included lifestyle factors like nutrition in there. It’s something that more PTs should be talking about and educating their patients on. How much of that have you integrated into your work with patients?

That’s the approach that I tend to work day-to-day in the clinic. Changing someone’s lifestyle is entirely dependent on how much that is dominant in their presentation. It’s usually a window to get people back in doing the things that they value. Patients usually may come in and say, “I want to get rid of this pain.” When you ask them, they go, “I want to be able to play with my kids. I want to be able to mountain bike on the weekend. I want to play golf.” They are much more important goals because they are linked to social activities, family activities, work. Looking at some of those factors and going, “You’re not sleeping well, you have an unhealthy diet, you drink heaps of coffee and you’re telling me you’re not sleepy. You’re overweight.”

They’re tough conversations to have. There are things that the patients bring in and you go, “Do you know how much that can influence your nervous system sensitivity?” Some people may not know that. Some people say, “Yes, I do.” These are important factors. If we work on these things, they can assist you in your pain response. We can guide people through that process. It’s not like everyone that will come in, we’ll give them a lifestyle change approach or a little leaflet that these are the things you go to do. Some people sleep pretty well. They eat well. It’s more related to the fact that they are not doing the things that they like to because they are afraid that they may damage themselves.

They may get a scan that’s being relayed to them as being something that is quite harmful. They might not be capable of doing such a thing. They avoid those activities with fear of hurting themselves or because they are in pain when they do it. They don’t know how much they should push. Some people are reassuring that’s the very thing they need to do. Some people are creating some modifications. You have quite a lot of training and a lot of knowledge in terms of nutrition and diet and the effects of that in someone’s health. If we think there’s an important part, we’ll be cool working with a dietician or with the psychologist that it’s linked to weight loss behavior. It’s trying to create this integrated care for the sake of the patient.

As you’ve developed your work, do you have it such that you’re bringing people through like a seven-visit protocol or is it at this point you’re still evaluating the patient? Obviously based on your evaluation findings, that’s guiding your treatment.

We look at some of the studies that evaluated CFD. We look at my study in terms of the case series, looking at the number of visits and it varies. Some people respond quickly. After four visits, there are doing the things that they’re doing. Some people need a bit more guidance and they may need eight visits or ten visits. The interesting thing is that if we are honest with what pain is, for instance, if we think about persistent pain. You look at trajectories, those beautiful study where they looked at five, seven-year trajectories of people in pain. It fluctuates along the lifespan. It’s potentially a long-term problem for a group of people. Sometimes we go coming in for six sessions and then you’re fine. You’re fine at this stage. What if you have a flare up? What are you going to do? Do you have a plan and can you self-manage? If you can’t self-manage yet, are you free to come in? We reassess things because when you have a flare up, probably some of those beliefs that have been changed during the intervention, they probably light up again. They come together with some behaviors and some lifestyle changes. Those things need to be modified so people can keep going.

The idea is not to keep them dependent on us. It’s quite the opposite. It’s to provide the tools so they can self-manage. At times people get in trouble and they can’t think straight. They forget about some of the key messages and they come back and go, “What was happening?” They relate to you what’s happening or if you have tried these things. “I wasn’t quite sure.” You may be reinforcing that message. One of the things in one of my studies that we looked at with looking at the process of change with CFD and that wasn’t a study to test the effectiveness because it’s a single case experimental design. It wasn’t designed for that. It was designed to unravel this journey of change.

One of the things that we saw is that for the first eight weeks where no intervention was provided, people were fluctuating at pretty high levels of disability, pain, and fear. Once they had that first encounter, there was quite a rapid change for some of these patients. Some of them are quite rapid. Others are more gradual. The shape of the change was different. Something happened in that first session. There all of these factors, disability, pain, fear, ability to control their pain, they all changed together around that session.

We think that that first session is quite powerful or important to take the person through. It’s a leap into a new journey. Depending on how that goes, the process may be quicker or slower for other people. If I think in the clinic, you’re in between four sessions, ten sessions for a period of three to six months. I probably will review this person over a year or over the next couple of years but intermittently. It’s not a set thing. If I get someone that back to the things that they do and go, “What were your goals in the first session?” or “I want it to play with my kids. I want to run and I want to play golf.” “Are you doing those things?” “Yes.” “Is there anything you were avoiding?” “No.” “Is there nothing to fear for?” “No.” “You’re happy to do everything?” “Yes.”

Let’s talk about an exacerbation plan. What would happen if you had a flare up? “I would do this or that.” We may adjust and we write down an exacerbation plan. If you have a flare up, this is where you’re going to have a look at. If you’re struggling, you’ve got to contact me. Sometimes they don’t come in. They may send an email or they may come in and they need a booster session or something like that. We say, “Let’s aim to catch up in a couple of months.” In a couple of months, if they’re going okay, they shift their appointments. We may not see them or we may see them a year later. It’s flexible. The whole point is it’s not me telling them that they are ready. It’s them going, “I’ve been coached enough. I’m doing everything I wanted to.” That’s the idea behind it.

They’re great points though because so often therapists don’t follow up with patients six months, a year or a year and a half to see how they’re doing. Have they continued to progress in the right direction? Have they had pain, they would start taking a couple of steps back. For PTs out there, they should put their patients in a yearly email responder where they can send an email, say, “How you’re doing? Do you want to come back in and come for a checkup or are you see how your back is doing?” It could be important for a private practitioner looking to follow patients, make sure their quality of care is good, make sure their outcomes are good because patients obviously talk about us one to five years down the line with regard to the care they had in conversations. JP, the work you’re doing is awesome. The work all you guys are doing over at Pain-Ed is awesome. Can you tell people how they can learn more about you with regard to your research, all the information you have, patient care or everything you have going on?

I’m part of this international group of clinicians and researchers. We have a website where we provide resources for health professionals and patients. That’s Pain-Ed.com. You can find some patient stories. It’s quite useful for some patients. We tend to use that in our assessments with patients. We direct them to those websites and say, “There’s a patient story there that matches or may resemble your story and you may find some important things.” There are some data on people looking at other patients going through a journey and having results that they can provide them some reassurance that there is a lot. Also at BodyLogic.physio, that’s where I work clinically. We are quite fortunate because our research is quite embedded in our clinical practice. That makes it easier for us to move forward and answer some of these questions.

I’m going to send everyone to www.Pain-Ed.com. That’s the main place where you can go. You can find a lot of information. You can go there and click on the link and access all the clinicians and their bios and JP’s bio will be there. Everything about JP will be on the website. You can access everything there. At the end of every podcast, I ask you to share this information out with your friends and family on Facebook, Twitter or LinkedIn. Grab the link to the podcast and drop it in your favorite Facebook group where there may be physios or other pain practitioners who could benefit from JP’s great work on how to take people from disabling low back pain to living a life that they value and returning to the activities they love. I want to thank JP once again for lending his time. We’ll see you next time on the Healing Pain Podcast.

Thank you so much.

Important Links:

• Peter O’Sullivan – previous episode
• Evaluation of Implicit Associations Between Back Posture and Safety of Bending and Lifting in People Without Pain
• BodyLogic.physio
• www.Pain-Ed.com
• http://www.Pain-Ed.com/Healthcare-Professionals/Pain-Ed-Team/
• https://www.Facebook.com/Joao.P.Caneiro

About Dr. JP Caneiro, PT, PhD

Dr. JP Caneiro is a Specialist Physiotherapist and has a Ph.D. in Musculoskeletal Physiotherapy. JP is part of an international team of clinician-researchers that developed a behavioral intervention named Cognitive Functional Therapy.

At Curtin University, JP has a research position part of an NHMRC Centre of Research Excellence in Knee OA, and a multicenter trial for back pain. At Curtin, he also lectures in the Master of Clinical Physiotherapy.

Clinically, JP focuses on the management of complex musculoskeletal pain presentations, working at Body Logic Physiotherapy in Perth, Australia. JP is an Associate Editor for the British Journal of Sports Medicine, and for two educational websites, Body in Mind.org and Pain-Ed.com. He has published several research papers and presented his work internationally.