Low Back Pain and Cognitive Functional Therapy with Dr. Peter O’Sullivan, PT, PhD

Welcome back to the Healing Pain Podcast with Dr. Peter O’Sullivan, PT, PhD

Joe discusses chronic low back pain with Dr. Peter O’Sullivan, PT, PhD. Dr. O’Sullivan shares his journey from clinician to researcher and educator, how his research and study into back pain physiotherapy and behavioral psychology has changed his own belief system, treatment approach, and practice in treating chronic low back pain. Dr. O’Sullivan developed and continues to refine the cognitive functional therapy model for treating low back pain. He shows how to effectively use exposure therapy for people with pain, and how to make sense of pain whether you’re a practitioner or a patient. Dr. O’Sullivan is a professor of Musculoskeletal Physiotherapy at Curtin University in Perth, Australia. In addition to his teaching and research, he works in clinical practice as a physiotherapist. He is recognized internationally as a leading clinician, researcher, and educator in the management of complex musculoskeletal pain disorders.


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Low Back Pain and Cognitive Functional Therapy with Dr. Peter O’Sullivan, PT, PhD

We are discussing chronic low back pain with Dr. Peter O’Sullivan. If you are a physical therapist, you may have already heard of Dr. O’Sullivan’s work or possibly read some of his research. If you’re someone who is looking to learn more about chronic low back pain so you can find some help, this will be one you’ll want to read over and over because it’s filled with some great information that you won’t find anywhere else. Dr. O’Sullivan is a professor of Musculoskeletal Physiotherapy at Curtin University in Perth, Australia. In addition to his teaching and research, he works in clinical practice as a physiotherapist. He is recognized internationally as a leading clinician, researcher and educator in the management of complex musculoskeletal pain disorders.

On this episode, you will learn about his journey from clinician to researcher and educator. How his research and study into back pain physiotherapy and behavioral psychology has changed his own belief system, treatment approach, and practice in treating chronic low back pain. How he developed and continues to refine the Cognitive Functional Therapy model for treating low back pain. How to effectively use Exposure Therapy for people with pain and finally, how to make sense of pain whether you’re a practitioner or a patient. We cover a lot of ground and include a lot of details. If you’re a practitioner, hop on over to IntegrativePainScienceInstitute.com and sign up for the mailing list there, so I can send you information about the latest educational offerings that will be coming out in early 2019. It will include a course on nutrition for pain as well as a course on ACT or Acceptance and Commitment Therapy for chronic pain, which I’ll be co-teaching with Dr. Joanne Dahl.

Peter, welcome to the show. It’s great to have you here.

Thanks, Joe. It’s nice to be here.

I’ve been excited to talk to you. You’ve got some great research and clinical work that you do. You’re a physiotherapist, who has studied back pain quite in-depth and started to create your own methodology and system. As a fellow physio, I’m curious to know how you went from your undergrad work in physiotherapy to pursuing a PhD and researching in low back pain.

That’s a 30-year journey for me. It’s a long journey in a number of turns I suppose. When I look back, it’s probably a process of evolution. I did my basic training in New Zealand. There was a pretty strong emphasis in terms of the McKinsey approach, very much of a pathoanatomical understanding of pain. It didn’t sit well with me in a lot of ways. I’m naturally a pretty active guy and not very fearful when a lot of the messages that we were giving people didn’t gel well. I suppose as a young physiotherapist and thinking back then, there was very little research in the world of pain. I can remember as a young graduate, I had the sense that there was this open space where research needed to be done in the space of pain that hadn’t been done. I ended up getting to Australia and doing my postgraduate on Manual Therapy Training in Perth, Western Australia.

Following that, I spent some time working with Bob Elvey who some of the older physios might remember as an amazing clinician, but he also worked in the pain clinic. That was an eye-opening experience for me where I realized that Manual Therapy didn’t have much of a role to play with these people who are disabled, highly sensitized, and very distressed with pain. I realized that we didn’t have much understanding in terms of research as to what was happening. That’s where I embarked in my research career. That’s been a tandem career for me between always working in clinical practice, which I’ve done my entire 30 years and also having a research career. A lot of that career has been underpinned by testing my beliefs and then realizing that much of what I believed in completely unraveled when we looked at the data that we were collecting.

HPP 115 | Cognitive Functional Therapy
There’s this massive increase in understanding of neuroscience and behavioral psychology which married so beautifully in the pain space.

If you followed my research career, a lot of it is testing hypotheses, which fundamentally tested my belief system, the stuff that I’ve been taught as a PT. The majority of that stuff wasn’t supported by the evidence. This constant updating of my belief system and then adapting that in terms of a change in practice and part of that as well is this massive increase in understanding of pain neuroscience and behavioral psychology, which married so beautifully in the pain space. That’s being the wave that I’ve ridden across my career. I see myself as incredibly fortunate to have been part of what has been the amazing journey of learning. Unraveling I suppose the complexity of the pain that we see in the people that we come across.

That pain neuroscience, that change in our perspective of what pain is, would that precipitate you to go back for your PhD or is it more your own self-exploration at that point?

It’s a combination of so many different things. I can think of numerous patients that I saw and I can still remember them vividly. People who have been told they had unstable pelvises and had their pelvises fused. They got pregnant and all the pain came back. All the clinical signs came back that we thought were related to unstable pelvises. Patients who have become terrified of movement are having a panic attack with the thought of doing a movement that might involve bending the back. People with widespread body pain you couldn’t touch. I suppose because I was working in a space coming across people who were failed primary care and desperate. They were often very open to tell and share their story. I changed my practice around 1996 where I decided that I could no longer work on short appointment times. I’ve spent an hour with every new patient. It gave me a lot of time to listen. It gave me time to explore. It gave me time to reflect. It gave me time to play, to learn and then to readapt what I was doing. That was a critical shift in terms of my practice to allow the people I worked with to become teachers.

The time we spend with patients is not only critical for the patient, but I also think it’s critical for us in our profession. It’s something that physios tackle globally, which probably could be a PhD or/another podcast in and of itself. Let’s talk about back pain first. Let’s set the stage as far as back pain goes. Let’s spend a moment or two on that 10% of back pain where there are serious pathology involved.

The whole issue of pathology if you’re talking serious stuff around malignancies, fractures and infections, that’s probably around 1% to 2%. There’s a group of people who might have radiculopathy and neurological deficit and that’s probably of a few percent. Then you’ve got this other group. This is where we get blurry around what we call pathology because the problem we’ve got now is that with MRI scanning, pretty much everyone gets damp with a pathology label particularly as they get older because everyone’s got stuff on a scan. What we know about most the stuff that you see in an MRI scan if you take out a malignancy and infection that most of the structural stuff that you see is also prevalent in five different people.

The whole idea of pathology is a gray area where we know that there are 30% of people who walk around with protrusions and 60% with disc bulges. There are people with stress reactions of the bones that don’t have pain and others do have pain. Pain may have an association with structure, but the full story is not told by the structure. That’s where we have a multi-dimensional view of understanding pain that gives you such a clearer view of why some people can present with so-called structural changes that may be associated with pain. Others might have similar changes on that scan but very little pain and disability. That’s explained through other processes.

What you’re saying is that in probably 95% of the cases, there’s not a single pathoanatomical cause that can be identified?

There may be things on a scan that might be associated with the pain. It is not adequate enough to explain the person’s pain experience and the level of disability. That’s an area that’s important. How you experience pain and how I do is informed by so many things across our life. Contextual factors, early life experiences and how you respond to it will be massively informed by your coping responses. Your belief systems, your levels of self-efficacy, all kinds of things will influence how you respond to pain. The clinical presentation of someone who may have something like a disc prolapse with radiculopathy can be completely different between two individuals who may look like they have the same thing on a scan. The clinical presentation might be completely different. That’s explained by all these other factors that we know are important.

We’re going to talk about some of that factor. If you want to sample some of Peter O’Sullivan’s work, if you go to the Physical Therapy Journal and look up Cognitive Functional Therapy and integrative behavioral approach for the targeted management of disabling low back pain. It’s a wonderful perspective paper on not only low back pain but also Cognitive Functional Therapy, which is something that Peter has been working on. In that paper, Peter, you talk about protective or resilience factors, which I love the terminology because so often we’re focusing on what could potentially be wrong versus what can we do to build ourselves up, make ourselves resilient. What are the factors that help protect our spine and protect us from persistent pain? Let’s first talk about positive beliefs, can we talk about that?

Resilience is an interesting area. It’s being researched across a whole bunch of different health issues. With pain, it’s very interesting because things like beliefs seemed to be important. If you have a belief that back pain is a pretty normal occurrence. That back pain means that you shouldn’t lie down, and still go to work with back pain. That movement is safe and healthy if you have back pain. You’re way less likely to become disabled and lose time off work with back pain. We’ve done research looking at some young people from early life and those beliefs emerge early in life. In terms of teenagers, you can identify these beliefs and they’re linked to behaviors. People with positive beliefs around back pain are less likely to seek care. They’re less likely to avoid physical activity. They’re less likely to report any functional limitations in their life.

HPP 115 | Cognitive Functional Therapy
Different cultures, like the Buddhist culture, have this idea of accepting suffering. We don’t do that in the Western world.

Those beliefs are quite closely married to their parents’ beliefs. Pain is something and how we respond to pain is something we learn really early in life and that’s formed by the culture around pain in a family situation. You realize that that’s why these beliefs are so strongly embedded. They’re not driven and the society would certainly play a role. We hold cultural beliefs around back pain, which is are not evidence-based. The negative ones are prevalent. We do know that there are people in our community who hold positive beliefs. That’s strongly linked to factors like the beliefs of the parent as well.

It’s almost like from early life, we set up these rule-governed behaviors that, “If I have pain, I cannot go to work. If I have pain, I cannot go to school.”

We published a paper showing that if a young person is taking time out of school because of their back pain, 70 years later, that’s significantly more likely to take time out of work for their back pain. These are life trajectories that emerge probably early in life and they set the course. We look where do you start intervening with this stuff? It’s got to be at a societal level. It probably has to happen early and has that happen within families because these beliefs are massively pervasive within their community.

Often those messages that are promoted out there, create a lot of vulnerabilities for people.

There is an industry that feeds off within that. That’s the thing that I find most distressing is we have a health industry that feeds off people suffering. Often, that reinforces a negative belief system as a mechanism of locking people into continuing care, which is great for business but crap to health. I find that completely disgusting. It’s a healthcare practitioner to think that we could be still funding care that could be detrimental to someone’s health.

Here in the United States, we have whole institutions created around a biomedical model. The names of the hospitals are in line with the biomedical model that it makes me think, “We have so much work to do.” Your work and others help push that message forward. In your paper, there’s another part of cognitive factors that you talk about. You call it cognitive flexibility. I saw that in the paper. I was like, “That’s so interesting,” because it has a little bit of a flavor of Acceptance and Commitment Therapy where they talk about psychological flexibility and how important that is when someone is coping and moving beyond some of these cognitive factors.

We’re exploring this in a big trial that we’re running at the moment in Australia. We’ve got some qualitative data that suggests that when we look at people with disabling back pain and track their journey. The people who look like they do well are the people who develop a bias psychosexual understanding of pain, they develop strategies to cope and manage their pain and get on with their lives. The people who look like they don’t do well from this approach are people who say look that’s all very well, but my back stuffed and I need it fixed. Before it gets fixed, I can’t get on with my life. They are stuck. That taps into this idea of cognitive flexibility where you can look at a problem and shift your thinking and adapt your life around it. It does happen to some of those factors around acceptance that allow you to explore a problem from a different perspective.

Changing perspective is so important when it comes to pain. A lot of explaining pain that has done so well for people provides them with a different perspective as to what their pain is and what the possibility is even if they have a little bit of pain in their life going forward.

If you look at different cultures like the Buddhist culture has this idea of accepting suffering. We don’t do that in the Western world. Pain is something you’ve got to fix, you’ve got to cure. You should have a right to have no pain. I personally have a problem with that. I personally have pain. I’ve had dozens of various injuries in my life. I would feel pain in my body pretty much every day. It’s pain that doesn’t define me. It doesn’t limit me. It doesn’t bother me. I don’t engage emotionally with this. I’ve learned to do that. I’ve certainly been very fortunate. I think because a health care practitioner to have a repetitive dose of pain in my life. I’ve been fortunate that I grew up in a household where the pain wasn’t something that was given too much attention to. I was encouraged to get on with it and move on in spite of it. I was fortunate that that was the background and framework in which I could learn to manage pain in my own life.

Talk to me about the physical factors that are involved with these resilience factors that you talked about in your paper.

HPP 115 | Cognitive Functional Therapy
It’s disabling persistent pain experience that opens people up to shift their cognitive thinking.

In terms of management or in terms of protection?

Let’s talk about in terms of protection first because I think that’s one part that people don’t quite think about.

There is some pretty good evidence around healthy lifestyle as being protected. Engaging in regular physical activity and physical activity is interesting because there’s a bit of a U-shape curve around people who are involved and engaged in high levels of activity. People who do very little have an increased risk in terms of pain. A healthy dose of physical activity is pretty protective. Similarly without lifestyle factors in terms of healthy body weight and regular sleep, these lifestyle factors look like they’re important. As a society, more sedentary, more sleep-deprived, and unhealthy in terms of diet. We tend to be extremes of either no exercise or crazy amounts of exercise. It’s obviously not often not well regulated. All of those factors can be factors around risk. The protective factors are the opposite of that around a healthy diet, good sleep, healthy sleep patterns, regular physical activity and breaking up sedentary behaviors in terms of engaging in the physical activity.

All the things that you and I have been talking about are things that are modifiable. The things that someone with low back pain if they’re reading this they can start to change on their own so they can start to improve the way they sleep. They can start to move. The number of people I’ve had here told me reading this has taken my anxiety away, which we know is helpful when it comes to pain. I know this is your journey, but now your story to craft and mold all this into what you call Cognitive Functional Therapy. Tell us what that is.

We didn’t know what to call it because there are elements. It’s an integrated approach and we’re very clear about that in the paper. It’s evolved out of the physical therapy practice essentially because we are physical therapists. It’s integrated other aspects in terms of behavioral learning, understanding of pain neuroscience, and understanding of behavior change to develop an integrated model. One of the things that we see in the current health climate is that we’ve got PTs on one side who will tend to be more structural and biomechanical. You’ve got the psychs on the other side, which of them are very much around more the CBT or the ACT approach, which is talking therapies. There’s this middle ground with the talking and the doing. What we see with CFT and the reason we call it FT is the F bit, the behavioral aspect seemed to be very important as we embody pain in their bodies.

We see that there are three main elements to the intervention. First is the exploration of the person’s story where we would capture the story, the contextual factors around their pain, their beliefs. Their behavioral responses to pain, the impact that it’s having on their life and how that might be affecting them emotionally. We would explore the things that the key factional barriers for them to engage in valued life activities. I think of a chap that I saw who was disabled. The things that distressed him is that he couldn’t go back to work and he needed to engage in lifting, bending and moving his body. He had been told he couldn’t. He wanted to play with his kid and he wants to ride a bike.

We would then end the physical examination. Explore the barriers for him engaging in those valued activities. For him, it would be bending and lifting with critical movements that we then explored. He was highly fearful and sensitized around that but very guarded in the way he did it. We run through a series of behavioral experiments where we say, “Let’s look at bending,” with the premise that bending is not dangerous. That’s the most important thing. That lifting is a normal healthy thing for a back. He’d been told that all these things were dangerous to him. Through that first examination, we got him to relax, got him to stopped guarding and bracing his abdominal wall. We started to get him to breathe. We started to get him to stop propping off his hands. Through a graded exposure process, while we got him to desist from his protective behaviors. He realized that he could touch his toes and then he could load his back.

That creates this massive cognitive shift for someone, who walks in thinking that they can’t do the job. That bending and lifting are dangerous and at the ended the session with a bunch of behavioral experiments, they walked out going, “I can bend my back and I can lift. It didn’t break my back and it hasn’t been a catastrophe.” That sits the person up to be educated. Where it’s the learning in the body that we think is critical to behavior change. What we see at the moment is that talking to people isn’t enough. That talks the cognitive part of the brain, but so much of pain is linked to the emotional brain. That is linked to things like fear, distress, worry, uncertainty and lack of confidence. It’s disabling persistent pain experienced that then opens people up to shift their cognitive thinking.

As I’m going through your paper and reading, I’ve read a couple of other papers that you have as well is that I think you’re the first practitioner who has started to put into the research that although movement may be a science, when it comes to movement in pain, movement is a behavior. It’s a delicate thing that most people probably glance over. When you look at movement as a behavior versus movement as a science, it changes a whole lot of things for people.

It’s helpful as a practitioner. I came to this whole process with thinking of movement as biomechanics. I shifted to see the movement as behavior. This fits well with the contemporary understanding of what changes when people have pain. If you look at the systematic reviews that compare people with and without back pain, the common story you say is that people with back pain, particularly if they are disabled or distressed has to move slower. They’re more guarded. They’re more co-contracted. The brain protects the bit that’s threatened. Often therapies and advice to people to reinforce that. Sit up straight go and say, “Don’t bend your back when you lift. Brace your core when you move.” We are reinforcing those protective behaviors and the very advice that we give people with pain. It’s the stuff that they already do. Those behaviors reflect beliefs and emotions.

HPP 115 | Cognitive Functional Therapy
Sense-making is creating a clear understanding of a person’s narrative and their pain experience for them.

We know for example that if someone is frightened, they’ll contract or they’ll move slower. They are more guarded. There’s this whole manifestation of someone’s beliefs and emotions in terms of the way they move. That’s the embodiment of how they see their problem. You see someone come into your room and they’re hobbling in and they squat down to pick something up. They’re bracing off the hand. That person is frightened. They’re terrified of bending. Having that understanding shifts the way you look at pain.

One of the aims of cognitive functional intervention is this is what you’ve been talking about is exposure, exposing them to these types of movements. A technical question as far as exposure goes because when the word exposure is like Kleenex. It means a lot of different things to different people. When you expose someone to movement, when you’re challenging those moving hands, are you looking for a sympathetic arousal in them?

We’re trying to dampen that. One of the things that you’ll notice with someone who is frightened of doing something is they’ll tend to ramp up this sympathetic arousal. You’ll see this by increased tension and may start hyperventilating or breathing more rapidly or they may breathe hold. We will explicitly dampen that process. Before we would expose anyone to something scary, we would explicitly relax them, slow their breathing right down, get them to diaphragm breathe. It’s like you’re disarming them before you expose them. That seems to be very important because where exposure goes wrong is if you say to someone who says, “I think I’m going to hurt myself by bending.” You go, “No, you’ll be fine, bend.” They bend and their experiences that they go to a panic response. You get to do it repetitively. If their pain ramps up and their distress increases, you’ve reinforced fear learning.

If you have someone who has this fear of bending, for example, and you get them to stop. You relax them. You calm them down. You shift your attention from the back. You get to relax and bend. They don’t ramp up. You often have a sense of disbelief because they’re expecting pain. They don’t feel it. You disarm them in that process and that builds safety learning. We would believe that how you go about exposure can either reinforce fear learning or safety learning. The safety learning is the key for building self-efficacy around movement and shift and reducing someone’s fear.

The exposure came out of psychology mostly around anxiety. That’s a little bit different in your perspective.

I was fortunate to be at a fantastic conference in Sweden with Steven Linton and Michelle Craske who is an expert in anxiety, particularly phobias and fear. It was interesting having this discussion around exposure as very effective for the phobias. For spiders, it’s effective unless you’re bitten by the spider. Then it’s life-threatening and then it’s also affected because it drives fear learning. The problem with pain is there is often a consequence. There is a punishment for doing that. Pain is such a powerful learning. It has this very powerful ability to influence behavior. If you are exposing someone to something that’s threatening and their pain levels ramp up, their distress ramps up, that can backfire massively and reinforce fear learning. The exposure literature around back pain would suggest that it doesn’t work for everybody. We would suggest that the reason for that is that if you’re not managing that person sensitively and carefully and they don’t trust you. You haven’t dampened down those sympathetic drivers at the beginning, then it can seriously backfire. What will happen is the person’s belief that bending is bad for them becomes reinforced.

I’ve read some of Michelle Craske’s work. In her work, she says you have to expose people to about 30-second increments and she’s mostly talking about anxiety. To your point, if you’re not good at managing that entire experience, it can go wrong. Even managing your own expectations and your own experience.

Part of the thing that fascinates us when we are training physios in this approach is probably not even to look at what they say, but it’s their body language. It’s almost built on us as human beings are to have this sense of not wanting to hurt someone. To calmly sit with someone while they have a panic attack is an important thing to learn to do when you’re doing exposure work. One of the things that I hold very strongly in my mind when I’m working with people with pain is understanding that pain doesn’t mean harm and that you can take someone back to something scary. It might be terrifying. How you manage that is so important. I’ll often use the example from if you are rock climbing with someone and you’ve got someone who’s scared of heights. You’ve got to be such a cool, calm person, who holds that person en route, gives them confidence, talks to them calmly. Your body language will dictate how that person responds. If you’re edgy, uncertain and a bit erratic that will freak out. I reckon it’s exactly like that with dealing with people in pain with exposure. How you manage that process, the way you talk, your body language is so important to keep that person calm during that process.

Tremendous points because exposure sounds great and you get into it. It’s like you’re sweating more than the patient is.

Humans are like dogs. They can smell fear.

HPP 115 | Cognitive Functional Therapy
We’ve got a massive problem in our society because we don’t have a lot of interventions that are showing to have much effect.

The first part of your CFT intervention or one of probably the parts where you start is something you call making sense of pain. I love the way that sounds.

This has come out of some of the work that come off in one of my PhD students, Sam Bunzli, who has written some lovely papers around the experience of people with back pain who are highly fearful. The model that was proposed a number of years back by Leventhal was called the Common Sense Model of understanding health illness perceptions. It proposed that every human being tries to make sense of their health problems. If it’s back pain, you’ll try and make sense of it from your historical perspective, what you understand is going on, what you think the consequences are, what’s the time frame, what solutions you can create around that. It’s common sense although she said in the paper that was published in HBT looking at back pain through that lens.

One of the things that we often see with patients when we work with them and we take their story and then we explore their story. We examine them through an exposure process then we sit down and we say, “This is how I see your story.” I see it a bit like someone brings a jigsaw puzzle to you with all the pieces, but have lost what the picture looks like. Your job as the practitioner is to go, “Let’s lay these pieces out and let’s make sense of your puzzle. Then we put the puzzle together and we turn around and say, “Do you reckon that’s what it looks like?” Often what the patient says is, “That makes sense.” This sense-making is it’s almost like you create a clear understanding of this person’s narrative and their pain experience for them. Often, this is a moment of going, “You listen to my story. You put the pieces together. This makes sense.” That’s why it’s not a typical pain education session. It’s about personalizing the person’s story and putting it into common sense understanding it is from the narrative. It is their words, but it’s done in a way that they can grasp how pain, behavior, and emotions all set up these loathes that leave people trapped.

Most of what happens in the first session or is that continuous?

That’s an evolving process. One of the things that interest us is that everyone’s journey is quite different. JP Caneiro has finished his PhD and he’s got a paper that has tracked the individual journeys of people going through this intervention. That’s a lovely paper that shows that everyone’s journey looks quite different. That people will shift often very quickly. For others, it might be a slower journey and for some, their beliefs will change fast. For others, it’s slower. That common sense understanding for some people takes time to shift. For others, it can be dramatic. That highlights the individuality of a person’s pain experience. It’s influenced by each stuff including those things we touched on.

The last part is a lifestyle in general. I’m big on lifestyle. I talk about lifestyle a lot. It’s funny I interviewed Jo Nijs, who is a great PT and researcher around that. A lot of his work is more on researching how lifestyle affects pain. As physios, we’re very into the movement aspect of things and we should be. How much of that lifestyle should start to trickle into our practice?

It’s huge. I see that we need to extend the scope of practice to adequately deal with the people who need that care. PT practice in Australia is dealing with the word well. These people are pretty well, but they’re not coming to us because they have bounced out of that care and are sitting in painful aches and orthopedic wards. They’re on opioids. That’s because we haven’t cared for them well. They’ll bounce in and out of healthcare without being adequately managed. The lifestyle is such an interesting area because it’s influenced by so many things. It’s influenced by our socio-economic status. It’s influenced by the neighborhood we live in. It’s influenced by a health literacy. There are so many things that influence those factors.

It’s tricky for some people when they’ve got very difficult life circumstances. I can think of numerous people who’ve got financial stress. Having to work massive hours and they’re caring for the sick family. It’s hard for those people to care for themselves well in terms of their lifestyle because there are so many factors that are working against them. We explore as creatively as we can to try and work out ways in which that person can shift their lifestyle to care better for themselves. It’s very easy for us to sit in judgment and say, “You’ve got to be doing an X amount of exercise or weight.” For some people, it’s not realistic because they’re caring for two sick kids. They’ve got a mom with Alzheimer’s at home and working X number of hours to pay for a mortgage. Those life situations are tough.

It is a sensitive area and similarly with some dietary factors and obesity is another area that we know more and more is around behavioral responses to stress that drives some of those behaviors. I feel sad when I see very poor judgmental comments that come out of social media around it’s just about what you ate, which highlight that people don’t understand the complexity of human behavior. We would say in terms of physical activity we don’t tell people they’ll have to do anything. We’d say that physical activity is a wonderful thing that is protective against the mood. It’s good for your mood. It’s good for pain. It’s good for your health, your cardiovascular health, your bone health, etc.

We would encourage people to engage with whatever physical activity they love. Ideally link it to social activities. It’s always based on preference as related to excess, cost and the things that they love. The problem that we have around that is people don’t like being physically active. You have to look at ways of engaging them with activity doing something else that they love like engaging with a friend, where they can all dance or whatever it is. It tough because some people have tough lives. Trying to create those opportunities for change in lifestyle realistically can be pretty hard.

As the physiotherapy or physical therapy profession starts to make sense of pain in a way that we didn’t have ten, fifteen, twenty years ago, how do you see our professional change in the next decade?

We have a huge opportunity to broaden the scope of practice. We’re writing a paper about this around what that might look like. We have a curriculum that’s full of stuff and a lot of it is stuff that’s probably not that helpful. Communication should be like 101. Learning to communicate well with other human beings is so important. Learning motivational techniques and reflective learning techniques and smart motivational practice. Patient-centered care should be a model of communication. We have to learn more about human behavior. We have to be comfortable. We know that PTs are not comfortable to ask people about how they feel about their pain and the emotional impact that pain has on their lives. We have to be good at doing that. That’s a whole upscaling in terms of practice. That’s not to make us psychologists because we’re not delivering care for people where depression is a primary problem, but we are caring for people who are distressed and who are down because they can’t do the stuff that they love.

Adequately acknowledging that and having the confidence to explore that with the person is an intervention on its own. We know the validation of a person and listening to their stories is therapeutic. I don’t think we have a workforce that is confident to do that. We have to build those skills as core skills. Behavior change is something that’s going to be a massive issue and a growing issue in terms of musculoskeletal pain in terms of these lifestyle factors. In terms of people developing confidence around movement. To me, that’s a whole area that needs to be embedded in terms of training. I can think of the hundreds of hours that I’ve spent in my career learning stuff that I don’t value anymore. That’s being part of my journey, but we could save people a heartache by shifting their focus towards areas that probably going to be much more fruitful in terms of their practice.

PT education has come a long way. I started practicing in 1997. It’s gone from Bachelor’s to Master’s to DPT and there’s some wonderful stuff in there and then there’s some stuff in there that needs to be pulled apart over a little bit.

What’s happened is we bolted stuff on to the old motto. It’s like we got this old car and we got bolted some stuff on and put on a new button on and you rip it. There’s some core stuff in there that needs to be checked because those things hang on like tentacles.

The flipside of that is as I read through your information on Cognitive Functional Therapy. It’s fantastic work. I’ve read through and I hear a little bit of mindfulness. I hear a little bit of the behavioral psychology, ACT, CBT, motivational intervening. Those things don’t show up in our education at all and they’re critical.

That’s where we see this is as an integrated model of care. It’s evolved out of an adapted physical therapy practice. The evidence is emerging. This is no cure for peptide, but it can certainly reduce people’s distress and reduce their disability and reduce their pain. It looks like it has an effect for people with both moderate and those who are pretty disabled. Not all of them, but a significant number of them. We’ve got a massive problem in our society because we don’t have a lot of interventions that are showing to have much effect. Where people fail to respond to primary care, they rapidly escalate into these risky interventions like taking opioids and having injections and implants in the spine. They have surgery. The problem with those interventions they come with great risks. We see that there’s an absolute need in the health environment to create another narrative around managing pain in a way that empowers people to take control of their health rather than being a passive recipient of a pretty average health.

Giving people options that are safe and that empower them and educate them and give them skills where they can cope in life and move on.

As a practitioner, having trained as a manual therapist, we haven’t had difficulty because I think it comes with a fair bit of responsibility that I can think of my history where people have become dependent on me providing short-term relief and yet they are disabled and distressed. That doesn’t sit well with me. Caring for someone to take control of their health to become independent in my career and to get back to the stuff they love. That’s the stuff that is the goal that sustains me in practice. The other things that give a great sense of satisfaction is that you’re doing good for people.

I want to take this opportunity to say thank you for your work. The work you have is critical not only for the physiotherapy profession, but I’ll spill over into other professions and it helps a lot of people. I want to extend a little bit of gratitude. Please let everyone know how they can learn more about you, about Cognitive Functional Therapy and all the things that you’re up to.

I need to acknowledge the team that I work with. I’m only one small cog in a much bigger engine and I’ve been incredibly fortunate to work with some wonderful people both here in Australia and internationally. People who you’re probably familiar with like Kieran O’Sullivan, Wim Dankaerts, Kjartan Fersum, Anne Smith, Peter Kent and many others, JP Caneiro, who are part of that team. Wonderful people who do the work that I do. As a team, we’re stronger but this work is not about me. It’s about a much bigger picture and a group of people. I’m eternally grateful for them for supporting me in my journey.

If you want to learn more about Peter O’Sullivan’s work, you can go to Pain-Ed.com. It’s a great website whether you’re a practitioner or someone who has pain. You can find lots of information with regards to how you treat low back pain from a physiotherapy perspective as well as to learn about Cognitive Functional Therapy. If you want to tweet directly to Peter, his Twitter handle is @PeteOSullivanPT. Share this information out with your friends and family on Facebook, on LinkedIn, on Twitter. Thank you, Peter, for being with us all the way from Australia. I well see you on the next episode.

Important Links:

About Dr. Peter O’Sullivan, PT, PhD

HPP 115 | Cognitive Functional Therapy

Peter O’Sullivan is Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, Australia. In addition to his teaching and research at Curtin University, he works in clinical practice as a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2005) in Perth, Australia. He is recognized internationally as a leading clinician, researcher, and educator in the management of complex musculoskeletal pain disorders.  

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