Welcome back to the Healing Pain Podcast with Bruno Saragiotto, PhD
As you know in 2020, many states, countries and in some ways, the entire globe went into lockdown from the Coronavirus pandemic. With that, many professionals, practitioners and people living with pain were introduced for the first time to telemedicine and telerehabilitation. I wanted to explore some of the research and the applications with you and invite a special guest who can help us talk about some of those topics.
Joining us is physiotherapist and researcher, Bruno Saragiotto. He is an Assistant Professor at the City University of São Paulo in Brazil. He’s also a Research Affiliate at the University of Sydney and Co-leader of the Centre for Pain, Health and Lifestyle. Bruno has published over 70 research articles that focus on telehealth, healthcare innovation and access to technology. In this episode, we discuss how you can use telerehabilitation to treat those with chronic pain, as well as how you can use it as an effective tool for the promotion of physical activity. Without further ado, let’s begin and meet Bruno.
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Using Telerehabilitation To Treat Pain And Promote Physical Activity With Bruno Saragiotto, PhD
Bruno, welcome to the show. It’s great to have you here.
Thanks, Joe. It’s a pleasure.
I’m excited to talk to you about exercise and the promotion of physical activity as it relates to the alleviation of pain, especially with regards to telerehabilitation, which has been important all throughout this year with COVID. I think it’s going to continue to be important as we move through COVID and move out of COVID. You published a paper in the Journal of Orthopaedic & Sports Physical Therapy called The Effectiveness of Strategies to Promote Walking in People With Musculoskeletal Disorders: A Systematic Review With Meta-analysis. Everyone can access that in the October edition of the Journal of Orthopaedic & Sports Physical Therapy. To get started, tell us what the aim of that paper was and why you decided to do this research.
In this paper, we looked at the promotion of walking. When I say promotion, I mean just the promotion of walking, not supervised walking activities or any supervised exercise. We looked at the promotion of walking for people with several chronic pain conditions, which included back pain, neck pain, osteoarthritis and rheumatoid arthritis. The idea of the paper came from something that I like, which is simple interventions that are scalable to public health. The promotion of walking was the case. We compared the promotion of walking with minimal or no treatments, usual care and supervised exercise. We investigated some out of the outcomes such as physical activity level, pain and function. We found the strategies to promote walking very interesting. They did not increase physical activity level, but they improved the small benefits for pain and function, even when compared with supervised exercise. These were interesting results because we didn’t expect that. We expected that would increase levels of activity and maybe would have some effect on pain stability. That was an interesting study to conduct.
In that study, you mentioned strategies to promote walking in people with musculoskeletal pain disorders. What type of strategies were included in that paper so the readers have an idea of the type of interventions that you reviewed?
It’s very mixed up. We have twelve studies including this study. We have studies with motivational interviews by a health practitioner like telephone calls and coaching. We had one-year coaching still around the motivation issues. We had the instructions for walking. We had some studies with pedometer. They had daily targets and education booklets. We had 1 or 2 studies that used our website with more in the formats of telehealth. They were implementing the comparisons for pretty much education. There was no treatment, waiting list or any other supervised exercise.
A wide range of strategies, motivational interview techniques, telephone counseling, in-person coaching, general instruction using a pedometer, which can help track steps and physical activity, exercise booklet or an education booklet and then a website. There were lots of different types of strategies. They all seem to have some kind of effect.
They did not significantly improve physical activity levels, but what was interesting to find were the small effects on pain and function. We didn’t have any cutoff for clinically meaningful results. We let it open on purpose because very small benefits could be interesting for public health interventions.
If a physical therapist is reading this paper, seeing all these different types of strategies and entering into an environment like we’ve been in the past months with regard to telerehab, which one should they choose? Should they feel confident that they can choose any of those? Is there something about the paper that points us in that direction with regard to helping a clinician decide, “I have someone interested in starting a walking program. How do I effectively counsel and help them with the behavior change needed?”
I’m not a psychologist or someone who studies in deep behavior, but I know that information usually doesn’t change behavior. We need more than that, especially when we talk about people with pain. We had a lot of evidence showing that the same strategies for promoting walking improved the steps per day and physical activity levels in the general population. When we talk about people especially those with chronic pain, the scenario is a little bit different. Maybe we need to focus more on the pain context and get into account the pain experience in general. Maybe there should be more explanation because people with chronic pain don’t improve the physical activity levels in the paper. These campaigns usually don’t take into account fear of movement that these people will develop. It’s something that we know happens with the pain experience. We need to take into account the context as well. Something that clinicians can take from the paper is that you need strategies of education, but especially, you need to show the patient that they can do it and they are able to. We don’t know the right answer. I don’t think we have but accounting for the specific things on pain is a way to go.
If there was a patient or a person interested in exercising, but walking wasn’t necessarily interesting for them, that’s not a particular activity they wanted to begin with, is there a particular type of exercise that benefits people with chronic pain?
The short answer is no. I said a few different types of exercising in my PhD. We have lots of types of exercises. We have some that focus on strength stabilization, strength, flexibility, general exercise or aerobics exercise. For me, it’s good news because all of the things that we have so far showed that there was no difference between those types of exercise. They seem to be all effective at some level. This is good because, from the patient’s point of view, they don’t need to spend more money on a specific exercise like Pilates exercise. They don’t want to do it because usually, it’s more costly.
If they like sports where they like to swim, they will probably get some benefits from it. Even for clinicians, this is a good point because they may not need specialized training, which is also costly. Sometimes a clinician doesn’t like a type of exercise or they have previous training on motor control exercise. I think they should use that. For public health, it’s great as well because simple strategies can work. It’s a win-win situation. We have the challenge to get people doing it more regularly and engaging in strategies.
That win-win is what we want to help engage people with any type of physical activity when they’re living with pain. If someone decides that walking is their method of choice for exercise and physical activity, how does walking help with chronic pain? How do we explain and describe to people how walking helps with pain?
We don’t know that answer. We don’t know much about the mechanism. For me, it’s one of the areas in science that we need more development, especially to explain to people with pain. We don’t even know exactly how that should work. In our study, we had a hypothesis that is not from a biological point of view. It was more about having the social components and having an activity that is very easy to engage in. This may be the way that people feel that they will get better. That’s why maybe they improved a little bit in pain and function. All of the interventions, including the review, had a social component. We decided to discuss more on this external point of view instead of going into the biology because we have few guesses, but we are not sure.
You mentioned two. The first was something that’s easy for someone to engage in. For example, walking is relatively easy. All you need is a pair of shoes and some loose clothing. You can do that outside of your home, in most neighborhoods. Also, a social component to it, either an activity that’s socially acceptable or socially engaging to someone or where there are friends and family and other people who are meaningful to you that you can engage in the activity with. Are there any other components that were important to how exercise may help people be effective with regard to pain?
It’s also good when you start walking. Maybe some people would like to start running, going to the gym or engaging in other activities. This is interesting because it’s the first activity for someone who is very sedentary. They start walking and then they start liking it. They see that it’s easy. They can see some people running and they try to run. They’re starting a running program. It’s a good way to healthy behaviors.
It’s taking that activity that’s easy for people. Once they feel that reward system and their brain starts to kick in, learning to use that activity in other life environments and other life contexts and then helping them with that exercise progression to things that are more challenging and physically demanding for them.
We have some strategies to help people like we had some studies that used a pedometer. It’s good feedback for people to see their progress. We have lots of technology helping with this monitoring reward. It’s a very simple device as well.
The technology could play a role and help people with walking. You mentioned in your study that you looked up pedometer tracking.
We had some pedometers included.
Bring us up-to-date and tell us about your research and the implications with regard to telerehabilitation and probably for you within the Brazilian health system, which may have some parallels to the US health system and some of the things we’re experiencing.
I like simple interventions that are scalable to public health. I’m conducting a lot of studies on telerehabilitation and ways to improve access to technology. We are creating a research team. We are leading three Cochrane reviews, mostly on testing the effectiveness of telerehabilitation for people with back pain, neck pain and osteoarthritis. Our main study is a clinical trial on telerehabilitation. We designed a telerehabilitation platform using some of the implementation steps of going to clinicians and asking them which exercise would work better remotely, going to psychologists and patients and asking them which information they prefer and then we are testing this trial. We are in half of the recruitment. Maybe it’s still another year to have some results.
We also have a few studies on how people access the internet to get information, some quantitative studies, why do they search for health on the internet and some studies on health literacy, which is a core for all internet interventions. You were asking about how this fits into the Brazilian health system. In Brazil, we have this unique health system where every citizen has free health services. It’s a beautiful model, but it has some practical problems. One of them is long waiting lists for diagnosis and treatments. Also, telehealth is not a reality. I was getting some data from the public system. We analyzed five million people who use telehealth in the public system between 2015 or 2016.
We found a very weird trend. During the COVID pandemic, the number of telehealth consultations has dropped. We found that from most of the care workers that specialize in health services like dermatology and orthopedics, and also family physicians or someone in first contact to our primary care. The right telehealth model would fit in the public system in Brazil very well if they can optimize the waiting list, perhaps with prediction models with triage or even for simple treatments. It wouldn’t solve all the problems but it’s part of the solution.
The telehealth system that you’re working on developed a video conferencing with a licensed physical therapist or a licensed practitioner.
It’s mixed. We have coaching with a physical therapist. We perform some live sessions. Most of the programs are on the website, where the patient can have the program coming every week. In week one, they’ll have access to a PDF plan with some exercises. The videos of the exercises are some very short animated videos for Pain Education. They have linked to blogs and some reading materials. Every week, they have a new package. We have the coaching controlling this. The coaching can tailor the intervention. If a patient starts feeling some pain or developed some fear of movement, the coaching can tweak the progress a little bit and change the exercise. It’s a total of an eight-week program. We think it would fit well in the public health system because we designed it for that. That’s why we have more asynchronous than live interactions.
Asynchronous is the important word as you said there. People can access it. They can download it, play it, read it on their own time and go through that at their own pace. You mentioned coaching. Is that coaching provided by a physical therapist or a health coach?
A physical therapist. He did some online training on health coaching. We needed a physical therapist because we need to change the exercise. He’s a physical therapist with some specialization in Behavior and Pain Education. It’s good because he can reinforce some of the animated videos. We have very short videos with one topic like I’ll explain what is pain. It’s two minutes. I’ll explain this in one minute and a half. During the coaching sessions, he can talk a little bit more about it. If they have questions, they can answer.
A little bit of Pain Education that’s mixed in with the promotion of exercise and physical activity as part of that platform and then it’s asynchronous over eight weeks. That’s a nice framework for lots of different diagnoses. I’m thinking with regard to the US system, eight weeks is probably the average time that we see someone in clinical practice. Brazil is a big country, with lots of people, lots of square kilometers. What are the barriers for something like telehealth in the country of Brazil and potentially maybe telerehabilitation across the globe?
The most known barriers are impersonality, privacy concerns, technical problems, digital health literacy like low-tech ability. For Brazil, this is the reality for all low and mid-income countries. The studies we’re conducting are showing that the main barrier is access. Brazil is the country with more internet access in Latin America, but still more than 1/3 of our population has limited or no internet access at all. While in the US, more than 90% of the population are connected. I think that’s the main barrier.
During the pandemic, we have an interesting example. The government launched an emergency fund for people with low income. All they have to do was to download an app and follow very simple steps. It’s simple for me. I have a PhD and I work with that. I have some tech ability. What we saw the next day or the next week when they launched these emergency funds, all the agency of the national bank were full of people who couldn’t follow those instructions or couldn’t access the internet. We have the problem of access and the problem with digital health literacy. It would bring us back to basic education.
We have the technology. It’s just a matter of making sure we can deliver it to everyone. The part of what you’re saying is the simplicity of it. Technology in and of itself is complex. Us, as practitioners, clinicians and researchers, are figuring out how we can deliver this in a way that’s simple for the varying different types of patient populations that we see. Also, their literacy with regard to accessing and using technology, and then understanding of what we’re delivering to them. That’s interesting to me.
It takes a lot of initiatives on using social media or the WhatsApp app that is messaging. They can have interesting results with simple things.
Is using WhatsApp messaging a good way to help facilitate and move these telerehabilitation initiatives forward?
In Brazil, we’re doing some studies with a low-income population. We found out that they have limited internet access and they don’t have much memory in their cell phones. With the WhatsApp app, they will have it because everyone has it in Brazil. If you design an intervention that you don’t need to download an app or you can interact through WhatsApp, which is something that people use in Brazil. You can send videos, photos and PDFs. You can even make video calls. You can deliver that using what people use. That’s key.
In the study you’re designing, is the content delivered via email or they have to log into a platform to access the content?
They have to log into a platform. It’s a website responsive to the phone. They have to log-in because the log-in is where they have the randomization process of the trial. We couldn’t skip the log-in. Otherwise, you have too much work to do. It’s a very simple website designed by an agency. They choose the colors and everything to the context of Brazilian people.
How do you think telerehabilitation and many other things that we’re talking about will change the way physical therapists or physiotherapists function in healthcare as we move forward with technology?
When I came back to Brazil after I did my PhD in Sydney in 2017, 2018, it wasn’t a reality in Brazil. We didn’t have any regulations. I started doing some lectures where I was telling people that telehealth, telerehabilitation is something that we need and we don’t have to be afraid. It will not take your job away. That was purely the aim of the lecture. We then have the pandemic. We have this emergency regulation of telehealth, telerehabilitation. Everyone started doing it, but they didn’t know how to do it. If you are a good physio, you have the knowledge, but when you’re in a different environment, you need more than that. You need better communications. You need more creativity. You need to think about things that you normally don’t think of when it’s a face-to-face consultation.
For example, in an emergency, it’s good that you have the phone number, the number of a relative of the patient or the address if you need to send an ambulance to the address. Maybe we need another training for telehealth. Maybe we need a discipline at the physiotherapy graduation because we don’t have it here in Brazil. We don’t talk about it. We don’t even have one about Pain Education. We need to learn more about technology. The way it will change is that every health professional needs to know a little bit about data science, how to manage data and how to interact with technology. We don’t need to start coding or programming, but we need to understand more about how data is gathered. Maybe in twenty years, the patient will arrive with one tera of data in his smartphone. We need to interact with it. I see a nice future, but we need to develop communication, creativity or a sense of collaboration. I don’t think we will lose our jobs.
Do you see this moving in the direction where some populations may have an asynchronous interaction? They log into a platform or download an app and everything is there for them. Do you see that eventually, it will become a hybrid, where there is one-on-one in-person care as well as the use of technology somewhere throughout that plan of care and course of treatment that helps with the behavior change, that helps optimize outcomes, that helps with the carryover that’s required when someone leaves the clinic and goes home, goes back to work or goes into their environment and the therapist is with them to supervise what’s happening?
The hybrid model is the best. It’s just my opinion. About the whole telehealth, I like the idea of patient empowerment. In a perfect telehealth world, a patient can have a diagnosis or even a self-management plan whenever they want using their smartphone. If you have back pain and it’s enough to bring you to a consultation, you do it at the same time. You don’t need to schedule and wait for weeks. Sometimes in the public system in Brazil, you wait for months to get a consultation. We know that for chronic pain, sometimes you don’t need imaging and scans.
In a perfect world, I see a patient having the power and going to a prediction model to look for red flags or their prognosis. They have a self-management plan. They can start the hybrid model by going into some face-to-face consultations or even live interactions with a physician or a physio. It’s good. This is the thing that I liked the most in telehealth. If you remove some of this medical paternalism that we have since Hippocrates thousands of years ago, where the law was the physician or the health professional or physio will give you an order and the patient just obeys. For me, that’s the beauty in telehealth. The patient having control and developing self-efficacy. We know that for chronic pain, maybe that’s the way to go.
The education part and the carry-through behavior change is one of the most important parts, which telehealth can help support us through that. With regards to pain research, what’s missing from telerehabilitation when you look at the literature? You’re working on three systematic reviews, but this is completely new. For researchers reading this, what are some areas that we have no idea about this condition or how telerehabilitation can be effective for X, Y or Z?
We have lots of research on effectiveness, either comparing with face-to-face or usual care or minimal interventions. We don’t have much cost-effectiveness studies. Although it seems intuitive to think that this is cost-effective, we don’t know. We are doing cost analysis in our study, but we are still far from our results. The cost is an area and also acceptability and implementation. We don’t know much about how this can be implemented, especially in low and mid-income countries.
For example, in this review that we talked about, or even the Cochrane reviews we are conducting, 90% of the studies came from the US, Australia, Norway, Switzerland, and none were from low and mid-income countries. That’s a barrier that we have. Brazil is fine because we have such diverse social economics. We have some neighborhoods where you can have people who reflect for external validity with people in Switzerland and people who reflect with people in Bangladesh. Brazil is so wide. We need to look more at the context. We need to do more research on costs, context-specific and for low and mid-income countries.
Bruno, it’s been great talking to you. We’re going to follow your work with regard to using telehealth. It’s such an important topic in pain care, physical therapy and physiotherapy. Tell everyone how they can learn more about you and how they can follow your great work.
I’m on social media. My Twitter is @BSaragiotto. I also have a blog for early-career researchers, which is called The ICECReam Blog. It’s not about ice cream. It’s about the research. I’m also on Facebook. You can find my name there. Here in Brazil, I’m from the Universidade Cidade de São Paulo, which the name means the City of São Paulo. I’m based in São Paulo doing some research here. We have a collaboration, which is called In Health. It’s a collaboration between Brazil, Australia, Canada and UK. We will have some accounts on social media and a website.
Make sure to share this with your friends and family on social media, which includes Facebook, LinkedIn, Twitter or a Facebook group, where people are talking about telerehabilitation for the treatment of chronic pain and physical therapy. I want to thank Bruno for joining us. Stay tuned. We’ll see you next episode.
Important Links:
- Bruno Saragiotto – LinkedIn
- The Effectiveness of Strategies to Promote Walking in People With Musculoskeletal Disorders: A Systematic Review With Meta-analysis – article
- @BSaragiotto – Twitter
- The ICECReam Blog
- Facebook – Bruno Saragiotto
About Bruno Saragiotto, Ph.D
Assistant professor at Universidade Cidade de Sao Paulo, Brazil. Research affiliate at University of Sydney and co-leader of the Centre for Pain, Health and Lifestyle. Bruno has published over 70 research articles and the overarching focus of his research is on telehealth, healthcare innovation and access to technology.
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