Transcript
Speaker: I'm conflicted on this one, Mitch, because in in some ways, i like I fully agree of how nuanced this this whole conversation is and how complex pain is.
Speaker: And yet on the other side, i know how it feels to have lived experience and be like, well, what do I actually do? They used to say that philosophy was, you know, a luxury of the rich. and And in the pain world, sometimes I wonder whether...
Speaker: philosophy is a luxury of those that don't have pain experience. You want to embrace the uncertainty and the complexities around it and you want to be truthful.
Speaker: But then on the other hand, like, what do we give people? Like, or do we just let them drown in the complexities? Big conversation around that probably to have. And we wouldn't land on an answer, ironically.
Speaker: Yes, yeah, yeah. I think, no, you've put that beautifully. If I put my teaching hat on, the way I kind of frame this with the students is,
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Speaker: So Mitch, you have your PhD in pain sciences, looking at, in particular, exercise and interventions for chronic pain.
Speaker: Give us a bit of a flyover view of the landscape when it comes to exercise for for chronic pain, and then we'll we'll dive a little deeper later. Yeah, starting off with an easy one, I guess. Mate, I think it's it's an evolving landscape.
Speaker: I think when I when i started um my my master's and then my PhD, we were still very much looking for specific exercise modalities and mechanisms.
Speaker: And now, while I'm not completely dismissing that, I think somewhere kind of throughout my PhD journey, The literature, as well as a lot of clinicians, shifted to, I guess, an understanding that, well, all exercise appears to work about the same. and It might not necessarily be about exercises as a fixer, but the act of doing And then it kind of emerged to this this really interesting phenomenon in the literature where it was like, let's look at all the things around exercise. Let's look at things like education, CBT, ACT, and all these adjunct kind of modalities.
Speaker: And that's still sort of the case, but I think now we're at a ah point, well, at least in in my research, I might be biased here, but I think we're at a point where we're coming back to the exercise, but we're looking at it through a different lens of,
Speaker: if all exercise has the capacity to help, how can we find exercise that is meaningful to the person, ah but also exercise that might impact broader overall health considerations and concerns?
Speaker: And so I think we've we've kind of gone full circle in terms of we started with with a specific exercise and now we've landed back on that, but the definition of specific looks entirely different. o Was that a bit of a paradigm shift for you yourself?
Speaker: Yeah, I think so. It took, It took quite a while, I think. you know when i When I started my master's, it was quite ah looking initially, it was looking at specific kind of patterns in people with chronic low back pain when they were doing certain movements from an EMG standpoint.
Speaker: And then my supervisor and I, we pivoted to looking at psychosocial mediators of pain and disability over time. and We did a longitudinal study. And I think that study there opened my eyes to an entirely different a paradigm as as you put it.
Speaker: And then it's been this learning journey throughout to come back to what that means for exercise. I think for for a long time, a lot of people thought exercise was just this thing we did and it was still kind of under this biomedical umbrella, even though it might've been attached to a very um conflicting narrative from from a kind of pain science or a biopsychosocial standpoint.
Speaker: I think my work ah primarily focused on how do we marry up those two approaches and create this cohesive narrative with our with our exercise pre description and our words and our narrative and our language.
Speaker: And now it's kind of gone that little bit further as to how do we make this even more holistic and consider the health of the person, the preferences, you know meaningful movements, all things like that, which which were in there initially. I won't say that's new, um but I think it's it's been this gradual process of zooming out and seeing how how the landscape has changed around it.
Speaker: So on social media, when there's those posts that say, do this exercise to cure lower back pain, well Is it garbage? I wish it wasn't.
Speaker: I'll preface what I'm about to say with that. I think there's this rhetoric that it's kind of, you know, biopsychosocial or pain science versus the the kind of biomedical crew.
Speaker: And I don't think that's a a fair representation. I think anyone in this space, no matter which kind of lens you see this space through, we all want to help people. I think if we apply the principle of charity, that's why we're here.
Speaker: Now, I wish there was an exercise that that fixed something. I really do. um However, you know, i' I'm probably going to misquote this slightly, but I listened to a talk. I've listened to it a few times now from ah Professor Mark Hutchinson, who's down in South Australia.
Speaker: And start of his talk, he says something along the lines of there's more potential reasons for pain than there are stars in the known galaxy. Now I might be misrepresenting that slightly, but it was something to that effect that made me zoom out and go, if that's the case from a you know a bench or basic science perspective, when we look at the applied science and and the practitioners and and we think we can solve this complex phenomenon that we we call pain with one movement, it seems a little bit silly.
Speaker: But as I said, i wish that to be the case. I hope that to be the case because you can only imagine the amount of people we could help. um But I think we we can no longer you know really have our head in the sand and and and not acknowledge that this is a complex system and we need to treat it as such.
Speaker: If people are frequent listeners, they would ah they would they would know that name. And um yeah, it was a good episode. He's doing some pretty pretty exciting things. Mitch, what's your thoughts on getting stronger ah to to reduce pain and what the research is is suggesting?
Speaker: I think it's it's a good question and it's one that I go back and forth on quite a lot. I think i think it would be I don't think I can give a strong answer in either direction, pardon the the pun. um But I do think getting strong and and strength training can tick a lot of boxes for kind of usual suspects of of what we see mediates improvement in in pain-related outcomes, pain and disability.
Speaker: When we look at those across the literature, we see self-efficacy, um fear or catastrophizing, and beliefs. And when we think about strength training as modality, it does tick the boxes of, you know, we can use an integrated exposure paradigm.
Speaker: We can use it to improve self-efficacy. you know, we're putting things back on the table that someone thought they may have not been able to do. By definition, we're increasing self-efficacy. We're addressing fear and we're maybe using some adjunct education as well as just that act of going through the graded exposure with strength training where,
Speaker: addressing those beliefs or having that kind of person have their own experiential violation. Now, do I think strength mediates the relationship? Probably not. I don't think you need to get stronger.
Speaker: I don't think, and I think there's lots of other modalities that can fit that that bucket. i So my PhD was powerlifting a combined with pain education versus pain education combined with more more traditional kind of trunk focused exercise.
Speaker: And at that time, I didn't think it was the act of getting strong, but I did think there was something with combining a cohesive narrative of we're telling people they're robust, they're resilient, they're not fragile, and then we're hopping in the gym and showing them.
Speaker: And I still think that there's something to that, but I do think it it depends on coming back to what i mentioned earlier, the goals and preferences of the individual.
Speaker: If you're not someone who wants to engage in a strength training dynamic, the good news is you don't have to. i think Where we think about it's this modality versus that modality, we start to forget that actually it's it's a really good thing to have a plethora of tools in our toolbox because we can help as many people in front of us as we can.
Speaker: Whereas if if one modality emerges as, you know, this is the thing we've got to do, well, then we have lots of implications around, well, what if someone doesn't have access to facilities that they can do that in?
Speaker: What if someone doesn't enjoy that whatsoever? And we start then thinking, well, now the number of people we were able to help with this intervention starts to decrease exponentially. So while I think it can be a fantastic modality, I don't think it's the kind of be all and end all.
Speaker: So it's more in the broader context of those other mediators like self-efficacy and the biopsychosocial model more broadly that influence the the change that might occur with with an increase in strength or engaging in that type of training. Does that summarise it?
Speaker: Yeah, i like i would I would completely agree with that. Yeah, okay. um Yeah, because, and I've looked at some of Jared Power's work in this space and it and it seems to be,
Speaker: you know, consistent with that idea of like, OK, well, if strength does help, it's very unlikely to be just simply because of strength. And it it makes sense when you look at it from a biopsychosocial lens. I remember Merv Travis was on the pod and he um he said, you know, we talk about the biopsychosocial model and then we say do threes three sets of ten.
Speaker: And that's the intervention. And he's like, how does it kind of align with with how we think that pain works? um and and the research in this area. What about pain?
Speaker: Should we work into pain or is it better to do non-painful exercises for those with chronic pain? Yeah, well, funny you mentioned Jared. Worked with Jared on on a review updating that. So the the previous review, I think, was done by Ben Smith in about 2017. And so Matt, myself, an honours student, Ivy, we worked with Jared and Ben.
Speaker: We also had another student, Nathan, on the paper. And what we found was there's no real difference in terms of your exercise is painful versus pain-free. Now, the previous review found a slight effect from memory that that painful exercise could be a little bit more advantageous.
Speaker: I think it's more about how we use painful exercise. I think the the trials and and a systematic review can miss a nuance. And I think the clinical application, it needs to be considered with the person in front of us.
Speaker: So if we're using painful exercise or exercise that nudges into pain, again, coming back to that concept of experiential violation of reinforcing a message that we're not causing damage because you know we're able to see this kind of pain trajectory come up and and kind of settle.
Speaker: And that can also, like, that can violate some assumptions. That can be really helpful. As well as if someone, you know, I'm not a big fan of putting, like, an NRS or a VAS on how much pain you can have during session because it doesn't account for individual variability at all. If someone walks in the door with a 2 out of 10 pain and we've put a cap of, say, 4 or 5 out of 10,
Speaker: But the next person walks through with four out of 10 pain, do we just tell them not today? Like, I think that that misses that clinical narrative. And so I think it's a discussion with the person we're working with under a ah broader shared decision-making framework.
Speaker: And it's having that open communication that, whatever we're doing is is manageable, it's tolerable, and that there's open communication that if if that ever crosses into something that doesn't feel tolerable and manageable, we can have that, um we can have those discussions and and we can make changes as needed.
Speaker: um So your research, it suggested that painful may be a little bit more helpful or was it what were the what was the outcome there when you when you did that systematic review comparing pain versus non-painful exercises?
Speaker: Yeah, so in ours, we pretty much didn't find a difference in the pull effect. Previously, in the 2017 review that we updated, there was a slight favour toward painful exercise.
Speaker: the so The kind of Conceptual issue with with some of these studies when making exercise painful or pain-free you know, how does that actually affect the communication around the exercise that's being done? How does that affect the narrative? I think it's it's an it's a good review. I'm biased, I have to say that, I was i was an author on it, um but it's helpful. But at the same time, I think,
Speaker: Reviews like that need to be put into the context of the person you're working with. I think we can't just take that review and say, okay, painful exercise is better or non-painful. I don't think it's a dichotomy. I think it's that the evidence is giving us essentially permission that both modalities can be feasible and it's having that that shared decision-making model with the person in front of us to talk about, well, these are the options on the table. What are you comfortable with and how can we set up a framework that is, you know, you feel safe and comfortable to move forward.
Speaker: Yeah. Yeah. Without knowing the the level of the systematic reviews, it's kind of my bias would be that potentially couched in good pain education and a reduction in the threat level of pain that that might change the outcome of painful exercise for chronic pain.
Speaker: what What's the your way of thinking around that? would What role does pain education play in in how you you practice clinically? I think there's ah there's a brilliant paper, I'm potentially gonna mess the year up a little bit, but was Adrian Luau, Think 2020. And it was, the title was something along the lines of revisiting the concept of pain education, an adjunct to modality for consumers, but a primary focus for clinicians or something like that.
Speaker: And I read that paper and I was right at the end of my PhD and you know my PhD was very strongly embedded within the pain education kind of space.
Speaker: the The one kind of side tangent I will say until until some of the recent work come along, there's been so many trials that have used pain education that just do not actually talk about how they've provided it or what they've done. They've just said, you know, we use Butler and Mosley's second edition 2015, full stop. And, you know, if you look at some of the work from from that group, you know, I think Lorimer was lead author on a paper recently about you know, how pain education should look and the the kind of evolution in it.
Speaker: And, you Hayley's brilliant work around what people value. And so I think there's a lot to it. But I think that coming back to that paper by Adrian Luau, and I might be mispronouncing that name, I do hope I'm not, um but it was it was very much about being purposive with it. if it's it's Again, it's if it helps to facilitate something else.
Speaker: So if we address an unhelpful belief, you know the Neu-Group call it kind of E-flags. So were we're having these initial consultations and we're just making these mental notes of like, okay, that might be something we can talk about later.
Speaker: We're not going to sit here and necessarily have this you know pain splanation in a first session but it's it's intentional whereas i think previously thinking around pain education was like curriculum based and we we kind of lay out this curriculum we kind of grow go through it and i don't think that really hits the mark i think if we have it intentionally and purposefully um I think that's where we we need to be with it. And that's how I try to to use it with the people I work with. That's how i teach it with the the students that i that I have in our courses as well.
Speaker: Definitely. it I guess it it's got to make sense to the individual and be contextualized to what what their needs are rather than this just this blanket thing.
Speaker: yeah, kind of curriculum-based approaches. um would you Would you kind of hypothesise that maybe like in in the context of good pain education, whatever that looks like, that... um pain with exercise would have slightly better outcomes or what is your, like, I know, I know you don't know. And obviously there's, there's nuance there, but if you had to, if you had to put a punt on, what would you, what would you bet there?
Speaker: Yeah. Um, mate, look, it's a, it's a brilliant question. And if, if you're interested in in coming along and doing a research degree, we can, we can try and answer it. Um, Look, I think it's the the difficult part about research is research is built on an entirely biomedical model.
Speaker: um Research is by definition reductionist. We're trying to change one variable and figure out one thing. And so it gets really tricky because the the the question that you're actually describing is how good can we be in in a clinical research environment at identifying the patients or the consumers, I should say, pardon me, that may or may not benefit from they these particular things.
Speaker: And so, Because if we we just had this trial of good pain education with painful exercise or good pain education without painful exercise, we're probably still coming back to that curriculum based of everyone gets the same thing in those those homogenous groups.
Speaker: Whereas I think your question is a bit more nuanced of how good are we at being able to almost screen or identify or pull out those e-flags in a console and then design that framework with the person in front of us.
Speaker: And so I think that's what research and and kind of science is inherently limited by. I like to think about clinical practice quite optimistically. I like to think the the results we see in in the literature are almost the minimum of what you can see in ah in a clinical environment because we're quite constrained.
Speaker: When we run pain education trials, with with exercise, it is homogenous because it has to be. That's the way the trial is designed. Whereas when we're in a clinical environment and we have the person in front of us, that's when we can really make things you know individualized for want of a better term.
Speaker: And so I think that I'm not sure I'd be able to to take a punt um for for your question there. um Because I think that it's ah it's a brilliant question and it's it's one that I think would take quite a while to figure out how to answer in ah in an appropriate way.
Speaker: Yeah, that can be the problem a little bit when you're on the cold phase clinically is like the nuance that you're you you you're outlying and especially also when you when you live ah with persistent pain.
Speaker: it i I'm conflicted on this one, Mitch, because in in some ways, i like I fully agree of how nuanced this this whole conversation is and how complex pain is. And yet on the other side, i know how it feels to have lived experience and be like, well, what do I actually do?
Speaker: um So like simply like what what do I do to actually help? And I've come up with this idea that – um There's a trade-off, right? there's There's nuance and conversation and philosophy and then there's like pragmatism, like do I do this or do I do that?
Speaker: um and And, you know, back in, like they used to say that philosophy was, you know, a luxury of the rich and and in the pain world sometimes I wonder whether...
Speaker: philosophy is a luxury of those that don't have pain experience. And know I mean, um there's probably a lot of researchers that do, but you know when when people are living with it, they're kind of like, what what do I do? Which way which way do I go um And yeah, I've kind of tossed back and forth at this because obviously,
Speaker: you want to embrace the uncertainty and the complexities around it and you want to be truthful but then on the other hand like what do we give people like or do we just let them drown in the complexities um and yeah there's a big conversation around that probably to have um and i we wouldn't land on an answer ah ironically Yes, yeah, yeah. I think, um no, you've put that beautifully. And I think that's the that's the difference in terms of of research and practice, and it's so it's always going to be.
Speaker: I do think, that ah if I put my my teaching hat on, because I teach our EP and and some of our kind of combined physio and exc exercise physiology students in musculoskeletal care, the way i I kind of frame this with the students is,
Speaker: in In that kind of overarching shared decision-making framework, we don't necessarily have to always embrace uncertainty to the point of, I don't know how to help you.
Speaker: We can put options on the table, And through conversation and through kind of building that that relationship and rapport, we decide which option makes the most sense for right now.
Speaker: But just because we pick option A doesn't mean options B through G are now off the table. You know, if that person comes back to me and says, like, I'm just not,
Speaker: getting what I want out of this. I'm just not kind of finding that this is helping, whatever the wordage might be. Well, we've always got these other, you know, couple, I can't count B to G off top my head at the moment. We've always got these other couple of options that we can pivot to and we can try.
Speaker: And so I think there's the the embracing certainty part that I think is a is a conversation in and of itself. I think there's also the the false dichotomy of we don't have to say this or this.
Speaker: We can consider, well, we can actually try all of these. And it's not about which one's better or worse. It's about which one makes sense right now. But knowing we can always pivot.
Speaker: Yeah, good point. Good point. Yeah, it's something I've wrestled with a lot yeah ah being on the cold face. And also i think people are ah drawn to certainty.
Speaker: um and And so sometimes it feels like really good clinicians that understand the nuance and that they they might not have necessarily get the biggest biggest numbers or, you know, like they might they might not look like Patients are coming back and engaging, et cetera.
Speaker: Yeah, it's ah it's a obviously a complex topic. On that note, like how how do you prescribe exercises? So like we've mentioned that painful versus non-painful doesn't work.
Speaker: really matter too much it it appears um getting stronger doesn't seem to have much of an influence um there's no particular best exercise so what how how do you prescribe exercises what is the what are the things that are important to you as a clinician
Speaker: I think the, so we're doing a a trial at the moment led by Dr. Matt Jones, which is capacity. And it's expanding on work by Tanya Gardner on patient-led goal setting. And I think, so I'll preface with with that something that hopefully we can give a bit more nuance to in another year or so. So hopefully that the evidence there will evolve this conversation if we were to have it again, you know, 12 months or so from now.
Speaker: In terms of how I approach exercise when working with people in in persistent pain or living with persistent pain, it it really just depends on the person and what they're looking to achieve. I think sometimes there's this conversation around how we address those those usual suspects that I have in the back of my head in terms of we're thinking about self-efficacy, fear and beliefs.
Speaker: But people, and um you know you would know this as well, people come to us at various different points in their journey. you know We can have someone that's been experiencing chronic pain, and persistent pain for a decade that comes to us and they're like, I'll try anything.
Speaker: And we can just launch right into, you know, this this extremely ah interesting conversation about the the weird and wacky world of pain. And we can try all these different things.
Speaker: And then there's people that might come to us, and this is some of the work we've done with Andrew and Atoli, that people might come to us and have this ingrained system of thinking around this movement is going to help me.
Speaker: And it it might not be about saying, well, no, it's not. Actually, you can do anything. It's about, well, how do we start that conversation? Maybe it's not day one.
Speaker: um So in terms of how I prescribe exercise, it it's it's no different to how I prescribe exercise for someone without pain from a ah perspective of how that initial consultation goes.
Speaker: It's just adjusting the starting point. So I do also think, and this is something that we've published recently, there's a conversation to be had around you know, physical activity and and increasing physical activity. We know from um some of the work out of the University of Newcastle a few years ago now that people living with persistent pain have higher higher risk of things like cardiometabolic diseases.
Speaker: Now, we also know that people living with persistent pain can have slightly lower activity matched to to asymptomatic community-dwelling individuals. And so i think sometimes we the the predominant narrative of exercise has been that we're fixing.
Speaker: Now, I think the the result of that has been that we've been prescribing exercise that isn a well doesn't look the same from a physical activity sound standpoint as we would prescribe if that person come to us as an asymptomatic individual.
Speaker: Now, when we put that literature hat back on, we go, well, hang on, all exercise works about the same. why am i why am I treating this person different from a clinical interaction standpoint?
Speaker: I should still be maybe having that lighthouse in the distance of, we're gonna work towards something like the physical activity guidelines. Now, we don't have to say, i want you to go and do that tomorrow, but that's that's still our guiding point. And I think we miss the boat if we think about just exercise for pain.
Speaker: And it's this age-old rhetoric that, you know, we've all been taught in university for decades upon decades now, which is treat the person, not the condition. But I think when it comes to persistent pain, if we look at the literature, it's very much been treating the condition and it's not been treating the person.
Speaker: And that's where I think the biggest paradigm shift still needs to happen in a lot of ways, that we're working with the person in front of us. Now, that has been an entirely it depends answer to a very simple question of how do I prescribe exercise?
Speaker: But hopefully that that kind of gives you some of the the conversation around why I don't think it's a you know, similar to what Merv said, it's not a three by 10. um You know, we don't have this cookie cutter. This is what we do type thing.
Speaker: Yeah, yeah. what What do you think more broadly about exercise? Like, is it, like, we're obviously having this conversation in the context of exercise and chronic pain and, like, your whole research is around exercise and chronic pain. On a on a large perspective, what's the research say about exercise just more broadly in for someone with chronic pain? Is it a good thing? is Is it a good idea? And why, why not? And what is the research sort of suggesting there?
Speaker: Yeah, it's definitely a good thing. If we take chronic low back pain, for example, it's first-line treatment um yeah in in all the clinical practice guidelines. um it's It's a very good thing.
Speaker: it's the I think where the research is is lacking um is we don't have a good understanding about dose or anything like that. It seems to be more the act of doing. And I think the the critical question that I'm trying to ask in my research is, Well, if we know that it's the act of doing, and if we know that all exercise works about the same, well, we really need to reframe how we're approaching exercise and start to consider the concept of multimorbidity.
Speaker: And if someone's coming to us with with back pain and say, um hypertension or type two diabetes, Well, it's it's maybe taking our our back pain hat off for a second and going, hang on, if this person came to me with type 2 diabetes but also back pain, would I approach this differently? And if the answer is yes, I think we need to really stop and reflect on why because that's the same person. It's just the order that those conditions have been written down on the referral.
Speaker: Yeah, yeah, I guess. And also probably depends on that that person's particular goal. Like if they're coming to you for the for the sake of reducing pain or, you know,
Speaker: rather than, you know, managing their diabetes, maybe it does, does change a little bit that the role. But yeah, no, that that makes sense. I think um a big one obviously would be like adherence is is crucial.
Speaker: um Because if we if overall, we're just generally we just can say like exercise is a good idea. Well, then getting the patient to do more of it is a good idea. um and which is where where some of these specific exercises i find quite interesting, um you know,
Speaker: is is they're very boring and that they don't reach the guidelines. You're right, like at all. Like they don't even they don't even really step us in the direction of reaching the guidelines unless the patient in front of you is very, very unfit, extremely unfit. They're they're unlikely to to to go there. So yeah, the two things for me would be adherence.
Speaker: ah Well, I've probably got three and I would love to hear your thoughts on this and maybe I'm a bit, unfounded on the dose one. So I've got adherence, I think is important. And so like, I don't really care what exercise, what's important for the person in front of me.
Speaker: Dose, which I think is important to to manage flare ups, to graded, you know, graded exposure and and to pace them into. And the third one is like something meaningful. um So it's stepping them towards like something that actually,
Speaker: you know, is going to make a difference in their life because they want to get back to a certain activity they've lost or whatever it may be. So the dose one. When you say we don't have much research around that, I just i do wonder sometimes where it's... Because, like, when it comes to research, and you'll be acutely aware of this, like, we're talking, like, as if they're homogenous group of people that all look the same, all the, you know... But really, they're they're not. um And so maybe, like, in a clinical setting, and when there's one person in front of you, dose is...
Speaker: really important but then when you zoom out and try to like just get all of these people in the in the pool it seems like it's not um
Speaker: what are your thoughts on on dose Yeah, I think it's you framed it perfectly. um I think I always encourage the students I work with that, you know, as as a practitioner, we're approaching every case that we're we're working with as an N of one experiment and we're finding what dose works for that person.
Speaker: um I think we do have a very good idea of the dose needed to impact other parts of physiology. um And I think pain is is a little bit different because Often the way that dose is talked about in the the pain literature is sessions per week.
Speaker: And if we think about dose in any other respect, that that doesn't really make sense. So dose, for example, if we were talking about dose for hypertrophy or strength, we're we're talking about variables of exercise that we're gonna manipulate.
Speaker: Whereas sessions per week, you know frequency, when it comes to, um in terms of how to affect hypertrophy or strength, frequency isn't a variable that we need to consider.
Speaker: Frequency is just how we organize training. And so the the way we talk about dose in the the clinical literature or the the kind of persistent pain literature isn't necessarily congruent with how we talk about dose in the exercise literature.
Speaker: So that would be like the first kind of consideration there. I think the dose in terms of what is helpful to the person in front of us is a journey that we go on with that person. Right.
Speaker: and I completely agree with you with your other point of finding something meaningful. I think that's probably been my biggest realization through getting into this research you know five or so years ago now, that working towards something meaningful is probably one of the most important things ah that that we can we can have on the table.
Speaker: and Just that act of of pursuing that. And I think, you know, we've we're we're looking at the patient-led goal-setting stuff at the moment. And ah while goal-setting is in the name of the intervention, it's really identifying what is that meaningful thing and how can we work towards it.
Speaker: And I think that is just such a powerful thing that um that we can we can kind of lean into. Mm-hmm. Yeah, um ah ah I feel like we should circle back in a year on the dose conversation. So tell us a little, like give us a sneak peek of what that research is going to look like.
Speaker: ah Yeah, so... i Yeah, it's still it's still, we're about halfway through recruitment. um So we've got about, I think, 400 people is the total total sample for the trial.
Speaker: um the I can send you the the paper. it's It's a couple of years now. It was published in, i think, BJSM by Tanya Gardner and and a few people that are working on this trial with us.
Speaker: And it was basically a patient-led goal setting in terms of We're asking the the people to identify what they want to work towards rather than us defining a goal for them. It's really giving the person agency in that clinical interaction and and how their kind of journey with us looks like.
Speaker: The really cool thing was this this intervention from ah a couple of years ago now, i think there was around 75 people in in that trial. It had a large effect on pain and disability.
Speaker: Now, we, Emily Walker, took this trial led this paper, we did a mediation analysis of of what it was that explained that improvement. And what we saw was self-efficacy, fear, and quality of life.
Speaker: And so quality of life is one that hasn't emerged as a mediator in the broader literature. um So we we need to kind of investigate that further. But self-efficacy and and kind of are fear, kinesiophobia in this case,
Speaker: are pretty consistent. They're two of our ah kind of big three or usual suspects, right? And so what that tells me is giving the person agency, identifying that meaningful task or activity or whatever it might be, and working towards it with support and care and compassion that That kind of ticks two of our our big three. And I think this is what good clinicians are already doing.
Speaker: um And I think this is is how we've landed on how we approach persistent pain of exactly what you said. Let's identify what that meaningful thing is and let's work towards it together.
Speaker: Mm-hmm. Yeah, cool. oh Exciting exciting to to see that come to life. the The other thing that I do, and I just want to like, this is just me being selfish and asking you questions now. um But sometimes I just want them to hit a threshold of like cardiovascular exercise that is going to, in my mind, release, you know, some of those endorphins and neurochemicals, et cetera, that will are pain relieving, right?
Speaker: oh yeah And so sometimes I, like, for instance, ah I have um this put this patient that's dropped something on, he dropped something on his foot, had a fracture, it's become like sensitized and he's developed chronic pain with it.
Speaker: And for him, it's like, I've just been doing like stand up boxing, Like it's doesn't even like he doesn't ah move his feet at all pretty much or much. It's like, let's just move away from the painful part for now. And let's just try to get a dose that kind of gives you these, these feel good endorphins and like, you know, couched in the, the, the influence that that can have on you, psychological wellbeing and all of these factors. um,
Speaker: Yeah, it's just it's a way that I've approached it recently is like i'm gonna I want you to reach the guidelines and And to get a dose that's going to like you know be be helpful for you from biopsychosocial point of view.
Speaker: and and it's pretty rare, to be honest. um Like there's behavioral factors and you know behavior change factors that are hard. But for someone that's like use used to being active and like that's been a big part of their life, it's pretty rare that you can't find some way that doesn't actually aggravate their their their symptoms to get that kind of level of intensity up.
Speaker: um Yeah. what are your What are your thoughts on that as like logic approach, et cetera? Yeah, I think it's...
Speaker: yeah Sorry, putting my clinical practice under the spotlight. No, no, mate, I think it's awesome. I think, yeah when you know, before when you were describing the the things that that you come back to and it was something meaningful, dose, and and there was a ah third one. Adherence.
Speaker: Adherence. well So Paul Marshall was my PhD supervisor. And when Paul and i i'm I'm very sorry, I like to go on tangents when I answer questions. No, love it. um So Paul and I sat down at the end of of the the trial that we ran and we were like, if we could boil it down to to kind of dot points exactly like you just put, what would they be?
Speaker: And it was do something that's meaningful, do something that's fun or work towards something that's meaningful, do something that's fun and work towards something that challenges you. And so i think that's that's kind of what you're describing. You've found something that's fun.
Speaker: um I think, you know, we've we've just published that paper on on chronic pain as a component of multimorbidity. And so I think anytime we can have that conversation about meeting the exercise guidelines and and physical activity guidelines, pardon me, and and introducing that dose from from a health-related perspective, I think that that does fall within a biopsychosocial understanding because it's holistic approach to the person.
Speaker: The biopsychosocial model, as you know, isn't of pain, it's of health. And so I think that it's it's fantastic. Now, I think there are people out there that might come to us that maybe that journey takes a little bit longer.
Speaker: And maybe that that dose of exercise is that lighthouse in the distance. And this is where, so at the moment we've got two PhD candidates, Ethan Grimman and and Brad Cullen, and we're looking at um feasibility and acceptability of exercise snacks as a ah starting point for some of those people.
Speaker: And having exercise snacks, this is in people with chronic lab pain and knee and hip away, and having exercise snacks as a really low barrier to entry And then how can we over time potentially build those snacks into a lunch, you know, for example, and increase our dose.
Speaker: um But the important thing is this is, and this is where I i kind of lean a little bit on ah the strength of conditioning literature. And I really like the the concept of the control chaos model.
Speaker: And that model, the reason I like it so much is because it doesn't have time points that are restrictive. It's not like, okay, we're gonna do three exercise snacks a day for a week, then we're gonna do four, then five, then a lunch, nothing like that.
Speaker: It's a shared decision-making model or or the way I utilize it and teach it is a shared decision-making model that we agree on these graduation points. So at what point would you have the confidence that we can add another snack or that we can add another dose or whatever it might be?
Speaker: And so if if someone comes in and and and like this this gentleman you're describing, and, you know, I've i've had, it brings up a and ah person that I've worked with that wow it was after a double knee replacement.
Speaker: And they came in and and in the first conversation, it was an older gentleman. He was like, i just want to feel how I felt when I was in the gym, when I was playing footy. And so we were like, let's just get your bench press as heavy as possible and just have a bunch of fun. And after after we kind of finished working together, it's been about 10 years now and I still go past the local gym and he's still in their training.
Speaker: And it's like, you know, that that's, you know, I'm not going to, um like, that's a ah very great story, but it's it's let's find those things with people that they enjoy and let's lean into them. Exercise should be fun.
Speaker: um You know, exercise is hard. Most people don't meet the guidelines. How can we make it fun? And I think that's that's what you're describing. I think it's it's exceptional. Yeah, that's awesome. That's cool. Mate, you're obviously a very curious person and that's why you kind of, that lends itself to progress and and research. And i i honor that and I feel like I have similar traits, um I think lived experiences kind of challenged that and and gone like, okay, I need to be more pragmatic about what what do I actually do um as well. Not to say that you aren't, but one question I have for you is like, what you what have you changed your mind on recently?
Speaker: um Because, you know, often that curiosity leads to to progress and change of mind and the research develops and you go, oh, I was way off there.
Speaker: Yeah. um So much. I mean, I think if I give, if I give, I'll give a recent example. um But I think if I give a slight backstory, when I, the reason I got into my master's by research was I started practicing as a personal trainer when I was in my second year of undergrad.
Speaker: And mate, that, you know, 19, 20 year old version of me, i knew how to fix back pain, eh? Like I was so absurdly confident. And i think just by by nature of, ah you know, you're right, I'm a curious person. And I think I went out and I applied these things. I was i was kind of working with a bunch of people that that were, it was mainly persistent back pain.
Speaker: And mate, no one was getting better. And I was like, well, but but i'm like I'm doing the thing, you know, i know how to fix it. I'm not fixing it. What's going on? And so I went into Paul, my my who was to become my supervisor's office and I was like, mate, what am I doing wrong?
Speaker: And he just kind of sat back in his chair and chuckled and he was like, now you get it. And so I think from there, the amount that I've changed my mind on is is pretty much everything.
Speaker: um In terms of if of kind of an approach to pain, i when I finished my PhD and the first kind of year or two after, i was very focused on the the exercise itself and how do we modify or modulate the exercise.
Speaker: And I think now I've zoomed out and I've thought, well, actually exercise is is a powerful tool, but it's maybe more powerful for other things. And that's where the multimorbidity pieces come in.
Speaker: The thing I've probably changed my mind on most recently, and and this is something that I think, it's it's not, maybe not a change of mind, but I was having a conversation with a colleague recently about um sports injury and and um kind of working with the more acute phase.
Speaker: And this was maybe six or eight weeks ago and we had a conversation and and my colleague said, I think we can both agree that sports injury is probably more on the, you know, the biological kind of biomedical side in terms you know, getting a player back on field.
Speaker: And I kind of went, yeah, I agree with that. And then I sat on that because it's just something just sat back there going, like I don't know about this. And I do a fair bit of work with a couple of rugby union and rugby league teams. I do some consulting and some testing. and it just kind of dawned on me that people are people and it doesn't matter in terms of, you know, the proximity to when something's occurred.
Speaker: All of these factors are influencing the overall experience all of the time. And I think it was just this maybe the unconscious assumption that that it it took a colleague saying that to bring it out and make me question it.
Speaker: But I think it was kind of just there and i was like, oh yeah, yeah, yeah, no, i've I've definitely heard that before. I've probably said that before, yep. And then it was just like, oh, hang on, no, like that's that's not the case at all.
Speaker: Have you circled back, had that debate? Yeah, yeah. We we had ah we had a good conversation. And um he he's he's awesome and and he 100% agrees. It was just one of those throwaway comments that yeah i think he probably walked away and thought about it as much as I did.
Speaker: yeah But yeah, that was that was probably one recently that made me challenge some some assumptions that probably existed from when I was an undergrad or probably even before so. ah If the the normal...
Speaker: kind of restrictions when it comes to research and getting funding and all that wasn't a problem. What would you what would you research? Like what's something that you think has legs to make a difference in in people with chronic pain that you'd like to to delve into?
Speaker: at sinknc I I'm going to say an answer that's probably extremely unexciting and say ah I'd hope that I'd still be doing the same thing. um I'm quite early in my research career. So I'm i'm about five years post PhD.
Speaker: And so from a ah funding perspective, I'm kind of building my research to the point that I know that question that I need funding for, right? So there's, there's the funding landscape in Australia is, is kind of like, I, I, it's going to take me time to figure out what that question is. I'm still very young a, as a researcher.
Speaker: So in terms of what that idea is, at the moment, what I'm investigating is around utility of exercise snacks and ultimate approaches to physical activity, but under this broader umbrella of chronic pain existing as a component of multimorbidity.
Speaker: um So i would I would like to say if if funding wasn't an issue and I had access to um you know millions of dollars, that I would still be investigating the same thing. I think where that leads to, if it leads to a large trial, that's when that might be you know that hypothesis hypothetical question might become a reality.
Speaker: But at the moment, you know research is inherently slow. And so I think we're we're building at the moment. So at the moment, we're co-designing these feasibility trials. So we're getting consumers involved and clinicians because we don't want to We don't want to design a model of care that isn't feasible for either the people that it's intended for or the people that are intended to use it. And so that's going to take some time. And hopefully that will that'll be wrapped up by the end of the year. Then next year we'll have a feasibility trial and then we'll try and launch into ah a larger randomized control trial.
Speaker: Yeah, awesome. Tell us a little bit more about the ah multi-morbidity study that just came out. Yeah, um so basically there's some evidence, and I mentioned it before from a few years ago, that when we look at persistent pain, we see higher rates of of other comorbidities.
Speaker: And so multimorbidity is is defined as two or more long-term health conditions. And so when we we think about it, we've got, say, chronic low back pain is defined as a long-term health condition.
Speaker: Now, if we add diabetes or or something on top of that, that's multimorbidity. But when we look at the literature, we see that these things are addressed in silos. And so Jill Hayden published her review in 2021, and we reached out to Jill and basically said, we want to take a look at the data and see how many exercise interventions for chronic low back pain are dosed to meet the physical activity guidelines.
Speaker: And it was less than 1%. And so that was pretty shocking. And we've recently replicated that for knee osteoarthritis and it's about, it's it's quite similar. And so when you kind of take it all together and and Matt Jones and I were sitting down and having a conversation one day and we were like, well, when we we look at the pieces individually, it it kind of leads us here. So we've got people with persistent pain are at higher risk for chronic non-communicable disease.
Speaker: We've got exercise, all exercise works the same. And we've got these exercises aren't dosed to address the risk factors associated with or management of chronic noncommunicable disease.
Speaker: And so when you look at those three kind of sections of the literature together, it really makes sense in terms of, well, we've got this really strong body of evidence on the effect of exercise and physical activity on health outcomes.
Speaker: And the other side, i must admit a lot of my i I do my best for a lot of my research to be informed by questions that are going to help practitioners. If the question is not going to help practitioners, it's not worth the the time invested because research is very slow. I'm a very applied and pragmatic scientist. That's not speaking for it for anyone else. And I think the the science that other people do is beautiful. It's just not who who I am as ah as ah as an applied scientist.
Speaker: And so the other kind of notion from a more um anecdotal perspective is there's this argument on on Twitter, and Twitter is a horrible place. like Physio Twitter is the worst place in the world, right? But there's this constant argument about like manual therapy versus exercise.
Speaker: And this, well, there there was a couple of years ago, i i've I'm off Twitter now, so I've got no idea if it's still there. But the argument for exercise was, yeah, but it incurs secondary health outcomes. There's secondary benefits to exercise that you don't have with manual therapy.
Speaker: And so my question there was, well, is there? Like based on the way we're prescribing exercise for something like chronic low back pain for the last 20 years, exactly what you've said before, I genuinely don't think there's a way to get to something like the physical activity health, World Health Organization, physical activity guidelines.
Speaker: with isolated trunk muscle contractions. Like if you want to try all the power to you, but I do not think that that is feasible in any way, shape or form. And so when we've got this kind of section of the literature, and then we've got this notion of, of well, this is the purpose of exercise.
Speaker: That was what really started that that logic of, well, I think we need to investigate this. And so our study that was published in the Brazilian Journal of Physiotherapy was a, It's called masterclass in that journal and it's an editorial. and And what we tried to do there was frame the problem of chronic pain as a component of multimorbidity. mo Multimorbidity is is a problem. There's um a lot of literature out there kind of defining multimorbidity as the largest challenge for the Australian healthcare system.
Speaker: Chronic pain, we know, or chronic low back pain, is to get more specific, is the leading core of cause of disability adjusted life years. And so we tried to to frame this kind of issue and then present how we can manage it. We've got another paper under review at the moment with a framework for how we can systemize our thinking for exactly what you mentioned before. How can we be pragmatic and approach this?
Speaker: But I think the the last thing, and this is a very long answer again, I do apologize, but the last thing i'll I'll say is the other burning thing in the back of my mind for years now has been there's this notion that clinicians will often say to researchers,
Speaker: but these aren't the people I see in practice. And a lot of researchers over time have dismissed that and been like, these are real people. What are you talking about? But when we look at the literature, it's true.
Speaker: So we're doing a review at the moment with, I mentioned Brad Cullen before, he's doing the exercise snacks in in knee and hip away. That's what we're looking at at the moment is how many of the guidelines for knee and hip osteoarthritis mention multimorbidity.
Speaker: And it's overwhelmingly low. So then what we did was, that was a scoping review. And the second part is a systematic review, which we're about halfway through now. And we're looking at how many of the trials on people with knee or hip-a-way, or with people with knee or hip-a-way, I should say, pardon of me, include people with multimorbidity.
Speaker: And the reality is most trials have exclusion criteria as things like other health outcomes. Because as a researcher, people have decided, well, it's just easier to make it that more homogenous sample.
Speaker: We're looking at knee osteoarthritis. We're not looking at diabetes and the complications that may or may not come along with exercise or hypertension or whatever it might be. And so when we've got the literature, we're seeing these studies that are largely based around a cohort of people that are presenting with say back pain or knee OA that are otherwise apparently healthy.
Speaker: And then we talk to clinicians and that's not the people that are presenting to clinic. And so that's the other burning question in the back of my mind is how can we make research more ecologically valid for the consumers of research, which are clinicians?
Speaker: Yeah, that's cool. No, that's awesome. That's a great, great point there. What would your advice be, you main mainly lower back pain, chronic lower back pain is your area of research and and exercise intervention for that.
Speaker: What would your advice be to someone that's listening to this thinking they've got lower back pain and and they're they're in a bit of a dark place? What would your advice be for them?
Speaker: um Look, I think if someone's in a dark place, I think talking to someone is always first port of call. I think we we probably underestimate the value of compassion and support and having a support network.
Speaker: And often I think as as practitioners, we fill that role for a lot of people. And that is that is such a a gift to be able to have that.
Speaker: And so I think that talking can can be the starting point. Don't even think about exercise, don't even think about anything like that. Just starting with a conversation. Now, if it was someone who was listening to this, who was maybe wanting to engage with, we've just talked about exercise for the last, you know, 40, 50 odd minutes. And so if they've stuck around this long, maybe their biases towards exercise.
Speaker: um And so if that was if that was the case, I would come back to the points of find something you enjoy, work towards something that challenges you and have that end goal be something that's really meaningful. And I think if you can if you can think about those three pillars, you're on the right track.
Speaker: Awesome. Thank you so much, Mitch. It's been a pleasure to chatting with you and picking your brain. And ah yeah, we'll probably circle back in a year or so's time as your research sort of develops and there's more talking points.
Speaker: Excellent, mate. Thank you very much for having me. My pleasure. Cheers.
