Empowering Chronic Pain Patients through a Paradigm Shift in Physiotherapy

What's up everybody. It's Mark Karcher, your host of the Modern Pain Podcast. This week we have a repeat guest, morton Hu, who has been in and discussed some great topics with us in the past. Morton's doing some international teaching. He teaches on chronic pain. He's a part-time professor at Alberg University over in Denmark. He's done a PhD under Mick Thacker over at King's College in London. He's got some amazing experience and he shares it with us in the podcast. We have some great discussions on the paradigm shift that we're seeing in the literature to more person-centered care, to really incorporating patient voice some of the challenges that we see with that. So I think you're gonna enjoy the episode. He has some great things to offer for us and I hope you guys soak it all in. Enjoy the episode. This is the Modern Pain Podcast with Mark Karcherla. Welcome to the podcast.

Morton. Well, thank you very much, mark, very pleased to meet you.

It's good to have you back. I had you on the podcast. You were like one of the early days guests and I greatly appreciate you coming back on for a second go. I reflect back on that episode and I cringe, not because it wasn't great content from you, because it always is, but my podcasting tech skills were not quite up to par at that moment. We had some audio issues. We had all sorts of fun stuff. It's still made for a decent episode and it's a learning path we all take as we're starting to especially figure out tech. But this will go around. I think we're gonna be in good shape on the podcast tech front. But what we wanted to talk about today, I'd reached out to Morton and we had some exchanges on Twitter via messaging and discussed some of the paradigm shift we're seeing Morton's kind of in the similar age group as myself and we've seen our profession kind of change as far as how we were maybe trained earlier in our careers and then how our careers have kind of maybe changed trajectory due to the science and what research has been telling us. So we wanted to kind of reflect on that a little bit and then get into some discussions of how this may impact our clinical practice, but not even just clinical practice, maybe looking bigger picture, societal level, how this might need to change healthcare education and even post professional, post graduate courses. There I think we have some work to do there, but we'll definitely touch upon those topics. But before we do that, Morton, if you don't mind introducing yourself a little bit I know a lot of folks who are listening probably know you already, but for those who don't, if you don't mind just introducing yourself where you're at and what you're up to.

Yes, well, yeah, of course. Well, thank you again for having me. I reflect on the first episode as well. I remember that was was it either just before or right after I handed in my PhD thesis, so it was quite technical and there was a lot of things on my mind that I wanted to get out and, having listening back on it, it was quite technical on my side as well, so I hope this one will be perhaps more in a helicopter perspective of sorts. Anyways, my name is Morton, i'm based in Denmark, i'm Danish, i have a physio background. I was trained as a physio. I worked in the clinical practice for almost two decades Before I really transitioned into do more academic work. Then I was sort of invited into the world of pain science through the Neu Group. I was quite enthusiastic about explain pain when it came out in the early days, so about two or five, i think, was the first time I started reflecting on the and going to the courses. I attended quite a few of the explain pain courses and I felt there was a lot to learn And that sort of spiraled into getting to know people who have a similar interest and listening to people with deep insights. And by 2010,. I attended the MSC program at Kings College with Professor Mick Thacker, which was obviously, you know, mind blowing in so many ways, and it changed my perspective on many things, including pain, obviously, but many things about humanism and philosophy as well And from there I went back to the clinic but had this you know, some people refer to it as the academic bug. There was something I didn't finish, so I teamed up with a person I knew at the time and he became my PhD supervisor, professor Thomas Graven Nilsson, who's a very let's call it very decent, to be modest, very decent basic researcher. He's got an engineering background. He has no clinical experience, obviously, so he's straight on the basics of Moscow's skeletal pain, and the Institute at Auburn University where he resides is one of the foremost in the quality and amount of research on Moscow's skeletal pain. So it was quite a privilege to be able to do my PhD there on basic mechanisms, again under descending motor system, using this model of condition, pain modulation to study healthy humans and how they were manipulable through different kinds of things like stress and attention. And having done that, i realized that basic science is incredibly important for understanding of pain, and this you know. Obviously, if you're on Twitter, you would notice that every now and then we discuss ways, no deception in relations to pain. How do they relate? and are they just you know, two things that may exist in the same universe, or are they actually more related than we think? So all of that, in order to understand that, you need a decent understanding of basic science. But on the other hand, if you wanna know pain, you also need to understand the patients and you need to understand the society we live in. So I guess this episode could be part of maybe that part of the perspective. Not that I would dodge if there was any basic science questions, but I guess we could take the other approach. And just to finish off, i'm now an associate professor at Orbe University, where I am affiliated with the program We have the postgraduate program in Moscow, skeletal Pain for physiotherapists, working closely with the General Practitioners Research Unit as well.

Nice, nice. Definitely you've been up to some things. I do remember you were at the end game of your PhD when we last spoke and I know it was a busy time. It continues to be busy, probably just different busy for you. You know we spoke a little bit about the paradigm shift. I'm curious, before we get into what we're seeing like in the literature and different things, i'm wondering if you could kind of reflect on kind of the paradigm shift you've seen in your own practice. I know obviously you see patients as well and obviously have academic responsibilities and other things. But I'm just curious if you can cause I think it's a similar journey. A lot of folks who are listening, some are currently maybe struggling with it, some are maybe feeling like they've kind of crossed over the other side, although there's never I mean, the journey never stops, of course. But I'm wondering if you can kind of reflect on kind of your paradigm shift as you've seen it in your practice.

Yeah, i mean I'm old enough now. So my first career was in the late 90s. That was when I came out of school and I was very enthusiastic about the whole Musculoskeletal Medicine, or MenopheraPy. I was first sort of involved in the first wave of all this motor control and dynamic stability, kinetic control of that And it never occurred to me that there was patients who had pain that we couldn't fix. So I strongly believed in the fact that we could find the problem or you could say, the stimulus, and then we could release the pain or the response. And it actually took me quite a while to formulate and understand the theoretical constructs and the philosophy that suggests that people are not. So the problems that people have, including pain, cannot be reduced to a single stimulus which we can then manipulate And I know it's again coming basic science-wise. You need that reductionism. You need to reduce things down to things you can control, in both ends essentially, but we tend to do it in a clinic as well. So I think the paradigm shift is that we are trying to. In the beginning we were talking about a bi-psychological model, even back in the late 1970s and then up through the 80s and the 90s it was a buzzword, but not really anything that you would just mention it right. And I think now, finally, we are starting to realize that it has consequences. And it may not sit so well with some people. I think actually, quite a few people feel comfortable being reductionistic and looking at a single factor and giving that single factor enough attention to make sure that it is not the reason for their pain. But we have started to realize that we are not the only ones in the room, right? So the construct that patients are there as well and we are there for the patients, but the patients are experts on the pain and what is the problem with the pain becomes very important when we realize that maybe not all pain is gonna go away, or maybe it needs to be controlled and we'll still have recurrences. So the patient's problem with the pain becomes the center of the treatment. And I think, in essence, that's where the paradigm shift has led me to see differently and understand things in a different perspective.

Yeah, yeah, i think a lot of people can relate to that Training where it's the I spoke with Adrian Lo yesterday, which will be probably a week or two from this podcast release, but that kind of find it and fix it mentality that we get trained in early in our careers, as far as this nice, tidy, black and white version of we're gonna find that one factor, that one stimulus, and manipulate it and make a change. And sometimes there's a lot of things that go into our supposed one factor, manipulation that might change things that we don't consider early in our careers. but maybe we can touch upon that a little bit. But one thing I'm curious to because we've seen and I know I kind of discussed it on our messaging as far as some of the trials. The most recent one is the restore trial that Peter Kent and colleagues over in Australia have put out that have shown some encouraging results with cognitive functional therapy. You had mentioned too, an encouraging trial that was, i think, 2021 or 2022 with the pain reprocessing theory that's out there. And I'm just curious kind of your perspective on that kind of that paradigm shift that you're seeing in the literature where we're starting to look at some of these methods and theories that are more into that, psychologically informed, more working with the kind of mode and approach that you speak of, that you've transitioned to And we're seeing some encouraging results. but I'm curious what your thoughts are on what you see in that paradigm shift there.

Thanks, maybe if we could start from where we were before. So we both have an interest in understanding how we can improve maybe not only physiotherapy but the care for people with correct pain. And I think a major part of that is also remembering that when we talk about education and talk about what's the next step and what can I do and how should my career be built, or when you advise on that, we need to understand that it's not, it doesn't have to be instrumental. So there's many things that are not necessarily instrumental that we can do. And just coming back to those two very nice studies, we've done a range of studies over a long period of time, including the GLAT exercise program for osteoarthritis of the knee, which came out of Denmark about a decade ago, and it's had a huge impact on how people see osteoarthritis of the knee and it's been reflected on the hip as well and back, and so you can sort of transition the idea. But interestingly, even though it's consisting of equal parts of education and sort of education and support and experimental learning and, of course, exercises, then it's always the exercises that are put forefront. So it's an exercise program with attachments, right? Or at least that's how people perceive it, and I think the two articles you mentioned so Yonni Asher's and Peter Kent's articles their first author of those articles have done some amazing work where they actually demonstrate that treatment works. Essentially, that's what they show, right? Not necessarily a single treatment is better than another treatment. I'm not confident that that's what they show, but I am very, very enthusiastic about that. They can show long term effects, albeit mild to moderate in effect sizes, or small to moderate, but they are showing consistent effects. And, more importantly, particularly from Peter Kent and Peter Sullivan and Jan Hartley's and their paper, it's really obvious that they have a different perspective on the person in the room When they write it. Obviously, the headline would be CFT or cognitive functional therapy, but again, what is that? And I really think it's a deep insight into what they're doing when they say what we do is we listen to the patient, we reflect their pain into a narrative that they feel comfortable living with. And I think this may be the most important bit as well is that they have the patients experiment with their own barriers, whether that be lifting or walking, or working for that sake, or sleeping, so they provide a safe space where the patient feels safe and perhaps engaged in the therapeutic relationship as well, but the patient becomes the person who experience and learn instead of come to us for exercises. So imagine we have two different kinds of learning models. One is where we feed the patients with the right technique to be the right person. That fits the textbook example. The other one is where we listen to the patient and listen to what they can't do, and then we ask the patient to experiment by, as I would say, by a different understanding and more maybe skeptical understanding of the literature, saying I'm not sure what needs done for you, but I know where the problem is, i know where we're going, so why don't we experiment? And my role would be to make sure that you keep yourself within the boundaries of safeness during those experimental, experimental or experimental movements, as they would say. And I really appreciate that part about the paper, and obviously particularly in the second paper as well, the CFT paper They're quite explicit about the amount of training that the physios doing the trials have actually gotten. So it's not only having the knowledge, it's having the skills, which is, as any skill clinician would approve, i'm sure, much about being able to implement it into the situation where the situation with the patient. You can't just add the same let's say exercise to all patients or use the same communication models with all patients, and you cannot always be right. You can't just sit and wait for them to say what you want them to say and then expect it to go away, like to some extent we myself included have been doing with the pain signs approach in the early days, where we thought that just explaining pain in a way that was simple and biological plausible would make the pain go away. I think it's safe to say that that's no more effective than doing an instrumental exercise, for instance. So that's a long talk for me.

No, no, i have a few things that I'd like to just kind of follow up with on that, because it's a major shift for a clinician. I think you know I probably can both relate to that discomfort because you know we're trained to have this confidence in this. You know that we know the thing, the stimulus that we can remove and treat, like you said, and manipulate, and when we go in that with a confidence whether it's founded in science or not is another debate. But and then you're we're talking about you need to go into a clinical encounters with a skepticism to the research and purposeful I don't know. But I do know what you've told me are valuable movement goals, valuable living things that you have as a person, and we can start moving towards those goals and we're going to experiment. So again, i find that what makes me enjoy the clinic more than ever as far as seeing what we can do that gets somebody to move in a positive direction, towards things that are meaningful to them. But it takes this discomfort as a clinician to not be this all knowing sage on the stage, you know, a person who really can just identify and eradicate this issue for the patient, because a lot of patients come in for that And it's maybe even a paradigm shift for them to kind of do this. But I've never really found a patient that has had troubles when you take this approach. But I'm just curious what you've seen, maybe personally yourself, and maybe the struggles that you see as clinicians as a whole, as a group of us, to make that transition from the, the all knowing, the I identify and fix And there's this right answer for everybody versus that kind of skeptical. Let's trial and error, experiment some things with you to see what, what, what sticks and what moves somebody in a positive direction.

I'm curious. Maybe you have the same experience, but I don't find it difficult with patients. One is I sit down and listen to the patient And you know I always the sort of metaphor I use is that I sit down and then I pretend I'm a portrait painter So I tell the patient that you have a, you have a long life and some of that is is important, and my role is sort of to pick the bits up so that every time you tell me something, i'm painting a portrait of you And by the end of this history taking I should show you my portrait of you And and it's your role to tell me if I got you right, so you might say that's exactly who I am. Or you might say, well, it looks more like Picasso. So you may be good, but it's not me. So that sort of differentiation, because essentially what I'm treating is the mental picture of the person in my head, right, once you know these are basic communication skills, so once you get to that you can ask the patient, get enough information so that you understand what they want to convey to you. Then I find that most therapies go pretty well, not necessarily in the sense that people get pain free. But in in the communication relationship pathway, what I find particularly different is actually to communicate it in postgraduate education, when you have patients, or, sorry, when you have students who are themselves clinicians and they have ample evidence from the clinic of doing a specific thing That works, then it's so easy to believe that it worked because I did the thing. So it's like conditioned learning, isn't it so? whenever i do my exercises, i see more patients get better. Therefore, the exercises work, and this, this idea of it, is that you know, we know it by many names, but i think That's struggling. So i sometimes find it easier to agree with Clinicians with a lot of experience, with who might disagree on almost anything, theoretically, what's who perceived the person in the room as a patient with expertise or person with expertise Where, as i find it significantly more difficult to talk to someone who cannot separate the value of having a theory or an idea from the effect of the treatment. I'm not trying to say that there are two types of people in the world, and i'm one of them, because i guess we everyone, everyone is on a spectrum and it depends on how comfortable we are with the person in the room and And there are complaints, how much of you know resonate with them or how much experience you have that. So i guess we are all both ends of the spectrum, but i find it increasingly more difficult if, if we can't have you know, if we can separate theory from practice or theory from evidence. So this, going back actually to the evidence based practice triangle, isn't it understanding that they are different things but they're all important but they're not the same? So your question was do i, do i see that? is it difficult? i don't don't see it as difficult with the patients, because i get to be the person i want to be and i invite them into my room and that's easy, but it's much harder when you try to educate someone, i think.

Yeah, yeah, no, i would agree. I think the pay i have not had any major like running into roadblocks with patients and fact. Sometimes it's a refreshing change for patients who feel like I know in the US sometimes it's a very productivity driven system where the time is of the essence and the ability to sit down and just you know Not very your face in the laptop and just you know, paint that portrait, like you said, with a person in front of you. Sometimes people are a little bit like maybe surprise, taking a back, that that's happening because they haven't had it happen, when sometimes it's lucky if they get like five to ten minutes of a conversation with somebody and then it's just on the exercises, the things that are gonna fix us or fix you. So yeah, i would agree, i haven't seen that but it is. It is more of a challenge. I would agree with clinicians to kind of maybe take that approach. It takes a little, maybe, i think, destabilization, and purposeful destabilization, of Not always having to have the answer And being humble and, like you said, respecting that expertise that sits in front of you, that that person's the only one that has lived that life that allows you to paint that portrait And you have to respect that expertise because it gives us a lot of information. And i've talked to this with multiple guests. My frustrations and i know i'd be pretty sure similar we. We have cordon, this soap notes, where it's a subjective which isn't looked at as the real data situation and we can get into Philosophy of science and empiricism and all these things that maybe drive some of that thought process Where the objective data the stuff that we gather clinicians is the real stuff that's gonna really dictate how things move forward. But i buy the paradigm shift. i think that's really. Research is supported so much more of the influence of psycho social factors and things like that that impact outcomes that we need to flip that on its head. That you know the real data is often The unique story that that person brings to the table. Not saying we're thrown away that objective data. Of course it's important, but it needs to fit into the narrative instead of like Shew horning patient stories or at least, or maybe even just kind of push them to the side like let's get to the real stuff. That you need to understand that that Objective data is just one part of a very complex story and often a story that maybe we're weaving versus the one the patients. We've been curious what you thought about kind of that whole Subjective versus objective demarcation that exists i completely agree.

I mean Again, if you allow me to reflect it, on teaching courses, for instance. Again, i think that the way we are in this paradigm shift let's call it that I think it's agreeing. Everyone agrees now that patient center is good to buy us. A social model is not. You know, it's not a thing is. It's a good idea and several good ideas, and i have lights. I think it's great, but it can be used very differently. There's a brilliant paper with the steel woman, i think ben kormick's first author And gibson last author, on the bias i social models i definitely recommend to share. But anyways, so we are agreeing on it on a, you know, on a theoretical level. But when you look at what happens in the clinic, or what people tend to think they are doing, or why what they do works, we, we struggle with this. I this what i came from, this idea that we look for the thing that we can change. That's again, that's the premise of pretty much all theories, or all clinical theories at least, because the idea is you find something that is manipulable And then you manipulate it and the patient gets better. While study is essential for good theory, i think we need to remember that the theories are wrong so That they are just guidelines, right. So guidelines essentially does not fit everyone. There's supposed to be good guidelines for the majority of people, but you need to adjust them as well. So when, when, when we talk to each other about how we manage people with pain, on people who live alive and pain It easily comes down to let's imagine i'm teaching a group of people No, even better. So my good friend, tim Beams, was teaching a course on CRPS the other day, and one of the things that he was a bit frustrated about Was not being able to convey the complexity and the nest. Then what do you call it the benefit of actually spending enough time to talk to a patient and finding out what's wrong with them? because the next question would be okay. So how do we treat them? And it's as if there was a thing that could be changed and then CRPS would go away. Or if there's an instrument like mirror therapy or whatever. That is the one thing that makes them better, and i think the bulk of research now we have on musculoskeletal pain suggests that we don't know what that one thing is. And the two papers we just discussed have a different approach, albeit one more explicit than the other, where the person is center and the care is much more than an exercise. So the way i read your nearsius paper on the paper processing therapies, that they still frame it as a concept Where there's focus on explaining pain, doing exercises and making sure people understand why they should move or behave differently. Where is, i think, the? the peter kens paper suggests a slightly more experimental approach, more pragmatic approach, essentially where they open up for The two people in the room to collaborate and the effectiveness of that being the essence of what they try to study. Which again reflects, i think, in the results where you see, when you don't do that, don't be the control group, they don't see the effects, but if you do that, it doesn't matter if you had a biofeedback unit. So i guess they were quite disappointed to see there's no difference between the two cft groups. But essentially, the way i understand what they're doing, that makes perfect sense because you are, you know, you're respectful and you you work with a person. You're not dealing with a thing that can be changed through your therapy so that the patient gets better.

Yeah, that's a. that's a such a challenging, you know, thought for some, something. i know it was challenging for myself and it just was a big shift with that and Sometimes to me, relieving as a clinician where i don't have this massive weight on my shoulders to find it and then repeatedly feel like your failure, especially as you get More advanced in training. sometimes you get sent complex cases from younger clinicians who are trying to lean on some mentors and things and i remember clearly my fellowship that you know i was in it to Get better at finding it and fixing it and then remember seeing some very accomplished manual therapist in the US who Just were having the same struggles. i see the same patients i remember struggling with in my practice having the same struggling in their practice with that approach again, there's some great things that you can learn from it, but it's limited and it's just one of those things where, as clinicians, you gotta be willing to, you know, humble yourself, i guess. and shelf, shelf are clinical egos and you know that collaborative approach can be so powerful. and i agree with you on the take on the paper. as far as You know, collaboration, whether it's with information, instrumentation in form of that biofeedback device or not. That's maybe not the but that device isn't maybe the secret sauce of the thing. it's that whole creative shared expertise environment, that third space like you know kohen and quitner kind of coined That you're creating, where people are equal partners in a journey that you share together with somebody. you know i'll see everybody in that child and have a perfect outcome, but it was encouraging, definitely with that.

What is the outcome of a twelve months on a group level is is is quite extraordinary. I mean, of course, people can spend time debating with or not they could have done a different study and all of that. But I think in all lessons it's it's really important study and it highlights that we can make changes. But we also need to be respectful about the limitations of those changes on a group level, meaning that you would expect some patients to get much better in the clinic and maybe some not getting so good. So you need to always monitor with or not the patient gets better from your treatment, obviously with you in the treatment session. And also maybe we need to challenge new methods. Instead of looking at group averages, maybe like single case experimental designs Could be a way to study a single person over many different time points, or even at many different levels at different time points, to see if there's a change that occurs, let's say, immediately after therapy or right after good night sleep or just when you had your argument with your wife or whatever. So having that in single cases and then you know enough of those single cases Maybe a different way to study changes that relates to events as opposed to group level changes on a date Yeah no, i think that's a much better a progress, possibilities at least. Yeah, no, i think i was. I was just when you said it. This is just me, because i always I feel a bit misunderstood, sometimes the old baby in the bathwater. So i'm not trying to throw anything out with the bathwater. What we are talking about here is, of course, people who have a pain for more than six months or so, where they might even during those first six months, i've had really good therapy. They've done the obvious things. So i guess, if you want to be very, very pragmatic or even very skeptical, you could say that anything seems to work in the only phase even nothing. So time is really curing love, acute onset pain and then, as it goes on, there is a good argument to do some of those treatments that we are taught to do, even perhaps in those structured ways, as there was a post. But once you get out that maybe three to six months period where they've done The advice or most common things in a, in a variation not all of them, obviously, but on variations of that, in a good relationship, i saw a good therapeutic alliance and it still doesn't work then then Something else needs to happen, and I think that's where we are talking about. We need to sit down and make sure that we understand where we're going, because maybe we can reach the goal, even if it means you still have pain, because that is a realistic goal for some people. At the other end, of course, we still have serious pathologies, we have acute injuries, essentially. So I do some work with elite sports as well and and like Olympic, the coaches and and and physiotherapists and doctors and trainers. Obviously they would see different kinds of things than you and I would see in the clinic. So we need to remember that it's a spectrum and you know, when people have acute injuries, you need to understand that pain is usually there for reason, even if that reason is something that the body can maintain itself or care for itself. So it's not necessarily dangerous in the sense that you know be bad if you don't treat it, but it still needs attention and there's a lot we can do with that. So that was just a me being cautious that people don't get me wrong here.

Yeah, no, i know, sometimes I've had to feel those those messages on social media things of the the old baby with the bathwater arguments. I appreciate you clarifying, because I'm with you on that, that, that Take you have there, as far as there's a tendency to feel like our treatments are getting threatened and we need to really, you know, make sure it's known that the stuff is important. Again, like you said, in the context where acute injury or things where and I agree, they're a good portion of things work, if not most things, everything is and time is a good friend to if we, if we give it a chance and don't, you know, push somebody into catastrophizing fear, avoidance and all the things that we know are Things that can kind of predict a less ideal trajectory of people. But if we can circle back to what you had mentioned with that kind of research design, which I'm fully in support of, like the single case, maybe over time and different periods and in different context, to study how these things can, because I think that's where you encapsulate a better narrative of a person in research versus, you know, i get like we need randomized, controlled trials, big, highly powered trials that can give us, you know, some good information to make decisions on. You know treatments and clinical practice guidelines, but I fear and I'm sure you're aware of like cause health, and you know Roger carries great work and Matt Lowe and Ronnie Lillian and you know a lot of the folks over there that are doing some great stuff to kind of say, hey, we need to step back and make sure we don't forget that The narrative and and that is more than just this empirical, positivist way of looking at data that you know, having studies where a single subject, case design can be very powerful this to for us to inform Some of the things that can inform change in patients in certain contexts and we get enough of those studies built up over time. It can really you can start seeing some trends versus Trying to resolve a very complex individual. Individual experience to a group means averages, standard deviations, p values and all those things, and again, i don't want to throw that baby out with the bathwater either. They are important studies, but I just think they obviously are limited in being able to Drill down to a unique human in front of you.

Yeah, no, i completely agree in and again this, there's a lot of things. So when we say paradigm shift, it almost seems as if the one thing we did was wrong. Therefore, what we're doing now is right, and I think it's important to be cautious and remember that just because what we we know, what we shouldn't do, it doesn't mean that we know what we should do. So we are still learning and I think that's why philosophy and sociology and topology and neuroscience, obviously, and a lot of other disciplines like basic science and science disciplines, need to contribute And give what they have to the topic. Only there by we can make it more clinical. And I understand, and I admittedly have been part of this Diversion and perhaps even you know, clouding the picture by using terminology that may not be relevant. So just about, i think about a year half ago, we started doing a series with the JOSPT, the Journal of all the people's sports, with therapy on neuroscience based. So it was written for clinicians. If you are a basic scientist you would look at it. You say there's so many things that are not in there but also important. So that has been the editorial decision. This is what we're going to put in the editorial series. Having said that we try to be quite precise on what's in there. So the things are in there, are supposedly faithful to the science, because there are some important things in neuroscience like what is sensitization really? Otherwise it might transition into being these fluffy terms that we use and then everything is sensitization as, as we would now know, right, but they're not. I mean, it is a thing, and I'm happy with you, call it anything, as long as we can agree what is the thing, and the same with philosophy and and what you know cause health and other people have been doing, reflect and saying there there is a. You know, there are actually some very basic things in philosophy that we should import into the clinical world And then, when we know them good enough and when we maybe have been, you know, trying them out for a period of time, i think the real task is to make them clinical relevant, and that's what we're trying to do now with neuroscience, and lots of people are doing it with their different fields. So I don't think we should lose the good handling skills. I don't think we should stop doing exercises, but I do think we need to reflect on are there theories that might explain what we see better? And then, of course, the big issue is to find out how do we measure outcomes? Essentially, one asked the patient right, but it is so obvious to ask the question Do you still have pain? But that is a really difficult question for the patient to reflect on, because should I have the pain you were asking me about, is that the pain you told me to live with, or is it the pain that I'm supposed to be able to get rid of, which I don't believe anymore? And there's so many layers of that. Right, but it's easy to use a 0 to 10 scale. So what are we really talking about? And I think that's why, for me at least, the portrait is so important, because during that portrait I would get to understand what is it really, to paraphrase John Lozier, professor John Lozier from Washington State. He said so what is it that pain keeps you from doing that you either need to or want to do? That was his sort of replacement strategy for the onion model which he created back in the day. So we just need to just again rotations marks here. So it is not just simply doing that, but essentially we need to understand what is it that pain does to you, and can I help you with that. If not, then could we twist it, could we be part of it, could we? you know, could you learn some basic skills and then move from here? Again, metaphorically, i would talk to my patients about you know they might have a long period ahead of them, so I talked to them about. This is more like a driver's license So you get some theory and you get some driver's license. So that's the experiential learning, where you go out and try the stuff that we talked about and you come back and reflect on how it went And I create a safe space for you to do it in, whether that be the clinic or your life or your job or whatever. But once you've learned to sort of work with it, then you get your driver's license. But from there until you are an elite driver is, you know, many, many hours of training. But essentially what I can do for you is to help you reach the point where you can practice on your own And then you can come back for booster sessions or you know you can contact me if things go wrong or if you have questions. Obviously you can do that, but at some point it's probably how we need to understand what we can do for our patients to make them care more for themselves.

Yeah, and you speak of the booster sessions And I know that was one of the keys. You know that CFT researchers Peter Kentonis Group and Peter O'Sullivan had mentioned. You know they had found some holes where it wasn't. Some of the it was losing its steam in the longer term, but those booster sessions really helped them maintain that. So sometimes patients may need those driving lessons to recur from on a regular interval, because I just think too, you send people out, back out in the society. I don't know how it is in Denmark, but the US is full of all sorts of lovely messages around pain that really can pull people back into beliefs and behaviors that may not have them driving in the right direction of towards their valued goals and things. So yeah, i can definitely see those benefits of booster session sessions for sure.

Yeah, it makes so much sense to you know, to understand their frustrations and their worries, and even you know I can call it anything. So I can call it kinesophobia or catastrophizing, which is not essentially the thing that I'm going to treat. Anyways, i'm going to treat the person in front of me. So I have the theory, but I want to hear them say it, i want to know what they think it is, and then hopefully, over time, they will be different, so they will behave differently. Things that used to be a problem is not a problem, or they will meet new people or get a new job and there will be new problems, and I think that's where a booster sessions might be very handy to you know, come back into this safe space that we created So you can go out and learn those competences which essentially, i believe that you know pain self management is. It's a competence that we don't have, or do some people don't have it. There may be some who don't have it, and obviously they wouldn't be patients then, but the majority of patients who come in with ongoing, persistent pain probably don't have this. As would I not have it, i'm sure. So if I was having pain every day, i'd be frustrated, worried and all that as well, and I would need someone to guide me in the direction. But I wouldn't expect them to fix me based on what I know about pain and the possibilities and chances of that happening. So you know, some get better from any treatment, but we don't know why. So it's really well, it's not easy. It's probably not possible to predict at baseline who will be the ones who will benefit from X treatment versus Y treatment, which is what I guess. The study shows some benefit And then we try to reverse engineer and say what was it in the treatment that seemed to be working? And that's essentially what we do with the RCT. So we control for something we in advance thought that will make the difference between the groups. But there are many things that they all got, or maybe they didn't, but we don't control for that.

Yeah, some of those contextual things that we speak of sometimes go maybe unmeasured and unrecorded and maybe unrecognized as contributors to what drives some of the change in these interventions and in these studies. So, yeah, no, i think it's always fascinating to kind of really look 10,000 foot views instead of really trying to distill it down to these discrete single variables, when there's so much overlap with treatment, response and some of these best ways we have currently to measure change. And I've you spoke to the NRPS scale, which is not my, one of my least favorite things that I had sometimes required to do in the clinic due to our systemic challenges that we face. I'm sure similar over your way. But you know, with some of this you know approach and some of this you know shared expertise and the things that we spoke to, with the paradigm shifting today, there comes some blurring of like professional lines a little bit, where I just kind of reflect back and I think, well, when these professional lines were created it was in the knowledge base that existed at the time. So there were psychologists who focused strictly on the mind. There was the physios, who are the physical doctors you know. Medical physicians, you know, tend to look more at the biology, but obviously more than that. But I'm curious, like, how do we, you know, help clinicians where the research and the knowledge definitely is telling us that these lines don't help patients? that when we try to cordon people off, i always say the US, especially, is full of a million tree specialists with very little people who talk about the forest. It's just a you know which tree do I specialize in and I'm going to give you a title and a diagnosis that relates to that tree and my immunology tree or my endocrinology tree, or my physiology tree or my physio tree, and you get these people get like pulled in 15 directions. I have had three patients this week just where I seen all these different people and I'm getting all different reasons of why I'm having this pain. I have no idea what the heck's going on with me. So obviously the distress meters are only going in the wrong direction for some people. I'm curious, maybe, what your approach is or what you think you know in an ideal which none of us live in, a world where we could. These lines may not be hard and fast. I know there's obviously political and all these other things that go into some of these professional lines that are a whole another ball of you know business that we don't want to kick. But I'm curious what your thoughts are on some of those professional lines blurring and kind of some of the necessity of it and maybe some of the challenges that are come along with that.

There's so many things I want to say here. I guess the first thing that comes to mind is this I guess everyone's read the book about thinking fast and slow about DNA carnival, and he has a quote which I won't give. It's too long, but it's on what you call theory induced blindness. Essentially it means that once you've used the theory to explain why your patient got better by specific technique, and the patient got gets better than you say it was because of the technique. So every time you use the same technique for the same type of patients and you see again and again they get better. And when they don't, you would I say well, maybe they didn't do the exercise as well enough, or maybe they were lacy, or maybe they were too fat or whatever. So it's all about them when it doesn't work. So essentially we'll say you give the theory the benefit of the doubt. I'm, you know, by by no measure. Even you know, close to his, his whiteness. So I like metaphors And I think theories in that sense are like farts. So they are all made out of hot air and we prefer our own. But they're also necessary. So if we start to realize that, then when the patient comes in and they say I have a. You know I need hormone replacement therapy And you know I would. I would go into a discussion with them or I would, you know, ask them as a okay, so, first of all, how are you measuring that? How do you know the hormones are whatever they are? And then I would ask them about how do you make sure that better, okay, so maybe maybe they are actually measuring it. If they're not, if they're just like saying that you know your brain changes or whatever, and they're not measuring brains, then perhaps it's just. I would just, you know, say, well, that's what we say, and just like we had just joined or whatever, we don't, but it's what we say, because that's how we contextualize it. But sometimes they actually do measure it. And then you need to reflect on do those changes actually reflect on something? Is that are they changing? Are they really, you know, scientifically based? Could you measure that at all? Would a change be related to your therapy Or could it just be a diurnal change or whatever? So so you need to be able to discuss that with the patient, i think, because if I, if I have an idea that what they're doing, what they are subscribing to as an explanation is not going to good for them, that that is really not going to help my patient. But I think there might be a reason why I don't think that. So I would talk to my patient about it and have them reflect on it, give them questions that they can reflect on And maybe, maybe, if it's necessary, i'll give them a few hints of the science that could go behind it and say this is actually how we could measure it. But if you're not doing that, then what I think you are meaning is that you want this to be better And you think that hormone replacement therapy is going to be the thing for you. If that's the case, then how many trials have you had and did it help? Or what if there are other alternatives with you know lesser side effects, would you be willing to consider them? And and then coming back to to professions I was fortunate enough to to work with. So Lance McCracken, professor Lance McCracken, he was visiting Professor at our university earlier this year And we were discussing over a few times, what is it really that psychologists do very well, that physiotherapists could learn to do or should learn to do, even And and the sort of short list that he gave us three things. So he said building relations, what we usually refer to as the therapeutic alliance. So how do you do that? Psychologists have very decent tools and and are very, you know, excelling in that, as a, as a therapy or as a you know a theory. Well, i'll come back to it. It'll probably pop up in a second, anyways. So I think, coming back to a question, what can we learn from each other? I think every profession has specialities, but there are some that are so close, like there are a lot of different approaches to menopathy, but maybe we are not that different. If you know, if spinal manipulation is not different, why do we have different professions? And I think you are alluding to this. It's probably more political than anything, or because it it. Maybe it's how it works and it's easier that way, but it there's not a, i don't think there's a good, sound argument for why a chiropractor and a physio should be any different. I think we have, you know, good tools in all toolboxes and maybe we could be better together. That would be my approach. I also would sometimes reflect on if you exclude surgeons and perhaps general practitioners, but probably not but surgeons. If you exclude them, then doctors are specializing in something that is pathological, which works fairly well, i must say, but what we tend to do is we specialize in a technique, so you know, chiropractic manipulation or physiotherapeutic exercises or whatever, and maybe that's not beneficial. Maybe that's not how we should go about it. Maybe we should reflect on what does the patient need and what are the generic skills that we should all have in order to work with these patients. And then, second line, where are the experts? If my skills, my generic skills, are not enough, how can I work better with them and then coordinate, as opposed to be in competition with each other? Does that make sense, or is that how you think?

No, yeah, no, I would agree. I think the better together thing I'm full supportive. I think sometimes this like protecting our piece of the pie type thing, especially in the US where it's a very revenue driven, capitalistic way of looking at healthcare which you know benefits pros and cons I'm not again not only want to start that the discussion because it can get a little heated.

But can I just say, the minute I stopped talking I reflected that. So the third thing was, of course, outcome measures, So being able to measure something that actually relates to how the patient is living their life. So it's creating a relationship, it's setting up good goals and then reflecting on the outcomes. Are they really something that reflects what you were goal setting and what the patient needed? That's the three things.

Yeah, and not super complex things that you know as a physio, we couldn't easily improve on and upskill or practice in that situation. So, yeah, no, i'm jealous because I've read a lot of Lance McCracken's work, obviously big in the act field And so being able to pick people's brains like that. I wish I was in that discussion with you guys to start teasing through some of those topics. You also got a chance to have Mick Thacker, you know, tease your brain for a while. So, like every time I talk to Mick, i feel like you know I have new thoughts that I didn't even think I thought of before, just with how DP goes, with theory and amazing guy. But I'm dovetailing a little bit. But just to kind of come back to you know some of the you know interprofessional boundaries and things. I'm with you. I think we need to be willing to, if we're in this, truly to help the person in front of us, we need to be willing to blur the lines. I know in the US I can't again speak for Denmark, but the availability of a psychologist who's very sound in pain is very scarce. It's just not something that's. I'd love to multiply the, you know Rachel Zoffniss' and you know the other amazing pain psychologist we have here in the US. They're just not the existence of it. I can. apparently it's not the most popular. You know part of that psychology profession that folks want to specialize in, but men or patients sure need it.

I mirror that completely. But again, i need to stress that it's not about the instrument, it's more about how you deal with the person, isn't it? So there are generic skills and I think that we can go a long way if we understand that you can't. You know, there is a skill set that you need in order to be in a room with another person who essentially needs to do the hard bit of the work, and I agree that psychologists have really good tools for that, but we shouldn't forget that we have those as well. I mean, we use the touching Therapeutic. Touch is, you know, an amazing skill, so we wouldn't lose that. I also think that we can actually do quite a bit of good manual therapy. That could be pain relieving. Maybe that is a good way to create that safe space where your patient is more comfortable, knowing that, even if it hurt to do a thing, then you have, you know, a supply set that you can add on to them to make them feel good again. So I think we have different skill sets And I really, when you said it, it just I had to say that what I see a lot of times is that when people sit together. There's almost never a psychologist in the room. So therefore, when we can't agree, so doctors are there, the physios are there, there might be nurses and a diet, diet and everyone says this is a really difficult patient I think they need to see a psychologist. So it's almost by exclusion, which I don't think is a good idea. So I mean, the reference to any other healthcare professional shouldn't be by exclusion, it should be by inclusion. You need this. They are better at it, just like you would do MRI scans. I mean, we know now that MRI scans by exclusion I'm not sure what's wrong with you. Let's MRI scan your back is a really bad idea. So why should we refer to other people by the same false way?

Yeah, that's a great point, i would wholeheartedly agree. I've been fortunate enough to be in some rooms with where we're starting to include psychologists, but it is a rare occurrence And, i think, one that hopefully will improve with time, and just hopefully we see more psychology folks entering the pain world and get involved in discussions More. We could talk for probably another two hours about some of these topics. I've really enjoyed the discussion and always come out of your talking to you with more things to think about and more things to ponder, which I appreciate. That's why I like having these discussions. But is there anything you're up to or where folks can get in contact with you or what are ways they can kind of learn what you're up to? And I know you have some things going on at your university that you spoke of, so if you can share that with the audience, i'd appreciate it.

Yeah. So what are we up to now? We're looking into if we can communicate differently. So you know this idea that the patient always wanted a diagnosis Have you ever heard that? So I can't give them a diagnosis. So what am I supposed to say? We're actually working on that. So we're working on trying to see if we can create better what we call credible explanations. So it's sort of a narrative medicine approach to basic conditions which we are familiar with, like patellofemoral pain, or it could be oscate slather disease, where we know there's a good reason for why they have pain, but we can't stop it. So, essentially, the theory lesson, if you like, of the driver's license could we conceptualize that? And then we're testing that on some adolescents now. So I think that's really important to try to look into different approaches and to structure it so that the science goes into the clinic. And, speaking of that we are going to be looking for. I think by the time this comes out, we would be in the midst of looking for an assistant professor in our research group. So if anybody has interest in it, do send me a message or, even better, an email at mshhtaaudk or find me on Twitter and go through there. And as for the rest of what I'm doing, well, i like to travel about and talk about this. So an hour on the podcast is very short for me. I gladly speak for days and hours. So I do that quite a bit. And if anybody was ever in an area, i'll be at the Oregon Pain Summit later this year. I'll be closer to where you guys are, or I'll be different places in Europe as well. So if you ever come by and you've listened to the podcast, do let me know, and it'll be good to hear what you thought. Yeah.

I have yet to be able to. I was kicking myself I couldn't make the San Diego Pain Summit when you were over there delivering your course, And then I may have to see if I can get up to Oregon. Oregon is a great place to be. I love Pacific Northwest, So maybe we'll actually finally get to hang out in person, versus the virtual hangouts we've had over the years. So yeah, i just want to They have good beer as well.

So what's that? They have good beer.

They do have good beer. I can definitely vouch for that. I have sampled my share of the Pacific Northwest fine beers and they are definitely good. So yeah, we could. That's where some of the best discussions are having. Some of the most highly depth philosophizing happens is over a good beverage, So yeah, we'll have to do that. Now I just got to start working on my wife to see if we can make a family trip out of it or something like that. So that'll be next task after the podcast ends. But again I want to thank you for your time, Morton. I really appreciated the discussion today. I greatly admire what you're doing in Denmark and keep up the great work.

Thank you, Mark. It's been an absolute pleasure and thank you for having me again. Have a good day.

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