The Future of Chronic Low Back Pain Management: Exploring Cognitive Functional Therapy and the Restore Trial

Speaker 1: What's going on everybody. Thanks for joining us for another episode of the Modern Pain Podcast Really excited. This week We have a great episode. We were able to have the privilege of sitting down and speaking with Peter Kent and Peter O'Sullivan on their recent Restore trial. They're one of a group of authors, peter Kent being the lead author of the study. For those of you who are researchers, you understand the breadth of work that went into this trial And this trial of course tickles the biases of Modern Pain Care and Modern Pain Podcast.

Speaker 1: It's all about person-centered care and getting away from this find-it-fix-it mentality and getting into this guide by the side versus the stage on the stage approach that tends to pervade physical therapy at times. I know it has traditionally in my practice as well. So it's a great episode. They're going to lay out the trial, kind of what went into it, what went into the training of the clinicians and the results that they found. We'll talk about some of the criticisms they had and some of the things they think that are going to happen, going forward to build off this trial and build on creating clinical communities for not just clinicians but for patients to start seeking the help they need And Modern Pain Care. Stay tuned. We're going to try to create some communities around this transition that I think we have to make as a profession. We have to transition from this find-it-fix-it. Of course, a tissue-based examination to rule out specific tissue-based issues is still important, but if we want to be relevant in healthcare and truly help and fit the need that's out there, we have to make this transition from a strict find-it-fix-it approach to a person-centered guide by the side approach with folks and really helping people navigate some challenging situations where healthcare is strictly failing them. So enough of me talking. Enjoy the episode.

Speaker 1: This is the Modern Pain Podcast with Mark Karjula. Alright, welcome everybody to our live stream and discussion on the Restore trial. I was talking with our guests on the way into this live stream And just kind of at all with the probably massive undertaking that this trial was. We'll talk about that today, but wanted to thank you all for joining us. We'd love to hear where you're all tuning in from. So if you can drop your where you're at in the chat, we'd love to kind of hear where you're tuning in from.

Speaker 1: It is 7pm here in Phoenix, arizona. I know it's at 10am over in Australia, so appreciate you all in the morning in Australia tuning in. For those of you in the US tuning in in the evening, good to have you here, but let's get into the discussion today. I wanted to welcome our two guests who are generously donating their time today. I'm going to have them both introduce themselves, but why don't we start with you? And it's a little difficult today because I have Peter and Peter. So we've decided PK That's what Peter Kent goes by, and Pete as for Mr O'Sullivan. So we're going to go by that today. Pk, do you mind introducing yourself to the folks?

Speaker 2: Sure, my name is Peter Well PK and my clinical training is as a chiropractor and a physiotherapist. I practiced for about 20 years in musculoskeletal care, mostly in spinal pain, and then became an academic. I've been an academic for the last 15 years.

Speaker 1: Great Well, appreciate you joining us today. Pete, you mind introducing yourself a little bit to the audience.

Speaker 3: Yeah, hi. So I originally came from New Zealand. I trained as a physiotherapist, i did my postgraduate manual therapy training in Australia West, australia, perth And then kind of realized I had a bit of a crossroads where I then started to do a PhD And I'm pretty much since that time that was in the 90s I've worked both as a clinician and as a researcher. So I kind of got these. I run these two roads, both clinical research and practice, which is a beautiful interplay between working with patients and pain testing hypotheses, essentially.

Speaker 1: Yeah, it is unique. You have your own laboratory to kind of work with patients with, which is awesome. I wanted to get a little bit into just the history kind of CFT. I've been fortunate enough to take a course with you at the San Diego Pain Summit, pete, and really have enjoyed the approach And it's definitely synced our biases here as far as person-centered care and the things that we talk about on the podcast. But I'd love to hear, and maybe Peeke, if you can lead us off as far as kind of your kind of history with the approach. what brought you to the approach with CFT?

Speaker 2: That's a great question, mark. So I worked in a variety of settings in hospitals and rehab centers and in primary care And I realized that I felt like I was missing something in particular. I was missing something in terms of the biopsychosocial side. I was really into manual therapy and I'd done a postgraduate course in physiomanual therapy as well as chiropractic, but I felt like there was something that I couldn't quite get my finger on And it was really around dealing with people's distress and the relationship between that and pain. And that led me into thinking about subgrouping.

Speaker 2: And I did a PhD in subgrouping methodology and I went from Australia after that to Denmark and worked for seven years on large clinical registries looking at subgrouping, and that wasn't all that revealing and my sense was that maybe subgrouping was useful for identifying clinical pathways, but probably not so much about making decisions clinical decisions about individual patients. And it was in Denmark that I got exposed to cognitive functional therapy and I was attracted to it because it seemed a way of actually actualizing or doing in the clinic the biopsychosocial model, but it also did it within the structured clinical reasoning model that allowed you to make decisions about individual patients. So not long after that I got invited by Pete's group to come back to Australia and go to Perth and work with them on that approach And the restore trial is one of the things that came out of that collaboration.

Speaker 1: Awesome, awesome. Pete, I know you've had a big hand in this as well, but I'd love to hear kind of your background and kind of history leading up into it.

Speaker 3: Yeah, so look, you know, I suppose, my background. As I said, i trained as a man your therapist And I remember my first year after training as a man your therapist. I come out with all these tools like of handling skills, and I had two jobs. One was in a pain clinic with people who are profoundly disabled, people on morphine, who are, you know, wheelchairs couldn't function, who were so sensitized couldn't do anything with, and I realized my skill set was just completely inadequate to deal with that group of patients. I was also worked in a private practice setting where people come in with aches and pains and a bit of stiffness and I could crack and push them and make them feel better for a short time. Sometimes they'd come back And I realized at that point as well there was very little evidence that we could really that physiotherapist had anything to offer for these people who are profoundly disabled, and it really led me down this path of going.

Speaker 3: We need to understand what's going on better and we need better tools to direct care towards these people. And so that's really been my career of, you know, being part of a journey which has also incorporated a lot of development of understanding pain but also seeing through the patient's lens, and I think so often we've come to treatment through our lens and not the patient's lens. They're saying, actually, what's the lived experience of people in pain? What are the beliefs that these people have? Where do they get them from? What are the things that we're doing with them? Why is it that? why is it back pain is the leading cause of disability, with people who are profoundly distressed? What have we done in our system to create that? And then what can we do to help people on a journey out of it? And that's sort of been our, you know, such a privileged journey of learning from people with lived experience.

Speaker 3: So we've been able to go back to the clinic and take the time and learn from people and learn about you know what this has kind of evolved from that clinical space, but also to test, road test it in terms of testing hypotheses and pretty much. You know, my career has been unraveling all my own clinical beliefs and then luckily replacing it with stuff that actually seems to make sense and work. So there are still trials really a really important trial for our team because it was the biggest trial that could systematically number one train a bunch of physiotherapists to competency, which is part of that. It's kind of like a double trial. One was can we train people deliver this who relatively you know, mixed bag of people from different walks of life across two cities? And then, if we do train them, doesn't make a difference for a really tough group of patients who are pretty much at the end of the line around back pain, sure.

Speaker 1: Yeah, I had some questions just kind of on the training to. It was quite extensive in the study I think. I think it was somewhere in the neighborhood of like 80 hours or somewhere in that ballpark. Yeah, yeah, yeah.

Speaker 1: I'm curious couple of things and we'll bring up the kind of graphic on CFT for those of you who are watching the training. I'd love to hear if you hope that went and kind of maybe go into you know the structure of all that. and then also like maybe, as you've kind of were training, i'd be curious. just my own curiosity is like did you have any more difficulties with the older clinicians or difficulty experience? I just know for me personally, and I think you mentioned it, like unraveling that needs to take place. Yeah, there's less unravel when you're a little earlier in the profession, so I'm just wondering what your experience was there.

Speaker 3: Yeah, it's a really good question. So there are lots of questions in that question actually. So we were lucky to include people from two years post graduation to people with 35 years Post graduation and, and you know, with experience we you know that can be hugely advantageous around understanding and seeing a lot of different people with different perspectives, but it can also mean that we have our own clinical behaviors that are really ingrained that we can't even see anymore. So I think you know a lack of experience. you don't have the the, the, the colloadas on the really miles on the clock, but but you do come with a freshness, i suppose, and probably a more. You know your training hopefully would be more up to date in terms of understanding pain etc. So that was a mixture of pros and cons And I think you know what we saw is that we could train both groups basically towards developing competency, the things that really you know.

Speaker 3: We often hear about this oh my God, it's 80 hours. 80 hours is nothing. When you look at how much money is spent on this problem, you know what does it take to train a surgeon to fuse a back which costs 50 grand and it delivers the same outcomes with significant risk of, you know, non surgical care, like we have to stop apologizing for upskilling our profession. And if you look at where physios have come from or PTs have come from, we come from a very structural, biomechanical understanding of pain. And then we've we know the guidelines are saying we need to address the physical and psychosocial barriers to recovery. Right, what skills and training we had on that. And we see in the, in the qualitative synthesis that are out there, that physios are saying we don't have confidence to explore these things, we don't have the skills to do that. And so the training was number one up, upskilling knowledge and then creating skills.

Speaker 3: And then the really key part of this training was mentor, direct mentoring while they work with people with disabling pain. And a lot of the physios in the training is said we haven't even seen these people before. We haven't seen people who have had a panic attack during a consult. We haven't seen people who are this disabled, who are this distressed. We don't know how to manage it. And so part of the training was really given them tools and confidence to to help these people understand what was going on, to give them confidence in their body, to get back to stuff in life that we, that they valued. Because a lot of us are fearful about pain. We're often fearful, as clinicians, of hurting our patients. We don't. We don't feel comfort with dealing with their stress, distress, and so that's actually not a huge dose of training for the mountain to climb, in my mind.

Speaker 1: Yeah, yeah, i'm curious to like, when you look at the, the infographic here we, how deep are you into like the, the sciences and stuff, or is this more just like conceptual? This is getting, like, you know, more experiential learning for the physios And I know there was a lot of mentor practice and you guys utilized social media kind of with Facebook groups and things like that. I'm curious if you can speak to the like kind of the, the mode of learning that these folks, because I think that's one thing to kind of learn it in a two day course, but when you're having mentor practice with skilled clinicians to help you deliver, i think it's a different animal.

Speaker 3: Yeah, totally. And look, the knowledge part for us is about we have to understand the science of pain. We have to understand the facts of it. We have to understand it's multi factorial. We have to understand the fact. Is it different for every single person? We have to explore them, identify them. We have to be patient center. We have to understand their goals. We have to understand their motivations, their fears.

Speaker 3: That's a whole jigsaw puzzle to unravel And then to take that back to the person who's been told they're damaged and that pain is a sign of damage and they have to protect their body And there are all these rules around posture and brace in their core and all the stuff we tell people. And to validate the person and invalidate their beliefs is a really tricky dance And that's the really critical part of like I think it's relatively easy to identify the factors. It's a way harder job to take someone on a journey to really do a U-turn on their belief systems and their behaviors and to do it in a sensitive way where they feel validated and supported and guide them away from looking for effects to actually realizing that they can be in charge of their own health care. That's a massive U-turn. So that's kind of like the journey that we see CFT going on, and that was a journey that we coached the clinicians to go on. And so you know, to be clear on how it looked, we had a group of, say, nine PT's in a room across two days. Every one of them would see a patient with disabling back pain. We would, as a trainer, would sit with them and coach them through it, around the interview, the examination of framing the understanding of pain, which we don't call pain science, we kind of call it making sense. It's around identifying the factors that are relevant for that person and helping them make sense of it through their own experience and their own, you know, their own lived experience essentially.

Speaker 3: And so there was a learning from watching each, from everyone, watching the physios do it, and we saw about 80 people across that time would be 40 in each of the groups. There's a group trained in Sydney, a group. So there was this kind of database of 40 people they've been exposed to, of listening to their stories and seeing their individual behaviors, their goals, their obstacles, their roadblocks, looking at how we could negotiate them and kind of working that, workshopping that through as a group, which was a really rewarding experience And you know we saw people physios who were so in, confident or, you know, really felt distressed at someone else's distress towards actually feeling you know, us sitting back, watching them competently, you know, explore what was happening in someone's life, explore their distress, being comfortable with their you know their emotions of helping them make sense of it and then building a pathway for them. That was such a rewarding experience for us to see that kind of shift over a period of five months.

Speaker 2: What Pete didn't mention was that there was a competency checklist which all of the consultations were marked against. So the physios went away with what they had done well and what they needed to work on, and also those videos were in a private video channel that the clinicians could look at subsequently. so they could look at their own or they could go back to something that occurred in someone else's, where they really were interested in what did happen there and what. can I learn more about that?

Speaker 3: Yeah, I think that's really important, PK, And just on that, we sort of see the checklist not as you got to follow a set structure. It's like this is the, this is the field you're playing. We just didn't want people doing crazy stuff or saying crazy stuff, But we wanted them to really follow the structure of what we thought were the key elements of the intervention, And the checklist was a really helpful guide for us as trainers, but also for the clinicians to self reflect, which kind of allow them to go. These are the things that I need to work on each month as I go away and work with patients.

Speaker 2: So yeah, another element was there was an ebook which the clinicians could also refer to, which was quite thorough, so they could go away from a consultation like that and then go back into the ebook and go. You know what is it that's there that can help me better understand how I might do this better or guide me to different options, etc.

Speaker 1: I will say I'm jealous of these clinicians because I, you know it's an approach just having a little taste of it for two days in San Diego is, i mean it just again tickles the biases of things and just speaking to both of you, and that transition from the find it, fix it mentality of the manual therapy world and, you know, again for acute maybe tissue specific type things, of course there might be some place for it, but it's a hard transition and then being able to have that mentored with you know some folks overseeing that transition and helping you gain some stability in that destabilizing dance that happens when you're, when you're questioning some of those approaches I'm sure was was nice for those folks.

Speaker 3: Yeah, i suppose the nice thing is, from my own perspective, that's been my journey, like I've done that, like I've been in that situation. So you know it's not like we're sitting there in judgment, we're sitting there going yep, that's tough, i know that feeling.

Speaker 2: Yeah, And yeah, and that was so. Another element in that, the way in which these clinicians were trained, is the product of the long period of experimentation, if you like, and how to train people. Maybe you'd like to talk to the Finnish experience.

Speaker 3: Yeah, we'd, we'd. We had copped quite a lot of criticism around the hours of training, so we thought we'd do a short training program to see whether it was enough. And this was carried out in Finland, where there were two two workshops, essentially with a gap in between and some support via Facebook page. And we re re was interesting. The physiotherapist said it wasn't enough. So they're like we still don't feel skilled. You know, we need mentor, we need basic skills, we need feedback. It's not enough to go to a workshop And you know, i think a kind of reflects on what's out there in our PT landscape.

Speaker 3: We have so many workshops And it's like we have a smorgasbord of knowledge and a few technical skills, but how do you actually package that together to take a highly distressed person on a journey that makes sense for them, teaches them self management, to get their life back? That's a whole different story that you can't do in a workshop And that's what we found in the Finnish study essentially was it wasn't enough to give knowledge, not enough to go to a workshop. You know, what we often hear is people go oh yeah, i do that, yeah, i've done that workshop, i do that, and the thing is we have blind spots And there was a recent study, lovely study, that looked at this what people think they do and what they actually do. And you take a film and watch what we do. We all have blind spots.

Speaker 3: We don't even know half the time what we say, the body language, the kind of non verbal cues that we give when we shut people down and we ignore their cues. We don't pick up on the cues We might shut down, the emotions, etc. We don't know. Until you see it and you get the feedback, you go back and go shit. And I've had that experience myself of going back and watching the video myself with a patient going, oh, that was awful, like I didn't know I'd said that. And it's kind of elicits these implicit responses, that kind of tap into our deep, often discomfort around dealing with emotional factors ourselves or, you know, dealing with people's distress, and you know it kind of taps into our you know, and that's what the video has told us is that that was a behavior change intervention for them.

Speaker 1: Yeah, no, i can imagine is, and I would agree. I mean, i didn't do it obviously in this context, but having yourself videoed in a examination is a very humbling experience because, again, it does definitely, you know, bring the light some of the implicit behaviors that when you start reflecting upon may not be the most ideal when you're trying to validate somebody's experience and move them in a positive direction. I'm wondering in PK, if you don't mind kind of discuss in a little bit of I brought the, the infographic for those you're watching on YouTube and those who can watch the recording of course if you can kind of go over the kind of summary of the trial. You don't have to go into every nuts and bolts, but just the summary of how the trial kind of was laid out and some of the results.

Speaker 2: Sure happy to. So we've been talking about the training of 18 physios and perhaps what's worth adding is that they all had little exposure to CFT before they came into the trial. So we recruited 496 people who had chronic low back pain. On average they had pain for four years. That wasn't an inclusion criteria, was just three months or more, but that gives you a sense of the population that we had. On average they had 30 and a half points on a R&D cure Roland Morris disability scale, and that's quite a lot. That that's more than most large low back pain trials, typically around 9.5, 9.6. And in our population they also had an average pain intensity of six out of 10. So considerable pain and considerable disability. We were also more inclusive of people who had physical comorbidities and mental health challenges and older age compared with traditional large low back pain trials. So when we were looking at clinical effectiveness, the primary outcome was the Roland Morris disability questionnaire or pain related activity limitation, and the primary economic outcome was quality adjusted life years.

Speaker 2: So what did we find? Sorry, i should say that the follow up period was 12 months and we were something every three months and a little bit more frequently during the treatment period, which was three months. So what do we find? Well, on that primary outcome measure of disability, we found large and clinically important effects for the two groups. That's the top or larger diagram you can see at the moment. And we saw those effects at the end of the treatment period. But we also saw them continue through to 12 months, which is unusual not unprecedented, but unusual at that size. So the interesting thing was, when you look at the rest of that diagram you can see these three. There's six other outcomes there which are secondary clinical outcomes. Basically, we see the same thing occurred on every outcome that we measured And there were some dichotomous outcomes and we saw the same for those as well. Now, that is also unusual in low back pain. Often it's a bit patchy. So when we see this consistent change of large, clinically important effects that persist to 12 months, it gives us more confidence that something really did happen and whatever changed, that change endured. So the sort of things that were the secondary outcomes were pain intensity, anxiety, depression, pains, self-efficacy, treatment satisfaction.

Speaker 2: In terms of the economic outcomes, what we also saw, the same as with the clinical outcomes, was that both the CFT groups were more cost effective than usual care. So at a societal level, what that means is that there were cost savings of more than $5,000 Australian dollars per patient over that year. So just to put that in context, that's half a million dollars for 100 patients. So that's a considerable saving to society. And most of those economic gains were through increased participation and paid and unpaid work, and that's usually where the money is. In terms of treating chronic low back pain, yes, there are direct costs, but the real cost is this participation component.

Speaker 2: Now I've been talking about two CFT groups, but I haven't yet told you what was the difference between the two groups. So one group was CFT only, the other group was CFT plus wearable sensor biofeedback. So these were wireless sensors that we put on people. They were on both the CFT groups. We put them on people, and the difference between the third group, the sensor biofeedback group, was the information that those senses measured was visible to the patient and the clinician in the consultation. But also it had a capacity for individualized biofeedback to be programmed so that when the patient went home or back to work then there were reminders in real time based on the movements that were important for that person to either facilitate movement or encourage them to not do something. What we found was the addition of that sensor biofeedback did not improve either the clinical outcomes or the economic outcomes in the context of cognitive functional therapy. The last thing that we found was that CFT was safe, so there was no difference across the three groups and the rate of adverse events or serious adverse events.

Speaker 3: And just to pick up on that point, i think one of the things that we get criticized for is we explicitly try and break these rules that we tell people back pain, you gotta sit up straight, you gotta lift with the straight back, you gotta brace your core when you move. We're like, no, no evidence for that. And people go that's dangerous. You can't say that to people. They're gonna rupture disks. We didn't see that. So I think that's actually really important that often we don't look at those things.

Speaker 3: But because we get that feedback all the time is like oh God, you guys are so irresponsible saying this stuff. But actually that's not the lived experience that we saw with people going through this program, that actually we explicitly train people not to protect their back, to re-engage with movement in normal ways and not be hyper-vigilant around the body and posture to get their life back. And it reduced pain, it reduced disability and it was safe And it made them more confident and they were less fearful and they were thinking less catastrophic thoughts about their back. It all kind of lines up.

Speaker 1: You know you speak to that And I still remember at the course I went to with CFT when you were having some people doing some exposure with control, there was a sports physio we're not gonna I won't name names but very highly followed on the social media scene and was just I remember reading the social media feed oh, this person's gonna be destroyed tomorrow. All these things. It's just like this implicit beliefs that we operate so rigidly under that we have a hard time just stepping above and just looking down and saying, gosh, are these founded in truth or is this what? and it's just a hard challenge And I still see it and I agree I'd watch in some of the social media reactions just to this trial has been interesting to see where people are at with it.

Speaker 1: But yeah, i'm curious with this trial. With this trial like and there's been some trials in the low back, you know, chronic low back literature I'm just curious and maybe PK you can start as far as why you think this trial is kind of unique and what kind of unique things it adds to the literature. As far as you know, there's some treatment effect things and some long-term things I know you spoke to. But I'm just curious like what makes this trial unique and maybe a significant value add to what we have in the chronic low back pain literature.

Speaker 2: So there were sort of three largest or medium sized trials before this. There were a bit disparate. They had different, or two had the same comparison group, one had a different comparison group, but there were differences about the design, there were differences about the training and so there were also differences about the outcome. So there was a need for a large trial. There had been no trial in Australia, there had been nothing that compared with the most pragmatic comparison group, which is usual care. And it's interesting that you know, as a field we know very little about usual care And yet that's in fact the comparator that patients are interested in. It's the comparator that funders are interested if they're paying for usual care.

Speaker 2: We took the trouble to try and understand a bit about what usual care is, and that's also unusual in a clinical trial. There had been no comparisons, there had been no clinical trials of CFT looking at the economic outcomes. And we were really interested in that because, yes, there's some training involved but it also takes longer consultation times, and so we were interested to get a sense of does an incremental cost of a treatment save money downstream? So that's why we did the economic investigation. Of course the wearable sense of things was a new element to it.

Speaker 1: So all of those things I think to some extent or rather not only hallmarks of the trial or differences, but there are also things that I think we have some sense of an answer to now- Yeah, and as you speak to the biofeedback device, i'm curious what spurred that to be added to the study I know you mentioned a little bit of and maybe, if you have I know it's anecdotal, but maybe there was something you both saw clinically that said, hey, maybe there's something to this. I'm just curious where the biofeedback device it makes sense to me from some of the movement challenges that our folks with chronic low back pain have. I'm just curious what your thoughts are on that.

Speaker 2: Sure, that's a great question. So as PTs, we spend a lot of time thinking about movement And as manual therapists, we spend an extraordinary amount of time trying to influence movement. In some time and trying to think biomechanically, what we were thoughtful about is what is the relationship between change in movement and change in other outcomes, like change in pain, change in disability? What is that relationship? And we know very little about that.

Speaker 2: So we wanted to collect sensor data, both to see did the biofeedback work? but we also had a kind of sleeper in there, in that we had the sensors recording the data, sending it to the cloud without the clinician needing to see it, which would allow us to try and do some mechanistic work of unteasing, if you like, some of the causal mechanisms of what's going on, which is to say so, when someone does change their movement in a clinically relevant movement, what's the relationship of that? Particularly, what's the temporal relationship? Does that shift occur before change in pain and change in activity limitation, or is it the reverse? So there was a mechanistic element to that, but there was also that I'd been involved in a clinical trial which used sensors in an individualized intervention and had quite large clinical effects, but we didn't know whether it was the sensors or whether it was the individualized approach, so that was a sort of design or architectural element of the design where it was constructed to say so, is it the individualized bit or is it the addition of the sensor feedback bit?

Speaker 1: So I'm wondering should we expect some further kind of perusing of this data? It sounds like with the mechanistic stuff. No, i'll be interested to see. It sure makes sense and I'll be anxious to see when that kind of comes down the pipeline. I know you all have a pretty big research agenda going so And there's another element.

Speaker 2: There's a delicious element in this, and that is we could look at this from a purely research, purely mechanistic, and say which is the driver on the causal pathway, if that was our model. But one possibility is they all change together. There is no temporal separation, They're all part of the dance that's going on in the clinical encounter. And then it raises the question of so is working with the movement important or not? And that's such a deep question for us as clinicians, because it's one of the things that separates us from clinical psychologists, for example, And from a holistic perspective, I was recently watching a video of an Aboriginal man talking about his experience with CFT.

Speaker 2: And he was talking about he's a psychologist and he was talking about this key moment in the therapy where he realized that there was a lot kind of buried in the body that he had to acknowledge and work with before his mind shifted. And it struck me this is holistic care. We have to work with both these things And it's not that the movement is just a whipping boy, it's just a convenient way of placing a clinical attention. It's a way in it's the sleeper when we're really doing other things. I think it's more nuanced than that. My view is it's holistic. There's a dance going on between the body and the person and their mind and their experience, And that's a great place for PTs to be, because we're good at that.

Speaker 1: I think that sometimes you hear the criticisms and like where the lines are blurring too much we're stepping way into the psychologist role. Yet I'm guessing it's the same over in Australia where it's like pain psychologists like finding a unicorn over here in the US. It just they're far and few between And I know they're begging for more assistance to help kind of the mental health challenges that I'm just curious where you're at with some of those discussions of like crossing those lines.

Speaker 1: I mean, to me it's like our patients sure need it, They sure are benefiting from it And you can do it in a skilled fashion. I'd love to hear your thoughts.

Speaker 3: Yeah, it's a real like. We think deeply in this space and we've been very lucky to work with some amazing pain psychologists as well, and the psychologists that I work with tell us like, and the patients tell us the patients that are sitting in the between in the middle, and often the PTs here and the psychologists is here, we haven't met in the middle. You know we have to move. For us to adequately and effectively treat people with pain. We have to understand that there is deeply, it's an emotional, cognitive and social element to pain. Like you. Just, if you don't, you shouldn't be working with people with pain. If you don't acknowledge that, in my view, and we haven't been adequately skilled or trained to work with that Now, from a clinician perspective, that may be unraveling a history of early life trauma that we can then refer that patient on to a clinical psychologist, but we may be the first person to be told that in that person's experience. So that's on us in my mind If we don't ask, we will never find out, and I know in my history you know, i've seen traumatized people who I never would have asked that question of. You need a trusting relationship to do that with And so we have to move as a profession.

Speaker 3: In my view, we have to move to be with the patient, because the other thing is responding to what the patients are asking for.

Speaker 3: They are asking for us to consider their you know what's happening in their world and to incorporate that into our care. We're not doing it And there's this whole embodiment piece which I think is you know where a lot of my understanding has grown as a clinician and as a researcher. That is a really pivotal piece of this work which the clinical psychologists are telling us they don't do. It's different, it's not what they do or the people I've talked to. And so we have this beautiful opportunity in my mind and obviously completely biased, to shift physiotherapy practice to be bi-psychosocial but to have boundaries where we're not. You know, i am not skilled to deal with people with, you know, early life trauma, but I will support them as they work in co-care with a psychologist to walk that path and to kind of, you know, move beyond trauma to getting their life back. But yeah, we see a clear line around scope of practice, but we need to move further towards the centre of being person-centered in my mind.

Speaker 1: I would agree, i think So. You know these lines of professional boundaries were drawn with knowledge bases around pain that were very old school. You know to where we're not. You know our knowledge bases long exceeded these professional lines for especially around pain. So it's and we're doing patients into service if we continue to describe to this very rigid, narrow space of musculoskeletal only versus the psychological. Yeah, i would agree.

Speaker 3: And CFT is not there to replace clinical psychology. We work with clinical psychologists. We have really really tough you know We're really tough life circumstances with mental, comorbid, mental health challenges, who we need additional support. So it's not like it. We don't go oh, this is the panoramic for everybody Like this has made an impact on people, which is, we think, looks like it's important. That's not. It didn't help everyone. We need to get better at understanding what we need to do to help those people as well, and we see co-care, integrated co-care, as a next opportunity beyond this trial.

Speaker 1: You know, i'd love to hear a little bit about the criticisms. You know, pika, i'm not sure how active you are on social media. I haven't seen you on social media as much which I'm guessing.

Speaker 3: I feed him.

Speaker 1: I feed him. Yeah, so Pete distills the message that he's hearing from Twitter, because I know Pete's primary mode of interaction is Twitter. I'm just curious like.

Speaker 1: I share the pain with them You know I applaud you both and I applaud anybody for putting it out there. You know they're putting your work out there for a freak critique And maybe we'll talk about some of the PR components behind this, because I think you've really done a great job with the website and all these different things. But I'm wondering if you can discuss a little bit about the critiques you've received. I mean, you don't have to get into some of the ridiculous ones. Some of them are probably don't even warrant discussion. but any of the critiques you've found and heard so far that you would want to respond to or maybe discuss would be.

Speaker 2: Sure. Well, i think one of the criticisms that I've heard is around the usual care, that this wasn't enough care. It's an interesting position to take, because we didn't set out to control for the type of treatment or the number of consultations. We just set out to take people from the usual care experience and expose them to something else, and we didn't restrict them from the usual care. So this was what would happen if someone came off the street looking for a new approach and had this. And so, when we look at the cohort, around half 56% were taking pain medication at baseline and about 30% were taking analgesics, about 30% were taking anti-inflammatories and about 20% were taking opioids. Now there's a piece that we're going to do that we haven't started yet, which is to look at did that medication use change and did it change differentially over the treatment period? We don't know the answer to that, but they were taking medication In the usual care and in the CFT groups people sought care during the treatment session and after the treatment session.

Speaker 2: So around one in three people were seeking care and on average they saw or rather, more precisely, the median was three visits during the consultation period and that continued that pattern through 12 months. So they saw around 12 consultations in the year and the sort of people that they saw 75% of them were seeing medical doctors, mostly their GPs, and the next most common was physiotherapy. Now, that's all patient self-report. We don't have that in a clinical registry. It's not Europe, it's just people out doing their thing in the Australian health landscape. So there's an idea that somehow that isn't enough care, and so that really makes me think about. So what do we know about usual care and what do we know about people who have persistent musculoskeletal pain? And the answer is we know very little. But I was involved in a Danish PhD where Søren Moser, a Danish physiotherapist, looked at 3,000 people and he looked at data for 10 years. So these are 3,000 people with chronic musculoskeletal pain, most of its back pain. The Danish system is that almost every healthcare consultation has a government payment in it, so therefore the data is really high quality. You really get a sense of what's going on, and so what he did was look at trajectories of care seeking. So there was a high care seeking group that was about 10%. They saw about 22 consultations in a year. The other end of the spectrum was the biggest component, that's 40% of the cohort either saw no one or saw very few. So the median was zero, but it could have been as much. The interquartet was up to three And then in between you see a medium group which is about 12 consultations the same as in the restore trial And you see some people start low and are building up over 10 years. Some people start in the middle and then it tapers off.

Speaker 2: So he then interviewed people and the interview people primarily from the people that were seeing lots 22 consultations a year and the people that were seeing almost none or none. He also interviewed a few people who were in the median group And the overwhelming thing that they all said was it's not working for us. The system is failing us in the sense we're not getting the care that we feel we need. And people responded to that in different ways.

Speaker 2: The people in the high care group just kept shopping. They just went for it to see could they find someone who eventually would kind of answer their questions and give them the care that would make them satisfied. And the people at the other end the 40%, most people, the biggest group simply decided it wasn't worth it anymore. Pain was part of their life and they just get on with it, and so our group on average was 12. That looks like this chronic back pain population. On average, people sought 12 consultations a year. That's what our population was like, so I don't think the sample that we had was any different from Sorin Moses' study of 3,000 people. I think we just kept into that population.

Speaker 3: And just on that too, you know from we've got qualitative studies embedded in this trial and the story we're hearing is very much like that. We've had stories of people who've just had so much care and this given up. They're just going. This is my lot. I'm just exhausted. I don't trust healthcare practitioners. I'm done. I've had it.

Speaker 3: You know, i've been to physios. Caros had injections, i might have had spinal surgery, i've taken these drugs and I'm just exhausted and fatigued by this. And so it's very tempting to go, oh, that trial's got exaggerated effects because these people, you know, if we compare it to good mania therapy, they would have done really well. It's kind of interesting to consider, if you've had it, to give it more. You know like and look, you know that's the nature of this trial. It's what we set out to do was to go okay, let's, you know we've been criticised. Let's see, i already they criticised the past to go well, you've compared it to this physio intervention, to that one. What about usual care? Because we, you know what's the natural course of these people And interestingly, they did get a bit better, but not a huge amount better, which is also what we know a bit about that group of people who are really in trouble is they don't get off that trajectory very easily.

Speaker 3: It's hard to shift that, particularly in the long term. You can make a dent in it, but they often go back to their old trajectory Again. We didn't see that in this trial. We're doing a three year follow-up of this group as well, because we're really interested in how enduring these effects are, because we actually saw a trend towards the effects getting bigger, not less, at 12 months, which is different to the two previous trials that we've been involved in with really tough people, which is why we put the booster in there at six months, yeah, and I thought that was interesting And I know it reflects some of what you found in earlier studies where that booster session you know some of the effects were trailing off And is that something you see as something that's a necessary kind of?

Speaker 1: I do?

Speaker 3: And I don't know. We don't quite know exactly what it does, But I think what it tells it's a signal to people you're not done with us. You know we've got you back. This is a tough journey. You will have roadblocks, you'll have flare-ups. We want you to help you and support you with that journey. It's a chronic health problem. It's not like you go to the doctor with diabetes and go, yeah, we're done with your treatment, See you later, Never see you again.

Speaker 3: I think we have to change how we think about managing chronic pain to say this is a journey. We want to help you build tools to self-care, But there will be times in your life where you have a flare-up or a step back and you might freak out and you're not in control. We want you to be, to come back to us. We want to support you on that journey, to help you navigate that, And I think that's what the six-month boost is signalled. That's my belief. Again, the quality data will tell us more about this down the track, But I think it sends a signal that yeah, we're there. We're there to support you on the long haul.

Speaker 4: Exactly, exactly, yeah, oh God, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah Yeah.

Speaker 3: Yeah, and we don't always get it Like. I had a patient yesterday who came in and she goes oh, i'm so upset. You know I ended up getting my back fused and I'm in so much worse And I just so regret going down this path And I should have come back. And you know she'd had a mass of pain, flare. Lots of stuff was happening in this person's life. She'd been sold. This promise is going to fix her And actually she's in so much worse place now And you can't unturn that. And it's like, you know, and I'm like, oh, i just wish she'd come back to me.

Speaker 3: You know I was traveling, she tried, i was out of the country and she didn't. You know it just, and I it just highlighted to me that we have to. You know that that relationship of being the person they call and contact And you know when they're having a tough time we need to they will reach someone And it could be they go to emergency or they go and see the back to GP, gp. You know, look, you've tried this and you'll go well, but actually let's get that rotten disk fused. And it's so tantalizing when someone's in a really tough place in their life, they just want someone to chop their pain out And sadly it just doesn't work that way a lot of the time.

Speaker 1: Yeah, no, i can relate to that. Those type of stories it's tough, tough to hear with you talking about. You know the, the, and we just spoke to a little bit about some of the societal messages and things of that. You've made a pretty conscious effort and you've done it in the past with your work. I know there was the pain dot it or hyphen ed site And now the restore trial has its own website with you know a lot of kind of multimedia things. I'm just curious if either UPK or Pete could speak to a little bit of the, the, the digital strategy behind it, as far as to support what was kind of the thought process behind that. Maybe was it just, you know, strictly, let's spread the message and have some ability to the press and the public to get a get their eyes on it, or what was your purpose behind it?

Speaker 3: Yeah, i'm happy to speak to that first. I mean, we spend so much of our time around. Well, two things PK and I, before the trial came out, got a bunch of consumers together who've been through the intervention and said can you just tell us about how you think this is going to land? this paper will land And it was amazing, wasn't it, peter? We, we had this whole outpouring of the frustration, the lack of trust in healthcare, this failed treatments and this, you know, just this exhaustion of giving up around care and how tough it was to build trust again that actually there might be hope. So that we heard that. And then what that journey looked like, that there was. It was so tough for some people it was like they had all these hurdles and roadblocks and flare ups and that partnership was so important, and so that led that co-design around the infographic which is on the website. I love it because it's their words. We've just packaged together.

Speaker 3: We got a you know, emma was the designer of that who kind of told the story of that the tree that was kind of dead and this kind of bringing back to the life of the garden and that kind of enriching of their lives in so many other ways. So we we kind of wanted to share that message. But we also know that a lot of people find scientific literature really hard to digest. So we wanted to tell the story of the clinician's journey and we wanted to tell the story of the trial and how we got to it and what it meant and kind of more, in a more accessible way. And we also wanted to share stories of patients who've gone through the journey and they will also. They'll be coming up on the website soon. They're amazing stories, they're heart wrenching, they'll bring you to tears of real stories, of people who've with real, who've just got to the end of the line and thought it was all over.

Speaker 3: We think that's so important because there is a fundamental lack of hope in my mind around healthcare. When you've done it all and you're just going, that's my lot. And I think there's a lack of hope amongst clinicians. I mean, they hear those stories, they lose hope. So for us, the translational space is so important And we're grateful that people are giving us good feedback on that, because it's what. That's our main agenda actually. That's why we do what we do. We don't bust their houses working evenings and nights to just get a lance of paper. It's about can we make a difference for people? Can we support clinicians on that journey? If we can do a little bit in that space, then it was worth it.

Speaker 1: Yeah, no, i think I've really enjoyed just the approach with that And I think the we'll talk a little bit about some of the future publication. I know you have some things in the pipeline with this data set, it sounds like. But the patient's stories like, are you doing anything more? I know you're putting those up. It sounds like to where I think that's so powerful because when it's coming from a clinician's voice, i mean they've already been talked to by clinicians and promised a bag of goods and have it continuously not deliver the things. Where are you using those patient voice, patient stories? And do you see, i mean you've done a lot of great qualitative. I know you've done some mixed methods. There's qualitative within this trial I know you mentioned. I'm just curious where you find those patient stories and the value that they bring to just the whole change that you're looking to engender.

Speaker 3: I think that's central to that's central to CFT. It's the patient. It's all about the patient's story and their agenda and their dance and their journey, and we want this to be about the patient. So it's so important and the qualitative work will capture that as well. You know where we've not met people's. You know where we're not helped them as well. That's also really important for us to learn about how we can negotiate, support people, because we don't. We know we don't. This is not, it's not a panacea. It's tough.

Speaker 1: Yeah, no, I appreciate that We had a question of any plans to release any qualitative research around this.

Speaker 3: Yeah, there are two qualitative studies that will come out of this.

Speaker 1: You may or may not be able to answer this, because maybe the conclusion needs to wait till the paper comes out, but was there encouraging mechanistic results that you, with the movement, the biofeedback that you think will be helpful to guide maybe some, some decision making, some treatments in the future?

Speaker 2: Yeah, look, honestly, we have no results yet. We both got a text yesterday from a PhD student who's deep in this analysis, but we have no results yet. As you can imagine, it's an enormous amount of data and it takes an enormous amount of time to clean and analyze, but we're getting close Just going back. Oh sorry, a little more about the sort of mechanistic approach. We're looking at the relationship between movement and the outcomes that I mentioned. But we're also looking at change in distress, so change in anxiety and depression and pain, self-efficacy and saying what's the relationship between those things? Are they on, are they mediators of the outcome? but we're also going to look at them together to see if we can better understand, you know, the whole system because of course it's all going on at once. And just going back to Pete's point about qualitative and Pete said too, we have two papers coming out from qualitative, papers from clinicians about the clinician journey, but we also have qualitative papers from the patient perspective.

Speaker 1: That's great. I think that's a unique perspective. I mean we do have some qualitative work in the clinician space, but it's not. I'll be definitely interested to hear their perspectives and their journeys because I think sometimes that transition I mean we talk about it in the struggles and the you know the cross and the chasm and different things that we have to make when we're switching kind of our mode of operation. But I look forward to that paper for sure Any other things that you feel like maybe are coming out of that dataset that are going to offer some value, or things that you think have really pushed into more questions. Obviously, research only generates more questions and more things we want to ask and I'm just curious what your thoughts are on this, and we have a few other questions coming in, so I'll start posing those once you guys chat about that.

Speaker 2: We are very interested in implementation and have a number of implementation studies either underway or about to start and more kind of stacked up.

Speaker 2: The conversation with clinicians and the conversation with patients is integral to our approach to analysing implementation. That is that this is an evolution and we want to keep hearing back from clinicians about what are the bits that look like they're going well and what are the bits that they're struggling with. What are the ways of teaching which seem to be working, what are the ways of mentoring that are working and what are the bits that are still works in progress. And similarly, from the patient perspective Pete mentioned earlier we want to know more about who it didn't work for. So the other line of research that we've got going from the restore trial is moderation analysis. So mediation is about trying to understand why does something work or why does something not work, whereas moderation is about trying to understand for whom is it working and for whom is it not working and what are the things that identify that, because CFT wasn't for everyone and we want to understand more about that. So there's also a line of papers that will come out around moderation.

Speaker 1: I have one and it's a completely selfish question that I'll ask before I have the. I have the open it up to the questions we have kind of piled up here Any plans to bring this to the US? I mean the US needs it, i mean everywhere needs it, the whole world needs it. There's no. Nobody should be first in line by any means. But I'm just curious if there's any plans for expanding that's reached to start reaching more people.

Speaker 3: Yeah.

Speaker 3: So that probably fits in with what PK's highlighted, that we feel a huge responsibility as researchers to not overstate our data. To be very clear about what this doesn't tell us It's not a panacea, but it looks like it's doing something good for a tough group of people and the patients like it and the clinicians liked it. So that's the two really important things. So we're really interested in developing ways in which we can support clinical communities to upskill. That's what we're interested in doing and learn from that process. So we're interested in partnering with clinical communities to do that. And we realized that the next step from this trial is a series of implementation studies where we go okay, we've gone from a clinical trial to a real world setting and this is what's happening at the moment or as planned. It's a number of training, implementation trials where we train groups and clinicians in different care settings with different kind of patient groups in different countries to go. Can we replicate this in a real world setting And what is it like for the clinician And what is it like for the patient? Because that's really the important question Does this intervention work in America?

Speaker 3: Well, i've been to America. I've seen this, seen how this healthcare looks there, it's freaking scary And we're not that far away from it. So there are. But there are so many perverse incentives as well, like we know. In Australia, for example, you can get a $50,000 fusion covered by the government, but you can only get 250 bucks worth of treatment from a physio. It's bullshit Like that. That's a massive problem we have And what it does is it feeds this quick consult kind of treatment that physios are trapped in that come in, give them a push, give them a rub, give them a tweak, push them out the door, give them a couple of exercises. They have no time to take a story. They have no time to take a patient on a journey.

Speaker 3: We have to upend the health system to go. We need to spend more time with people. We need to upskill clinicians to adequately manage people Well and we need to prevent this stuff happening. We've got people who have four years of care-seeking. What if we got to them earlier? That's a whole another question and research down the track as well. Can we prevent that from happening at the very get-go Because they're done?

Speaker 3: Yeah, so there's a whole lot of thoughts around that we have and long answer to your question. Of course we want to be able to support clinicians in different communities. We're also really interested in supporting clinicians in lower-income countries because they don't get access to any knowledge. That's something we feel very, very strongly about of providing equitable access to knowledge for everybody. So that's kind of really big plans that we have and we're still working them through, but it's something that we're not interested in. We've never been interested in brand trademarking and creating a big business to enrich ourselves. We're really interested in partnering with people, with clinicians who've got an interest And this is not for everybody and for patients to support their journey. That's what we're interested in. So yeah, long answer, yes.

Speaker 1: And I appreciate it. No, that was great. I'm going to get into a few questions. We had a few people out. David, i think you spoke to this a bit already, but if you could just maybe clarify. He's wondering about the effects for patients with very high symptom severity. Was treatment more or less effective for those with mild pain versus severe pain?

Speaker 2: I was working on code two days ago. That's part of that moderation analysis. Was it more or less effective for people with higher pain, for more or less effective with people with high disability, more or less effective with people with higher distress, etc. We're not there yet, but we're on it.

Speaker 3: We're definitely interested in that. You know, just anecdotally, from a clinical point of view, we see people we often go oh, that person's got too high a pain. We see high pain and high distress go together. If you reduce people's distress you can see dramatic shifts in pain without doing something to them. And that's another area of research we're really interested in is actually looking at the in session change, because people think you have to do something to someone to give them pain relief. That is just not true. We see people come in literally with an orc-free frame, walk out.

Speaker 3: It sounds ridiculous but it's the real world. When a human being thinks they're screwed and they're really distressed, their pain system goes crazy. If you dial down the stress and you build confidence back in the body, you often see that system dial down dramatically. We're super interested in that And, as Peter said, we've got different pathways to explore these things that are really interesting for us. I don't think it's as simple as saying this works for this level of pain or for that level of pain. We deliberately included people in this trial who were on the higher risk category because we think this is who needs this care.

Speaker 1: Good. Now there was questions and you've already answered this. There's definitely plans to translate the website materials to expand it into other countries, so that's been answered. Another question do you think CFT will be effective with acute low back pain? Is it only going to be relevant for chronic cases?

Speaker 3: Yeah, i get asked this question all the time. So interesting. This will come out in Phoebe Simpson's qualitative work. But what we heard from the clinicians who went through the training is they said this has changed how I treat everybody. This has changed how I treat acute back pain. This changed how we treat knees and neck pain, shoulder pain. It's just changed how we work. So we have a view Again. We have a lot more work coming out on this. Jp Canaro has done a feasibility trial around people being told they need a knee replacement with Nearthritis. We've got some pilot work around chronic hip pain as well. We see these as just good basic model, good model care.

Speaker 3: In the acute back pain space, we were involved in a trial or a cohort study looking at who goes into emergency departments with acute, non-traumatic pain. The majority is back pain. These are people who have not had a trauma, had a massive pain flare-up, freak out and go to ED. Where do those people go? Because we know that most acute back pain is a flare-up of chronic pain. It's like your first events, normally during your adolescence. I think we've got this idea that acute pain is injury. Most acute back pain is not injury. It's like being able to brush your teeth. We are really interested in that.

Speaker 3: We've got so many plans for research. Just capacity and funding are our main limits. Of course we need to screen for red flags and serious pathology. That's just part of our clinical reasoning process. We have to do that. We don't want to be treading fractures and people are quarter equina and malignancies. That's just good care and triage. We don't want to do that. We rule out pathology. Where there's an absence of pathology, we address the biopsychosocial drivers and make sure that we support people's journeys so they don't get shit-care and get into trouble.

Speaker 1: Yeah, to me you mentioned my treatment has changed. I'm not by any means saying I'm certified in CFT, but a lot less intervention, a lot more supportive. Lo and behold, the interventions feel like they're collected, and does certain ones. I mean they're still definitely like you said, we need to be good triage, great musculoskeletal screeners making sure, red flags and all those things. It doesn't mean any of those skillful interventions or examination strategies go away.

Speaker 3: We're not anti-manuotherapists. I'm a manuotherapist. I use my hands all the time. Cft is hands-on, it's just not lying somewhere down and doing shit to them. I think we realize that manuotherapy can have a role, i think, in some cases, particularly if the patient's expecting and wanting it. But if we've tried it and it doesn't work, we've got to move on.

Speaker 1: Yeah, yeah, i agree, pk. did you have something you?

Speaker 2: wanted to add. Yeah, I was just going to say. Going back to the previous question about translating the website, if you go to the website using Google Chrome, you can ask it to auto-translate into whatever language you like. So that's a way of doing that now.

Speaker 1: It's a good point. Good point Modern technology can do some pretty cool things. There is one question about curious to see data following therapists who are trained in CFT for this trial, to see how their outcomes are with patients over an extended period of time. He had referenced some of the studies, I think, on motivation interviewing as, like therapists, their treatment fidelity faded over time to where they might have slipped into bad habits. I'm curious if there's anything you're doing to track that or is there any thoughts you have on some of the challenges to where, just like patients can slip back into maybe old beliefs and behaviors? Yeah, Totally.

Speaker 3: Yeah, well, that's why we're really interested in training clinical communities, not individuals, because we think the most sustainable way for this to evolve will be to train a community. We've heard that clinicians who are working in a practice, for example, or a clinical community, whereas very biomedical, is really tough for them And it could be really a very lonely place for them. So, yeah, we know that you'll get clinician drift If you don't have a supported community. That it's like growing a garden You just start watering it. It's going to die. So, you know, as clinicians, we need to keep watering and fertilizing and supporting our garden.

Speaker 3: And that's probably my gripe with social media It's so aggressive, it's like this thing against that thing, and there's bagging people.

Speaker 3: I hate it. And the only reason I'm still on there and there are days I really wonder if I should is because I feel like if there's an absence of you know, you know promoting some positive messages, who fills that gap. And so we really love this idea of supporting clinical communities, as we do supporting patient communities, and that's about growth, that's about encouragement, that's about not bagging each other out and telling them that's shit and you're this and my treatment is better than yours, honestly, like if the patient gets better. I don't care what you do, i don't care If they get their life back. I don't care if your body gives them herbs, i don't care. The bottom line is the patient, and that's where I think you know this idea of building communities and support a community, and they might be virtual communities. They'll be real, local communities. We love that thought because there are lots of good people around the world who might be feeling quite lonely in their workplace. We would love to pull those people together.

Speaker 1: Yeah, no, i definitely have talked to a few where they've struggled with some of that feeling like they're on an island, you know treating, trying to treat the way they want to and seeing that it's not necessarily being reflected around them. And, yeah, i think that's a good thing.

Speaker 3: Drift is important and we're interested in it And you know it's one of our. One of our thoughts is to to really look at the people who are trained down the years, down the train, go how well with something we will do actually, and go. Are they still delivering what we thought?

Speaker 1: Yeah, yeah, no, i will look forward to it. I mean I want to respect both your times. I mean you've been amazingly generous with your times today already Really, have got some huge value from what you guys are discussing, and I wanted to thank you both, for I can only imagine the immense amount of work you both put into this to make this kind of trial happen, and I know you have a team of folks that you're working with that are doing some amazing things to help the cause out. I know if we could get more. You know researchers like yourselves and pushing this message forward, which I really applaud you both for doing all the great work you're doing. So thank you so much.

Speaker 3: Can I just say something to that, mark? You know Peter Kent is not a guy on social media. You won't see him out there, but oh my God, this guy has just nearly well. A few of us have nearly killed ourselves in their journey, but he has. You know, his leadership has been unbelievable but also backed up with some amazing people Mark Hancock, ann Smith, jp Canaro. You know the clinicians delivered this intervention. We have to put a huge hand up to them, the patients who trusted in us to come into this trial. There's a whole network of people who supported Rob Schützer. You know the different. There are so many people and they're on the website. We acknowledge them that have done so much work. You might want to add to that, peter as well, but you know we have to. We have to really acknowledge this is a monster thing to pull off huge amount of work from a lot of people.

Speaker 2: And also, of course, to thank the funders the National Health and Medical Research Council, which is our peak medical funding body, and Curtin University also put in some top up money. But I think my last comment would be I think Pete's pointer towards the clinician is a really good final thing to say, which is these results are not our results. These results are the clinicians' results. We trained them as best as we could and we supported them as best as they could. But those 18 physios who had a little exposure to the FT at the beginning of the trial but were brave enough to say yes, i'm willing to expose myself and go through the training period, no matter how rigorous that is. This is their results. With a really tough group of cohorts, it's no one on the trial team. So all credit to them.

Speaker 3: And just on that too, mark, you probably want to get out of here, but I was banished. I was banished from the trial when the training finished. I didn't want my fingerprints on anything, so that was really good in some ways. My job was done theoretically once the training. Jp supported me with that, but after that I had no influence on that trial or any patient discussions or anything.

Speaker 1: For that reason, Yeah, no, i greatly appreciated all the work and with all the support team that you guys have. thanks to them, i know we put the website on the chat here for those. We'll link it in the show notes when we post a podcast in the YouTube episode so everybody can check that out and get to see the immense amount of work that went into that with a great team of folks. So again, thank you both for your time tonight. I really appreciate it. For those of you who were watching, I hope you enjoyed and we will talk to you next time.