James: Welcome to the first episode of Supervisions in Pain. For the next 20 minutes, we’re going to dive into a supervision session where Alex will bring one of her clients to the table that brought up some feelings of overwhelm. And we’ll talk through the process of how she initially engaged with him. We’ll then come back at the end to talk through some of the research surrounding this type of client and discuss how the research informed her decisions when managing the client that she was working with. And then at the very end, we’ll leave you with three practical tips that may help you get started when you come across these challenging clients in the community.

So, for our first episode, we’re going to be talking through a client of Alex’s. Um, Alex, would you like to introduce the client? We’ll – we’ll get stuck in.

Alex: Yes. So, um, this is a client, a 14-year-old boy, um, who was referred to me from a musculoskeletal physio for a complaint of low back pain which had come on insidiously in 6 months um post a bike versus car accident. So this young person was riding his bike to school and was knocked off his bike from a car. He experienced a – severe TBI, was in PTA for 5 weeks um as a result of this injury. In addition, had some orthopaedic, um, broken bones in his arms and legs, but not in his back. Um, he – uh, he had had a whole bunch of scans on his back, hadn’t revealed anything significant. He had been cleared of red flags from a um structural perspective and, uh, yes, he was sent to me because of my neuro experience.

Um, he – in addition to this, his – the other significant part of his history was his psychosocial history. So this young person came from a – um, a family who grew up in Afghanistan, had, um, in a few years prior to, um, the accident, had, um, sought asylum in Australia. Um, they were fleeing a sort of war-torn country, um, and they had been granted refugee status in Australia, um, in the past 12 months. Um, as a result, I guess, of the – um, uh, refugee status and journey, he was also experiencing PTSD, um, and had, uh, had a few psychotic episodes, um, in the years prior. He was under a psychiatrist and a psychologist and had a huge team of, um, mental health providers as well.

But I was there to support him with his back pain, which was his biggest, um, complaint at that point in time. It was interfering in his school. Um, in particular, he was finding it really hard to pay attention at school, which was also compounded by the fact that he had some cognitive impairments. So he was, um – he was – had difficulty concentrating. His, um, memory was quite poor. Um, and he just could not sit in the classroom, which he attributed entirely to his – his back being uncomfortable.

James: A lot going on. Probably came across as just a referral for pain, and then I imagine in that initial session it kind of all unravelled. Did it – did it feel – well, how did it feel coming out of that first appointment with all of those things going on?

Alex: It was pretty full-on. It was in, like, my first few years of – um, of working in neuro and pain together. Um, and he – and I also had very little experience working in paediatrics or especially teenagers. Um, so I – I was, yeah, I was absolutely intimidated by his presentation. Um, and also I – he had a lot of very senior, um, expert clinicians in his care team at the time, and I just was like, “what can I bring to this picture?” Um, so I absolutely harboured that sort of imposter syndrome from the start.

James: Um, I can relate to that. I can remember quite a few that hit in the same way, that I come out of that first session thinking, like, “there’s these huge things going on. I don’t even know if I could impact them at all.” This is a good example of a client where we’re not sure where to start because of that feeling of overwhelm. I think so. Were you stuck a little at the start, or did you have a relatively clear idea of what you wanted to target first?

Alex: I – with this young person, I was pretty eager to get stuck into something quickly, mainly because he had – he did not trust me. I don’t think he liked me very much either. So he, um – and he had, um – he had sacked a lot of people prior to me. So I did feel the pressure of finding something. So I was really searching for anything that we’d connect over. Um, I really went deep on his interests and things that actually were bringing him, um, joy or, you know, to use that Dim Sim model, like, what were the things in his life that he was already doing that were, um, activities of safety and wellness and health, um, and well-being. Um, which ended up being, um, uh, gym.

So he had a – he was very – the one thing he was really motivated to do was to bulk up in the gym. Um, which he had been discouraged to do from a lot of his, um, health providers. His GP and his exercise physiologist and his physio wanted him to, um, do some more sort of core and Pilates-based exercise, which he just wasn’t into at all. Um, and there was this kind of scary gym that was around the corner from his house that he really wanted to go to. Um, that, um – basically just to like bulk up. That was his – his motivation at that time was more of an aesthetic outcome. Um, and I guess I kind of jumped on that and thought, “okay, let’s – let’s go for that. Maybe we can pepper some pain education and make sure that at least the exercises he’s doing in there are safe and not going to cause him harm.” Um, and in the meantime, we can get some endogenous, um, opioids happening. We can hopefully get some improvements to his sleep, which was highly dysfunctional.

James: Most importantly, also just finding a space for you to develop some form of trust where he may not get to the point where he likes you, but at least respects what you have to say and gives you a space where you could potentially guide rather than just jumping in.

Alex: Yeah. I mean, there were – there were many – he had a lot of maladaptive beliefs around what was happening to his body. He was in a state of hypervigilance. He was quite catastrophic in his, uh, language around pain and his feelings around what his – what that indicated was going on in his body. But it was really clear from the first couple of sessions that he was not there to sit down and have a formal pain education session or for me to challenge those beliefs. Certainly not initially. So, um, I didn’t think it would be – I was at risk of losing him if we – if we tried to address those contributors first.

James: Yeah. So, so early on, I mean, you – you cleared any red flags and made sure you had an appropriate team involved. He had the psych and the neuropsych involved managing that side of things. And then instead of tackling those huge barriers – the PTSD, his traumatic background, and a few other things going on in his life at the time – you made the call to sort of almost put the blinders on a little and focus on something that he already had going for him and was a potential easy place to get a win. Is that right?

Alex: Yeah, that’s it. Um, and the – I guess the outcome – the one – the one message I tried to get across was that we’re not – we’re not looking for your pain to – to go away. That is not going to be the outcome measure that we’re striving for here. It’s really we want to build a routine. So that was – that was the goal, and that seemed to be acceptable to him. Um, so I supported him in getting his membership funded. We – we actually had all of our therapy sessions at the gym because his house was not, um – his family home wasn’t really a place of safety for him. He had quite a volatile relationship with his family or his parents. So we ended up, um, you know, asking the gym admin staff if we could borrow an office space for us to carry out our sessions. Um, and yeah, he – he showed up to every session, which was great. Um, he didn’t necessarily – um, he wasn’t necessarily thrilled with the ideas that I had in the gym, but he, um – there was a level of engagement there, and we were – we did achieve the goal of getting him – he would go there after school every day.

James: Okay. That’s a starting point, isn’t it?

Alex: Yeah. Yes. Um, in terms of – I guess the reason I wanted to bring this case up as well is he – he – I wouldn’t necessarily label this client as sort of a, um, a success story, um, from a physiotherapy perspective or from a pain perspective either. Um, he – um, he did have a lot of other complex things going on in his life. Um, and, uh, he was engaging in a lot of risky behaviours, and his attendance at school continued to, um, diminish, and he ended up – he actually ended up in, um, juvenile detention for, um, a number of years where I was able to go in and continue to treat him and set up a gym program there.

Uh, and in some – some ways he, because of the routine and the consistency and, I guess, like the safety of routine, um, his pain was pretty well controlled when he was in that environment. Um, but life continued to be complicated, and because of his vulnerability and, I guess, his, um, his lack of social supports – his parents ended up going back to Afghanistan a few years later, leaving him in Australia – um, he – the outcome wasn’t great for him, um, which is probably an important thing to highlight, that not all of our clients are we going to get big wins out of and successes out of. But all we can do is control what we can.

James: And I guess the – the flip side would have been if you had have tried to approach this by either waiting for one of the experts in the sort of the psych space to unpack or dismantle some of those bigger barriers, or you had tried to attempt to manage some of those yourselves, the outcome would have been worse or you may have not have seen him for long.

Alex: I think he would have sacked me. Um, and to be honest, he – I still didn’t get – I think if I – if I were to have done something differently, um, I – I think him having a – a male therapist would have been more impactful and would have, um – he would have felt more comfortable around, um – yeah, around a male therapist who can, you know, felt like had expertise in the gym space. I don’t think he really bought that I knew what I was doing in there. Um –

James: Right. Yeah.

Alex: Um, but – but that’s okay. Uh, yeah.

James: Would you consider an AHA at any point if that was – if that was getting in the way a little, potentially?

Alex: Yeah. If – if I was able to recruit one that was really good and was able to be quite consistent and, um – but he was very – he, you know, he was a classic teenager. Like, he was, um, would – would – would always be wanting to negotiate and push boundaries and, um, so I think he – he did need someone who was quite clear on what they were doing, so probably not actually, in retrospect.

James: Okay, yeah. And to – you then lose the opportunity to actually sort of plant some seeds, because obviously the – his motivation of getting bigger in the gym, I mean, there’s some positives there, but it’s – it’s also there’s some sort of flags in that mindset in the chronic pain space, particularly – particularly if he’s really trying to push himself and extremely heavy and, and there’s a – an interesting relationship between the gym, um, and his goals. Having you there to sort of plant some subtle seeds and try and I guess steer some of his beliefs towards a more, I guess, like a more positive version or one that more aligns with persistent pain research would have been pretty helpful if you had have had more time with him.

Alex: I think so. I think if he – things – if – if what was happening in his broader life were a little more stable and consistent, I think, um, he – he – he really benefited from having long-lasting relationships with his therapist who could very slowly support him along the way. Um, just thinking what else, you know, in terms of when working with people with a severe trauma, and he – he would present in sessions with, um, you know, with traumatic symptoms. Like, there would be moments where he would become very agitated and, um, this sort of hyperarousal presentation would come in, and then other times where he would almost, um, sort of vague out and leave the chat a bit because he was almost dissociated.

Um, and we did – we did attempt a lot of things. Like, we tried breathing and meditation and all of these, like, grounding exercises within the session, um, particularly around sleep as well, because he would, um – he would wake, like, 10 times a night. Um, but, uh, I hope some of those things stuck, even if he didn’t, um – he wasn’t doing them routinely. Uh, but his – there wasn’t anything that I could do, particularly as a allied health professional, to, um, directly address his trauma. I suppose just using a trauma-informed approach was – I was very conscious of – of – of doing.

James: Right. Yeah. I guess that’s probably an important thing to note, that like, just while you did not sort of directly address those big trauma barriers to his sort of pain – um, what’s the word I’m trying to find? Uh, to his pain presentation, you weren’t ignoring them completely by moving to the gym and doing sessions there away from that all and just focusing on his progression there. There was a trauma-informed development to – to your management.

Alex: Yes. And I – we absolutely would have had conversations about the way that, um, pain operates in the body, and, um, that, you know, his – his pain system is in an overprotective state, and, um, his history of PTSD and anxiety, you know, can mimic that in terms of hypervigilance, and, um – yeah, that those two conditions, um, feed into each other and, um, are very, very integrated. I’m not sure how much he, um, really took on there. Um, and even moving the sessions away from the home environment where there was – you’d identified there was some element of trauma that existed in that space, and it – by you moving away from that – that environment into the gym, that’s it’s another example of that trauma-in – trauma-informed component to your management.

Alex: Yeah. So the – the gym for him represents – so he chose the gym. The gym was a place of, um, safety. It was where he felt empowered, um, to try new things, and it was, like, quite literally a place of where he could exercise his power and feel strong in his life where he had very little agency over what was happening to him. So, yeah, it worked. It worked really well, and I’m glad that as a community therapist, we had the option to – to pivot the physical space. Um, yeah, so that –

James: Despite that, it must have been pretty frustrating along the process of, despite all of these things you were trying to put in place, those bigger picture barriers just kept on getting in the way and sort of prevented you from progressing the way you wanted it to.

Alex: Yes, there are a lot of – I mean, it’s so hard. Pain – pain in adolescence and kids is so hard, especially with those compounding factors of, um, of – of PTSD and, and pain and brain injury. Like, holy moly. Um, it – I – I don’t – and – and I’m really glad that I never overpromised. I was quite cautious on, um, just taking it step by step. I wasn’t confident that his pain would – would shift, particularly given how generalised and – it didn’t follow any kind of, um, temporal pattern or – he had a full range of mo – like movement, and, um, but the pain was jumping all over the place, and it was, um – yeah, I – I – I felt that this was a pain presentation that was unlikely to shift given how primed his system was to be in this overprotective state. But I guess one that definitely could have become a lot worse.

James: Yeah. Yes. So where did he end up last time you saw him? How did he progress over time?

Alex: So I saw him over the course of five years, and we sort of had, um – our therapy went in sort of bursts where I would go in and do several weeks of intensive work with him and then sort of leave him, um, to his own devices. And each time I, um – I caught up with him, some other complicated situation had unravelled. But in the end, he, um – he was incarcerated, and, uh, I was no longer able to continue working with him because he had moved, um, into the – yeah, the – the justice system. And the, I guess, like, the overlap of the justice system and, and health and disability was, um – I, I was no longer able to work with him. So I – the answer is I don’t know. Um, and at least I know that he did have the – this – the skills to, um, to – to work with his body and continue to exercise and look after his body in that way. He had a lot of, um, confidence to do that.

James: And it – it sounds like he did – he did get to the gym and start to get stronger and fitter despite the pain as well.

Alex: Yes. Yes. So his – his reports of pain were still quite high, but in terms of, um, his function and what he could do with his body, he was almost operating in a, you know, what is typical for a teenager.

James: Yeah, I’ll take it. I’ll take – you mentioned earlier that you, in retrospect, you might have considered moving across to a male clinician at the start of his rehab journey. Was there anything else that you think you would have done differently looking back?

Alex: I don’t think so. No, I do think that would have been impactful, though. And he did have a very extensive care team of, um, a very skilled clinicians, and we did work together quite closely. There was very regular care team big meetings, and we tried to have a lot of joint visits with his neuropsych to see what his capacity was to take on, you know, education around pain and, um – and so, yeah, I really do – I do think that the gender piece in this particular scenario was quite important.

James: It’s a really tough one. It’s tough when there’s no sort of clear resolution or clear progress. But sometimes I guess that’s part of the point, and thanks for bringing this client to the table, that sometimes is – it’s just complex, and we don’t get anywhere, and that’s got to be – we’ve got to learn to be okay with that sometimes as well.

Alex: Yes. Yes.

James: Yeah, I agree. All right, well, thanks for bringing that to the table.

Alex: Thanks, James.

James: …a couple of minutes and, um, have a look through the evidence behind the treatment and figure out why we did – well, why you did what you did.

Alex: Sounds great.

James: Okay, so that’s the first supervision session done and dusted. Thanks, Alex. That was a really complex client, um, and a good one to unpack a bit further. So, Alex is now going to talk through some of the research and the evidence behind working with these kind of really complex clients, um, and a few of the key points that we sort of took out from that discussion.

Alex: Yeah. So, let’s kick off by talking about the relationship of trauma and pain and where the evidence sits on that. Um, we know that, um, the two processes within the body, um, prime the nervous system, um, and one – the symptoms of – of trauma can perpetuate and feed into, um, persistent pain. Um, PTSD in particular causes hypervigilance, and, um, a person with a history of trauma is more likely to scan their body for pain, which makes them notice and feel sensations more intensely. And we know that persistent pain is a state of overprotection of or dysregulation of body protection systems. So, um, understanding that, it’s no surprise that, um, if you have experienced trauma or childhood trauma in particular, you will have a 45% increased likelihood of, um, of experiencing persistent pain at some point in your life, which is a massive, um, statistic.

So, um, I guess in working with our – and, and there are often times we won’t – there won’t be a disclosure, um, when we’re working with clients about whether they have experienced trauma or whether trauma is impacting their pain experience. So, um, you know, some clients will not feel comfortable discussing that with us. So we sort of almost have to assume that there may be, given 45% likelihood.

Um, and part of that, as part of our responsibility as therapists, is, um, working with a trauma-informed, um, practice, which doesn’t treat trauma directly, but uses a strengths-based approach to, um, foster engagement in our service. So we could do an entire episode on trauma and pain. I think that we should, but, um, I’ll – I’ll sort of run through trauma-informed, um, care. Uh, this is from the New South Wales Agency for Clinical Innovation. There are, um – there’s a framework which – which details five key pillars of trauma-informed care, which are: safety, choice, empowerment, trustworthiness, and collaboration.

James: Um, so can we have a bit of a think about how – I guess, well, what – what those are more specifically, but then how you applied at least some of those to the client that you brought up in our supervision session?

Alex: Yeah. So I guess with – with my client, we – the – the physical environment was – was a great example. We shifted our therapy space from the home, which was – had, um, triggers and, um, was likely to enhance, um, traumatic responses within the session. And we moved to a setting that the – that he had chosen, um, and where we had – I was intentional at building a relationship with the administration staff there, and we were able to use their office for us to have our – our physiotherapy sessions. He, um – and I guess that also touches on him having choice and control of the way and the direction that his therapy was going. He – it was literally a place of empowerment, as we spoke about. He felt he was working on his physical strength, which metaphorically I think made him feel like he had, um, more agency over his life.

Um, and I guess as well, trustworthiness was an important one for me. I wanted to make sure that I was a consistent and reliable adult figure in his life. So, I was very careful to, um, be very consistent with our appointments. I was never late. Um, I always communicated, um, and reminded him of appointments. Um, and I guess as well, where possible, I wanted him to feel a sense of ownership over, um, what we were doing together and that his – his thoughts and ideas were respected and honoured, and that we would – um, it was a safe space for him to bring those things with me. I was not trying to be an – an expert in his – on his body or what would necessarily help him.

Um, I think in addition to that, it was very obvious as a – a teenage boy where he was, like, very assertive in what he wanted. So that kind of helped in that – in that sense. Um, yeah. So I guess –

James: So like really setting up a – well, being, I guess, being a safe, positive, stable presence in a safe, positive, stable environment, really. And I guess that ties in nicely with sort of the state we want to set him up in, being trying to move away from this sort of sympathetic, uh, position in a sort of a sympathetic nervous system where – where that’s sort of overactive into an environment that allows and encourages his body to move into this sort of more parasympathetic state and recovering.

Alex: Yeah. And closely, don’t they?

James: Yes. Yeah. We’re lucky in that, I guess, our – the biggest, um, tool we have in our toolbox as physios is – is exercise, which is inherently a – will help to regulate the – the nervous system. Um, so it was sort of a winning combination from that perspective.

James: And I guess even for OTs or speechies, it’s – you can – it’s still the opportunity to find these sort of neutral environments that are client-led, uh, and aren’t provoking sort of traumatic responses. There’s still plenty of opportunity to do that in the community.

Alex: Oh, absolutely. And even if you’re not a community therapist, you can still manipulate the physical environment in a way that is conducive to, um, to safety and choice and empowerment.

James: Yeah. Okay. Okay, so the research – research is saying that while we don’t have a direct impact, it’s sort of outside of our scope and expertise to directly manage the trauma, but appropriate referrals to those who can, and then being trauma-informed is part of our responsibility.

Alex: Yeah. Uh, and the – the – the third, um, thing I wanted to touch on was exercise prescription and what the evidence says we should do in terms of the type of exercise we prescribe for persistent and non-specific low back pain in particular. So there were two massive Cochrane reviews in 2021 and 2024 that delved into this, and, um, the outcome essentially is that there’s no – there’s no magic type or dose of exercise, but that the best type is the one that the person is most likely to do consistently, and one that is graded in a way that doesn’t, um, flare up their symptoms.

So, uh, I guess that for – for this particular person, moving into a weightlifting environment was, um, absolutely okay to do, provided that we managed risks of – of that sort of boom-bust, um, pattern and making sure that he had skills to be able to reassess how his body felt post-session and modify appropriately. Um, so he didn’t end up skipping school for, like, three days post-workout. So that was probably where the skill came in, was – was supporting him to upgrade and pace his activity in a safe way.

James: That’s really nice. That idea of not having to be too specific is quite freeing, I think, because I – I can think of a few situations with clients of mine where we’ve – we’ve gone down one route of a specific movement or exercise because we thought that would be beneficial for them to get us started. But there, it just exacerbated a pain response. And I think if I had have been going into that with the – the idea that this was *the* exercise, I would have got really stuck. Mhm, the idea that we can be quite, uh, creative and flexible with the type, uh, and the setting and the intensity to just find a movement that’s not pain-provoking and then build up from there and then add variety, it’s really – uh, it’s quite liberating.

Alex: Yeah, totally. Um, absolutely. And I think I always try to just do a few things that are specific to the body part and then – so you do some localised stuff and then some generalised conditioning work. But finding the starting or the baseline is really important, because you want to get – you want exercise to be associated with – with a positive – you want to be a positive experience. A lot of people have, um, a lot of fear around exercise, or they have, um – you know, they – it was never – that exercise settings are never places where they felt confident or, um, good about themselves. So you want to – yeah, really important to get that right in the first few sessions, I think.

James: Yeah, totally. Beautiful. All right. Thank you.

James: So the key take-homes that we thought were most relevant to this supervision discussion was, firstly, the importance of following the trauma-informed care framework. So those five points that Alex mentioned were safety, choice, empowerment, trustworthiness, and collaboration. And we can put some more resources in the description below so you can have a further look. And I think definitely worth us touching on in more detail as a – its own episode some point in the future as well.

Uh, secondly, really important to make sure that they’ve got an appropriate team early in their care. So like Alex’s client, they had that psych and neuropsych involved early. Um, always worth getting a referral in.

Once those things are sort of set up, we can then start to make some decisions around where to start. And in our experience, rather than going for the big ones, the big barriers, uh, that are really overwhelming to start, we feel like it’s better to go for the lowest hanging fruit. The importance of getting a win on the board early and building some trust with the client is really, really important in these cases, particularly if they’ve been through clinician after clinician after clinician for years and years.

So that could be, uh, building their capacity and resources in something positive that the client’s already doing and already really passionate about, which is what Alex did in this case. It could be something like organizing, uh, quickly a piece of low-cost equipment that just immediately gives them some more independence and freedom, and then using that to build on, uh, and – and I guess once you’ve got that trust, you’ve got more opportunity and space to build and work on those bigger, more complex problems that are getting in the way.

So that’s it from us. Thanks for listening. We’ll see you in a couple of months for episode two. Thanks very much, Alex.

Alex: Thanks, James. Bye.