Alex: Hello and welcome to Supervisions in Pain, the podcast where we reflect on our clinical practice and chat through client cases in an effort to bridge a gap between pain evidence and real-world therapy. I’m Alex and this is my colleague James. We are community therapists working in Melbourne.

This week we’re focusing on the art and science of engagement, and we’ll work through barriers to engagement, what enhances engagement. James will bring a case where he really struggled to build rapport initially. We’ll then review what the evidence has to say about the importance of therapeutic alliance and educational theory in delivering pain education. We’ll finish with three take-home strategies to try with your clients.

So, James, over to you. Take it away.

James: This was a client that I – I started working with maybe six years ago, so it was well – even seven or eight. It was the – one of the first pain clients that I ever worked with. Um, a young guy in his 30s, a chippy, um, who had experienced a traumatic car accident maybe three years before I saw him. Uh, and at the time I met him, he’d been through the system. He’d returned to living home with his parents. He wasn’t working. Uh, and he had really severe flare-ups of pain. It was just debilitating him.

Uh, I came to the first initial assessment sort of brimming with persistent pain knowledge and ready to kind of get stuck in. Um, but was pretty abruptly met with, uh, resistance. Uh, and – and it was really, really tough to engage, and it kind of – it was a curveball early on in my sort of pain – pain work, I guess.

Alex: How did the resistance present itself? Like, how did you sense that things were going to be tricky?

James: Uh, it wasn’t anything outward from him. More this sort of feeling of: here’s another therapist that’s not going to be able to do much to help. He – he – he’d worked with a long list of sort of surgeons and exercise physiologists and physios, uh, that hadn’t really approached it from a persistent pain perspective, but had set lots of limitations on what he could and couldn’t do.

And I guess that that had resulted in – in him feeling really fearful about any type of movement. And the resistance came with me being, you know, a pretty green junior clinician, uh, coming along and saying, “Hey, maybe there’s another way of going about this.” And it being sort of my inexperienced word against this plethora of – of sort of medical “no”s, basically. And so it was really, I think, hard for me to get any inroads early on providing an option – an alternate option for the way that we can manage things.

So yeah, the first couple of sessions, I – I – I kind of went through the textbook approach of, you know, we made sure we had a team involved that could support him. We cleared the red flags, and then it was me setting him up with some exercises at home around some persistent pain education and trying to show him that there might be another way that he, uh, that I guess another way that he could approach this rather than just resting and waiting for the pain to ease.

Alex: An avoidance strategy.

James: So, so after his initial accident, he’d experienced multiple lumbar vertebral fractures. He’d had, I think, a – a T10 to L4 spinal fusion, multiple laminectomies, and following, I think, six to seven surgeries was then told in his own words, “If you ever lift more than 5 kg again, your spine will shatter,” which was such a – an evocative, colourful word that had just stuck with him for years and years. And that avoidance was the result – this fear of “I can’t move, I can’t lift, I’ve got to be really precious with my spine because it’s like glass effectively.”

Alex: So what process did you go through to, well, first of all, know that it was in fact safe for him to start to load his back and expand what he was doing physically?

James: Well, so, firstly, it had been 3 years since his surgeries. Um, there were no current surgical restrictions on his movement. Um, so in our – in his discharge paperwork that we got from the hospital that was, you know, 2 and a half, 3 years ago didn’t mention any specific restrictions on movement range. Um, and at that stage of injury without any new neural symptoms and signs, uh, I was confident that at least we could start with a low weight and build himself up. We weren’t, you know, never aware of what the exact limitations are.

But he’d had two titanium rods fused to his spine, and I was confident enough that he could at least lift kilograms without a shatter.

Alex: Yeah. What was his pain profile like? How was it actually manifesting in his body?

James: His – his baseline pain probably sat at about a six or a seven out of 10. Then he’d get these really extreme flare-ups where, for him, moved up to a 10 out of 10 and could last two to three days. Any – any sort of lumbar flexion, anything that put pressure through his lumbar spine or, um, put pressure through what he could feel as the – the bars, or any touch – really, really sensitised to any type of touch. He would then move into a flare-up that could last, yeah, two to three days of 10 out of 10 pain, and he would be debilitated on the couch.

Uh, and so that also played into this avoidance that, you know, if something small happened to him and he experienced a flare-up, he was out of action for days, which –

Alex: Sorry, you go. I’m assuming that wasn’t an acceptable, you know, um, side effect for him – being rendered bed-bound for days post-moving.

James: No, it was so distressing for him. And I think added to that as well, you know, he – he was living completely independently. He was working full-time. He’d had his own business and had a couple of apprentices that he was working with. So that was pre-accident. When I met him, he’d then moved back to live at home with his parents, uh, and his girlfriend. And I – they were also, you know, their lack of understanding in that – in this pain space added to it. I think he felt a lot of shame, um, that he was letting a lot of people down and really stuck. So that was all adding into this sort of feeling of helplessness for him.

Alex: There’s so much wrapped up in it.

James: Yeah, totally. So you can imagine, I mean, a new graduate physiotherapist coming out and saying, “Hey, this is what the evidence says about persistent pain, and I think maybe we could move,” was – initially, it was just not received well. So I did provide that pain education. I did provide a program for him. The program wasn’t that appropriate. I overstretched a little bit and it resulted in a flare-up. And so from the get-go, it was – it was really tough.

Alex: Okay. So your initial treatment was ineffective. Not only was it ineffective, but it also resulted in a – a flare-up which made his symptoms worse and reinforced the message that I was trying to argue against.

James: Yes. Yes.

Alex: Okay. So, you’re like digging yourself out of the hole.

James: Yeah.

Alex: Um, and you mentioned you cleared red flags. So you were confident physiologically that he could achieve an – an increase in function with the symptoms that he was presenting with?

James: Yeah. Yep. And some of the – the things that he described doing, you know, day to day as well, if he was trying to help out with tasks at home, help his mom out with some washing and things, every now and then he’d try to, and he would lift a full basket of wet laundry and definitely more than 5 kg worth. And so the evidence was there that, you know, things are strong as well. But yeah, you’re right. There were – there were not – there were no red flags from scans. There was no, uh, neural symptoms that I was concerned about. It indicated no cord injury or anything. Um, no changes to his continence. So I – I was confident that he could physically, just the pain was getting in the way, and the fear in particular.

So yeah, I did get to this sort of crossroads with him where I felt like I’m about to become another clinician in that list of ex-clinicians. Um, that –

Alex: Yeah. Yeah. And – and I probably wasn’t – I was close to being on the chopping block. So –

James: I – I kind of had to change tack a little bit. Um, and for me at the time, I was really just trying to find a way to show him. I’d told – I’d told him that things were, you know, safe for him to start pushing himself a little bit within, you know, within a realistic sort of realms of, you know, pain. We didn’t want to flare things up initially, but we did want to get him moving again in a safe way.

The talking was doing nothing, so I felt like I really needed to show him. Um, and so what I ended up doing was I went down to Bunnings before a session and I – I bought a steel bar that was sort of roughly the length of the titanium rods that were in his back. Went to his place and, you know, he’s a chippy. He – he’s got a shed that he’s very proud of. He’s had all the tools. We stuck that in a vise and spent the first 30 minutes of the session trying to bend that and break it. Um, which was pretty incredible for him, to be honest. I was able to sort of show him, you know, we got nowhere. We couldn’t even make a dent in it.

We know that titanium has four times the tensile strength as of steel. He knew that. Uh, and so that was sort of the lesson of, you know, “You’ve got two of these fused to your spine. Uh, the idea that your spine will shatter if you pick up a washing basket or something the equivalent of 5 kg – maybe that’s – there’s not – that’s not a whole truth, and maybe we could start, uh, being curious about what you could do.” And – and that was huge for him. Uh, it was a pretty cool session.

Alex: That’s so – like, so ballsy. Such a ballsy move. And I guess you were – like, you had nothing to lose at that point, hey?

James: Yeah. Nothing to lose. Yeah. Yeah. Absolutely.

Alex: So, yeah, that’s really interesting because essentially what you’re doing is you’re using that as a metaphor to instil confidence in his – the – the strength of his spine. But you do – the metaphor is being delivered in a way that is resonant with him given his career and the fact that he’s not – he’s not going to, um, relate to a formal pain education session where you sit down and work through exercises and stuff like that.

James: Yeah. Yeah. Absolutely. It was really practical and tactile, and I mean, it was sort of just laid out there in front of him. It’s like almost couldn’t refute the fact that that bar was incredibly strong. And – and for him – and it’s – it’s not always the case for our clients, but for him, it really flicked a switch.

I think it was helped by the fact that he had had three years of experiencing relatively ill-informed management around pain. He was pretty disenfranchised with the medical system. And so once I was sort of a little bit separate from that and it was giving a new, a potentially new approach and a different way of doing things, it – it didn’t take him long to sort of jump on board and think, “Oh, the doctors are wrong,” because he – he – he already had sort of pretty negative connotations about how they managed him and things like that. So that kind of worked in my favour a little bit.

So from there, it was kind of the leverage.

Alex: Sorry.

James: It was, yeah, it was that – it was that leverage that we needed to then say, “Oh, all right, well, maybe – maybe this is – maybe there’s some mistruths and maybe we can start to move in small ways and just see what happens.” It opened a bit of curiosity for him, which was what we needed to just get in. We took off pretty well.

Alex: And talk me through how things evolved from there. So you got – you got that little in, which opened up this, you know, hope, essentially, or it – it allowed him to see the – the dissonance in him – in his beliefs, like, “I believe – I believe that titanium is strong, and also I believe that my back is fragile, or do I?” Or like, “How do these two things – how can I reconcile these two beliefs that I have?” What – what then – how did he, um, how was he able to adapt that change in belief to his function over a period of time?

James: Well, yeah, you’re right. It’s – it’s – it’s sort of on that – you’re kind of referring to that – the sort of the stages of change, right, where we started developing these sort of discrepancies and split beliefs in his mind. So he was able to relatively quickly jump from this – he was not ready for change at all, really, into this – almost through the contemplation into like this preparation stage of readiness to change where he was open to giving things a go a little bit.

I started really gentle because we’d already had this sort of fail with a – a pretty standard generic home program that didn’t do the job. So it was very much – it was a list of a few pain management strategies that we’d identified would likely work for him, and that was some information that we picked up from that initial pain assessment. We knew that heat was a real, uh, protective factor and helped settle his pain. Lying on his back was really helpful, uh, and being at the beach was a really safe space for him. He lived pretty close to the beach at the time.

Um, and so we developed a list of pain management strategies that he could do before and after he tried these gentle exercises to really set his system up for success. Lots of feelings of safety, um, and warmth and relaxation, and then really gentle movements. There was one movement which was just a little bit of pelvic tilting, which was just starting to introduce the idea of moving his back into a little bit of lumbar flexion. We had to go so gentle with that because it was so provoking for him.

And then the rest were actually movements that weren’t related to his back at all. So some upper body work, uh, and then some work with his – his calves basically, calf raises – just some movement that wasn’t connected to this sort of pain point for him.

Alex: Wow. That’s so interesting that like calf raises can – I mean, he would have been pretty deconditioned, hey, because he – all of the disuse.

James: Yeah. Yeah. But I mean, he’s a young, strong guy, and he had lost – as he – he still had strength, particularly in his upper body. So the calf raises for the purpose of whatever they could provide from a, you know, physical perspective weren’t doing much.

Alex: Yeah.

James: But they gave him permission to move and they won’t – and that was – that was really important for him. Yeah.

Alex: I love that. And so where is – you know, zoom out a few years down the track, where – where did he get to?

James: He did pretty well. He – he, um – so his long-term goals were return to work, some form of work. It was relatively unlikely it would be something as physical as – as a hands-on trade, but it was some form of work. It was getting back onto his bike and being able to ride around town, because he’d lost his license and that was challenging for him because of the amount of lumbar flexion you need to get onto the bike. So it was a range problem, but it was also a pain-provoking problem.

Uh, but you – you know, we had started the process towards return to work. We’d started to explore – we – we got a neuropsychologist involved that had some experience in pain. We had a case manager involved that had started to look at, uh, modified returns of duties for, I think it was, uh, some office-based work, some core work – and sitting for long periods was also pain-provoking. So that was the work we were doing in that space.

The – the big progress that we made was being able to get him back on a bike, and it was, I think, three years that I worked with him for – he was back at the gym. He was lifting some moderately heavy weights, you know, at least 20 to 30 kilos, riding through the back that wasn’t provoking his pain.

Alex: And he was heavy.

James: Yeah, it was great. It was great. He – he’d come a long way. When he did get the pain flare-ups – and they still – they still happened – they would maybe last an hour to two, and they definitely weren’t that sort of 10 out of 10 out of 10 pain cycle that he used to get himself into. And he had strategies to manage it. But yeah, he was – he was able to get on his bike. He was able to ride to the beach, so he was doing that each day and doing some swimming in the ocean. So yeah, a real success story. Not all of our clients –

Alex: You know, you’re putting me to shame. My god –

James: It was a real confidence booster. But I – I do think that that – that sort of Hail Mary in that – in that second or third session was pretty pivotal.

Alex: And he – remind me, he had a brain injury in addition to his orthopedic injuries.

James: Yeah, he did. He had a mild brain injury. It wasn’t – there was some mild impairments to executive function, some short-term memory loss, but it wasn’t going to limit him of return to work or return to cycling.

Alex: And in terms of your considerations around his cognitive – um, his cognitive abilities and pain education, did that – do you think that that factored into the engagement? The fact that your in was a very physical and practical representation of pain as opposed to –

James: Yeah, that’s a good point. I don’t think I was sort of – I think it was a happy coincidence that his preferred learning approach also matched pretty well with someone that had some executive function impairments.

Alex: The practicality of it and the physicality of it.

James: Yeah, I think that that lent itself really well to those, but I can’t say that that was deliberate.

Alex: Something that we always consider now.

James: Totally. Totally. Um, yeah. So I think, I mean, like I said, not – not all of our clients make these kind of leaps, but I – but I do think that – and – and I have tried to – to keep this in mind with other clients that I work with – that really tangible, uh, examples that are really specific to the client go a long way – way further than me just sitting there and saying, “Hey, did you know that pain is, you know, subjective?” It doesn’t, in the same ways.

Um, so yeah, uh, it was a – it was a cool – it was a cool process to be a part of.

Alex: It’s incredibly cool, and yeah, that’s the kind of beauty of community work, hey? You can be as creative and out-of-the-box as you – as you need to be. Um, and it’s so funny, like, I can’t think of many other people where taking, you know, carrying some steel rods in your backpack to a client session to, um, prove a or demonstrate a metaphor is going to be effective. So, it was just so on point.

James: Yeah.

Alex: Perfectly suitable for that – that person. Is there anything you would have done differently on reflection?

James: I think, yeah. Yeah. I think the – I mean, the first two sessions I kind of got myself in a bit of hot water and was forced to do something a little bit drastic. I – I definitely try now to go in a little bit more open at the start and hear their story a little bit more, and try and get a sense of who they are and how they think before I start pushing a particular brand of pain education or a certain type of exercise. You know, it was just not appropriate for him, for me to be jumping in that quickly, and particularly with how disenfranchised he was with the – the health system in general. That was just my naive and my inexperience at the time.

Um, but I really try now to – yeah, the f – at least the first two sessions, the inputs relatively minimal. It’s planting a few seeds and giving them an idea that we might be trying something different and bringing some optimism to what they’re experiencing, but the input’s pretty – pretty minimal for those of us that – I mean, partly it’s to get a better understanding of what they’re going through, and for them to see that I’m getting a better understanding of where they’re coming from. But it’s also given me a bit of a chance to – to build the relationship a little bit before I start talking to them, because if there’s no – if there’s no relationship there, then it’s just sort of empty words, and it’s not, you know, it’s not tailored and it doesn’t – holds no weight, completely.

Alex: Yeah. So you take your time in, and – and also your story really highlights to me that we all learn really differently. And, you know, whether or not you’ve had a brain injury or, um, even you and I learn differently. Some people want to have a lot of information before they try something. Some people just want to delve in. Some people –

James: Yeah. And we don’t actually include that in our standard assessments, but I guess it’s something that we are trying to intuit it as we get to know the person and – and the only – the only way you can do that is by hearing their story, learning about their life.

Alex: Yeah. Yep. And finding commonalities between you so that – so that they can really feel like they can trust you.

James: Yeah. It’s so – you’re right. Some – for some clients now, it’ll be going through sending – letting them do some – some learning in their own time. So sending them some videos or, you know, mailing them a copy of Explain Pain and just planting a few seeds. Um, for some, it’s just sitting down and having a conversation. For some, like this client, it’s something physical and practical. It could even be, you know, a walk and talk with a client and just chatting about things, and then halfway through the walk saying, “Hey, you – we’re doing pretty well right now. You, you know, you’ve already walked 500 metres, you haven’t mentioned the pain. That’s interesting.” Nothing more than that.

Alex: The “do – the do first, reflect later,” I – I is a technique I use a lot. Um, and – and you’re right, just leaving it there, not forcing it down their throat. “Oh, hey, we’ve been walking for 30 minutes and we haven’t had any pain. That’s, you know, that’s different to what you were telling.” You just want to, you know, trust that the person is capable of – of processing and reflecting on things outside of the session, and that that happens slowly as well. Um, slowly, slowly is the key.

James: Very cool.

Alex: Okay, we might – we might end it there, and we’ll jump over, um, into our evidence section and talk about what the, um, best practice says about engagement and educational theory.

James: Okay. So, now we’re going to talk through some of the research and evidence behind what I was doing, whether I knew it or not at the time, and explain why it worked.

Alex: Yes. Turns out you’re actually a genius, um, new graduate, and you were on point with the way in which you chose to engage this person. Um, so, we’ll talk about two things that are really interested in – in the evidence. The first one is around engagement, um, and I’ll use the terminology “therapeutic alliance,” which is used a lot in the literature, um, which is essentially the – the strength of the relationship that you have with your client, um, and it’s hugely impactful, and it can change disability scores, and in pain, it can modulate pain within a session. There’s loads of studies which highlight the influence of therapeutic alliance on the effectiveness of our therapies. Um, it’s not just in the pain community. It can – there’s also studies in the cardiovascular rehab space where, um, patients who have a really strong relationship with their therapists are more likely to, um, experience, um, you know, better outcomes on six-minute walk tests. Uh, they lose more weight, they return to work quicker, which is super interesting.

James: Yeah.

Alex: So, um, and if we’re – if we’re to talk about other strategies for engagement, um, having a – a truly client-centred approach where we are setting aside our preconceived ideas, um, of what – of the person and what we think is best for them and really allowing them to lead their – their therapy. Uh, and I guess that begins with a really thorough assessment to really listen to their story, do your due diligence, um, so that they know that you have, um, you have unturned every stone. Um, uh, and that also that you’re listening and incorporating their goals into your assessment.

So if they tell you that they want to get back on the bike, for example, with your guy, incorporate that into your initial assessment. Look, you know, talk about bringing in the posture that they’re most likely to have on the bike. How, you know, what’s their pelvic tilt like? Just keep – keep peppering their goals into the conversation as often as you can so they know that you’re both working on the same thing and that the thing that you’re working on is their idea, um, and that you’re really respectful of that.

James: So important, isn’t it? That’s – that’s sort of almost demonstrating to them that you’ve heard them, because so – it’s so such a common experience for our chronic pain clients that have been in the system for years and years is that they just haven’t felt heard or understood across the whole process. Um, so it’s a nice way to, yeah, to show them that, “Hey, I – I see you and I hear you, and this is how we’re going to actually implement into what we’re going to do.”

Alex: And even if you don’t think that it’s achievable, I – it’s still important to go through that process of discovering together that actually, “I don’t think this is going to work.” But you can’t tell them that from the f – from the get-go. You need to demonstrate that you’re going to test – test it and – and at least try it. Like, did you think that your guy would be able to get back on a bike?

James: Uh, no, no chance – that kind of range, that kind of movement. No. But – but I knew that there were versions of riding a bike that he could potentially do. And I knew that if we started working towards it, he would probably make that decision for himself. And then he surprised us both. If I had have put a ceiling on that early, we wouldn’t have found that out.

Alex: Yeah. So I guess like not – not overpromising, but also not undermining someone’s ideas about what they would like to do. Um, I guess also part of a client-centred approach is that, yeah, again, that collaborative problem-solving, testing a theory together, taking it to its, um, conclusion, making a decision: are we going to keep going with this or should we try something else? Avoiding the “expert trap,” um, which just like embeds and strengthens unhelpful beliefs. If you – if you go in hot, just telling someone what to do, no one wants to be told what to do. It’s – it’s a yucky feeling. You can feel yourself just like, you know, um –

James: You like contract against it. Yeah. Completely.

Alex: Completely. Even if you – even if you might have entertained the idea, you know, someone just like – even when friend – when my mom does it, you know, like, get really stubborn and just – so yeah, don’t avoid being an expert and refrain from telling someone what to do.

Um, we use a lot of MI, which is Motivational Interviewing, which is a great tool for engagement at IRS. It’s also just a great, um, kind of philosophy to have as a – as a therapist, which at its centre, um, kind of defines your role as – as a support person, and you’re there to help a person identify and strengthen their own motivation for change. You’re not trying to trick them or convince them or force them into doing what you think is best. You’re – um, you’re offering your expertise, and they can – um, you’re asking permission to share your expertise with the person and permission to collaborate and problem solve together.

Uh, the second – the second interesting bit of evidence is around your – can education, and the – and the – and the way in which you chose to – to deliver that metaphor around the steel bar. So you were tapping into conceptual change theory there, James, whether you were cognisant of that or not. Um, but when we’re talking about pain education, we know that there’s a growing body of evidence that suggests that understanding pain biology can change the way we perceive painful stimuli. So when – and it’s essentially like a cognitively mediated shift in the sensory perception of pain.

So if we can shift the threat value of pain, then we can modulate it up or down. So you can ramp up, you know, um, education that some of – a surgeon may have provided your client that their – their back was likely to shatter if they lifted more than 5 kilos. That’s a piece of information which massively drove up the threat value of their pain. Um, so that was something that you were contending with. So the power – you know, they talk a lot about power of language and words in – in pain education.

Um, and the way in which you can achieve really, um, transformative pain education is not in – in delivering new information, but in achie – achieving a – a conceptual change, which is a process where someone begins to reframe and challenge their existing beliefs in a way that allows them then to kind of extrapolate that to the rest of their life.

Um, so your – your client was holding two truths within that session. He – he knew fundamentally that steel was not as strong as titanium, and that titanium was bloody strong, and he had two – his – his back was fortified with titanium. So that he – he – he – he – he believed that, and he also had a fear and a strong belief that his back was going to crumble and was really, um, fragile. So those two things were sort of conflicting in his mind. Um, and it was then that reconceptualisation which allowed that little in – inroad for him to be like, “Hey, wait, is this like – maybe James has a point?” And you didn’t ask for – for him to, you know, acknowledge that you are the expert and you are right. You know, I’m sure that reconceptualisation happened – happens slowly over time.

James: Definitely. Yeah. It wouldn’t have gone as well as it did if I had have sort of pushed the message hard at the back end of that session and say – it said, you know, “See, I’m – I’m right, I’m so right.” We definitely left some ambiguity at the end of the session, and he was sort of – he was left, I guess, rather than – rather than being directly challenged, he was sort of left with some sort of a question mark at least. Whereas prior to the session, the belief was: if I lift more than 5 kilos, my spine will shatter. By the end of the session, it was more of a – well, it was a question mark: if – if I lift more than 5 kilos, I don’t know what’ll happen. And then he had time to sort of work with those two conflicting pieces of information outside of the session.

Alex: Yeah, so that was a powerful metaphor, and the delivery of it was a very physical, practical, um, deeply personal one, which really resonated with his – his identity as a tradie, as a carpenter. Um, super clever. Um, so yeah, bravo.

James: Thank you very much. Can’t say it was all deliberate, but it was, uh – it – it reinforced a lot of what I’ve done since then.

The key things to take out of this really is the overwhelming importance of engagement, and – and – and a few things that support that is spending time developing the therapeutic alliance. Number two would be approaching this incredibly client-centred, so letting them take the lead. We work with them. They set the goals, and we work with them to help achieve those goals. And the third being motivational interviewing – very, very powerful tool in – in what we do. And then the last thing Alex talked about was the – the – the con – the, well, conceptual change theory and how that can impact people starting on this sort of persistent pain process or journey.

So we’ll leave some links in the description below around conceptual change theory and engagement, some of the research around those. Thanks for listening. We’ll see you in six to eight weeks with another one.

Alex: Thanks, James.