Welcome back to the Healing Pain Podcast with Dr. Samantha Bunzli
In this episode, we’re talking about making sense of beliefs and behaviors in pain care. Our expert guest is Dr. Samantha Bunzli who is a physiotherapist and has worked in clinical practice for several years before undertaking a PhD with Professor Peter O’Sullivan at Curtin University in Australia. Her PhD research was entitled, “A Qualitative Investigation of Pain-Related Fear in People with Low Back Pain.” She is a post-doctoral researcher at the University of Melbourne working to optimize treatment outcomes for people with osteoarthritis. Dr. Bunzli’s work is part of an international effort to change the narrative in musculoskeletal pain care. She’s been awarded major grants by the National Health and Medical Research Council of Australia to improve evidence-based decision-making among orthopedic surgeons and implement non-surgical care pathways for people with end-stage osteoarthritis.
In this episode, you’ll learn why the beliefs people hold about their musculoskeletal pain matter, where do unhelpful beliefs come from, and how the common-sense model could help us understand unhelpful beliefs and behaviors. Samantha describes findings from her qualitative research based on data collected through interviews from both patients as well as clinicians. She is keen to emphasize the qualitative research is more than just the collection of stories. It involves robust methods of data collection and analysis.
Rather than going into detail about these methods, Samantha has provided free access to all of her research in which she explains the science behind qualitative research and describes the contribution qualitative approaches can make in the field of pain science. This includes some of her first work in the Journal Of Orthopedic and Sports Physical Therapy. In 2017, an article titled, “Making Sense of Low Back Pain and Pain-Related Fear,” as well as the 2019 study in the Journal of Clinical Orthopedic Simulated Research titled, “Misconceptions and the Acceptance of Evidence-Based Nonsurgical Interventions for Knee Osteoarthritis: A Qualitative Study.” Let’s learn about how the common-sense model can help us understand unhelpful beliefs and behaviors when it comes to chronic musculoskeletal pain with Dr. Samantha Bunzli.
Watch the episode here:
Making Sense Of Pain Beliefs And Behaviors With Dr. Samantha Bunzli
Samantha, welcome to the show. It’s great to have you here.
Thanks, Joe. It’s good to be here.
Thanks for joining us. I know you’re a bit far away from where I am in New York City, but tell our readers where you are and what you’re doing with your work.
I’m in Brisbane, Queensland in Australia. I have an academic position at the University of Melbourne. That’s quite a long way from Brisbane. It’s about a 2-hour flight to the South. The life circumstances moved me away from my postdoc that I’m lucky to be part of a supportive group at Melbourne University. They’re open-minded and they’re happy for me to the go-between. I spend my time between Brisbane and Melbourne.
You’re a physiotherapist or a physical therapist as we say here in the US. You study things about pain and related to pain, especially beliefs.
Yes. I have many types of research in the physio world. I worked clinically for several years in musculoskeletal physio and have a strong background in a biomedical model in my undergrad training. I was always interested in those nonspecific aspects. People call them to have that clinical encounter with patients. All the other things like that relationship with the patients, their beliefs, their understanding of pain. I also loved the patient story side of things and story gathering. That was something that drew me. That’s the part that I love about my job. Life circumstances took me to Perth in Western Australia. There I was on the doorstep of Peter O’Sullivan and his group at Curtin University there. I knocked on Pete’s door and we had a coffee. Over the course of that coffee we thought we could make out a PhD. All around gathering people’s stories, we would look at qualitative interview-based study looking at the experiences and beliefs of people with high pain-related fear. That’s where I started on my research journey.
I know you’ve done some great work obviously with Peter O’Sullivan. He’s been on this show and some people from his group, JP Caneiro has been on the show as well. I know all of you working together and making nice leeway with regard to CFT, Cognitive Functional Therapy and other aspects of it. You’re a qualitative researcher, which it’s always interesting because I interview a lot of researchers and they love to talk about the hard stats, connotative-type stuff. What attracted you more toward the qualitative side? I feel like we need more of it in the pain world.
At the time when I was sitting out on my PhD, we were interested in knowing more about patient beliefs. We realized that there hadn’t been a lot of people asking what the patients themselves believed. We had measures that we thought were measuring what we thought they were measuring. I often get asked what the difference between a survey and an interview is. Both of them are important, they’re scientific tools in that sense. They’re used to answer different research questions. If we wanted to know what patients believe, we could sit down as researchers or as clinicians and we could make a list of all the things we think are important to ask patients and then we could distribute that survey to patients. We would be confirming or disconfirming our beliefs as clinicians.
The alternative way to do that is to flip it on the other side and to go to the patients themselves, the people that we’re interested in, and ask them what they believe. We’re collecting that information from the ground up since that obviously leads to a different scientific validity in that sense that the patients themselves are validating that information. In the case of my PhD, we were interested in taking that approach and it’s something that group at Curtin hadn’t explored. We hadn’t used those methods much before. My PhD was a little bit new and methodologically new. We saw the need for it.
As we went along in this PhD, we saw the value that these methods can contribute to the space. Since then, I’ve moved to my postdoctoral work. I’m part of a group of orthopedic surgeons at the University of Melbourne. I’m doing osteoarthritis research. I’m lucky to be part of an open-minded group too of orthopedic surgeons that love the stuff. I’ve interviewed a lot of surgeons too. They’re open to sitting down and having a chat with me, which I’m in a lucky position for. Also, we’re interested in doing a lot of implementation work too. When we have an intervention that we know works in theory, it can be quite different from implementing that into real-world contexts. That’s where qualitative methods are important because they can understand that contextual information that might explain why promising interventions can fall down when you get to the implementation phase.
What are the beliefs that people hold about their musculoskeletal pain matter?
On a basic level, any person, if we feel pain somewhere, say in our lower back. Whether we’re going to cry when we feel that pain or reach for our running shoes or the anti-inflammatories or we’re going to go to bed or call the doctor, those behaviors are going to depend on lots of different factors. We know that amongst the strongest of those factors is going to be the person’s beliefs about their pain. Many years ago, now that Waddell said that what we believe and do about pain can be more disabling than pain itself. Time and time again, we see the importance of beliefs. Zion and Linton, going back to the fear of Waddell’s model, it was the leading explanation for a long time and still is a widely used model. It describes how when at the onset of pain, when we feel pain, how we interpret that pain. If we interpret it as having catastrophic consequences, then that can lead to pain-related fear and the avoidance of activities associated with the threat of pain or the threat of harm. That can lead to this vicious cycle of avoidance, disuse, disability and so on. On the other side of that cycle, the absence of pain catastrophizing facilitates that normal confrontation of movement and that trajectory of recovery. That’s been a model that’s safe and widely used.
In addition to those direct influences is the avoidance of something that we are afraid of. That avoidance can be the outright avoidance or the guarding and the bracing and tensing, changing a movement while changing the pattern of the way you move to protect your back during movement. We have those direct behaviors, but also at the start of my PhD when we were looking at the literature to see what some qualitative studies, what interview-based studies had been done in patients exploring beliefs from the patient’s perspective. What we’ve found is not a lot of studies are directly exploring beliefs but around 18 or 20 studies that had been exploring the lived experience of back pain and nonspecific back pain, people that hadn’t had a diagnosis for their pain or had been diagnosed with nonspecific low back pain. Looking at those stories, there was this common theme the same across all of these papers. It involved hundreds of patients that there was a sense amongst these patients that there was an underlying pathoanatomical explanation to their pain, which hadn’t been diagnosed or identified yet. There was this sense that if they could only get that diagnosis, then they could enter into that pathway of diagnosis, treatment and then cure.
That resolution and pain, it returned to normal function. Because they couldn’t enter that pathway with this diagnosis of nonspecific back pain, they were stuck. We describe in that early paper in 2013 that solved my PhD this idea of biographical suspension. Because of these biomedical beliefs, people were putting their lives on hold. It’s like a pause button until they could then get a diagnosis and press the play button on their lives again. They were suspended in wellness while they were trying to prove that they were sick or prove that they had a legitimate pain experience. It described before that once you’re fighting to prove that you’re sick, you can’t get well. It’s this idea of suspended wellness. In the stories we also heard suspend self. It was the idea that I’m not myself while I’m experiencing pain, there’s some temporary imposter. Once I get that diagnosis and get that cure, I’ll go back to my true self.
The self is suspended and then we had suspended futures. People were describing how without that diagnosis you don’t have a prognosis. It’s an uncertain future, but also how unpredictable pain was. It’s hard to plan for the future, short, mid and long-term when you don’t know how your pain is going to behave. That future, that trajectory is suspended too. In addition to those direct behaviors that someone might avoid movement or those behaviors, we’ve also got to this big impact that these biomedical beliefs were having on the lives of these sufferers that are profound across their life spectrum. That’s where beliefs are and play an important part in the pain experience.
When someone experiences pain, there’s a cognitive appraisal that happens. Cognitively, they’re appraising what’s happened. Traditionally in CBT, they break that up into a threat, a loss and a challenge. Your work has gone much deeper and it sounds like you have at least five if not more areas that the appraisal is happening and people are either taking action or not taking action. For some people, avoidance is in effect taking action. There is a period of time where avoidance of pain makes sense.
It’s that the common-sense model that we’ve been using to try to understand some of these behaviors because it does make sense.
I want to get to that common-sense model because I know it’s the pivotal piece of your research. Before we get to the common-sense model, they’re unhelpful beliefs for people with pain. Where are they coming from? Are there certain key areas that we should look for as practitioners and laypeople?
Yeah. In my PhD, what I did is that I recruited a group of people who had high levels of pain-related fear to try to understand where some of these unhelpful beliefs came from. In exploring that, we came across them. We identified the key areas that they appear to be influenced by. This resonated with some of the things that we see in the literature too. A lot of it was the sense that these were societal beliefs and we know that these biomedical beliefs and beliefs about pain directly being associated with damage are prevalent in society. Ben Darlow has done some great work in New Zealand. He’s done a survey of the New Zealand population. He showed that, for example, 50% of the New Zealand population believed that pain in the back meant that the back is damaged. Around 90% believed that ignoring pain can damage the back and 70% believe that there’s some ongoing weakness after an episode of back pain. There are strong beliefs that he found across the population.
What that tells us is that often these beliefs are likely to be predating the onset of pain and a lot of our patients that come to see us. It’s the things that they’ve observed. A lot of children might’ve observed their parents. We hear about them in the media. That’s one aspect of it, these societal beliefs. The other thing we found that these beliefs were heavily influenced by the clinical encounter. As we are talking to the patients, we see this. The participants in my study would say things like, “The doctor said that I have to avoid bending because that could damage my disc. The sense there appeared to be some patients that were explicitly being told to be careful of their backs, being told that their backs were fragile or vulnerable, that was an aspect of it. The other aspect was it appeared that some implicit advice from the doctors could be influencing some of these beliefs. People would say things like, “The physio gave me stabilizing exercises and told me my tummy is weak. That must mean that my back is weak.” It’s correlating those two things directly.
The other interesting one that I’m passionate about was the misinterpretation of jargon that was used during the clinical encounter. That seemed to be important. People would say things to me like, “I have degeneration.” To preface this, these were people who had experienced a lot of pain for a long time. They have a diagnosis of non-specific back pain. Most have experienced it for over a year. They’d widely sought care for this pain. When they were using terms like this, they were familiar with the diagnostic jargon. When I would ask them something like a term like, “What does degeneration mean to you?” They’ll say things like, “It means that I’ll end up in a wheelchair,” or even things like, “It made me worry if it’s carried through the genes, does that mean my son could end up experiencing it?”
Things like disc bulge, which are problematic, “Tell me what a disc bulge means.” “It means surgery.” “What does neurological mean?” This is a real problematic one. People are saying things like, “It means the doctor doesn’t believe me, but I can’t be a hypochondriac or now they think I’m barmy, I’m crazy.” It was interesting to see some of these misinterpretations because it was a lovely paper done quite a long time ago, I think it was 2008, 2009. They did focus groups with laypeople and asked them what they thought some of these diagnostic terms meant. These weren’t patients, they hadn’t necessarily experienced back pain and they found shocking things.
Simple terms like chronic wear and tear that we think would be relatively benign and patients would interpret in the same way that we mean them would sometimes be quite problematic how they were being interpreted. Wear and tear is shrinkage on natural running away, but again neurological involvement and what they documented with things like something’s going wrong in your head. That it could be a tumor or death within six months for some of the things that they documented. That’s powerful because if we use those terms in a clinical setting and patients are going away thinking that’s what was said or misinterpreting that, it has huge consequences.
I’m interested in how some of that miscommunication happens in the clinical encounter and how that influences belief. We’ve got the societal beliefs being a problem, we’ve got that clinical encounter is a problem in developing these unhelpful beliefs. What we also found was that as the third key area was that some people have appeared to be trying to make sense of a pain experience, which they couldn’t make sense of. “I’ve tried everything. I don’t know what else to do. This isn’t making sense. That was a real key that we were seeing.” When we think back to that fear-avoidance model and the idea that the literature came from the phobic literature. It’s the idea that someone can easy phobic or has an irrational fear of movement and re-injury. What we were saying in the people we were interviewing is not everyone seemed to be phobic. Not everyone seemed to have this irrational fear. It was that they couldn’t make sense. It was a logical process they seemed to be going through.
I’m happy you said that because I’ve talked to certain psychologists who are not trained in pain and pain science. They can be helpful because if they’re treating things like anxiety and depression that can help someone with pain. I’m a big advocate of pain psychology on this show, except if it’s by a provider who doesn’t understand pain, they start to look at things like you have a phobia almost like you have an anxiety disorder or you have a problem like that. I appreciate what you’re saying because it makes sense to practitioners as well as the person with pain. Your take-home message that everyone should know this and read this and you as well as other people on this show talk about this is that words can hurt and cause harm.
As I understood from your story, one thing I’ve suddenly become interested in is you are a licensed healthcare practitioner, but in this case you’re acting as a researcher. You’re working with these people, asking them questions, taking in all this information and hearing these beliefs that are quite frankly incorrect so to speak, but you can’t necessarily act on it and educate them out of it at that point. You’re working as a researcher and not as a clinician. I’m curious, do you provide services to the people after and tried to help them through what’s going on? The reason why I find it interesting is that every pain practitioner I’ve ever met, running through their veins is the fact that they want to help someone. You’re listening to people’s qualitative stories. They’re pouring their hearts out to you about what they’ve been through, what they’re feeling, what people have told them, what they grew up with. You may or may not be able to intervene on that.
It’s one of the biggest challenges as a qualitative researcher absolutely. Taking off that clinical hat doesn’t come easily. I was faced with that early on in my PhD because my PhD was also a prospective study. I was interviewing people at one point and following the map at other time points. Often people who volunteer to be part of a study like this because they want information and they want someone from the university who can perhaps help them a little, know the latest research evidence. They also knew at the time that I was attached to a very successful group of back pain researchers and that I would have access to that information. It was difficult.
Ethics, when we think of research ethics, we’re not focused so much on the good of the individual. We’re focused on more the societal good. I gave each person an option. A couple of times in my PhD, I was directly asked, “Can you tell me what the right thing for me to do is?” It’s important to give those people the option to withdraw from the study if they feel passionate about that, otherwise with the premise that when I come back, I will be able to give you that information afterward. I can’t influence that trajectory at this time point. I find that challenging and still as a researcher. One thing that I can say is that sitting down and asking someone their story when you have an hour in front of you and there is no judgment and there is no perhaps therapy that’s coming afterward, it’s an incredibly therapeutic experience I think for many people to have their story heard and retold and the dissemination of our work.
When you say that, it brings me back to when I was on affiliation as a physical therapy student. I remember one of the therapists who was leading the affiliation said, “During the initial evaluation, take the full history but make sure you always give them something to do,” meaning an exercise or manual therapy. As I listened to you speak, there may be a place for physiotherapists to just sit and talk.
We often don’t have the privilege of time to do that. There’s an aspect of that is important.
For most physios, it makes the most sense for the initial evaluation. Depending on the patient population you’re with, that half-an-hour of talking and educating and listening could be powerful. Tell us about the common-sense model, which I know is the bread and butter of what you worked on and it has a lot of great important information that you want to share.
You know this model and I know that you’ve interviewed other people in your show that have used this model. We got to this idea that sense-making processes were somehow involved in that story of these people with high fear. Perhaps it’s easy. To illustrate the common-sense model, I’ll use the example of say that you imagine you woke up and you have a pain in your head. You immediately attach a label to that pain you say that you’ve got a headache. You think it’s caused by dehydration. “I haven’t been drinking enough. It’s going to stop me concentrating for the rest of the day if I don’t have a big glass of water and I maybe take some Paracetamol and then it’s going to get better around twenty minutes and I’ll get back to doing what I want to do.” Now imagine you’ve got that same pain in your head, but someone close to you had been perhaps diagnosed with a brain tumor. Immediately, that might give rise to a different set of beliefs around that pain and might give rise to a different set of behaviors. That’s a simple example to illustrate what this model says. What it is trying to say and it’s been around a long time, this model, that when we experience a health symptom, we draw on a set of beliefs about the symptom to decide what to do about it.
That includes our beliefs around the identity of the pain, the cause of the pain, the consequences of the pain, how long we think the pain is going to last and how much control we think we have of the pain. That’s these five belief dimensions and we develop those beliefs based on our previous experiences with the symptom, observing others and what we’ve been told about the symptom. When we experience that symptom, we draw in the set of beliefs that gives rise to what we call problem-solving behavior. As long as the outcome of that behavior is in the direction of our target goal, then we will sustain that behavior over time.
If it’s not, then we might adapt our beliefs. We upgrade and change our beliefs and that can then adjust our behavior accordingly. We have this ongoing problem solving that’s happening. The problem in people with pain is that sometimes we don’t have or the outcome of the behaviors is never in the direction that we want it to be. We may keep thinking this representation we call it, these five beliefs aren’t helping me make sense of my pain. Suddenly, we don’t know where else to draw from these beliefs. We’ve got gaps in our understanding. If we can’t have a cognitive representation to guide problem-solving behavior, what happens according to the common-sense model is that our behavior will be driven by our emotional response to the symptoms or our emotional response to that cognitive representation. Consistently, in the literature we see that a symptom that is interpreted as having catastrophic consequences will be intense or to be quite unpredictable, then they likely give rise to a fear response. That’s where fear can come into this common-sense model well.
If the higher-level centers aren’t able to figure out the problem because pain is a problem to the organism, the middle-level emotional centers will take over.
If we use an example of back pain, say we had somebody who bent over and felt pain in their back a few weeks ago or maybe a few days ago. They haven’t had an episode of back pain before, but they’ve seen plenty of people that have, then they might think, “I know that from bending over you could get a bulging disc.” Maybe my identity label is, “Maybe I’ve got a bulging disc and I know that can be caused by bending and lifting.” Those are cause beliefs. “I know that if that disc bulges out, then maybe it could push on my spinal cord and then maybe I could end up in a wheelchair. That can have big consequences. Maybe I need to rest and avoid doing any bending, lifting or anything, using my back too much.” That’s control. “Maybe it’ll get better in a couple of weeks.” There’s a timeline. Maybe we have a representation that looks like that. A common-sense response to a representation like that would be to avoid bending and lifting and to rest more. That’s completely logical. That’s what we’ve heard our whole lives. As long as the outcome of that resting is that we have no increase in pain, therefore we don’t think we’re causing any more damage, then we’re going to keep on doing that behavior. That’s logical. The problem is what happens down the track.
We go beyond that timeline. Suddenly, we go to two weeks and we’ve been resting and we’re still feeling some pain. We might upgrade our thinking. We think, “Maybe my back is weak now. There’s injury and now my rest has made my back weak. I’m worried that I could be injured in the future. Maybe I need to get some exercises to strengthen up my back and then I can expect a full recovery.” We go see a physio. That’s common sense problem-solving behavior. If we jump forward, three months down the track, and this is beyond the time that the physio instead that my back should be getting stronger by now. “I’ve been doing all the strengthening, all this exercising, lots of physio. Why am I still feeling this pain?”
This is where we can start getting into problems. We might upgrade our thinking. We think, “Maybe I could have a damaged disc here and movement is making it worse. I’m worried about the wheelchair. When is this getting better? Maybe I need surgery?” We go and see the surgeon or we get a scan. That comes back saying, “You’ve got some degenerative changes, but surgery is not an option.” Here we get a bit stuck now. We upgrade our representation, we think, “What degeneration? It’s difficult to know what that means.” Pain is still being unpredictable. We still got this uncertain trajectory. Suddenly, we start withdrawing a little bit more, we’re resting more, we’re withdrawing from activities. Nothing is starting to make sense and this is where we can get trapped into a cycle of fear. That’s where we think this model is quite helpful for us to understand how some people can get trapped in that cycle through this problematic problem-solving. There’s an inability to make sense.
People can be stuck there for years and decades without running into this great information as you have. If I’m a practitioner and practitioners are reading this blog, which they are, and they’re thinking, “What are the questions that I can start to ask my patients to run the initiative evaluation or perhaps at visit number two that will help me to assess these pain-related fear beliefs?” That they can start to tweeze this out and start to identify and treat it.
What’s important before I go into maybe some of those questions is that this model helps physios to understand how we can play a role. Often physiotherapists are worried. You said that line with maybe the pain psychologists and we’re feeling maybe we don’t have a role to play in managing those emotional responses to pain and that’s distress. This model shows that it helps physios understand that we do play a role, in my opinion, in addressing those emotional responses by helping people make sense of their pain. This is something that is well within our scope of practice. We also play an important role as far as belief change going hand-in-hand and behavior change. For any clinician that has a patient coming to see them with pain, it’s important that we know how that individual is representing their pain. We need to tap into these five belief dimensions. How do they make sense of their pain experience? We can ask those questions around that identity domain. Do you have a diagnosis for your pain? Can you explain to me what that means? That problematic interpretation, some of the jargon. Have you had any scans? What did the scans show you? It’s trying to look around those beliefs.
Around the cause domain, do you know what causes your pain? How predictable is your pain? Is there always a cause and effect of how predictable it is that cause-effect? The consequences of your pain, what do you think the consequences of your pain or your diagnosis are? Can you prevent your pain from flaring up? Does everyone that control domain and can you control the pain once it’s let up? Patients often distinguish between those two control factors. The timeline beliefs, how long do you expect your pain will last? How hopefully for the future? What do you think it’s going to take to get your pain better? As clinicians, we should be listening for any gaps and understanding that we need to help fill or any incorrect beliefs that we need to try maybe to adjust. That’s why behavioral techniques are important and obviously I’ve done a lot of work with patients in CFT and that puts a lot of emphasis on exposure to feared movements and activities as a mechanism to disconfirm beliefs.
Giving some of this information needs to go hand-in-hand with exposing somebody or letting someone experience this for themselves. It’s one thing to be telling them, it’s another thing to experiencing it due to experiencing it yourself. Physios have an important role in exposing patients to movement, but also in such a way that doesn’t then increase their pain. Often, these people are highly sensitized and doing a repeated movement for example or exposing that can cause more pain and then we get trapped in that cycle thinking it is causing pain. Is it causing damage? These light bulbs go off. Helping somebody to move with pain control during this process is important.
How long does it typically take a practitioner to run through that and to collect that information from a patient?
I don’t think it needs to take long. This is where it’s a challenging group to be working with the orthopedic surgeons who have a short amount of time with patients. Even then in a short session, even spending five minutes is better than nothing of asking someone, “What have you been told about your pain? How long?” These are quick questions that you can run through and get a lot of information fairly quickly from patients.
They are real, they’re brief cognitive interventions is what they are. They’re well within the scope of physical therapy practice as well as other practitioners who work with people with pain. At this point, even a lot of fitness professionals are starting to understand what pain is and what it means for people. Those are the sample questions. We talked about the common-sense model. A lot of your work has informed Peter O’Sullivan’s work with CFT. Where would you like to see your research move forward next? The orthopedic surgeons, I wanted to get back to that.
Yeah. They’re similar principles across the board. One thing that we’re trying to do and I sent a link as part of the resources I provided, but Peters’ group has developed some nice communications training tools. That’s because we often get asked by clinicians, “I know what to say, but how do I say it?” Modeling those clinician behaviors can be helpful. He’s developed tools that are interactive. We’ve got an example of a clinical encounter happening and the patients ask a good question and we give an example of a helpful response to that and unhelpful response. It’s a bit interactive. You can have a look through that tool and click on what you think is the right response and have some evidence as to why which one is correct.
Those interactive tools can be helpful and we’re trying to disseminate that information out to the pain world. Obviously, we’ve got close links with the physio community, but it’s great if we can tap into the GP and the orthopedic surgeon and these other clinicians. At the moment, we’re doing a lot of work in osteoarthritis. Primary care and the GPS, the orthopedic surgeons and the physios are important there. I’ve developed this tool in back pain, but we’re interested in developing some more of these tools. At the moment, hip and knee osteoarthritis too are two other key areas that we see a lot of problematic beliefs.
That’s where my work has progressed to and where I’m at the moment with my group of orthopedic surgeons. Maybe to summarize a little bit of my work there, we are attached to a hospital where we do one of the biggest joint replacement services in Australia. What we’re interested in looking at is in Australia and around the world, there’s quite a high rate of joint replacement in patients who are perhaps not the best candidates for surgery, they don’t meet evidence-based criteria for surgery. This is a high-volume procedure and lots of people have osteoarthritis. This is placing untenable strain on the health systems. One thing we’re looking at is those pathways. How did this person get to the joint replacement point in time?
A lot of the interview work that I’ve done is with these people that are on a waiting list and we see quite often that the guidelines would tell us everyone with osteoarthritis needs to engage in an exercise intervention. Exercise, weight loss, these interventions need to be the first line of care. Often people are getting right through to the point of surgery and haven’t tried any of these things and certainly haven’t given them a good goal if they have ever done any, engaged in any. That’s something that is backed up with literature elsewhere as well. How do people get to this point?
Some of the work we’ve been doing with patients is I’m asking them about their beliefs too and their beliefs around the treatment. What we’ve published in our 2009 paper and clinical Peter’s related research was that many people are saying, “Once I’ve been diagnosed with bone on bone, what’s the point in doing any physio? A physio can’t replace cartilage in my knee. It can only do damage to my knee.” As soon as they hear bone on bone from any clinician, whether it’s the GP who showed that there’s a little bit of bone changes in your knee or the physio, it’s the end then. It’s this engagement from those nonsurgical interventions and then it’s a matter of getting yourself onto a waiting list for joint replacement. That’s the only definitive way to be able to fix my knee.
In the meantime, while there are some people considered too young to get on a waiting list or it could be lots of barriers to them getting there. Often, we have a lot of people sitting around for a long time that is not engaging any active intervention. We did see interestingly a high uptake of experimental interventions of people trying different supplementary as medication or even stems cell medication, things which seem to regenerate cartilage in the patient’s minds potentially. A lot of them are going down that route while they’re waiting to get on surgical waiting lists.
One side of the work we’ve been looking at is how these beliefs have influenced the treatment-seeking behaviors. What treatments have they sought out? That’s been insightful. It has given us some interesting ideas of how we can maybe change the messaging at the GP level, especially in Australia. It’s the general practitioners who are the gatekeepers of care. That’s where we’re tied in some of these interventions that if we can try to change some of that communication in the GP setting, hopefully we can send more referrals towards physio and less straight to the orthopedic surgeons. That’s one aspect.
How long does someone wait for a joint replacement in Australia?
That’s quite variable. It depends on the service. It’d tricky for me to say. At our service, people are waiting between 3 and 6 months.
When you say service, meaning the hospital?
The hospital service, yes. It can vary. Also, the other side of it that then we’ve been doing work with the orthopedic surgeons too is to have a look at a case as to why the specimen has got to here. Why are you offering this person in surgery when perhaps they don’t meet these evidence-based criteria and they haven’t gone through the nonsurgical route to arrive at this point? That’s insightful to hear some of those perceptions. At the end of the day, orthopedic surgeons have their hands in the right place and they’ve got a person in front of them who needs help and is asking for help. If it’s perceived that the person is at the end of the road and that there’s no alternative intermission, then the surgeon wants to offer them something and what they can offer is surgery. We were doing a lot of work around educating the orthopedic sessions too that there are different routes that can still be effective in end-stage osteoarthritis, these non-surgical routes. Making those routes easy for those surgeons to refer to you as well as is important.
I’m curious to know how the primary care physicians respond to probably you’re explaining pain to them first and then helping them out with some of this common-sense model. The university where I teach, the physical therapy staff trains the third-year medical students on how to do a musculoskeletal exam. At our university, we have a little bit of getting to them early so to speak, which is great. We feel we’re being valued and they love it. How did the GPs who’ve been out a while already practicing learning about, “There is no bone on bone, it’s not a correct term,” and some of the other terms that they’re using in clinical practice with patients to explain the pain?
For now, that’s a difficult group for us to tap into because we’ve got strong links with the orthopedic surgeons. With the Australian Orthopedic Association, we’re trying to embed some of this information, these tools that we’re developing into their training programs. The GPs because of our connections have been a little bit more difficult to tap into. They have a tough call, GPs. It’s hard for them with it being short and time-pressured. I don’t know how that is other countries, certainly in Australia there’s a lot of pressure on a GP. When a patient is sitting there saying, “I need to see the orthopedic surgeon,” and requesting that from the GP, it’s difficult for them to spend the time to say why that might not be appropriate. Trying to facilitate behavior change towards the exercise is tricky in an initial consultation. That’s where we’re also interested and open to ideas of how we can tap into a general practitioner group.
That’s when I listened to your questions before, those brief interventions, which are comments on the law, psychology literature, like brief cognitive interventions. I’m like, “This is cool because this can fit into a busy GP, a busy physiatrist. Even some of the clinics in the United States are busy physiotherapy clinics that see multiple patients an hour. That’s unfortunately the way it is in certain clinics. You’re doing incredible research and I appreciate you being here and sharing your knowledge with us. Tell everyone how they can learn more about you.
I’ve got my web page at the University of Melbourne that people can go and have a look at the work that I’m doing. My publications appear there and if there’s anyone that would like to access any of these papers, then it’s got my contact details there. That’s probably the easiest way.
I want to thank Samantha for joining us here on the show talking about how to make sense of patient beliefs and behaviors when it comes to chronic pain. Grab this link and share it with your friends and family on Facebook, LinkedIn and Twitter. Drop it into your favorite Facebook group where there are lots of pain geeks, physiotherapists, pain psychologists, people with pain who are interested in learning more. This is an intervention right here. Reading about Samantha can help a lot of people. It’s a pleasure being with all of you. We’ll see you.
Thanks so much, Joe. Bye.
- Dr. Samantha Bunzli
- National Health and Medical Research Council of Australia
- Making Sense of Low Back Pain and Pain-Related Fear
- Misconceptions and the Acceptance of Evidence-Based Nonsurgical Interventions for Knee Osteoarthritis: A Qualitative Study
- Peter O’Sullivan – past episode
- JP Caneiro – past episode
- Australian Orthopedic Association
- https://www.Facebook.com/groups/IPSICommunity/ – The Integrative Pain Science Institute
About Dr. Samantha Bunzli
Dr. Samantha Bunzli is a physiotherapist who worked in clinical practice for 10 years before undertaking a PhD with Prof. Peter O’Sullivan at Curtin University in Australia. Her PhD research was entitled: ‘A prospective, qualitative investigation of pain-related fear in people with low back pain’.
She is currently a postdoctoral researcher at the University of Melbourne, Department of Surgery working in a team lead by orthopaedic surgeon, Prof. Peter Choong seeking to optimize treatment outcomes for people with osteoarthritis. Dr. Bunzli has methodological expertise in qualitative research and content expertise in health beliefs and behaviours.
She has been awarded major grants from the National Health and Medical Research Council of Australia to improve evidence-based decision making among orthopaedic surgeons and patients, and implement non-surgical care pathways for people with end-stage osteoarthritis. Dr. Bunzli has co-authored over 30 articles/book chapters and is part of international efforts to ‘change the narrative’ in musculoskeletal care.
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