Jared Powell:
Today's guest is Lianne Wood. Lianne is an academic clinical specialist, spinal physiotherapist, currently working as a senior research fellow at the University of Exeter, and clinically at Nottingham University Hospitals, NHS Trust. She holds a postdoctoral early career research fellowship with Orthopedic Research UK and is collaborating with Neuroscience Research Australia, otherwise known as Neuro, to deliver the memoir study in the UK. Lianne has published many great papers in the area of exercise for chronic low back pain. However, for today's conversation, we will hone in on a recent study of hers where she investigated how clinical Pilates might help people with chronic low back pain. This is a landmark study that could change how you communicate about causal mechanisms of Pilates for low back pain.
Jared Powell:
Without any further delay, I bring to you my conversation with Lianne Wood. Lianne Wood, welcome to the show.
Lianne Wood:
Hi. Thanks for having me, Jared.
Jared Powell:
No problem, Lianne. I'm super excited to talk to you today. I've read a lot of your work in preparation and specifically a particular paper. We're gonna talk today about Pilates and how, how Pilates may actually work for people with chronic low back pain, which we'll get into in a little bit. But to set up the convo, I just want people to find out a little bit more about you, Lianne. So, who are you, what do you do? What do you like doing when you're not in the book studying causal inference? What do you, what do you like to do for fun?
Lianne Wood:
What I like to, I like to go mountain biking and trail running are my, my two favorite things. But probably adventuring, just getting out, seeing new places, trying new things. Yeah.
Jared Powell:
Cool. Yeah. And you're based in the UK, but South African? Yep.
Lianne Wood:
So I south African was originally from Durban and Cape Town for 10 years before moving to the UK and we've just relocated to Devon Exeter. So yeah, trying new things.
Jared Powell:
Cool. And Springbox, are you a rugby fan?
Lianne Wood:
? We're probably, yes. Probably not. As not, we don't watch every single game as as some people be horrified to know, but we were watching on Saturday and you're very sad that they lost .
Jared Powell:
Yeah, it was a cracking game though. It was one of the best games I've ever watched. So, congratulations to Ireland. That was a, a fabulous performance by them as well. So you're not, you haven't felt the need to support England yet? No.
Lianne Wood:
Jared Powell:
Sacrilege shut up.
Lianne Wood:
South Africans through and through for life. Yeah.
Jared Powell:
Yeah. Good. No, I love it. Spring box is such a fabulous team. The spring box and the All Blacks if I wasn't Australian , they would, I would just pick them anyway, because they're, they're so very impressive. Lianne, sorry. Are you reading any interesting books right now? This is always a question that I like to ask people because I think it gives an insight into what you're interested in and you can't say causal inference, so anything outside Yeah. Of what you do for work.
Lianne Wood:
I've just finished reading a book called Eleanor Aliant is completely fine and it fascinating. It's a story of a girl who basically, I mean, she must have lived in you, you're trying to unpick the story of her. Basically her mother was abusive to her and her sister, and that she's now a functioning adult that has this kind of very set routine, but through coming, coming out of the, the other end of the social kind of services. And it's really a story about loneliness and kindness and someone's kindness and how she realizes she thinks she's completely fine by herself, not needing anyone else because she doesn't wanna get hurt again, but actually kindness and friendships and just, it was, it was really beautiful in the end. I couldn't put it down, but
Jared Powell:
Sounds very uplifting. It's, I'm like, it's better than reading about murder all the time. So I might actually read something. That's nice. Sounds good. Yeah, it
Lianne Wood:
Was good. It was a good book, .
Jared Powell:
Good, good. And so that aside, I wanna get into the, to the meat of the conversation today, which is about this, this really cool paper that was published in the Journal of Physiotherapy. It was this year, I believe, 2023. And I'll let, I'll let you introduce and talk about the paper a bit, how you came to do it, and I guess the key results that you derive from doing the study. I'll hand the floor over to you, Lianne.
Lianne Wood:
Thank you. So the paper is a, a, a product of, of a really great international collaboration. I wouldn't have, the paper would never have come to life if, if I hadn't had the Twitter friends I made through Geronimo ano Ben Cernik really were the guys who kind of spurred me onto deliver it. And, and they were just great to work with and, and I just loved Twitter for the fact that you just get these international communities that pop up and, you know, make things happen. This paper was kind of a sideline of my PhD where we'd got this data set from Giselle Miyamoto and her team in Brazil where they delivered a four r c t testing different dosages of Pilates exercise compared to a booklet control. And they tested pain and physical function as their primary outcomes. But they had a really lovely blurb in the beginning of their trial describing that they thought possibly some of these psychosocial factors such as fear avoidance and pain catastrophizing might be important in the process to changing pain and physical, physical function.
Lianne Wood:
So we brought them through my PhD and, and used their trial in a few different analysis. And because they had measured all these different components, they were perfectly designed to be able to use for a mediation analysis. And my PhD really demonstrated that as physios, we, and as trial designers, we probably don't design our trials very well a lot of the time where we don't often specify what we're trying to change or measure the thing we're trying to change. And many of those things when we do specify them, are probably often biomedical. So things like physical, you know movements, strength, flexibility and so forth. And our, my research team through my PhD really felt that possibly other factors might be more important given the, the bio-psychosocial components of back pain. So this trial was a great way to try and test whether those psychosocial components did actually change or where the pathway through which exercise made a change. So we used a causal inference model to test these things. Statistically, we collapsed all three of the Pilates groups into one group compared to the, the controlled arm. And then used a causal inference methods to analyze the data. And we did find that kinesio phobia and pain catastrophizing were important mediators on changing pain intensity and physical function. However, the most important was really the Kinesia phobia, which really interestingly mediated around 50% of the pathway to physical function. So it seemed to have a really important role to play for physical function particularly.
Jared Powell:
Yeah, so, so much to, to dig in there. So, so kinesio phobia. So that explained almost half of the effect on with Pilates and physical function. Right. And that's, that's quite, it's quite dramatic. Do you, what, what do we often see in these studies? It's psychological factors, usually 20 to 30% mediate of outcomes. Is that right?
Lianne Wood:
Yeah. So in, in most studies that have been done, I think there's, there's probably about, let's say five or six other RCTs that have done mediation analysis on exercise trials. And most of them, them have used their pain catastrophizing as quite quite a key or common mediated, tested or distress. And very often they're 20 to 30% of the pathway to pain intensity or physical function.
Jared Powell:
So Pilates may work primarily, or at least partially by reducing fear of movement. And that's, that sort of might be the causal pathway towards improving physical function in a cohort of people with chronic low back pain. So I think that's a really, really important point here. I know in Australia, I'm gonna talk about Australia 'cause I have taught Pilates. I, I, I hated doing it. I was made to do it by my employer. I phoned it in. I wasn't very passionate about it. I, I found myself questioning the narrative of what I was teaching here. And you've gotta control your, you gotta activate your multifidus and your, you gotta activate your transverses abdominis and you've gotta blah, blah, blah, blah, blah. I've forgotten it all. Thankfully. And I just, I just couldn't reconcile that with what I saw coming out in the literature. And so your study came out and I'm like, bingo, possibly Pilates might work. The causal mechanisms, mechanisms underpinning the effect of Pilates might be psychologically mediated. And that was, that was really cool to see. So what are the clinical implications of this, Lianne, if you were, and there will, there will be some people listening who are physios who teach Pilates, will, does this study change their practice? Should it change their education? Should it change their rhetoric around how Pilates may work for people with chronic low back pain?
Lianne Wood:
I'm not sure to be honest. And the reason I say that is that there's things that are difficult to unpick within the study in that when we look at Pilates and how it's delivered, you're often thinking small groups, six to eight people with a, you know, supervised clinician. So Pilates instructor, they've often had a one-to-one assessments, you know, so there's a lot of individualized care going on. There's a lot of queuing going on. There's usually, I don't recommend people go to a Pilates class in the gym with 30 people, but you know, we are looking at, in this trial is you're looking at individualized sessions of Pilates as well. So I suppose my, my first question is, do we know enough to say that it's the Pilates that was the thing that is, you know, the thing that we we're testing? Or is it that individualized supervised exercise that is the thing that's important?
Lianne Wood:
So that would be my first thing to say. The second thing to say is, I haven't discussed this with Gisela, who's the author of the trial dataset, but although they specified that they thought Pilates might work through this path of fear avoidance and pain catastrophizing, I didn't see anywhere in their transcripts that they, as Pilates teachers spoke ab in a way that said, you need, you know, let's try and reduce your fear of movements, or we're particularly prescribing their Pilates in a way that reduce those things. So I suppose my question is, does that mean we have to change how people deliver Pilates or is it enough to just go, right, we're gonna do individualized sessions and that's enough to reduce your fear because it's individualized and tailored to your needs? Or should we be increasing the verbal cues and assessments of fear avoidance in order to get an effect? I'm not sure is the answer. I think what it says to us is this is an important thing to get an outcome, a, a change in those outcomes. And so we might want to consider assessing for it, you know, individual consultations with patients or, you know, when we're giving them exercises, we wanna probably assess for it and if present, potentially try and target it. But should it change? I don't know. I dunno if we know enough from this, this study and the Pilates component alone.
Jared Powell:
Now you raise a really, really interesting point there. As we're starting to understand more about how exercise works for reducing pain or improving physical function, we're starting to see that it's exercise probably doesn't work via biomechanical or, or classic biomechanical variables such as strength, motor control, so on and so forth. I think there was a study that's just come out recently in osteoarthritis, which shows that muscle strength only explained 2% of the effect of of exercise for a knee and hip oa. So 98% was unexplained. So, so strength is, strength is the one that's been bashed recently. But I think the same thing, I'm gonna talk about the shoulder because that's my area of expertise. We know that scapular dyskinesis isn't really a problem. So you can do motor control exercises to try and change scapular dyskinesis, and that person improves in terms of shoulder pain and function, but the scapular dyskinesis remains.
Jared Powell:
So that wasn't really a mediating variable, so on and so forth. So as we start to understand more about how our treatments are working, it's, it's coming back to these kinesio phobia pain, self-efficacy, pain, catastrophizing, blah, blah, blah, blah, blah. But then do we need to specifically target those in intermediary variables? Like do we need to start focusing more on, yeah, you don't need to be so fearful, you're safe, you're free to move the spine is robust, resilient, your shoulders robust and resilient, so on and so forth. Or do you just, as you said, conduct individualized exercise, you give that person all of their attention, you reassure you, you know, you sort of just say what you normally do as a kind caring clinician, and that will target those intermediary variables. I'm kind of just repeating what you said to corroborate it, but it's fascinating. Do you have anything more to add?
Lianne Wood:
Yeah, I, I, I, I feel like, so the work that I'm, I'm doing at the moment, kind of, which is, it's under review at the moment. It's been looking at, well, what do we do to, to optimize exercise prescription? And again, a lot of, I, I think there'll be a lot of critics of, of it in the sense that a lot of it's shown that the things that optimize our exercise prescription are the contextual effects. You know, it's that therapeutic alliance, it's trust, it's, you know, having that individualized care. It's having someone explain things specific to your circumstance. So what I see the key components of this Pilates trial are that, you know, it was individualized, it was supervised those are P two B really key things for any, for exercise prescription. And I think Jill Hayden's work has, has shown that over the years, that those appear to be key features which improve the delivery and the effects of exercise.
Lianne Wood:
And I suppose the next steps are, and, and something Jill and I have spoken about is, is, you know, do we need to look at, well, what are the key components that make up different exercise types? You know, and is there something similar or, you know, shared mechanisms within those exercise types? Because I think you and I have already discussed, you know, you're right, we don't, we don't deliver exercise at a dosage that's effective for physiological changes. So if it's not that, then what are we, what are we doing? And I think it's more about the kind of the context of the therapeutic consultation, probably more, or is it other things like the aerobic, you know, physical activity, you know, again, going to that whole, the whole person wellness bit, you know, like in terms of is it getting out outdoors and and or is it being with people, you know, being a part of a group and having those peer support group, you know, what, what are the things that, I don't know how we can optimize it effectively in, in our clinical clinical consultations.
Jared Powell:
Yeah, it's, I think you mentioned in your paper, it's the, the range of, of mechanisms so diverse that could sort of, in some way mediate outcomes, you know, the full range of biological, psychological, and social mechanisms really. And they could be interacting together to explain the beneficial effects of exercise. It, it, it really is fascinating, and I'm with you. I think, I think there is, so this concept of shared me mechanisms, I think there is something underpinning all movement-based approaches, really all therapeutic exercise-based approaches that they all kind of share. And we like to bash on one. So we like to strength, people like to bash on motor control people and motor control people like to patch on the gym bros and say, you're not doing it properly. And that, but it's the same with manual therapy. Like even manual therapy I think will have similar shared mechanisms underpinning the effect as exercise. It might just be feeling confident to move again or reducing sensitization somehow, or, or just feeling listened to or whatever, right? Like, so within physiotherapy, I think this study of causal mechanisms is it's gonna elucidate shared mechanisms that all of our treatments, which we like to kind of compete against each other, that they all have. And perhaps we're all more alike than we think that we are
Lianne Wood:
Completely. And I think what's, and I think this is probably this thinking's so much that us to kind of understand these treatments more. And I think what's hard with exercise, and certainly that's where I'm at with my research career at the moment with it, is that, you know, we've used exercise for so long, you know, but we don't really understand it very well, you know, and so there's this given like, oh, exercise is effective. Yes, yes, it's effective, but well, how is it effective and, and why? And you know, like all these other questions, like, it's really hard to get those answers because there's this assumption that we just, we think we know enough, you know, and, and trying to break it down. It's quite tricky.
Jared Powell:
Yeah. And the, the thing that I, yeah, I totally agree. So exercise is pretty much recommended in every clinical practice guideline for every musculoskeletal condition since the dawn of humankind, which is crazy. Well, it's not crazy. I think, I mean, it's, as you said, it's, it's an effective treatment, small to modest effects most of the time. But it's pretty amazing to think that we have really no idea how it works. And yet we at scale recommended it for pretty much every musculoskeletal condition. So we're really putting the cart before the horse there, which is fascinating 'cause in science, right? Like to have a mature theory in science, you need to know how and why that theory works. And then if you know how and why, then that should lead to predictions. So the predictions should come after, you know, the how and the why, but somehow in health science we, we have the prediction that exercise will work, but we don't know how the how and the why.
Jared Powell:
And then I think is that somehow responsible for the small to modest effects that we see. So is there some way of leveraging, like if we find out how exercise works, and it might, it might be a bunch of different mechanisms. It's not gonna come down to one mechanism, right? It's gonna be, and it could be different for each person, but if we have a group of mechanisms which we think mostly explain how exercise works for certain conditions, are we able to manipulate and leverage those mechanisms in our clinical practice? And will that lead to better clinical outcomes? So I think that's the sort of the, the next frontier where it's not just finding out the mechanisms, but by, by really targeting these mechanisms and manipulating them and leveraging them and, and trying to optimize them, does that lead to better effects than what we see these small to modest effects? Do you have any, can you, philosophers, can you speculate on some possible answers earlier? Can you, can you save me from my nightmares ?
Lianne Wood:
Well, you know, I suppose, like it's been a bit of my, my research story with it in the sense that like, you know, you look at even the who, you know, like what, what the World Health Organization supports, you know, everything with exercise that we know it's, it's good for you, you know, it's good from cardiovascular point of view, from bone health point of view, from a mental health point of view. So then it begs the question, why is it only small to moderate effects? You know, why isn't it bigger? And yeah, I think the, the question is is, is the R C T the best way to test for that? Because if exercise is so individualized to the busy mom who has three kids and is struggling to fit time and for herself to the lonely old pensioner who has more time on his hands than he knows what to do with, you know, and they all have back pain.
Lianne Wood:
What exercise is the right one to be prescribed for each one? And therefore standardization becomes tricky across different individuals who have different contexts and different settings and different circumstances and backgrounds. And how we then test it in a gold standard approach becomes tricky. And there's also a limiter in the sense of training for clinicians. How do we know that clinicians are delivering any intervention to the degree that is optimizing each of these identified mechanisms in a way of fidelity? You know, we look at the recent restore trial, I think the cognitive functional therapy one, which had 60 hours of training for clinicians and the exam to pass at the end. Is that what we need? You know, I, I don't know, but you know, there has to be, there are barriers I think in the current research world as to how we answer those questions in a feasible and pragmatic way. Because as a clinician it has to be pragmatic. Do you know what I mean? We have to be able to deliver it in clinical practice otherwise, like, doesn't help, do you know what I mean? Like
Jared Powell:
Yeah. Otherwise it's all just academic fluff. Yeah. Philosophy fluff. It doesn't change real world. Yeah. Such good questions. What do you think, like what do you, what do you think with the randomized control trial is that, is that, I mean it's obviously it's gotta be the basis, it's gotta be the gold standard to an extent, but we can discuss nuances and limitations to the randomized control trial. So we're not gonna bash the R C T No, but I think it's, I think it, we can ask a question. Is it, is that, is that the best method to answer these questions?
Lianne Wood:
I, I don't know is the answer. I mean, I, I, I'm in the process of trying to develop a, a training tool for my kind of current postdoc fellowship and everyone said, well, no one wants to fund any more trials for exercise. So, you know, we we're not taking it further to trial, you know, and you're just like, oh, this is really sad, you know, but at the same time, I dunno how we get, you know, we can't do causal influence mediation analysis without good RCTs. So, you know, the, the reality is to, we need high quality RCTs that are of lots of people, but have the ability therefore to ta tailor treatments that have probably similar components or similar principles of treatments, but they need to be big enough so that we can therefore control for those factors and, and compare appropriately. Yeah.
Jared Powell:
Can I tell you something crazy, Lianne? So in, in in rotator cuff related shoulder pain, rotator cuff tendinopathy, shoulder impingement cohorts, do you know, there's only been one mediation analysis published ever on that For exercise? Yeah, for exercise, literally. And that was just published like one or two years ago. There's been nothing else. So there's been hundreds and hundreds of clinical trials that have tested exercise against control or another exercise or usual care. There's been one mediation analysis, which I just find absolutely mind boggling. So there's, there's heaps more in the, in the, in low back and, and osteoarthritis, but the shoulder is lagging 20 odd years behind. And so that's, that's crazy. So it is sort of depressing when, when I hear that they're, they're reluctant to fund these trials and therefore making mediation analysis harder, where in the shoulder, which is MySpace, there's nothing there.
Jared Powell:
So we're all just speculating. And then I did a scoping review recently where I looked at the clinical rationale and causal explanations for why clinical researchers think that exercise works for shoulder pain. And 95% of the time they, their causal explanation was biome mechanical. It was, this exercise will increase strength, strength which will decrease pain. This exercise will stabilize the scapula, which will decrease pain. Only 5% of 110 studies mentioned a a psychological phenomena. Wow. And a social construct wasn't mentioned once at all. At all. So that's crazy. So this is where we are, right? And I, we're not gonna get any further if we don't fund the research.
Lianne Wood:
And, and to some degree, I, I mean there's, there's still, I, I kind of think, and this is a slight slide, but as clinicians, there's, there's still gotta be a, a shift in that what you're saying in terms of shoulders still so focused on biomedical essentially is that as, as a clinical profession, we, we haven't made that jump though in terms of our treatments. We don't, you know, we, we we're all about talking about psychosocial and saying that we're holistically treating and assessing the person, but we don't, and I just, I, I don't know. My sense is that we don't have the clinical skills to feel comfortable prescribing exercise for other things other than the biomedical. We're all very comfortable to give someone sticking with the shoulder, you know, range of movement exercises or strengthening exercises. But if I told you to, to, you know, if I asked for exercises to reduce my fear, you know, we were suddenly a little bit less confident doing that. Yeah. And I think as clinicians, that's probably where we need to step into from an education point of view, is trying to help clinicians feel more confident treating the psychosocial components. And probably this study shows that those psychosocial components are really important, but I don't know if we know how to address them in our treatments adequately.
Jared Powell:
Yeah, no, I agree. We're certainly not trained to going through university it was all very much, you're a clinical detective, you've gotta diagnose this and you've gotta give this to fix that. Right? And it was very linear. Like this equals that. It was an isomorphic relationship between that person is weak, you strengthen that person's pain will go away. But there's so much more complexity as you, as you well know in it. And I look honestly, Lianne, I I'm gonna be controversial here and say I don't think, I don't think it's that hard. So I still, I think we can give exercise, right? So say for example, someone comes in with knee pain and it hurts when they do a squat. And so this is why I like Peter Sullivan's work, and I, this is why I like the restore trial a lot, this cognitive functional therapy, because you take that because you, you can use movement to do these behavioral experiments, right?
Jared Powell:
So you take that person out into the gym, you go, okay, it hurts when you squat and this is after you've built a rapport and you've got a therapeutic alliance and all of that. And then you try and manipulate certain variables. You're like, okay, how about we try a lunge? Does that hurt? How about we lessen the load? How about we go knees over toes? How about we go stick your bum out? How, how about we go just sit down, like sit to stand. You manipulate all of these variables and then that person hopefully will find a movement that they can do, they can accomplish. And then over time you might titrate that up until they're eventually squatting again. So this is where I think you can use exercise as we're just traditionally and classically trained, but you can, you can use it in a behavioral experiment type setup where you are affecting their cognitions, you're affecting their psychology, you're affecting their, their deep dark fears and emotions, you know? And so you can, you can bring it all together
Lianne Wood:
Completely, but I would say that this is you after how many years of practicing and you've learned how to do that. Yeah. You know, and, and I think that's, so with the research I've been ongoing with, I've had a lot of patients who I speak to, you know, about their experiences and, and yes, the more experienced clinicians have developed those things over time and, and trial, you know, by making mistakes and going, oh, that person never came back. What did I do wrong? You know, or like, what happened there that that didn't go so well? You know, like, but we've all learned kind of the hard way through Yeah. Through practice, you know, or through, through either either training. And I think that's where it's how, how we get this in into to the beginning of it's because as I say, the patients I've spoken to, there's so many of them who have not had that good experience from their clin, their physios or their clinicians.
Lianne Wood:
You know, they've been given a sheet of paper and said, there we go, there's your exercises. I'll see you in three weeks time, you know, six weeks time. And they aren't individualizing or tailoring that exercise to them because there's evidence to support that doing what you've just suggested. You know, taking someone to the gym and moving them around and you're building their trust that they can see, you're trying to find the right thing for them. And if they can find an exercise that doesn't aggravate them, but makes them feel better than they will have more trust in you and therefore more motivation to do their exercises 'cause they can see the benefit of it and therefore there should be a change. So there's lots of these other kind of things going on in the background, I think.
Jared Powell:
Yeah, that's, that's, that's super important I think, Lianne, that's, I think you hit the nail on the head there. Perhaps it is just the context, perhaps it is the relationship and maybe natural history and time takes care of the rest. That, that, that's a, that's a really fascinating point actually where, so in my head I'm thinking, oh look, you're just, I'm sort of thinking real time here and I've got too many thoughts running through my head. I'm, I might just shelve that thought because there, we could, could end up down a whole different pathway, , but I think Dave Poulter on Twitter has this context exercise, which I sort of thing where whenever you give exercise, there's always contextual effects involved, right? And that's, and that's always gonna be happening no matter what exercise you give, you give and you can't get away from it. And I think everything you say is really resonating with that. And, and I think this is why this, this mediation analysis that you've done is really, really important because it, it shows in quantifiable terms that things outside of Omo variables do matter. And kudos to you for, for doing it. I'm sure it was a, a labor of love trying to learn causal inference and then, and then do it. I'm sure there were some dark moments there for you.
Lianne Wood:
Yeah. We won't go into this ,
Jared Powell:
Would you do another one?
Lianne Wood:
Yeah, I, we'd do another one. I mean, it's, it's exciting to, to show that there's, there's this other side to exercise and kind of be part of building that picture. I think that's really exciting. And I probably like, it's really nice to be able to answer a question and I think that's, you know, it's really cool to be able to go Yeah, it does. It's really important.
Jared Powell:
So when you, if have, have you had a musculoskeletal injury recently, Lianne?
Lianne Wood:
I struggle with back pain. Of course you do.
Jared Powell:
Lianne Wood:
Only, only recently, again, because I've been moving out, I'm stressed. Have you done,
Jared Powell:
Have you done a, a course of Pilates yet? A 12 week course of individualized Pilates? No ,
Lianne Wood:
No .
Jared Powell:
So I, yeah, look, I I definitely don't practice what I preach, but no, you're, I, so I've, I've been through a bunch of different injuries recently and I always try and think about, you know, what I'm feeling and how I'm gonna fix it and blah, blah, blah, blah, blah. And I always sort of come back to doing a bit of exercise for the various conditions. And I, and I really think a lot of it is for me, and I, it's very hard to, you can't, we're always biased when you're talking about yourself, but I feel like it's, for me, it, it always comes, comes down to between the ears. Like, am I confident to do this exercise today? And so, so for whatever reason, someday I've got a so a sore back and I just, I, I don't want to do a deadlift and because it does, it hurts my back, right?
Jared Powell:
But then a day I wake up, I really wanna do a deadlift and I've still got the same back pain. But because I wanna do it, my, my, my motivation is high. I managed to reframe and re sort of conceptualize that exercise and I can do it. And I think to myself, what's, what's going on here? My back pain feels it's three out of 10 on two different days. One day I don't wanna do a deadlift because I'm some, maybe I'm fearful 'cause I'm gonna aggravate it and the next day I do and I do it and it's okay. So I just, I think to myself, and I'm sure there's millions of people throughout the world who are sort of going through this, like, it is fascinating the tricks that the mind can play on you when you have a bit of pain and how exercise can be used as a tool to try and manage that pain.
Lianne Wood:
So there was a paper and we did reference thing and I can't remember who wrote it, but spoke about the common sense model and, and including the fear avoidance model into that and talking about how it's perfectly talking about those two experiences of fear. And if you could imagine that, you know, the one day that you've got three outta 10 back pain and you don't wanna do a deadlift, but the next day you've got a really important like, thing you've gotta be at and you know, you, you know, whatever it is you really, that puts more pressure on you. You know, you're fearful, you don't wanna hurt your back more so that you don't suffer more that next day with another day you might think, well actually, like, you know, I'm, I'm feeling good, I'm I'm gonna go for it. You know, again, those contextual factors are, are important.
Lianne Wood:
But the other thing is just what this study was saying was that it's really about that common sense. It's, it's quite normal, you know, if you have something big coming up, one impending, whatever, or you know, you're gonna be more, you've got more onus or you know, pressure on that decision. So that's perfectly normal. And so why don't we normalize that within the back pain world and normalize that for our patients as well in terms of reassuring them that that's quite a normal model or, or you know, fear is a, a perfectly normal part of that. It's how we break, break that cycle, you know?
Jared Powell:
Yeah. That common sense model is, is an excellent model. Is it leave and fo I think
Lianne Wood:
That was the original I think. Yeah, yeah,
Jared Powell:
Yeah. Matt. Yeah, true. Yeah. That might be the original. And it just, the fear of volumes model. Obviously it's famous, the common sense model, all of these things, which I think we've heard of, but when you go back and read them, they do, no pun intended, but they do just make sense. They, they, they do just feel like it's, it's common sense, right? You know, it's not common sense isn't common, but like, I think we should all go back and read these, these papers because they do sort of just bring, they zoom out a little bit and you go, oh, okay. It sort of just makes a, a bit of sense there. And so I would encourage everybody to go back and, 'cause you do reference it. I remember reading your paper you do reference the common sense model, but
Lianne Wood:
The study where they, they use the common sense model on fear avoidance in back pain is the, is the one that I'm thinking of and I can't find it now.
Jared Powell:
Sorry. Gotcha. Okay. I I've got your paper up here so I can probably
Lianne Wood:
It. Yeah, I'm trying to find it. Sorry, . If I see it. That's right. If I find it, I'll let you know.
Jared Powell:
So what are you working on now, Lianne? Have you got, have you got things in the pipeline that are gonna change? How are we approach another particular exercise? Or, or what are you up to?
Lianne Wood:
I've just finished a realist review looking at how, what are the key mechanisms of exer exercise prescription for back pain? So probably that's where my head is so much into the contextual factors at the moment, because that's really looked at what our key mechanisms are. So that's under review at the moment and the results of that we're trying to develop into an online training tool for clinicians to try and help them deliver exercise better.
Jared Powell:
So that's a systematic review or is that a,
Lianne Wood:
So a realist review is a different type of review. It's got a, so realist ontology is essentially what, it's different to systematic reviews, quite complimentary, but it looks at what works for whom in what circumstance or context and why. So whereas a systematic view would look at generally as a effectiveness, you know, so you know, what kind of exercise is most effective for back pain or, you know, pain intensity, you know, let look at pain intensity or physical function scores and compare usual care to exercise treatments. Whereas a realist review tries to unpick the context and the, and the mechanisms that relate to those outcomes.
Jared Powell:
Yeah. Awesome. I I just used a, a critical realist methodology for a qualitative study. So similar sort of thing with a realist ontology and then a constructive as epistemology. So that was, so I, I, I love that stuff. So, so tell me more about that. So what are you , what are you trying to do with that review? If you don't, if you're not going to, if you're not giving anything away. Well,
Lianne Wood:
Essentially we've looked at what are the key mechanisms of how exercise may work to affect changes in back pain. Yeah. And the key mechanisms at play appear to be trust, motivation, and confidence. So those are the things that kind of appear to really help drive exercise effectiveness.
Jared Powell:
And so where are you getting the, where were you getting those mechanisms from? From clinical trials? From
Lianne Wood:
Mostly qualitative papers. Yep. Cool. So we included about 72 papers in total. Majority were qualitative, but a bunch of trials. Mediation analysis, secondary data analysis, narrative reviews you name it, we kind of, we had it in there, . Cool. So yeah, so you kind of do it. We, the realist processes was really interesting in that we did a program theory, which we developed with patients and clinicians and from a lot of the work of my PhD, and then took it to kind of a scoping review, refined that initial program theory of how we thought things might work, tested it, took it to the literature, did this initial scoping review about 40 50 page papers modified and created these kind of context mechanism output configurations. And then we tested them with the literature. So went back out and got more kind of systematic reviews and, you know, things like that to then test the results and then refined them. Love
Jared Powell:
It. This is, this is great. I, i, we should have been, this should have been the subject of the conversation. This is . It's good to talk to someone, those
Lianne Wood:
When the paper gets released .
Jared Powell:
Yeah. Yes, exactly. I'll, I'll get you, I'll get you back on for sure. But that's, that's, that's fascinating because you mentioned context and mechanism outcome, and that's, that's super important. Like, so what I, what I found in, in my qualitative paper was that, you know, mechanisms are only activated in certain contexts, right? Yeah. And there can be contexts which inhibit the activation of these mechanisms. Yeah. Such as therapeutic alliance. So if, if you hate your clinician, then that's clearly not gonna activate a mechanism, perhaps because you're not gonna do the bloody exercises in the first place and you're gonna go to somebody else. So there are contexts which can really activate and inhibit these mechanisms. And this is something that's really not talked about, not, it's probably talked about a little bit, but certainly not enough. And, and I think that in the day-to-day clinical practices where the magic happens, and that's why therapeutic alliance is so bloody important.
Lianne Wood:
Completely. Yeah, completely. And we, we don't, I, I feel like we've only really been talking about therapeutic alliance the last few years. Like, like certainly as clinicians, like mm-hmm. There are lots of papers about therapeutic clients. So clearly the research world has been, but certainly as a clinician, I didn't feel like we've had much emphasis on that or, you know, how important it's, and it seems to really be the, the foundation your, your, your foundation stone for, for, for which everything happens from, you know,
Jared Powell:
I think therapeutic alliance is, is why the, the quack on the street corner has everybody coming back to him every week, you know, because he remembers the name of their children, he takes an interest, he talks to them, you know, he is not aligning any chakras and he is not, you know, what deactivating trigger points, just time and perhaps and putting your hands on a sore spot, you know? So I think, I think all of that sort of stuff there underpins health and medicine going back thousands of years to Hippocrates probably.
Lianne Wood:
And, and so here my question is philosophical question is, is is that because we've lost community, that therefore those things are so important today, we want that community.
Jared Powell:
Absolutely. Especially when you get in today's medical world of, you know, shorter and shorter appointments in a physio practice I used to work in, it was 15 to 20 minute follow ups. And you know, you do that for 20 times in a day. I can tell you from experience, I was struggling to care about the people. At the end of the day. I was worried about doing my notes, I was worried about getting home, not two hours late. I was worried about what I was gonna have for dinner. I was worried about, you know, all of these things. Right? And so, yeah, you're right, the system isn't really facilitating community.
Lianne Wood:
Yeah. Completely. But, you know, people also have lost in their lives, you know, urban lives where you don't know your neighbor, that that doesn't facilitate community either. And so people who, you know, may not have social structures that are going Yeah. Back gonna social again.
Jared Powell:
Social for sure. And that's, yeah. Anyway, I think, I think we're gonna distract, we're gonna, we're we're gonna begin to draw things to a close here because we've, we've, we've covered a lot of ground. I want you to, so, you know, there's this whole thing in modern day email, I think too long didn't read, and it's like a two minute snapshot of the conversation, Lianne. So if you could give someone a one minute, 32nd synopsis of your paper a too long, didn't read, what is the take home
Lianne Wood:
Pain? Catastrophizing and kinesio phobia appear to be important mediators on the pathway from Pilates exercise to changes in pain intensity and physical function. And so in our clinical settings, it's probably important to assess for these factors and see if we can design our treatments to incorporate them. Beautiful.
Jared Powell:
Love it. And would you recommend the Tampa Kinesiophobia Phobia Scale and the pain catastrophizing scale?
Lianne Wood:
Yeah. So people should start, start to use them. I think we should probably be using more outcome measures, validated outcome measures in our clinical practice. I don't think we do that enough as physios, but we probably should be using them more often to assess them and then treat them if, if it's a problem.
Jared Powell:
Love it. Lianne Wood, thank you very much.
Lianne Wood:
No Problem.
Jared Powell:
Thank you for listening to this episode of The Shoulder Physio Podcast with Lianne Wood. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
