Pain in Practice—Sports | Dr Peter Roberts FACP

[Music] Welcome to Physios on the mic, bought to you by the Australian Physiotherapy Association. I'm Sophie Shepherd. And I'm that far. We'll be your co-host for season two, pain in practice. Welcome back everyone, and we are very, very excited to have with this Fizzy's episode, Dr. Peter Roberts. Peter is a specialist musculoskeletal and titled, Pain in Sports Physiotherapist, with quite a few decades of experience. Now, how many years are we up to now, Pete? We're up to 51. Just a couple of just a couple of years of experience there. Peter has had a lot of experience over these decades. He's worked across a lot of diverse settings, starting his early career with working under Jeff Maitland as an early grad, and then going on to work in sports, supporting athletes that lots of different levels from a local cricket and netball teams, all the way up to working for national netball teams, as well as the track and field at the Sydney 2000 Olympics. He then went on to develop a passion for helping those who were a bit stuck in their recovery and proceeded to delve into the space of persistent pain, founding the Paragon Pain Program in 1999, alongside two psychologists. And he's been very active in the educational space and supporting the profession, having taught us a guest lecturer in the undergraduate and postgraduate physio program at the University of South Australia since 1980, and he currently lectures to physios in complex pain management in the Master of Advanced Clinical Physio Therapy Musculoskeletal Program. He wrote and delivered the Advanced Clinical Pain Course, which is soon to be the pain level 2 course for the APA, and his active member and volunteer with pain revolution, where I was very privileged to have him as my pain rev mentor. So I struggled to fit a succinct bio in their peak because you've been very, very, very busy, many hats there, but so thank you so much for joining us. Pleasure. I'm really excited to be part of this podcast, and hopefully I can influence other people on their journeys to really get on their bikes and enjoy it, and go forward in curiosity. I'd have to say that I was thinking about the podcast and thinking about what sort of things have driven me. It's curiosity. I really wanted to know more. What do I just say about what's going on? And I was very curious about people, you know, the very complex. And I guess as my career has evolved, I've got more and more interested in people, and their stories, the complexity of the individual, and discovered that the individual is the key in how we go about things. We're struggling to show to our CSTs what really works best, although we're getting closer. There's more studies now targeting down to individual. If you like, packages to match the individual's needs, and the tools they need, and they're still complex as art. And so we're still not getting the great data that we were hoping to get. But we're getting much closer, I guess, Peter O'Cell, is leading the way recently with his CFD three-year outcomes. But it was on a lot of mostly. He's had several projects that have been demonstrating some good shifts. And it's really lovely to say. And it's just adding more magic to our toolkit. So I'm really glad that these guys are out there really putting their feet forward. They're both passionate and driven. And I'm really pleased to be part of Losers Bad Revolution. The culture there is something I can't describe. And I feel very privileged to be there in that group. Amazing. Awesome. Thanks, mate. You know, I think the other big thing is to stop learning as a physiognomist. I've done every course that I feel is relevant every year, every conference. I love to learn to hear. And there's always gems that you could take home with you. And part of it's the gems of catching up with people and sharing ideas. I really loved bedrilling you so because you're so passionate. And the danger was that I was quite passionate as well. So I pretended to go pretty literally at times, which was fun. But you always come back to the centre, don't you? And that's enjoyable part about teaching and collaborating. And I said, no, the more you give the more you get really. And I do like that part of that. Absolutely. And I think, you know, because I mean, we know each other pretty well, Pete. And we've already spoken about, you know, really, I guess the complexity of individual people. And I know that particularly Matt, who's not really met you before, had the opportunity to meet. I know he was really keen to hear a little bit more about, I guess, your journey. So Matt, what jumps out at you, you know, what do you want to know about Pete? I feel like you all all over the place. Kind of thing like, you know, you talk about starting in sports, which is I feel like that's every physio as I start out. It's like, oh, I want to be that sports physio. So, you know, it's where I'll start. And then you move on to more pain programs and, I'm staying more complex pain issues as well. Maybe we'll start simple and what kind of drew you into physiotherapy? Because a man of your skills, I feel like you could have done anything. Thank you. Look, it's a beer journey, really. The fascinating part is, as a young boy, 11-year-old, I fell off a super stack and was about three meters high. And I really hope myself. I still remember that I couldn't move for about a week and I was on a farm and I sort of had a grot to keep back from then on. You know, I'm really never understood it too quite a few years later. That led me to be dressed in the body, I think. And then my grandmother had quite severe rib joint arthritis. And I remember the physio. And by that time, we'd moved over to the city because I was a college. The physio used to come in and the physio was like a god-set. There was a really hope of movement and relief. I thought, well, you know, that's a really special job that physio is doing. And they really motivated me to get into physio initially. I struggled to get in because actually I don't have a mathematical brain. I got the H and history prize. But I was always bottom in the class in maths. And in my days, you had to do a science pathway. Everyone did, you know, maths weren't maths to chemistry, physics. And none of them were very strong for me. So I had to repeat it to get into physio. You know, it's been a really wonderful journey. I mean, part of that too was that I was quite a high before the athlete myself. I was playing quite a high level tennis. I was running cross-country competition. You know, I was playing a lot of sports. I love sports. Right. And so I was very interested in sports. So that's where that started. And I think my interest in sports was from a scientific basis. And I wanted you to understand more about curiosity coming through. And then when I finished the physio degree, I was really lucky in that. In my day, you could actually, if you're with the public hospital system, the Queen Liz, they would actually sponsor you to do the investments, to do the physio therapy course. There wasn't a sports course in those days. It was all about manipulation, Jeff Maillan and lettuce into the world of moving from mass suicide. And you know, this whole clinical reasoning approach. So, you know, that was just such a wonderful time because Jeff's clinical reasoning, all those physicals are still all there today. The core of how we reason and un-family people. And you know, he would always prove what he'd done, had did a work, did a change. Proving the gaining all the time is exactly what it's all about. And that led me into that world. So I did say I'm diagnosed for a very heavy sporting career and looking after a stake. Nepal and local district cricket teams and, you know, really involved in that. But when I was at Jeff's practice, he had a very high manipulative hands on the bridge, which I did as well. I was manipulating probably to eight to ten times a day. Usually I'm about 20 patients in his practice. But I found there was a group that just were responding. And so I said to Jeff, "My day, give me one of my keep these patients, the stats are just fine. You're right back, man. I gathered about 100 of them over about six months. And they had some very common themes. They were their problem one three months. There was usually some sort of trauma, psychological stress going on. And that led me on that other path way of trying to understand this group. And because actually they ended up being the main ones that you have on your list. Because the sportsmen are all getting better. You just got to get a bit of good program. They got to recover. You know, they're driven. They've got great youth systems, usually both of that. And then there's the chronic ones. And then, you know, there's that psychosocial debate that seems to be highly usually stressed, depressed, lost their identity. And so, you know, you're in that world of chronic bad again. It's sort of started from there really. But, you know, sports careers are not good for families. You end up being an athlete before and after during. And so, I did sort of make a conscious decision to move into a more family-irritated pathway. Because, you know, you just can't have a family being an athlete world very well. So, that was motivated me a lot to be around it. have loved to done a lot more international sports like or even other Olympics but it's a big ask and if you are you've got to follow the Olympic team that you're excited to you know and go around with them so that led me away from that. But you know I did do a lot of things in that I was running basic and advanced table courses actually went over to India before their golf world games and we taught the Indian Physios how to do taping techniques and I was teaching at a UDSA as well so I was sort of a part of that already school was in my head so yeah it was quite good and I used to run taping workshops for Physios students at my breakfast and the school would send them down to do it because I didn't teach at school so I really loved all that and I'd get other Physios heavily involved and you know it's quite good and my breakfast was quite big I had up to 10 Physios there at one stage but we had a very strong commitment to having a year a apprenticeship for Physios or better shape where that after you sit in with a Physio every week that'd be able to three months assistant sort of booting their skills pathway and we never had any trouble getting Physios and they're really good Physios they knew it was offering good training and good opportunity so we're always lucky in that way. Pete is it okay if I come back to something that you mentioned before when you were sort of starting earlier on and you were working in that sport setting and noticing these people who were just stuck because I feel like that's an experience that I think most Physios who are listening and I know myself have had that experience of sort of coming out with all these skills from uni and going right I'm ready to help solve the problems of the world and then feeling like you know you're just hitting a wall sometimes and you sort of realise maybe there's more to this than what I thought and I need to you know upskill or I need to seek out more information so I can better support people and I mean the landscape now is very different when we're talking about pain science and pain management because you know you already mentioned lorimab among you know many other researchers at the moment there's a lot more resources and education now around pain but I'm interested in what that was like for you early on because I can only imagine that there was a lot less in the pain space available at that time how did you go on that journey and what was your learning and exploring pain more what did that look like for you? You're absolutely right so if there was there was very little out there I remember I had no awakening when I went to one national I think APS conference and there was a guy there I think it was Philip Sado and another guy I did an article about this whole thing of central sensitization and it was like it suddenly made sense there is another mechanism and so in those days it was only no susceptible in Europe I think and no simplistic we know is a new energy relatively but because there are these people are often sensitive you know and they're often protected and there was always psychosocial stressors in there there was a bigger wake me for me and that's that's when we started really working on the pain program idea it was a really funny story that started me on that what had happened was I had this lady who came in with all this spas I've been her back and she was locked up and I had a bit of a reputation this is about the 90 80s I reckon I'd have a reputation for being good with my hands and I should and I'm in the field later and she's straight and I'm gonna touch her and I'm like oh that's wonderful you know and I gave her a few little things to do she came back about a month later the same so I went through that I was going on I know nothing I know I can't work out what's going on and anyways did the same yep great two weeks later she's back again and I could just detect there was all this stress in about it people in those days are really scared of socologists they really saw it as see by your head look you've got all this tension in your body I think we need some of the hope is dry and lower this and socologists are experts and she bought that idea and so refer to this lady hot gum across who is Maria Polymanais actually you know and she was the one who I hope to co-found the pain program with but to come I was always taught she went to see Maria I don't did see her again I was like oh what happened so I rang Maria and I said oh I was very curious how you got up with this lady she said I was simple I just told I was okay don't have it affair with the minister to leave her husband so you know that was a problem but you know sometimes people weren't open up to you so you definitely need your colleagues to help you sort of unpack these things and you know some time and time again I define that you find your life back stuff socologists how had you buy that out and then this I got this didn't realize they were hurting themselves like that so you know having that age and just routine really struck home at that time and that you need your colleagues collaborating because we do tend to work in islands and always look for opportunity to reach out and have a chat you get somebody surprises and so many helps and it makes you really much more enjoyable when you're collaborating with others well that's certainly a story I think that tops all the stories I've heard before starting a pain program I guess what was your criteria all the the things that you found that was essential that people must know to help manage their pain when making a pain program it's a really good question I'm thinking about that you know I was always curious about you know what really concerned people most and and it surprises me what they did what I know and the way that I came across that was when people gave me to the program you should sit up down the screen but I was like well why are you here today and we do a brainstorm on the whiteboard you know all the reasons I was there but you know most of the time that didn't mention pain was you do my life shit I hate this it's ruined my marriage I can't work I lost my identity you know they don't talk about agony or pain and I was really frustrated by that but you know they this seemed to open up because they felt everyone the room was on the same page you know and they didn't think about the pain issue it's just how much of the rest of their life suffered and there was a real eye opening for me to really get on my bike about I need to understand people a lot more and in that space I did a motivational interview course and that was one of the best things I've ever done in my career because it taught me how to have conversations that allowed them to own and have have the vision to take control and it's such a powerful gift you know and actually we're not to run some motivational interviewing courses with psychologists for a few years there as well I had to pursue that because it's not my dream to be doing that I'd rather be teaching videos about chronic pain but it taught me so much about that relationship building and and there's something I do a little segment on and the advice was playing course you know because I think all physios you could call a motivational interviewing or interviewing skills that help them own and if you'd like to take a draw of things discover how can I go forward and get my life back. I agree it's such an important skill for us to have and to be honest I'm kind of a bit amazed that isn't the foundation of a lot of our communication skills even now because I know for me when you know I did an MI course a few years ago and I had a similar experience I found it so drastically altering to the way in which I sort of approached practice in the way that I thought about even just the structure of the consult and almost how can I get my own agenda and my own ego out of the way so we can actually get to the person who's in front of me which you know sounds strange to say but you know we don't realise how much we tend to center ourselves as clinicians a lot of the time unless we're not just thinking about it so yeah I agree with you totally I'm really interested actually people you know you had this journey this transition you know from doing a lot of sports work early on and then moving into this sort of complex persistent pain space and I know you drew comparisons earlier about how you know many sporting patients do tend to recover and get better and you know maybe are a bit of a different presentation but I'm interested with all that you've learnt going down that journey of venturing into the pain space when you reflect back on the sporting context and sort of some of those you know sort of athletic populations are there aspects of the pain science and pain management that you still feel are you know really critical that you sort of still use in that sporting context or that you see as being really important even though it's maybe not traditional pain management sort of setting absolutely so I still see quite a few elites, Walthamon, treating government state grade state ones, quest plays at the moment and I've seen a lot of runners because I was running running courses for physioes and physioes do refer me complex rolling injuries but also my name's still out there a bit so I'm often in the back lane assessing running and/or squash or tennis so I do have a big interest there I mean you know in my lecturing and teaching a uni it was on rehab of movement movement, our analysis of the training and that started from Shirley Salmon I thought she was gold when I first met her because she didn't actually start by looking at people from the objective movement but she started looking from how they moved well hers went again out of chair How do you do that? And that shit just changed it and after that's better. And you know, she would go to that level. So with athletes, I go to that space a lot. Where does it hurt? And how did you do that? And you know, it's often breaking down with video analysis and also getting into the detail and depending that, the flexibility. And there's also a big group with chronic recurrent pain. This white squash player in particular recently I had. He's had a bit of a chronic body all his life. He's quite an anxious stress sort of personality. And he developed this really funny pain that didn't make sense. He was sort of going from his elbow up to his shoulder. You know, when he was trying to, you know, high smash, which he says he always stuffs up. So we started out begging that and he had some sets. He sets an even e with pit brick. I actually got him to do the recognized program. And he was really low for his squash player. That was really unusual. Like, it was only getting 60% recognition on the recognized. And then I put him in the mirror with the other doing a smash. And I brought out his elbow to shoulder plate the other arm. So, you know, that was really exciting. You know, and he liked the label. This is a disappearia. The novel, you know, like he liked a diagnostic label. But he turned it around with it two weeks. You know, he did mirror training. He realized it was his systems. So he did the recognize. We did some set trick. He did training. And he got re-evented. He's now playing number one state one. So, really before that, he'd be down to two or three levels. Because of this confidence issue with his arm and elbow. I got another squash player like that as well who was going to give up. When he was in state four with the chronic knee growing, ankle and sort of one-repanter. And again, he's a really smart personality. He's at Hectuary, which is all into stats and detail and energy and super funds and stuff like that. And he's actually a huge advocate for me. He's so good at racing state one as well. And he's in his late 40s, but still winning. He's a very good patient. He's very obsessive, you know. So anything you give him is good. You're going to be careful with his typical boom buster. So you can't sleep talking about the sweet zone and pacing. But he's onto it. And he'll give the detail. He'll do it. So I really enjoy those because, you know, they have a lot of energy and the motivations. And there is also good, you know, to get them on page. I mean, that's a lovely part about practice. In a way, it's funny with people often talking about, "Oh, I can't do the housework. Oh, I can't do it. My God, I think I said, "Oh, let's turn this into a gym." And so be it a bit of a gym program. And it sort of shifts the context like, you know, you can get fit in this gym. You've already got it. You're ready for anything. You fit for purpose. And that's losses a little bit, you know, purpose. So find the things that are relevant and meaningful that you value. And then, you know, you're into it. With your examples that you've given, it sounds like you were helping them explore the bi-circle social model without kind of making that more explicit to them to get them on board. Is that right? Yeah, it is. It's interesting. The big thing is to be listening and being present and silence is actually helpful for them to quite a plate because it's saying, "I want to sort of sit with you on this and I'm curious about what I was thinking." The guy had the orbit, water paint, had long term anxiety and had seen a psychiatrist. And I never knew he'd do that because I could tell he was very private about that. I sort of knew just from the things that have been said. He's now opened up right all up about it and we're often when he comes in with another injury or whatever we'll talk about, you know, what sort of stress he was under. How has that affected his before, was on the day? And he's got a really good body scanning and breathing and using techniques on the game done. You know, particularly if he's got a really hassling, challenging player that he's trying to work with. But you're right, Matt. There's always psychosocial domains. And it's actually making sure you're working in their comfortable space. You know, that's the thing. And I think, you know, just using simple language or how did you feel about that or did that affect you in any other way. When you're under that pressure, what happened? You run me over, lady, who I've seen a few times, I don't know, and she recently just had a flare up and went back and couldn't move. She's my art teacher, actually. I mean, there's a master class, our class. And those are the art class with her on the day. And she's really struggling with my back. Can you do anything? She'd soon have sent me a text that she would be struggling. So it took some tape with me just in case. You know, initially she thought, I bet down to do up a shoe laces. I think I've strained a disc. That's you're just pretty to do up a shoe laces. And you know, how much stress that's off. I guess there's not a lot of doing it all the time. Don't know. I said, yeah, well, what else was going on? She said, it was like a lipa. I had all these student exams. And there's a lot of stress. And we went through that. But she's a lady that's had like an autoimmune, chronic pain type thing. And we talked about her, a youth system of stress. And you know, she sort of suddenly let go of it all in a way, like, oh, be okay. You know, so pain, it really pushed me to this predicted worry stress zone. And then that becomes overwhelming to this day. She could only be, yeah, I'm very much into this world of how can you boost your new system? You know, I say a lot of people I talk about the bioplasticity of that. And our chronic pain, although you might have some genetic or gender redispelling weakness, you can work with genes around if you get actually enough and fit enough and enjoy your life and do things you love doing. So should I? It's such an interesting area, you know, delving into the, you know, the research around epigenetics and the nervous immune and decline ensemble and all of the, you know, really dense sort of pain neurobiology research that's coming out. It's so fascinating. I do have one question for you. And I am very conscious as I ask it that it has potential to be slightly controversial. You talked a lot about your early career and how, you know, you really started in that hands-on manipulative sort of therapy space. And I think the thing that's been fascinating for me is to see all of these discussions sort of emerging on, you know, cell linked in and professional channels and social media. And it seems like there's these two camps. You've got, you know, met pro-manual therapy and then you've got, you know, your pain therapists. And if you look at what you're seeing online, you'd think that it's such a stark divide between pro and anti-manual therapy. And I'm interested in your take on that because I think my suspicion is there's probably a lot more nuance in the middle there. But I'm interested in your experience and from the years that you've worked across a range of spaces. How do you see manual therapy these days and how it sort of fits within or alongside pain management? Have your views changed and evolved? Look, I think it's back to the individual's preferences. And what they like, some people's physicality is a double-a-thing and they want to be manually made to feel nice, you know, to feel you've given them some extra relief. So I think manual is always there. It's part of who we are, really, you know. And psychologists often say, we can put hands on people I can't, you know, and it's such a gift because people do like to be touched in pain and soothing, it's relaxing. And, you know, but there are lots of situations where manual therapy can unravel frozen shoulders and it becomes stiff in their later stages. You know, the evidence for early stages in there, but certainly in later stiff stages. And we see it over and over again, particularly in protectment states. Look, I think it's sad that people are making such a dance about them and us. I think it's always them and all. Us and all. One of the things I do with every patient that comes in, I spend a fair bit of time around their expectations and understandings as a spife, starting point. I'm surprised how many people say, look, I just want some good exercises. No, I've got a few people to cover. Can you just do some hands on? I don't need to know about anything else. Fine. I think you have to be adapting to that individual's view of what they see frequently though. If I see this more than that and where there's a recovery, I'm into nearly everyone could recover. And this is a disease or an autobearing condition. Some, you know, serious inflammatory disorder, 90% of people could recover. I'm always looking for the pigs that put that in their toolkit that leads up to recovery, you know. So I love the beta more UK's, 12 tools. And I love the pain else website that I love. The pain revolution, pain facts. I love pito-celeven stuff. I tend to send them wherever they're, probably, if you like. Seems to add a bit of niche. And, you know, the pain, it's made pain books and great books. It's got lots of stuff. It's a bit complex, but you can really pick out some good stuff in there. And, you know, the pacing and golf setting on the Bane Health WA website is treatment. If you do it like this, you pay certain greater up, you'll get better. There are lots of, I guess, gems of information, give people, you know, and it's also big in the right about. Some people just stayed a little bit. A little bit would ain't allowed. You've got to be prepared to work with people's hunger and interest for that information. How do you get around or encourage someone who feels like talking to a patient is not necessarily therapy or treatment? I know you did highlight that it is treatment. How do you convince a therapist or maybe help a therapist understand that we need to be talking to our patients and using. I guess the psychologically informed kind of speech. I think a few is like building a friendship. You know, it's around listening, building trust, understanding the workings of that person. They really feel like he understands me. I had one today who just felt she didn't think with a psychologist like she doesn't get me. And she was really upset about, she felt guilty that she didn't get the psychologist. And I said, "Well, you know, it's my friendship." And there's something where you just don't get it's quite okay. There are plenty out there for you. You know, they're like you've found in your life. A friendship is 80% of the treatment, I believe. You know, the treatment is about being hurt, being understood. And then I can do this. I'll tell you another story. I had a guy out of tennis. I played a bit of tennis and this guy, a young guy, I was playing one of the top players and he was running everywhere and it just looked like an injury ready to happen. Because he was so fit, he could chase everything down, but he wasn't such good player technically. Anyway, he went over on a crack and he was on the ground. So I was having to be there when I. And he's a lateral low of fibula was swelling up quite rapidly. So, you know, it was really sore. And I did some tests and I said, "Oh, this looks like if you're feeling like checked out, the lateral ligament and it was a highly tender compared to the fibula." So, I tapped him out and we hope he goes and look, I think he needed to go to the local sports clinic, see a doctor decide whether you need a scan, but he might need to crutches with you days and just make sure the fractures are lined. And, you know, they're all quite different. I said, "Look, it's not your way of being way, very well." And so, you sort of say, you know, some people don't have a fibula. So, I wasn't very sure him. He said, "It's not too bad, but, you know, we are your team and I, the manager." Anyway, I rang him two days later. I said, "Oh, I want to get a sports clinic." He said, "Oh, no, I decided I didn't need the sports clinic." And he said, "I mean, I'm slowly getting better." And, you know, he said, "I probably take a couple of weeks." And, you know, he said, "I'm pretty happy, the swelling's still there. It's quite dead in the touch, but I did the same taping technique you did. And it seems to be really helpful." And he said, "I'm flipping around and getting better." I said, "Oh, okay." That's the other extreme of someone who's just totally taking ownership. And, you know, I can manage this and I'm safe. And, you know, he was always going to do well. He's a resilient, sort of adaptable personality. So, you know, I think it's video, it's about your question, Matt. You know, I think we started to do our job. The Cess look, give you a opinion, because in that first assessment, you can't always tell what people are going to do, you know, how they got to go. You know, he was really going to do really well. And you get someone else's gone over a bit for three days. But he was always probably in that group that was going to do well because he's active, he's driven. Good decision-making and probably a bit risky, but someone's saying, but that's how he was playing it. Yeah, wow. I feel like a common theme for you and it's something abriable. You always want to connect with people. He said, "Friendship's like 80% of the treatment." It's almost like all your research and everything is just the icing on the cake that you've done. I often think, "If I can know more, then I can explain better or I can do better." But perhaps I need to take a step back and like, "Who's this person right in front of me? What do they need right now?" And a wholesome approach. Yeah, good point. It is such a challenge in what do they need right now? And how do you add back that? I think you can add back that. I often get, you know, I say, "Well, what do you take away for today?" You know, what do you think happened? I'm actually a bit disappointed sometimes because, you know, that I thought I was offering a bit more than that. But, you know, I wouldn't say that to them. But if they come back and they've reflected a bit, they've taken on a lot more. And I came back with one lady who I wasn't sure how much she'd taken on. And she'd written three pages. She'd read all these places. She'd written down everything. I feel so much more in ownership. Owning this now, she'd had a lot of other physio. Don't end well, you know. Personality factor there as well. So we're still in this juggle. It is complex. And, you know, it gets more complex when you have other strongest psychosocial factors like personality disorders, post-traumatic stress. There's so much juggling with their highs and lows with those issues. It's such a perseverance at a pathway, because it can be like this all the way. But eventually, it seems to gradually wind back and they get it. You know, and they take ownership. But they're on their personal journey often with their pain journey, sort of if you're like dancing with that, often in a negative way. So, you know, be patient. And, you know, something I always do at the end of my sessions is, often say to them, "Oh, where would you like to come back again?" And they look a bit flawed arm. "When do you think I should come back?" I say, "Well, I'm really flexible about it. What do you think you need?" Because I've worked their own, that idea of, "I'm managing this, so I'll be good to all." And I'm also testing that hypothesis. Are they really trying to? If they're not sure, so look, I'd like to give you two weeks in playing with these ideas and see what you do. So, because I get a cut back a bit earlier. So, I'll often get them back a bit earlier after the first session, because I want to make sure they've taken on the concepts and, you know, we need to buy two things a bit. But there is a lot of things. A lot of things. I think one very, very clear message, I'm getting from everything that you've said, Pete, is just how important it is that we can actually sit with and connect with the person in front of us. But importantly, really tailor what we do and the tools we use to their person and their presentation and their needs and their goals, because there isn't a one size fits all. And it's about us giving them the space so we can explore that together and go, well, what is going to work for this person and what can we pull on? And I think that's just such an amazing place to come at Physio from. I think, you know, that's a powerful thing. You just don't know. I guess asking patients their takeaways from a session and, you know, what have you learnt in this session and what are you taking away from this session? I'm going to take a page from your book, Pete, except I'm going to flip it a little bit and I'd like to ask you, what are your takeaways from the session? If people who are listening, you know, if you are going to give them, you know, one or two key things to walk away with or maybe one bit of advice from the conversation we've had today, what would you like people to take away from today's session? To take kindness to every patient. Guiness is really a joy and the government has so few people with that work on that motto, kindness and it's actually magic. And you hear patients talking highly about Physios and, you know, technically they're not very strong but they just love them and they'll do anything for them, you know. So kindness is a real gift and they just reward you back every time and make sure practice and life lovely really. So with that first and curiosity, be curious about everything because it means that you're giving them complete control of conversations and leading their joy to shape of their problem. And that's very rewarding when they do take ownership. I mean, I love it when people say, I don't think I need to go back from month, I think I've got the tools. It's like, yay. But I mean, the problem for a lot of Physio practices is the business model and there's a real conflict there for them because, you know, you do need to get turn over and return visits and I get that, you can still do your stuff in short sessions but it's hard to work and I think more frustrating work because you're not able to form such connected relationships that shared therapeutic relationships as much as because, you know, even if you've got a 20-minute consult, I know some practices work on 15 but 20 minutes is still 5 minutes in and out to stay on time and so you've got 15. 30 minutes is also hard in these complex ones. It sounds Australia, you can get restrictive consults where you get in and out, use it every time. It makes work so much more enjoyable and if you again become a specialist video, it's a joy. I have an hour with every patient and often with follow-up so I'll have our consults, you know. On the whole, I see a lot of complex patients within four to six times over six months but I'm usually involved with a Physio Bravers doing GM or an excise videologist and a huge psychologist there with touching bases where using shared goals with the other practitioners and particularly a lot of their program is goal-oriented, you know, with fighting sweet zones and facing and grading and developing their whole package. So, you know, it's a tough world for Physio Bravers as now because the overall expenditures have continued to go up. The Physio returns from compatible bodies and from the general public has not gone to the same degree so I do feel for them but if you want to really fly as an individual practitioner do this specialist Australian golf program. Whatever food you love, it brings in that time and I guess control over your income which I think is really special. I mean we've got the advanced clinical bank course that's coming out next year so you know there's going to be opportunity there if people are what did you hear what I do? I worked closely with the guy called Alice Deathlet. He's a really fantastic practitioner as well especially on this video and look there are so many good specials videos out there you know it's a whole pain especially go on now there's tips of really good musculoskeletal sports videos with myself's videos the other bedrooms I work with and I'm sure there's others in neurological and thoracic and other areas as well. Pete thank you for giving us your wisdom and sharing your time it's very much appreciated. Thank you man and we also do need to thank our listeners as well thank you listeners we hope you've got a lot out of this so now I have today as well and you can also check out our additional episodes by following Physios and the Mike on your preferred podcasting platform so thanks for tuning in and we'll see you next time on pain. Thank you.