Ep 187: Finding a digital way through depression and chronic pain, with Dr Pavlos Bobos

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] The relationship between musculoskeletal pain and mental distress is complex. Sometimes it can feel challenging to know even where to start when supporting people to get their life back when they're struggling with chronic or persistent pain.

[00:00:35] Today, my guest is Dr Pavlos Bobos who shares his own story of recovery from serious musculoskeletal injury and how that experience drives the work he does now as a researcher. We discussed the results of Dr Bobos and his team's network meta-analysis of digital interventions for

[00:00:53] managing musculoskeletal pain and depression. Dr Bobos is an assistant professor in musculoskeletal health at Western University in Canada where he studies mobility and activity interventions, clinical measurement methods and evidence synthesis. Dr Pavlos Bobos, welcome to JOSPT Insights. Thank you very much for having me.

[00:01:15] It's a pleasure to have you on the podcast today, Pavlos. And today we're talking about musculoskeletal pain, mental health and technology. And I think these topics are at a really important intersection for our musculoskeletal rehabilitation field. Perhaps we're even

[00:01:31] at an inflection point where rehab clinicians are taking on much more leadership in how musculoskeletal conditions are managed around the world. I think most clinicians could tell you from experience that chronic musculoskeletal

[00:01:45] pain and mental health are linked. Can you tell us what are the stats on the relationship between mental health conditions like depression and anxiety and musculoskeletal pain? So first of all, I would like to start the conversation by sharing a bit of my personal

[00:02:00] journey to illustrate the real life impact of musculoskeletal pain and mental health. So I served in the military. I'm a former paratrooper in the Special Forces. I experienced a severe accident when I was in the military during the training. So someone

[00:02:16] else collided with my parachute and I had a very hard landing which resulted in significant injuries and eventually led to chronic MSK pain and many mental health challenges for me, four years to come. So this personal experience also has driven my passion for research, effective interventions

[00:02:35] for chronic pain and depression, but also I appreciate what a physio can do for the people that they need care. To your question about what are the stats? So there is a significant relationship between mental health conditions like depression and anxiety and MSK pain.

[00:02:53] So I think some of the studies have shown that the large portion of individuals with chronic musculoskeletal pain also experience symptoms of depression and anxiety. There is around 20 to 50% of people dealing with chronic pain report symptoms of depression and I think

[00:03:12] roughly 20 to 40% anxiety disorders are common for this individual. And I think what's really interesting about this relationship is that it's bi-directional. So chronic pain can lead to the development of depression or anxiety due to the constant stress and disability that it brings.

[00:03:32] On the flip side, because I said it is bi-directional, having depression or anxiety can increase the risk of developing chronic pain. So for instance, people with depression are more likely to develop chronic pain conditions over time.

[00:03:47] And I think the impact of these mental health conditions on pain perception is quite profound. Those suffering from depression and anxiety offer report higher pain intensity, greater pain related disability. If you think about these individuals that they have both musculoskeletal pain and mental

[00:04:06] health issues tend to experience worse functional outcomes, I would say including lower physical functioning, higher levels of disability and a poorer quality of life. And of course there are also at higher risk of developing other comorbidities like

[00:04:22] cardiovascular diseases because these people eventually they cannot exercise as the others. So Pavlos, what works well for managing mental health for people with concurrent musculoskeletal pain bearing in mind this bi-directional relationship? I would say first listening to your patients and understanding their individual experiences

[00:04:43] and preferences is super important. So what works well for one patient might not be as effective for another one. So personalised approach is key actual to this condition. So engaging with patients to understand their pain, their mental health challenges and their

[00:05:01] lifestyle can help tailor interventions that are more likely to be effective and sustainable. So we really need to incorporate patient voice and preference into our treatment plan because it can lead to better I would say adherence and more meaningful outcomes.

[00:05:18] So combining psychological therapies like cognitive behavioural therapy with physical rehabilitation are shown to be effective. There are many studies out there actually. Exercise, mindfulness and CBT are particularly beneficial. For example, exercise can be a mood elevator, mindful stress reduction,

[00:05:38] health patients developing healthier relationship with their pain under stress. Cognitive behavioural therapy on the other hand can address negative thoughts, can alleviate both pain and depressive symptoms. So I think in general these interventions improve physical function and can enhance overall well-being.

[00:05:58] But I think we need to make our treatment more personalised because as I said, not everything works for everyone. Given the demands of your job and your injury, what worked for you to recover? I would say very complex case because I was severely injured.

[00:06:15] I had many fractures but I think my condition after I was out of the hospital, I realised that I needed to do some kind of rehabilitation to gain my functioning back. So I had a lot of sessions with physios that were addressing my own needs.

[00:06:37] For example, I was very active as an individual and I wanted to keep that active lifestyle. So the physios actually first, they asked me, what is your goal? What do we need to do here? And I think one of the first things that we did was,

[00:06:53] okay, we need to do some of the things that perhaps you were doing before but we need to do them differently. So we need to gradually stepping up your physical activity, your exercising.

[00:07:04] And I think what really works for me is that my therapist was actually listening to me and had specific needs. I was afraid also to do specific movements because they were aggravating my pain. So I really wanted that reassurance that what I'm doing at that moment

[00:07:21] is not bad for my own health. And that was reassuring that the therapist know exactly what to do. I think it's a great example of that point you made at the start about the bi-directional relationship between mental health

[00:07:38] or how we're thinking and feeling about movement and our bodies and physically what's going on. Pavlos, you and your colleagues have had a look across the research at how well remote or digital health interventions work for managing pain and depression.

[00:07:53] And you've used a network meta-analysis to do this. Why did you decide to look at digital health interventions specifically? So I think everything started with the COVID-19 pandemic. The pandemic actually exposed several vernal abilities of our healthcare systems and accelerated the adoption of digital health interventions.

[00:08:15] If you think about back then in the pandemic, pretty much everything was placed on hold, right? Traditional care, primary care, unless you had COVID-19. Our network meta-analysis, first of all, I want to say that the network meta-analysis is a powerful method that allows us to compare multiple interventions

[00:08:34] across different studies. And what we can do with that is we can run the interventions in terms of their effectiveness. So this method actually integrates data from various sources, multiple studies, and gives a much more clearer picture of which interventions perform best in different contexts.

[00:08:54] So the clinicians actually can use these insights to recommend the most effective remote interventions tailored to their patient-specific needs. I think the most important thing if you read and interpret the results of our network meta-analysis is understanding the relative effectiveness of different interventions.

[00:09:14] So the results typically include their ranking system that shows which interventions are most effective overall. So clinicians should look at the consistency of the findings, the quality of the included studies, and the specific outcomes measured. So when they do that, they can make informed decisions

[00:09:34] about which digital health strategies to implement and ensuring that they provide the best possible care for their patients. Thank you. And I think during the distinction between network meta-analysis and the traditional systematic review where you will see a head-to-head comparison

[00:09:53] of two treatments, treatment A compared to treatment B versus in the network meta-analysis. As you say, you've got a much bigger picture going on and capacity to look at relationship or to compare multiple interventions within the one analysis, which is why it makes it such a powerful tool

[00:10:10] when performed well. Now, Pavlos, what were the headline results of your network meta-analysis? Our analysis really shown that we have certain digital interventions such as remote cognitive behavioral therapy and tele-exercise programs. They can significantly reduce both chronic, musculoskeletal pain and depression symptoms.

[00:10:32] So some of the platforms, for example, that we have, interactive voice response and mobile app cognitive behavioral therapy combined with exercise, so similar treatment affects to in-person CVT. It was actually statistically comparable, which means that it can be beneficial for improving either pain or depressive symptoms.

[00:10:54] I think one of the stand-out findings was that remote cognitive behavioral therapy was especially effective in alleviating depressive symptoms while tele-exercise programs were more beneficial for reducing pain. And if you think about the convenience and flexibility of these digital interventions made that the patients

[00:11:15] are more likely to adhere to them, leading to better long-term outcomes. Now, that's a big hypothesis. I'm thinking this will be supported later. To go back to your questions, our results highlights the importance of integrating digital health solutions into standard care practices. So these interventions are indeed effective

[00:11:37] and I think this is important for patients who may have limited access to in-person care, either due to location, for example, or mobility constraints. I love that you make that point about flexibility and I think this idea of giving people choice is where tele-rehabilitation digital health interventions

[00:11:57] can really come into their own. It's not about saying that you can't have the in-person care if you would really like to receive it as a patient or to deliver it as a clinician. It means that you've got a lot more flexibility

[00:12:10] and if people jump back a week in the podcast feed, they'll hear Dr. Belinda Lawford from Melbourne University speaking about very similar ideas in Neostoastritis and their group at Melbourne University have done a lot of work around trying to understand the benefits of tele-rehabilitation

[00:12:27] and as you say, Pavlos, they're certainly there and patients really do like the flexibility. What would you suggest that clinicians think about when implementing these sorts of digital health interventions in practice? So yes, based on the latest evidence that we have,

[00:12:45] I think clinicians should consider integrating, for example, remote cognitive behavioral therapy and exercise programs. I think these interventions have proven to be highly effective, so if you check our network meta-analysis, they have high probability of reducing pain and depression. Also staying up to date on the latest,

[00:13:04] I would say digital health tools and how to use them effectively is very, very important for providing the best care possible. Another thing is engaging in continuous professional development seeking collaboration with other health professionals which really can enhance their ability to deliver these interventions.

[00:13:24] But I think also, in addition to delivering treatments, clinicians should also think about integrating remote assessments into the practice. If you think about how remote assessments can provide valuable insights into patient conditions and progress without requiring them to visit the clinic, again, I'm talking about that flexibility, right?

[00:13:45] So this can be particularly beneficial for the patients, as I said, that they have mobility issues or those living in remote areas. How do I make sure that the tests I do remotely are accurate? Can I trust the results that I get from a remote assessment?

[00:14:02] Yeah, so again, this will come for research. I think we have a great variety of digital tools that we can do the assessment. So it's a matter for all the scientists and researchers to come together and check those psychometrics, reliability, validity, responsiveness,

[00:14:16] especially if we're using outcome measures remotely. And then check all the platforms, right? How we can monitor symptoms, track treatment effectiveness, mobile health apps, wearable devices, telehealth platforms. I think they can facilitate remote assessments, but we need to seek the evidence outside there

[00:14:36] whether indeed are accurate in terms of measurements. So still a way to go in terms of really developing the tools that we need to do remote assessments and to really trust the results, but looking really promising. Pavlos, I didn't learn that much

[00:14:53] about cognitive behavioral therapy in in physio school or in PT school. And now the results of your network meta-analysis are suggesting that perhaps I should have. I'm not sure that I'm feeling all that confident to deliver CBT on my own. What should I do to best support patients?

[00:15:11] Yes, actually, you know what? It's quite common for physiotherapists now to have extensive training in cognitive behavioral therapy during the studies. I didn't have so because my curriculum emphasised physical rehabilitation techniques. So if you're new to CBT and not feeling confident about delivering CBT, there are several steps

[00:15:33] I think you need to take to support your patients. A, consider collaboration with mental health professionals. B, I think there are numerous training programmes and certifications that can be available to build your skills in delivering cognitive behavioral therapy. I think many professional organisations

[00:15:51] they offer workshops, online courses and certifications in cognitive behavioral therapy. And again, engaging in that continuous professional development after school through all these programmes can increase your confidence in using cognitive behavioral therapy techniques. But I would say another practical approach is to start integrating basic cognitive

[00:16:15] behavioral principles into your practice gradually. So I think for everyone, we don't need to become an expert overnight, right? We begin by learning and applying fundamental principle techniques, basic principles such as helping patients identify and challenge negative thoughts, setting achievable goals and using relaxation strategies.

[00:16:35] And I think these small steps can make a significant difference in your patient's treatment outcomes. It's a fine line between knowing what you can do within your scope of practice as a physiotherapist when it comes to supporting mental health and implementing these cognitive

[00:16:52] behavioral therapy techniques that have been traditionally, I think thought of as the domain of psychology. Where do you see the line, Pavlos, between what's within the scope of practice as a physiotherapist to deliver and when is it appropriate to refer on, refer someone on for psychological care,

[00:17:11] particularly given this complex relationship between musculoskeletal pain and mental health? I think first of all, we need to foster like an environment of open communication with our patients about their mental health, which is really important, what we can do and what we cannot do.

[00:17:30] It's always good to have multidisciplinary approach with these issues. So consulting colleagues as psychologists or psychiatrists or other healthcare professionals is really, really important. Encourage also the patients to share their thoughts and feelings and we need to be empathetic to their experience and understand their own feelings.

[00:17:51] So when we're showing that care about both their physical and mental well-being, we can create a trusting relationship that enhances that overall effectiveness of our treatment. But I believe it's very, very important to understand where are the boundaries, like where my job is ending

[00:18:09] and where another health professional, the work is starting. So it circles back when you said, you know, I have not learned so much about CBT in fidget school, but again, there are many resources and strategies so you can support your patients effectively and collaborating with mental health professionals,

[00:18:28] engaging for example in ongoing education, gradually integrating cognitive hero therapies using digital tools and maintaining open communication with your patients. I think all of these will contribute to providing a comprehensive and holistic care. Now, Pavlos, as we start to wrap up,

[00:18:48] what did you learn from your musculoskeletal condition and your injury that you've brought into your practice as a physio and as a musculoskeletal researcher? Yeah, so if you think about when I was in the military, how indestructible I think I was, you know, a healthy individual, daily training.

[00:19:10] And after my injury, I realized, you know what? Yes, I have pain, but probably something more than that then I started having issues with fear of movement, probably I injured myself. And there was this, I'm going to say, catastrophizing thoughts that I couldn't manage myself

[00:19:30] and it would be on my power, right? But learning care for me was to understand that, you know what, I cannot deal with this alone. I need some kind of help. I need the proper individual to take care of me because eventually the pain was coming back.

[00:19:45] Even when I was out of the hospital, the pain was coming back. I had mental health issues, for example, I couldn't go on board into a plane, I having, you know, those flashbacks about injury and everything. So it was really, how can I say?

[00:20:03] I was really disabled as an individual. I couldn't do anything at all. So I wasn't indestructible, that's what I'd say. I was human and that was the learning care that I passed and there are people, amazing people out there, extremely gifted physios that I really appreciate

[00:20:23] what care they can provide. And they really contribute to my overall wellbeing and my overall quality of life. I'm a thankfully to physios and that's why I went to physios school. Bringing the humanity back into care and into research.

[00:20:42] Pavlos, it's so great to have you on the podcast today. Thanks for sharing your story and thanks for joining me on JOSPT Insights. Thank you very much for inviting me. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal

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