Episode 6

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Welcome to episode 6 of the Empowered Beyond Pain podcast, proudly brought to you by Body Logic Physiotherapy. For the last two weeks we have spoken about the myths and facts of low back pain, including hearing patient stories of recovery, but this week’s episode kicks off a 4 week mini-series on the topic of Osteoarthritis (in particular hip and knee joint pain). Today you’ll hear two people talking about joint pain… but not just any people, two Professors. That’s right, mano-e-mano, professor-e-professor. Peter O’Sullivan, Professor of musculoskeletal pain and specialist physiotherapist at Body Logic Physiotherapy, chats to Stefan Lohmander, a leading voice on Osteoarthritis, Orthopaedic Surgeon, and an Emeritus Professor from Lund University in Sweden. The profs talk about the potential ignorance and lack of understanding about the disease, and how surgery may not be the ‘big fix’ for osteoarthritis that everyone hoped for. Later in the episode, I talk to Pete and JP about the common misconceptions about osteoarthritis, our current understanding of it, why the term ‘bone on bone’ may be an unhelpful and inaccurate term, and what you can be doing to help improve. We also discuss an infographic that has been created to accompany a fantastic paper JP Caneiro led in collaboration with surgeons and other international Professors to help change the narrative around Osteoarthritis. You can find that infographic, as well as all the resources discussed in this episode over on the shownotes page which is www.bodylogic.physio/podcast We hope you enjoy the conversation, and remember to ask, is there more to pain than damage?

So Stefan thanks for having this opportunity to have a chance we were discussing before that this issue of muscular civil pain and the burden that it carries is a huge problem for society and the costs are going up and the disability burden seems to be going up with us your background is an orthopedic surgeon and within the Health System there seems to be a lot of attempts to try and fix the problem a musculoskeletal pain how do you see the role of surgery in that space the surgery is an important part of dealing with these conditions musculoskeletal and in the particular osteoarthritis which I specialize in but it’s not possible to do a big fix just with the use of surgery clearly not sustained sustainable in the big picture so how do you see within contemporary understanding your muscle it’ll pain where it’s about a management of a patient and then patient journey how do you see the role of surgery within that well the patient most of the patients actually have a quite a long journey as osteoarthritis patients and most of that journey is taken without and for most of the patients is without surgery and the need for surgery the major part of the life in osteoarthritis that these patients spent is actually using other forms of management and that’s where I think we are having major challenges today can you talk about those forms of management I would argue that there is a large part of ignorance and lack of understanding in the disease patients as well as practitioners lead to a need to understand the disease better we also need to look at the different practices that we have today the different forms of management and we need to look hard at what might be low value management low value care we need to take that out of the picture and consider what is actually providing value for the patients so can you give me some examples of where low value care exists in surgery in surgery yes I Philippe yes any other would be for patients who’ve had a bit of a journey through their osteoarthritis disease and are getting to the point where they may have tried a logistics they may have tried various things on the way perhaps a bit of an exercise program as well which we often try to get them into but then they come up to the surgeon through various routes through referrals or thrown through on referral and there is a consideration or for example arthroscopic surgery which is frequently the case it’s very frequently practiced procedure one of the most common orthopedic procedures actually and that has now been shown through many studies that doing autoscopic surgery in the middle-aged and older person with chronic knee pain is not helpful really it’s actually low value care and it’s been shown in a series of studies that for example a structured exercise program is as effective in treating the problems that these patients have as surgery so within the current health climate how do we replace low value care like arthroscopic surgery with high-value care given that the funding seems to go to low value Kia yes that is a challenge and it’s a challenge for many reasons because number one the patient often expects a quick fix when they reached that point when they reach the consultation with the orthopedic surgeon in this case they expect it with the Pittock surgeon to provide the final and quick fix to their problem they’ve tried this they tried that and now they are looking at the final solution sort of site to their problem while actually this procedure is not the final solution to the problem and secondly the healthcare system as you’re suggesting may actually be funding subsidizing surgery while not subsidizing for example an exercise program led by a physiotherapist or some other form of exercise program and thirdly there is also of course the the routines that are ingrained in the system we work in where for example the general practitioner the GP might refer the patient with the knee problem uncharacteristic knee problem to the orthopedic surgeon and on the way by the way do an MRI investigation or MRI scan for example leading to the finding of a terror meniscus and then the patient has knowledge about to turn the meniscus Anini has pain in the knee and isn’t the office of the orthopedic surgeon what do you expect yeah so how do we change that system I think we need to really get the information out there the understanding out there that the evidence is not quite consistent and that you if any of these patients that I’m trying to summarize quickly here actually benefit from the arthroscopic surgery more than they would benefit from an exercise program and if this exercise program costs a fraction of what the surgery does if the exercise program does not have any cbins associated with it in contrast to the surgery and so on and so forth I think there is a lot of good arguments and strong arguments and we need to get this information out to the patients through the GPS to the surgeons of course and to the perhaps most importantly to those who make the decisions about what is subsidized by healthcare and what is not so PJP we’ve just listened to Stefan’s interview and one of the things that he raised was that this quarter I guess a misunderstanding of what osteoarthritis is amongst the public so I was hoping that maybe you pick talk about what are the common misconceptions around osteoarthritis yeah so I think um you know we as human beings tend to have a simplistic view of the human body and often we see it as a piece of machinery so a piece of machinery like in your car you’ve got a warm joint or you whip it out at your place ER yeah it’s quite a bit of you know lubricant to it you probably don’t use it as much if you don’t you want to preserve it so you avoid loading it you might not take it on rough roads etc and I think we have translated that view of the human body that this idea of arthritis is you know your joints wearing away and so there’s narrowing of the cartilage and that bone rubbing on the bone and the thing you’ve got to preserve it to you what are your options you clean it up just surgery and Stefan talked about arthroscopic surgery is like not doing what what you thought I did you might inject it with you know various products that might mean to be in improve the lubrication you the natural tendency for someone who is thinking that they’ve got a joint that is arthritic is that it’s dangerous to load it and to move it and in actual fact it’s the opposite so these are very common beliefs that people have it’s that this is that means that that tissue is not safe to load or that it’s got the more you use you know wear it out so we hear things like you know people having strong beliefs that running away your knees out that using binning and move loading your legs is dangerous for them because you know you’ve only go to last a certain life a bit like a car tire or a part of a car and and those beliefs unfortunately lead people down a pathway to think that the only solution for them is to clean it up trim it off injected replace it and the problem for that is is that some one is you’re missing out on all kinds of opportunities keffiyeh healthily uni which joke people talk about in a second but the other thing is is that once you’ve had those treatments this is sense of well why didn’t it work and so I had a lady in just a couple weeks ago who’s had two knee replacements and she’s really a profoundly distressed that neither of her knee replacements have given her the level of function she had pride in her first knee replacement and her knee pain is still present and now she’s gonna need she can’t trust and and and she can’t function and so she feels like she’s really hit a roadblock in terms in her life so probably that that whole belief system has led people down a pathway but also an expectation around when that care may not know can work well for some but for not for all and it’s very rare for people who’ve even had a knee replacement to become pain-free we know that a lot of people do have functional limitations and ongoing discomfort even after they’ve had the ultimate treatment which is replacing joint and so I think what that speaks to is that the fundamental beliefs we have about arthritis don’t really play out in terms of the ways in which we act and that’s why we go to this massive societal problem of pain and disability around that problem and and I think it highlights that we need to have a new understanding of what what arthritis means and is and how we care for it yeah sure so is it fair to say then to kind of summarize what you’re saying there is that we traditional understanding of osteoarthritis was that your joints wear out the more use them but can’t understanding which when I ask you to kind of elaborate on JP is that actually we’re almost the opposite as human beings where we are the opposite the more that we use our joints progressively and under the right conditions actually the healthier and the stronger they get so JP is wondering you’re a clinician a specialist physio but also a researcher researching arthritis so can you talk to what is that current understanding of osteoarthritis yeah so the understanding has evolved from thinking is just the bone structure and the wearing of the cartilage to a perception that is more around the whole joint that gets affected but well actually contemporary understanding of pain has been telling us is that it’s more than that it’s a whole person condition where every factor that affects your health your whole health can affect the experience of you of your knee pain so as Pete was saying before if you believe that your knee joint gets worse with loading and you have bone and bone that will make you worry and come back get concern about that leg will make you avoid putting weight on that leg we’ll make it protect and guard that leg and that can create further stress in that joint we also know that other factors such as your sleep your mood your stress levels they can affect they can change the chemistry of your body and they can synthesize structures in your knee so in the past you know for you to have a clinical diagnosis or way you needed to have an x-ray in addition to pain functional limitation and that has changed over the years because what they found is that you can have high levels of pain and live functional limitation without having as much change in your knee joint and one of the reasons for that is because these changes in your other factors in your life they can affect the sensitivity of knee structures and they can make that joint become sensitive and sore so when we look at managing a person with with osteoarthritis we are looking at their knee with if they do have an x-ray which is very common we’ll look at the x-ray but you also make sense of all the other factors that can influence a person’s paying experience so the way we kind of look at it is whereas before the what happens in the joint was at the center of understanding of someone’s playing experience now that becomes one of the manufactures so for instance are you participating in physical activity or have you you know moved yourself away from from doing physical activity or are you doing physical activity that is beyond your current capacity to tolerate and load in that knee I use sleeping well you know you do have enough sleep or are you getting enough rest in your body we know that if you don’t sleep you don’t have good quality or quantity of sleep that can affect instead of some inflammatory processes in your body that sensitized joints in your body and and the knee and the hip would be definitely affected by it do you carry any stress in your life and another thing that stress will do is change the chemistry of your body and can create more sensitivity and pain you know in terms of you of your body weight are you carry more weight have you put on weight as a consequence of not being physically active or because you’re more isolated or you have other health conditions that have led for you to have a weight gain and in the past we associated white with the fact that it increases the the physical weight in the joint and that is that is of course true but the other thing that is also true is that if you carry more especially abdominal fat that changes your metabolism and increases Pro inflammatory markers in your system so you carry white actually makes you more prone to become sensitive and you know there’s some research that demonstrates that losing 10% of your body weight if you are overweight can have a significant impact on on the pain that you experience so if we look at all those factors we are moving away from fixing the joint and loving it and replacing it to have you look at the overall perspective of the person’s health in order to manage it so that’s a much more contemporary understanding of how to manage this condition right so that’s all good and well right but we’ve got lots of patients that come and see us and you know one of the common things that they’ll say is that look I understand about the stress understand about my sleep but at the end of the day my knees bone-on-bone um they’ve either been told that they’ve had an MMR some sort of imaging to suggest that and so I guess can you kind of talk to what that means what’s the role of imaging here in nasi arthritis there it has a role there’s no doubt so we do know that what you see in a film and particularly some of the things that JP talked about around inflammation around the bone so we don’t get pain from in cartilage we get pain from the structures are under the bone and for some people they can become inflamed so that means you could have to scenario together to people with this exactly the same looking film the same degree of narrowing or cartilage loss where there is bone on bone and one person is functioning in a relatively high level with minimal pain and the other person is really disabled with pain and and what doesn’t different the scan doesn’t differentiate those two people what may differentiate them is the level the strength and conditioning that lifestyle factors that Jackie mentioned that we know a really important that can drive other processes so these things are all interact and so when we we get in I was related today who’s got bone on bone and when I first saw her she had no type ability to tolerate loading in her leg and see she was really disabled and she had a limp and she’s now able to walk everyday and she’s on a bike and she’s strong that she still has bone on bone if you took an x-ray of her but her functional capacity her confidence in her leg his strength and who mind sit around hood leg is completely changed and that she now sees that yes she has not really we can never take that away but now she has a life that she can use her leg confidently she has strength now she has to come into that so she has an ongoing program but that’s good for any human being with any health condition so it’s not like um and if for example she did end up down the track having surgery or they were she is so much better off to come out of that well and I think we don’t see these or you know this or you know one thing or other it’s like you have nothing to lose addressing those factors to then see what level you can get yourself before you commit to the next step because we know that if you walk into surgery with a limp you’ll walk out of surgery with a limp doesn’t change that you know having a new architecture the knee doesn’t give you a functioning knee and the functioning knee comes back to confidence and strength and mobility and you know your ability to integrate control of your body in your life yeah so it’s effectively shifting the the goal the the lens from the arthritis to what can you do how’s your function yeah and all that can improve regardless of what happens on your yeah and I think you the key thing there it’s not a panacea like we but no one has a panacea yeah you know like we aren’t talking about curing things we’re talking about improving people’s quality of life reducing their you know their pain levels their need for medication and proving their function but I think we need to be really honest about what we as a health profession can deliver for people some people can get fantastic outcomes and others there comes a heart again and also if we look at the you know thinking of this theme of being born on bond one of the things that we know is that if you look at the health of the cartilage what hydrates the cartilage is movement what makes the cartilage becomes become healthier is loading the college so in fact if you have supposedly bone on bone and you have an unhealthy joint taking your weight away from the joint or walking around with with a clenched muscles around the joint you know so I had arthritis in my wrist if I walk around with a clenched fist and I brush my teeth and write my name and I’m doing that all of that with a clenched fist and I protected I’m stressing that joint even more so if you have arthritis in your knee it means that the the physiology of that he has changed but it doesn’t mean that is completely stagnated it means that it’s at a point when it needs to readapt to to be able to tolerate load and the only way of doing that is gradually teaching that joint how to tolerate load again and if you look back at the the you know my new details of the joint one of the things that people lose over time with Oscars rises their building of the cartilage to hold onto water and if you don’t move the joint you lose that ability even further and the joint is stiffens up if you gradually move it and you put weight on it and you give good muscles around the joint actually the ability to hold onto water increases and that’s what we see with this patient is that initially the you know exercise and using the leg as hard as difficult as stiff and it’s uncomfortable and at times and it’s common actually that sometimes increase in spine but over time what happens is that they actually become quicker to move they get better range and they become stronger and more confident using the leg and that’s the paradox that they at times come up to us and say if I do have one how come I’m doing more now and I’m actually feeling better and that’s the beauty of the body which is an organic a biological structure that can deteriorate but it can also be if put in the right path you can actually thrive in that and become a healthier joint yeah yeah absolutely and is it fair to say that lots of people aren’t actually aware that they’re you know walking if you use the wrist analogy walking around with their wrists tense in there they’re not aware that potentially even just tension of muscles might be contributing to a certain aspect of their pain as well absolutely it’s almost like an automatic response of the body to protect the body region is to either take the weight away or to guard around the joint and that can be really helpful you know if you imagine you step on something very sharp you know your body automatically requires the leg to take it away from it or if you sprain your ankle you walk on a steep ankle for a few days and you’re limping but over time you know six weeks down the track you know the healing has occurred and you there’s no need for you to be pretend and then leg anymore but the person has to be very confident in themselves or have really good advice to understand actually using the light more feels better and like today I saw a lady who’s been she brought the question to me she said you know I’ve been told I’m a great candidate for knee replacement and I should do it but I’m really scared of having surgery and I don’t want to do that and I’m a bit lost but yes last year I couldn’t actually get up and down stairs but I’d be forcing myself to do it and now I can you know I’m not in leaps and bounds but I can do it but I I try not to do it because I don’t think that that’s right the thing to do the right thing to do so if you think about it her belief is holding her back despite the fact that her experience is actually challenging that yeah so as clinicians our job is to is to make her reflect on that belief and say and take that positive experience that she’s had and make her reflect on the benefit so that’s that’s me having for her and actually she realized today they’re moving her leg more and actually using the leg without protecting was in fact better yeah so that sets off on your trajectory you know I think the other thing that we often see is so important is taking baby steps you know we often see people with pain go through a bird bath cycle where they they go on overloaded joint it flares it up they rest it they get weaker they get frustrated they feel better they get frustrated they go and do it again and this boom-bust cycle is really bad for people with mental health and confidence and self-belief and it’s almost like you you lose that sense of trust in your body and I think part of that journey is to take those little steps to go it takes time to build confidence it takes time to build low tolerance take some time for tissue to adapt and that could be months it can take months it can be a journey over months of to change that process and for some people those changes can be quite quick and others are really hard journey and for others it’s kind of marked by peace and false and that that’s the key of a good coach I think is that that’s our role is to coach people to give them strategies but also they catch them when they fall to give them you know to reframe the program to dial it down and dial it up and to make sure that it’s within capacity but also sensitive to the to the body’s responses and that’s a delicate journey in Chile for a lot of people yeah it’s not easy no I just want to come back to a point that you talked about before in terms of imaging sort of mentioned it’s a hypothetical case of someone that’s got uni lateral or one-sided knee pain you know it kind of made me think of a study that we looked at shoulder imaging for people that had one-sided shoulder pain mm-hm so if you if that person had that one side of knee pain any image there other side or he didn’t exert an MRI from the other side other chances of that and then they would look pretty similar to their saw side it depends so the lady I saw today it had a trauma to her knee to a left knee and that was a side that was affected and she’s got a clear varus deformity on a knee very different the other side now and in her case you could bet on that they’d look different yeah so I think one of the things we know is traumatic injury is one of the risk factors that could alter the health of that knee that could change the trajectory for that joint but if you had someone who has had a very similar life in history for two days pretty good chance I’m gonna look the same yeah it would be the that would be the main thought around that the only other providers around that probably is what we often do see is when someone might have had developed pain on a knee years ago and then they’ve developed I hold it unhelpful habits like a piece talked about where they avoid loading that leg and we literally see it again last week half the size the leg is half the size now us was five years of loading a leg that’s got half the strength of the other leg I’m not trying to run and do stuff could really affect the health of that knee that’s again sets a trajectory where you may see a differences in imaging with what the health of that me is this is like a less healthy knee than the other knee that makes sense yeah and so that’s where you start seeing body parts changing in terms of their health based on how you care for it and so you know the my job for this this younger is to get this leg back to where and we start off with as like a traumatic injury that was never real attended properly yeah and now this is a lake he just famous all the time and it’s not trustworthy and now he’s not just playing his needs gotten his hip in his back and you know you just see that whole process kind of escalate yes and also it reminds me of a patient that I saw a couple of weeks ago who had a never had a history of any knee problems no trauma no incidents in the past and he’s over 50 and he was just walking and he tripped over and he tripped on the right knee he didn’t fall anything just got himself and a couple of days later he developed some knee pain and he became concerned about it he went and saw the doctor x-ray the one knee and he is over 50 so you know the likelihood of you finding changes in your joint are greater as you grow older because that’s what happens to the body so they found that he had a way in the knee and they had bone on bone and the next thing he’s booked in to see orthopedic consultant who looks at the x-ray and then he’s going down the track of potentially having surgery and luckily the surgeon said how about we try some physical therapy to strengthen your legs and he came in and I’m going you never had a history in his knee so the likelihood is that your knees look pretty much like you tripped over you’d set off a response of that knee joint is irritated and you’re not carrying the best of your health so maybe that’s when something like you know carry a bit more weight being active being sedentary not sleeping well that it that tripping over it is just a tipping point and all those things then play up because he it’s not conditioned to use the leg and he’s gonna happen on a stair is carrying extra weight so he started in a program and very quickly he started noticing some changes in his name so that is a very common case that you know people in the community over the age of 50 that developing gradually with no history they could be sent into this path because that is a very strong narrative for understanding knee pain and if you are in that Brad age and you get an x-ray you will see changes and that can set off this inevitable pathway to knee replacement and and at that time you know you may or may not be sent to see a physiotherapist for instance and and then we can have a hard look at our own professional on you know doing physiotherapy what does that entail and you may entail on one end a lot of passive therapy and some typing and some careful consideration of what you should do or you can entail looking at all the factors that can affect your pain and target those modifiable factors and empower you to become in control of this condition as we’ve been talking about which is a much more it’s an approach that is much more aligned with the contemporary understanding of pain and osteoarthritis yeah sure is it fair to say to take home from that kind of imaging story with that guy that had just developed knee pain after the fall is that if you did imaging before you know let’s say a day before is four and a day after his fall when he had the pain that those two feelings would look pretty much exactly the same yeah but the key thing there is that his pain wasn’t there to start and it was there in the end so it kind of softens to that poor relationship between imaging findings and and pain and disability yeah then the tricky aspect of this is that that reflection on the fumes and see someone down and asking them to think about that it’s not so easily identified or you can’t find that so easily but you can go easily on google and say I’ve got nearby I’m over the age of 50 first diagnosis that will come up is cost arthritis what do you do for that you inject you do a bit of exercise it doesn’t work in a few months you go and you have a knee replacement so that pathway is really strong and that’s the problem that we face as clinicians and and the the biology and the changes in the knee they are really strong and they’re really present and they can affect how you you decide your management but again all these other factors can be modifiable and in someone like this particular gentleman the story was not to operate on that knee the story was to get just gay active again and desensitize the knee and he may or may not need surgery in the future but that’s not because of what happened now yeah sure you know I think um just so long from that I kind of it springs to cases to my one it was an eight year old man I saw I’d seen previously for back problems he’d never reported knee pain and they moved house it was a pretty stressful time they can remove out of their home into like a retirement village but that was a massive traceur massively stressful transition where he reduced it he used to walk every day he stopped walking he put on weight probably about ten kilograms he developed a knee pain his knee was acutely painful hit any excess MRI scan was told he needed a retina replacement he came back to see me just for an opinion and I’ve gone you’ve know had an injury like you’ve actually done less exercise you know what’s precipitated you’re getting worse there’s a really stressful time of your life you put it on hold on a way you’ve lost conditioning and you stopped exercising so that’s an injury to me you know sure you’ve got these scans things of any he had like a really acute like bone edema very sore so I’ve got well let’s just give it three months because you had nothing to lose and everything to gain so let’s set up a plan where you’d lose that way we get you strong with simple exercise that’s like sitting stands and getting you you know basic strength back in your legs let’s get you back into a exercise program all his pain went away all the win away and he’s going I don’t get it I don’t get how I could have been so acutely Paley and my knee is degenerate and it needs a renewed replacement I only planned it and that’s because those factors that JP highlighted have been dealt with that have dampened that inflammatory response in the body now the other end of the spectrum I saw a young lady today 35 who’s been told she’s gotten in oh I know she’s coming 35 so what when did it start started the last year so what’s happened the last year well I’ve been in a busy job lots of stress not exercising put on weight same thing but at the other end of the spectrum so she’s got the early science the other guy had the late size but never got pain until those factors emerged she’s got them at the 35 what she done she’s singing physio you gave her some massage like didn’t work so she’s now stop dicks you know like careful with the nays tries not to bend them so we had a great opportunity today so hey let’s see you up the plan and she was going maybe if I warned the minute what I was dancing I go no that’s what would have kept your joints healthy what happened in the last few years you put on a whole it away stopped exercising you’ve lost conditioning that’s what’s gonna I think the health and that’s the narrative that is not told people now I think the other thing that strikes me in the health area is we want quick fixes and this to actually get health in your body is a journey and it’s a journey of a lifetime and that might take you months it might take you years but it’s part of your journey and I think that’s the story we need to really so hard to people is that you just can’t cut pain out it doesn’t work like that yeah it’s a journey of getting healthy and that’s a that’s a partnership as a partnership within your home environment and the people we seem to really well have wonderful support within their home environment it’s much harder if that’s not working for you but it’s also a partnership with your care environment with EGP and you know physio who are you working with psychology or dietitian as well as that’s necessary yeah now interestingly when we look at health and health problems such as cardiac problems or respiratory problems or diabetes it’s very easy for people now to understand that you know the management of some of those conditions they’re multifactorial and you need to take care of things such as your diet your sleep your physical activity your stress levels so that is very acceptable and joint pain and all the body pains have kind of be seen in a different place where it’s kind of it’s not your health it’s it’s joint pain and therefore is related to something structural in your body so we are playing catch-up and now the more we talk about these conditions if you take me away out of this conversation and you put back that you put neck pain or you put something like other health conditions the factors that we need to be working on a very similar because they’re factors that reflect our general health so you have you know a good body weight you slip in well you managing your stress you feeling like you’re supported at work and you engage well in society and you’re physically capable of doing the activities that your that your job requires or your lifestyle requires it speaks for your entire health and that’s that’s what we come from when we talk about Nia why being a changing that narrative from a knee disease and damage to a knee health perspective and that basically ties in a lot of musculoskeletal conditions and you know those are some lovely papers that came out last year talking about you know lifestyle as being a very important aspect to address across several comorbid health conditions and one of the underpinning mechanisms that can drive lots of these conditions is an inflammatory process an inflammatory processes they can come on with changes like the cases that we’ve highlighted you know they can come on really strongly if you had a forward you had a trauma or they can come on when several factors in your body respond in a different way so we have these all these domains in our body that speak for you know your general health and your immune system in your your physical system and your nervous system and their interplay along the way and keeping the status quo and and you’re going okay but at a point in time you make it become highly distressed you don’t sleep well you put on weight and you become less conditioned and that can tip you over the edge and that can affect your health now the outcome of that it could be pain it could be a skin condition it could be stomach pain it could be you know another health condition that can come up so the it’s almost like pain is another expression of a change in balance on factors that speak for your health yeah yeah kind of an unhealthy person in a big picture sense yeah and that could be temporary or it could be long-term yeah you know I think just along there then we can use that knowledge to reflect on your own lifestyle and their own health rather than becoming threat to say oh god I better stop use my body it’s it’s a wake-up call to go well am I going to bed you know am i exercising enough am i keeping fit am i keeping strong am i Grady and I’m doing the right you know am I am i doing a sensible amount of activity for my body’s capacity because that’s the other certainly common thing that we would say with people you know and I’m sure that’s gonna come out of the covert period where people you know frustrated as hell are being cooked up and just go on do boot camp right that’s like that’s a recipe disaster because the body is not conditioned to that degree of load as no doubt we’ll see a whole you know flurry of people coming in and the problem with that it gives exercise a bad name because people go oh I can’t do that anymore and then they get us you know you’ve worn out so give that away and that is so common yeah we’re people that experience of pain when it’s not pain ready to exercise when it’s not graded right gives a toxic experience that makes people think it shouldn’t be done and that’s a problem with the loading not with the exercise exactly yet yeah talk about does hello again capacity yeah and it creates another narrative which is which is this idea that pay relates to injury so I haven’t been exercise I started exercising I got sore I injured myself exercising where as a matter of fact you just did a bit too much and your body wasn’t ready for it yeah and it became sensitive which is very different because if it’s something sensitive yeah you kind of scale back for a couple of days and you gradually build it up to become healthy again and desensitize yeah I want to kind of wrap it up with maybe three more questions that we can try and answer relatively quickly the first one is around so you know all these factors that you’re talking about changing your lifestyle changing how much is sleep changing you beliefs around your knee or your hip or your osteoarthritis sound like really important things and we know they are really important things that can help people improve but when you have that as one option and that might take like you say it quite a journey of a few weeks a few months it’s actually really up should be it forever journey and then you pair that up against a surgery which is you know seen as a quick fix there typically patients aren’t out-of-pocket for that even though that cost you know three four five God knows how many more times more than a proper exercise program and we know all the guidelines suggest that exercise education and weight clock weight-loss are the cornerstones of management yeah it’s not happening and part of that I think is because it’s easier to get a quick fix it’s easier and it seems like there’s this perception that it’s you’re just gonna go in there you don’t have to do much work for it yeah I kind of wanted you guys to talk about the glad program which is something that started in Denmark a bunch of researchers over there were kind of getting frustrated that this was the the common path and yeah I was hoping you could sort of talk to that talk to that because that’s something that initially patients had to pay for that program in Denmark at the moment in Australia they have to pay for that but it’s now being fully funded in Denmark by the government and patients are getting pushed down that path so can you briefly talk about that so the the glaad program was a initiative in response to the evidence that was already well established for for osteoarthritis so there’s more than 50 randomized control trials demonstrating their exercise and a form of education in weight loss can be effective for reducing pain and improving function for people with near way so as you rightly said they implemented that and the problem is basically a couple of sessions educating patients on contemporary understanding of the knee osteoarthritis or knee and hip arthritis and after that there are twelve group sessions that patients will do and they have supervised exercise sessions so over six weeks or twice a week they will come in and they will do a series of exercises that are why although they are provided in a group environment they are tailored to the person’s level of condition so as people rightly said before that it depends on your level of entry in an exercise program so the exercises are gradually progressed and what I notice is that once they got people through that program initially people actually are getting level of discomfort in their name and the exercise were adjusted but they kept going gradually and progressively and what they found is that at the end of the program so they did that for six weeks by under supervision and then they were encouraged to do for another six weeks by themselves at home and the exercises are designed for them to be able to do at home by themselves as well and they found that there was a 35% reduction in pain intensity at the end of the program and the willingness to forego surgery at the end of that program was quite high in fact up to a year and two years later a high percentage of patients will be not interested in having surgery because they feel like they are doing the things that they they want in life and they are in control of their of their pain so that program is it was packaged in a way they could be he has a research component into it and it’s a way that making sure the clinicians they are delivering that are delivering the right dose of exercise and education because that’s another thing you’re not be talked about before patients going up and down with the exercise and you know your exercise gets all your rest whereas this program puts you in a structure where you keep moving forward you may fluctuate in terms of the intensity but you keep going forward and the reason for that is that there is a minimum dose of regular exercise that patients need to do so you take baby steps baby steps where you do that regularly and progressively and over a three-month period that’s when you can see changes in your physical capacity in your function and your pain intensity so the glaad program is one program that is out there that is offered in a group environment so some of the things that we talked about before can be delivered in a one-on-one set setting but also the group setting works really well for other people and also in terms of being quite affordable for for the community as well yeah sure and we’ll put links to the glad website so people can find out more because there’s loads of clinics and clinicians around Australia that are that I’m offering that and a couple of years ago the La Trobe University some researchers there so Kate Crosley Christian Barton and Joe Kemp they were directly involved in a group in Denmark and they brought that initiative to Australia so they’ve been now collecting data and training clinicians across Australia so in every major city in Australia you can find a GLAAD program and we were invited to partner with them so we brought that problem to Perth and we have trained more than 100 clinicians in Perth now they can deliver that same program and the cool thing about this is that it’s not just an initiative to get patients through the door in the clinic because if you come in to a GLAAD class it means that you’re if you consent to it your data is taken to a database that is central in Australia so we are providing good care which is evidence-based care for patients but you’re also collecting data for what to understand the trajectory of these patients but also to have enough data to then go to the private health funds and go to the government and say look there is an alternative here and look at the story in Denmark is that something that we want to reproduce yeah so that that will be showing up soon and I think the key is there that you know although yes it involves at least six weeks of structured rehabilitation they have really good outcomes you know one of the you kind of alluded to the statistics of these people were on a waitlist for surgery and a year the year follow-up mark 75% hadn’t had their surgery and then at two years it was 66% that still hadn’t you had this early so although there’s a bit of work involved it’s actually a chose to be quite quite effective and it’s probably not necessarily just the fact that it’s you know the title is it’s those glad Anders exercise but it’s actually a dosage of exercise you know it’s forcing people to get that minimum dose just really it’s interesting people often think there now I’ve got my knee replaced I’m going to be get active it doesn’t happen yet so it doesn’t there’s a lots of research to show that people whose levels of activity really don’t change once I had a knee replacement where something like this program gives them confidence and strategies to get active that’s that’s whole health benefit that’s gonna benefit potentially a social mental physical cardiovascular every health system in your body so that is a broad health intervention actually it’s not just about your knee oh yes and probably pretty previous to glad me implemented them like they’ve done studies where they looked at people that were going for knee replacement and they offered this a similar program and they went through knee replacement versus another group that didn’t do it structured program so both groups went through knee replacement but their outcomes afterwards in terms of returning to function yeah being able to do the things that they wanted and the outcome of the surgery was better in the group they had done a minimum dose and the scary statistic is that if you look at the number of patients that go into knee replacement in Australia or I’m sorry worldwide is up to 38 percent of patients that go to the replacement without having done evidence-based in like a program before being officer again so that’s a pretty staggering statistic that a lot of people actually would have got better outcomes after surgery or in fact wouldn’t need surgery for a long time or whatever yeah and it’s probably important to mention that you know this doesn’t mean that people never need surgery no absolutely not think we were probably important to make clear I know this chat it’s a really quite effective surgery in the right people yeah we just need to make sure that the the funnels are set up in a way that you can capture those people that you don’t need to have it’s a win-win because you know you get yourself healthy and fit and strong since you up for a better outcome surgery or it gives you the choice yep can’t lose on that so sorry yeah yeah the other point I was gonna make is that some people end up going to surgery on the premise that you know your bone and bone and and actually if you have really severe changes in your knee and your trial and you exhausted your exercise approach and you’re being educated you lost weight actually having the surgery puts you in a really good position to recover some function afterwards the problem is that people that don’t tend to respond very well people that have less severity or changes in their knee away which kind of alludes to the possibility that they other factors that are driving that irritation and about one in five people that go for that surgery may not get the outcomes that they were expecting absolutely so you know time during covert at the moment elective surgeries including knee replacements and hip replacements have effectively been cancelled they’re being brought back on in Australia but certainly not everywhere around the world can you talk to a potential silver lining around the those surgeries being cancelled we’ve kind of alluded to it but just think it really clear for the listeners yeah look I think what happens is people often feel like and when I have physiotherapy and you got to say what is it you don’t just have doctor yeah so what kind of treatment did you have from your physiotherapist and if it you know I always say to people if it if it wasn’t the physio working as a coach that gave you educated evidence and form education that gave you a program that put you in charge that graded it up to get you stronger if you weren’t more at a stronger and more confident fitter and healthier at the end of that program you didn’t get it so that’s the first thing is because a lot of people go on to a weightless like Joe Peter said not all is some don’t even get that opportunity some do have my descent a physio sorted a massage it’s not therapy so evidence-based physiotherapy for knee pain so the first thing is what kind of treatment have you had use that time wisely because you might be on a wait list for surgery use that time wisely because most people with similar wait list and literally sit on a weightless so from seeking out evidence-based treatment so like the burn program people who will commit to kochu to get well only to protect your health the other things that you can do now that will may not well you know that’s not effects but it may improve the quality of life and it may reduce your pain and it may reduce your distress and it may give you an opportunity to decide whether you need that surgery or not or and will put you in a better place to have the surgery yeah yeah yeah sure and good luck glad stands for good last week’s arthritis in Denmark intervention that’s one of the most common questions we get so I kind of want to wrap it up with something really practical for for our listeners so JP you’re involved in a paper last year that kind of looked at what are the what are the recommendations we should make for osteoarthritis it’s kind of breaking down the myths and then kind of supplementing them with facts so this is the infographic that was produced out of that which again we’ll link to in the show notes really quickly can you talk to talk to this in and maybe this can be out we have that we finished the podcast with it to try it today segment which tries to make information or turn information into action and maybe that can be there to try today is to have a look at this infographic and kind of reflect on okay is that something that I believe in where can I change so that you could talk about that sure some of the best set so so I think of what the infographic does it summarizes what we talked about today so we have at the top of the infographic we talked about the myths and the facts and some of the myths are around the fact that you know pay always equals damage the surgery such as total knee replacement is inevitable if you do have any joint pain and their exercise is harmful so and to all of those things things that we talked about today where they are not they are not entirely true and some of the facts the support that go against that is the fact that yes surgery can be help for the right candidate that has trialed and exhausted the right dose of program of evidence-based care which includes education exercise and weight loss for those that need and then people tend to respond better exercise is not harmful if done if it started and as graduated manner and progressive slowly and within your capacity at that time to achieve your goals and pain doesn’t always equal damage you know we talked about all the factors and that’s the next step of the of the infographic where we have we changed from knee pain to have knee health at the center and we have all these other factors that you know they go from lifestyle psychological factors and biological factors such as do you have a history of trauma in that knee do you have enough conditioning in that leg do you have Barney Dima on your skin so all those factors interplay to present or to affect the person’s knee health there or where those structures may become sensitive or not so if you do have the knee pain how do you how do you manage that and some of the on the mid side and things that are considered as low value care is if you provide massage by itself dry needling by itself where you send patients with form rollers and spiky balls and they’re doing that or electrotherapy so all those things they will not they may provide some symptomatic relief for mechanisms that we were not going to discuss here today but they they’re not gonna provide you to get your long-term goal so some of the cases that we talked about today that been offered just that there is not a process where the patient can land through and Pete talks about education and you know so you need to be educated you need to be guided through an active approach you may or may not need to lose weight you may or may not need to manage your stress in your sleep but one of the things that is really important is that education is not seating the patient down and taking them through this and lecturing them education is a process and the process is the journey where they tried a few exercises they got a bit sore we need to change the way we do that they had a flare-up and they realize that they need to change a few things or they went a bit too fast or they you know they actually didn’t work on their white and now they need to do that so this journey is an educational process a learning process where the patient starts to understand how the knee flares up and how they respond or not to that problems so on the high-value care is basically all these things that we’re talking about so if you go and you see a physio what do you want to hear you want someone that listens to your story you know did you have a trauma did you trip over or this started out of the blue when you’re moving houses for instance or at a time where you’re highly stressed incidentally and etc and based on that story what are you what are the things you want to do what is your current physical capacity what are your habits do you have unhelpful habits can we break them are they helpful when you break them and then set up a plan that is not just given by the physio but a plan that is you know it’s a dual process where both of you and the patient are designed in that plan and then you go you know the process from here on is that I’ll guide you until you achieve your goals and you learn how to manage that condition perfect awesome thanks so much for your time guys it’s gonna be very helpful for our listeners thank you so there you have it another episode of empowered to be on pain we’d love to hear what you think of the podcast so please reach out to Pete JP or IV Twitter or you can just email at podcast at body logic dot physio next week we have a guest host in the form of the award-winning Jennifer posad Jennifer is the manager of Health Services at arthritis and osteoporosis Western Australia a non-governmental organisation that offers a range of support services for people with arthritis we look forward to her interviewing a leading expert in osteoarthritis but until then stay safe stay active be kind and remember to ask is there more to pain than damage [Applause]

So there you have it, another episode of Empowered Beyond Pain. We’d love to hear what you think of the podcast, so please reach out to Pete, JP or I via twitter. Next week we have a guest host in the form of the award winning Jennifer Persaud. Jennifer is the manager of Health Services at Arthritis and Osteoporosis Western Australia, a non-governmental organisation that offers a range of support services for people with Arthritis. We look forward to her interviewing a leading expert in Osteoarthritis, but until then, stay safe, stay active, be kind, and remember to ask, is there more to pain than damage.