Episode 7

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Welcome back to another episode of the Empowered Beyond Pain podcast, proudly brought to you by Body Logic Physiotherapy. Before we get stuck into another episode, we just wanted to say a huge thanks to all of you amazing humans who have been listening in each week. Especially to itunes reviewer Ashlee who mentioned it was a fantastic podcast (with a capital F and an explanation mark). Ashlee gave us a five star review on iTunes, which apart from directly sending the podcast to someone, is probably the best way to help us bring evidence to more eardrums, plus we love hearing from you and what else you’d like to hear about, just like Ashlee did when recommending a potential future topic… we hear you!

So last week’s episode was a broad overview of Osteoarthritis. We heard from world leading orthopaedic surgeon, Professor Stefan Lohmander from Lund University in Sweden and then Pete and JP provided some absolute gold in the form of current evidence, common myths and tips on managing Osteoarthritis. It was a pretty long episode and the show-notes page was absolutely chock a block with info. In case you didn’t know, each episode has its own page where we link relevant infographics, research articles and links that were discussed in that episode. We also post the transcript of the podcast, as well as a link to watch the episode in video format on youtube for those that may not use podcast apps… we do this all on the quest help make sense of science, bring evidence to your eardrums and empower you to better health, as well as empowering clinicians to provide the best care for people in pain.

This week, I am absolutely thrilled to introduce Jennifer Persaud as our guest host! Jennifer is the Manager of Health, Education and Research Programs at Arthritis and Osteoporosis Western Australia. She is also an Advanced Scope Physiotherapist and was recently awarded the ‘Julie Michael Memorial Prize in Leadership for Social Impact’ from the University of Western Australia. Great recognition for the hard-work and dedication to her studies. This is the first of 3 shorter episodes where she has an Osteoporosis Q&A with our very own Dr JP Caneiro, who has a PhD in musculoskeletal pain and is a research fellow at Curtin University. It’s probably important to mention that this discussion occurred a few weeks ago during the peak of the Coronavirus outbreak here in Perth, Western Australia, so please keep that in mind as certain circumstances discussed have changed. Wherever you’re listening to this, we hope you’re safe and healthy, and if you’re able to listen to this while moving your body, then big ups to you! Again, a huge thanks to Jennifer and Arthritis and Osteoporosis Western Australia. We hope you enjoy this conversation, and remember to ask, is there more to pain than damage!

Hello everyone and welcome to this Q&A section my name is Jennifer Azad I’m a manager at arthritis and osteoporosis Western Australia we are the leading nonprofit and charitable organisation representing consumers needs and that is consumers with musculoskeletal conditions including arthritis in Western Australia and today I’m joined by Jane peek in here oh hello and welcome to JP I did it but I know Jamie is a clinical director at the body logic physiotherapy and he’s also a specialist sports physiotherapy as awarded by the Australian Australian College of physiotherapy in 2013 and the reason that we’re having this Q&A that is dedicated to osteoarthritis of the knee is because we would you to have a seminar and that was cancelled because of coded because the face-to-face contact but also we’ve received quite a lot of phone calls from consumers and also health professionals who have concerns about how to manage patients with a knee now that many of those elective procedures and outpatient clinics in the public hospitals had stopped because they’ve coded 19 so it’s a really opportune moment to be able to speak to somebody of expertise in this area and to try and get them some really good sensible tips out to consumers and also to health professionals who are trying to navigate this space on a background of code of 19 so welcome JP Thank You Simon your behavior your clarity welcome now I thought we might start off with you giving us a very brief overview of what osteoarthritis of the knee actually II sure so Oscar arthritis is basically an inflammation of the joint so it’s a joint response in which you have an inflammatory process they alter the structure of the joint so when you look at the structure of the need for example the the cartilage of the knee will change in response to these inflammatory changes and the changes are not only on the cartilage but also on the soft tissue that involves the cutlet the the joint itself and these changes they can out in severity so some people may have lower level changes and other people may have higher grade changes and these are visible on a on a plane x-ray and these structures they can become sensitized and probably the wood can is really important here because it’s not everyone that will develop pain as a consequence of having outer changes in their in their bone structure in terms of the what characterizes osteoarthritis is that you you can have these changes but you can also develop pain and functional limitation as a consequence of that so a person with knee away would be considered someone that has radiological changes so changes in a skin but also they develop pain in the knee that leads to functional limitation plus-or-minus joint stiffness in the you know in the early hours of the morning thank you for that now you mentioned some imaging studies that I helped pouring the diagnostic side of osteoarthritis for me but there were also some other components around that so is a scan or an x-ray by itself useful in making a diagnosis of omx no the short answer is is no the the x-ray which would be the most commonly used diagnostic tor imaging for people with near Y it just tells us about how the joint looks but the diagnosis of a way is a clinical one so that means that a clinical assessment is the is imperative and if we look at the international guidelines in fact they say that if the person presents pain and functional limitation and they’re over the age of 40 plus or minus stiffness in the morning they can be diagnosed as having new your way so you need a skin in fact when you look at the the use of scans for diagnosing me away it can actually lead to a an escalation of care and it can lead to a overuse of of the you know health services because of that of that skin so these days we are going the not us but the clinical guidelines are suggesting that you should be going towards a clinical assessment rather than using using a skin thank you and if you recently published an editorial piece in the British Journal of Sports Medicine just last month exactly about this and it was entitled something around changing the the narrative around osteoarthritis of the knee and that was really to empower clinicians to change the way that we communicate about osteoarthritis than they and also patients that are of course the most important person in that healthcare journey you didn’t mention in the article it’s really important to consider only as a whole person condition rather than every single joint condition could you expand on what you meant by that faith yeah absolutely so what we mean by that is to say that knee away and especially a person’s pain experience is much more than just a joint and that’s because what we know these days is that a person pain experience can be influenced by the individual context by their lifestyle but their stage in their life so by several factors that are beyond the joint so basically if we are looking at a person’s health in terms of of their social circumstances in terms of their biology in terms of their structure the physical conditioning and their lifestyle choices all those factors can come to play to influence a person’s pain experience so in the past we tended to look at knee osteoarthritis as been a problem so lowly of the joint and is still a common belief that patients and many clinicians will see that pain that comes from the people presenting with pain people with me a way that present with pain there is directly related to the level of damage in their joints and what contemporary evidence tells us is that there is much more that can lead to someone experiencing pain than just the structure okay so there’s baking conversation recently where in the literature around the difference between pain as a deception and tentative sensation and the thought process that well inflammation for instance is a biological process and that that cannot be altered by cognitive processes and trying to have the brain influence of biological processes can you expand on that sure so I think for you know if we think of this to the consumers that the biopsychosocial view on pain it’s basically telling us that we are looking at more than just the biology so if we break down the word and we look at the biological aspect of this of this view we are talking about inflammatory process processes as you rightly said the structure of the joint your muscle conditioning and size and strength if you have any you know your levels of physical activity your body weight and in the presence of other inflammatory markers in your system so all those factors and others who will basically comprise this biological aspect but you also have a psychological aspect which is you know how confident you are in using your body how worried you are about your body what is your stress levels and one of the of the of the side effects of stress or one of the physiological consequences of having especially chronic stress is it’s an inflammatory one so there is a physiological change in the body when someone is going through stressful periods or someone that carries stress in their life and you can imagine that if you have a knee condition that is painful and it stops you from doing the things they love potentially that could be socializing being physically active and working or even being able to be mobile you know things that we take for granted that would cause you a level of worry especially if you feel that there is nothing you can do about that condition so a byproduct of that is a physiological response and then we have the social aspect which is you know are you participating at work are you isolated or are you living in a place where you can communicate with others and you’re going out and doing the things that you love and in that in that regard these things also affect the physiology of our body you know these days we know that something like social isolation can lead to significant changes in the chemistry of your of your body and in addition to that we have lifestyle factors and choices such as you know your sleep quality your diet your levels of physical activity or you know under doing or overdoing so when we look at this biopsychosocial view we look at this intertwined relationship of all these factors and how they can play or interplay to out of the chemistry of the body and out of the physiology of the body and how – someone’s paying experience so things such as you know sleep stress physical activity levels and you know your your body weight they can definitely influence inflammatory processes you know there’s a couple of studies that came out in the last couple of years looking at you know what is the underlying factor across many comorbid conditions and these conditions would be cardiovascular disease mental health disease musculoskeletal disease such as foster arthritis and you know things such as Crohn’s disease and berries so all of those have an underpinning process of an inflammatory response so inflammation seems to be underlying across all these different comorbidities and you know as you as you know many of our patients that develop knee osteoarthritis they have other comorbidities that play a role in in their life so we have seen this this whole person response and you know when you look at some and how one understands about their problem that can definitely influence your actions and and the things you do and how are you going to use your body in response to that so if I could if I could give you an example you know let’s say I develop pain in my knee and I’m you know 45 150 years old and I have functional limitation and I got an x-ray and the doctor told me that my you know to make things simple he told me look it’s just a bit of wear and tear that’s normal but your joint is the generating and you know you gotta be careful otherwise you end up needing a knee replacement so basically the the message that is instilled in a in the conversation is that it’s a it’s a it’s a process that there’s nothing not much I can do about it’s a generation that is happening and there’s nothing I can do about it and I need to be careful and the more I love the joint the more I use it the more the generation that would cause so immediately you can see that a person would have a sensible response not to use the leg because they are thinking that if they use the leg they actually causing more this more stress on the joint and that can be problematic therefore exercise may not be the right thing to do so you can see that how one understands their condition and the beliefs that drive that can drive their behavior so they may become less socially active they may become less physically active in order to preserve that joint today because otherwise the only solution is to have a joint replacement so that whole person approach as you can see can can influence several levels of that of that person now the the contrary is also true because start rose to an end the first of this three-part miniseries we just heard JP described a really common but ultimately unhelpful response to a diagnosis of osteoarthritis that can lead to less function and more pain over time next week you hear JP discuss a more evidence-based and helpful response to the same diagnosis plus much much more we know it’s easy to get information overload when learning a new about a new topic so we thought we’d keep these episodes a bit shorter to allow you to reflect on some key learning points you’ll notice there’s a fair bit of overlap with previous episodes which we think is a good thing especially if it’s new information and contrast to believe that you may have had for many many years my take homes were arthritis is a whole person condition not just related to the joint imaging findings in isolation aren’t that useful in diagnosing osteoarthritis imaging findings are poorly related to pain and can result in unnecessary escalation of healthcare interventions and that there’s so much that individuals we are osteoarthritis can do themselves to improve their pain function and ultimately their quality of life sometimes you just need the help of the right coach what did you take out of the episode we’d love to hear your take homes and you can contact us via Twitter as always show notes can be found at WWE logic physio forward-slash podcast next week we welcome back Jennifer to bring you part two of the conversation but until then we hope you have a fun week and remember to ask is there more to pain than damage [Music] please note what you heard on this episode of empowered beyond pain is strictly for information purposes only and does not substitute individualized care from a trusted and licensed health professional if you would like individualized high value care for your pain sports or pelvic health problem head to the body logic website and make an appointment theme music generously provided by Thurman and cash body logic physiotherapy empowering people to achieve better health welcome back to another episode of the empowered beyond pain podcast proudly brought to you by body logics is your therapy before we get stuck into another episode we just wanted to say a huge thanks to all of you amazing humans who have been listening in each week especially to iTunes reviewer Ashley who mentioned it was a fantastic podcast with a capital F and an explanation mark Ashley gave us a five-star review on iTunes which apart from directly sending the podcast to someone is probably the best way to help us bring evidence to more eardrums plus we love hearing from you and what else you’d like to hear about just like Ashley did when recommending a potential future topic we hear you so last week’s episode was a broad overview of osteoarthritis we heard from a world-leading orthopedic surgeon professor Steffen l’amanda from Lund University in Sweden and then Payton JP provided some absolute gold in the form of current evidence common myths and tips on managing osteoarthritis it was a pretty long episode in the show notes page was absolutely chock-a-block with info in case you didn’t know each episode has its own page where we link all relevant infographics research articles and links that were discussed in that episode we also post the transcript of the podcast as well as a link to watch the episode in video format on YouTube for those that may not use podcast apps we do this all on the quest to help make sense of science bring evidence to your eardrums and empower you to better health as well as empowering clinicians to provide the best care for people in pain this week I’m absolutely thrilled to introduce Jennifer Persaud as our guest host Jennifer is the manager of health education and research programs at arthritis and osteoporosis Western Australia she’s also an advanced scope physiotherapist and was recently awarded the Julie Michael Memorial Prize in leadership for social impact from the University of Western Australia great recognition for the hard work and dedication to her studies this is the first of three shorter episodes where she has an osteoporosis Q&A with our very own dr. J peak Niro who has a PhD in musculoskeletal pain and is a research fellow at Curtin University as well as being a specialist physiotherapist it’s probably important to mention that these discussions occurred a few weeks ago during the peak of the corona virus outbreak here in Perth Western Australia so please keep that in mind as certain circumstances discussed have changed wherever you listening to this we hope you’re safe and healthy and if you are able to listen to this while moving your body then Big Ups to you again a huge thanks to Jennifer and arthritis and osteoporosis Western Australia we hope you enjoy this conversation and remember to ask is there more to pain than damage [Music] hello everyone and welcome to this Q&A section my name is Jennifer Azad I’m a manager at arthritis and osteoporosis Western Australia we are the leading nonprofit and charitable organisation representing consumers needs and that is consumers with musculoskeletal conditions including arthritis in Western Australia and today I’m joined by Jane peek in here oh hello and welcome to JP I did it but I know Jamie is a clinical director at the body logic physiotherapy and he’s also a specialist sports physiotherapy as awarded by the Australian Australian College of physiotherapy in 2013 and the reason that we’re having this Q&A that is dedicated to osteoarthritis of the knee is because we would you to have a seminar and that was cancelled because of coded because the face-to-face contact but also we’ve received quite a lot of phone calls from consumers and also health professionals who have concerns about how to manage patients with a knee now that many of those elective procedures and outpatient clinics in the public hospitals had stopped because they’ve coded 19 so it’s a really opportune moment to be able to speak to somebody of expertise in this area and to try and get them some really good sensible tips out to consumers and also to health professionals who are trying to navigate this space on a background of code of 19 so welcome JP Thank You Simon your behavior your clarity welcome now I thought we might start off with you giving us a very brief overview of what osteoarthritis of the knee actually II sure so Oscar arthritis is basically an inflammation of the joint so it’s a joint response in which you have an inflammatory process they alter the structure of the joint so when you look at the structure of the need for example the the cartilage of the knee will change in response to these inflammatory changes and the changes are not only on the cartilage but also on the soft tissue that involves the cutlet the the joint itself and these changes they can out in severity so some people may have lower level changes and other people may have higher grade changes and these are visible on a on a plane x-ray and these structures they can become sensitized and probably the wood can is really important here because it’s not everyone that will develop pain as a consequence of having outer changes in their in their bone structure in terms of the what characterizes osteoarthritis is that you you can have these changes but you can also develop pain and functional limitation as a consequence of that so a person with knee away would be considered someone that has radiological changes so changes in a skin but also they develop pain in the knee that leads to functional limitation plus-or-minus joint stiffness in the you know in the early hours of the morning thank you for that now you mentioned some imaging studies that I helped pouring the diagnostic side of osteoarthritis for me but there were also some other components around that so is a scan or an x-ray by itself useful in making a diagnosis of omx no the short answer is is no the the x-ray which would be the most commonly used diagnostic tor imaging for people with near Y it just tells us about how the joint looks but the diagnosis of a way is a clinical one so that means that a clinical assessment is the is imperative and if we look at the international guidelines in fact they say that if the person presents pain and functional limitation and they’re over the age of 40 plus or minus stiffness in the morning they can be diagnosed as having new your way so you need a skin in fact when you look at the the use of scans for diagnosing me away it can actually lead to a an escalation of care and it can lead to a overuse of of the you know health services because of that of that skin so these days we are going the not us but the clinical guidelines are suggesting that you should be going towards a clinical assessment rather than using using a skin thank you and if you recently published an editorial piece in the British Journal of Sports Medicine just last month exactly about this and it was entitled something around changing the the narrative around osteoarthritis of the knee and that was really to empower clinicians to change the way that we communicate about osteoarthritis than they and also patients that are of course the most important person in that healthcare journey you didn’t mention in the article it’s really important to consider only as a whole person condition rather than every single joint condition could you expand on what you meant by that faith yeah absolutely so what we mean by that is to say that knee away and especially a person’s pain experience is much more than just a joint and that’s because what we know these days is that a person pain experience can be influenced by the individual context by their lifestyle but their stage in their life so by several factors that are beyond the joint so basically if we are looking at a person’s health in terms of of their social circumstances in terms of their biology in terms of their structure the physical conditioning and their lifestyle choices all those factors can come to play to influence a person’s pain experience so in the past we tended to look at knee osteoarthritis as been a problem so lowly of the joint and is still a common belief that patients and many clinicians will see that pain that comes from the people presenting with pain people with me a way that present with pain there is directly related to the level of damage in their joints and what contemporary evidence tells us is that there is much more that can lead to someone experiencing pain than just the structure okay so there’s baking conversation recently where in the literature around the difference between pain as a deception and tentative sensation and the thought process that well inflammation for instance is a biological process and that that cannot be altered by cognitive processes and trying to have the brain influence of biological processes can you expand on that sure so I think for you know if we think of this to the consumers that the biopsychosocial view on pain it’s basically telling us that we are looking at more than just the biology so if we break down the word and we look at the biological aspect of this of this view we are talking about inflammatory process processes as you rightly said the structure of the joint your muscle conditioning and size and strength if you have any you know your levels of physical activity your body weight and in the presence of other inflammatory markers in your system so all those factors and others who will basically comprise this biological aspect but you also have a psychological aspect which is you know how confident you are in using your body how worried you are about your body what is your stress levels and one of the of the of the side effects of stress or one of the physiological consequences of having especially chronic stress is it’s an inflammatory one so there is a physiological change in the body when someone is going through stressful periods or someone that carries stress in their life and you can imagine that if you have a knee condition that is painful and it stops you from doing the things they love potentially that could be socializing being physically active and working or even being able to be mobile you know things that we take for granted that would cause you a level of worry especially if you feel that there is nothing you can do about that condition so a byproduct of that is a physiological response and then we have the social aspect which is you know are you participating at work are you isolated or are you living in a place where you can communicate with others and you’re going out and doing the things that you love and in that in that regard these things also affect the physiology of our body you know these days we know that something like social isolation can lead to significant changes in the chemistry of your of your body and in addition to that we have lifestyle factors and choices such as you know your sleep quality your diet your levels of physical activity or you know under doing or overdoing so when we look at this biopsychosocial view we look at this intertwined relationship of all these factors and how they can play or interplay to out of the chemistry of the body and out of the physiology of the body and how – someone’s paying experience so things such as you know sleep stress physical activity levels and you know your your body weight they can definitely influence inflammatory processes you know there’s a couple of studies that came out in the last couple of years looking at you know what is the underlying factor across many comorbid conditions and these conditions would be cardiovascular disease mental health disease musculoskeletal disease such as foster arthritis and you know things such as Crohn’s disease and berries so all of those have an underpinning process of an inflammatory response so inflammation seems to be underlying across all these different comorbidities and you know as you as you know many of our patients that develop knee osteoarthritis they have other comorbidities that play a role in in their life so we have seen this this whole person response and you know when you look at some and how one understands about their problem that can definitely influence your actions and and the things you do and how are you going to use your body in response to that so if I could if I could give you an example you know let’s say I develop pain in my knee and I’m you know 45 150 years old and I have functional limitation and I got an x-ray and the doctor told me that my you know to make things simple he told me look it’s just a bit of wear and tear that’s normal but your joint is the generating and you know you gotta be careful otherwise you end up needing a knee replacement so basically the the message that is instilled in a in the conversation is that it’s a it’s a it’s a process that there’s nothing not much I can do about it’s a generation that is happening and there’s nothing I can do about it and I need to be careful and the more I love the joint the more I use it the more the generation that would cause so immediately you can see that a person would have a sensible response not to use the leg because they are thinking that if they use the leg they actually causing more this more stress on the joint and that can be problematic therefore exercise may not be the right thing to do so you can see that how one understands their condition and the beliefs that drive that can drive their behavior so they may become less socially active they may become less physically active in order to preserve that joint today because otherwise the only solution is to have a joint replacement so that whole person approach as you can see can can influence several levels of that of that person now the the contrary is also true because

So that draws to an end the first of this 3 part mini-series. We just heard JP describe a really common but ultimately unhelpful response to a diagnosis of Osteoarthritis that can lead to less function and more pain over time. Next week you’ll hear JP discuss a more evidence-based and helpful response to the same diagnosis. Plus much more

We know it’s easy to get information overload when learning about a new topic, so we thought we’d keep these episodes a bit shorter to allow you to reflect on some key learning points. You’ll notice there is a fair bit of overlap with previous episodes which we think is a good thing, especially if it’s new information and contrasts to beliefs that you may have had for many years. My takehomes were:

• Arthritis is a whole person condition
• Imaging findings in isolation aren’t that useful in diagnosing Osteoarthritis
• Imaging findings are poorly related to pain and can result in unnecessary escalation of healthcare interventions.
• There is so much that individuals with osteoarthritis can do themselves to improve their pain, function and ultimately their quality of life, but sometimes they just need the help of the right coach.

What did you take out of the episode? We’d love to hear your take homes and you can contact us via twitter. As always, show notes can be found at www.bodylogic.physio/podcast

Next week, we welcome back Jennifer to bring you part 2 of the conversation, but until then we hope you have a fun week, and remember to ask, is there more to pain than damage.