Thorlene Edgerton

Okay, Good morning and welcome to the Hip and Knee Osteoarthritis podcast. As part of this APA IGNITE 2023 conference. I'd like to start by acknowledging the Turrbal and Jagera people's land of Meanjin as the original owners and custodians of the lands on which we meet, work and learn. We pay our respects to the elders past, present and emerging.

I'm Dr Thorlene Edgerton and I'm a physiotherapist by background from the physiotherapy department and the Centre for Health, Exercise and Sports Medicine at the University of Melbourne. And I'm joined by Ali Gibbs and Adrian Kan, who I'll just ask to introduce themselves now. So Ali, would you like to introduce yourself, please?

Ali Gibbs
Great. Thanks, Thorlene. My name's Ali. I'm also physio by background. I'm doing my PhD at the moment at La Trobe University in the La Trobe Sports and Exercise Medicine research Centre and work clinically in a hip and knee Osteoarthritis screening clinic and in public health in some advanced practice clinics. I'll now throw over to Adrian.

Adrian Kan
Morning, everyone. My name is Adrian. A physio by trade as well. I'm predominantly in the clinic across Gold Coast at Pinjarra and Bon Physiotherapy and Sports med, and I also do a bit of teaching at Bond University as well as a bit of research. And on the side I was working with Gold Coast Knee group with knees across all ages.

Thorlene 
Thanks very much, Adrian. It sounds like you've got quite a lot on your plate at the moment. And you did disclose to me just a few minutes ago that your first publication was accepted just a couple of days ago. So can you tell me a little bit more about.

Adrian 
Yeah, absolutely. So the research that I just did was looking at the addition of structured lifestyle modifications to a traditional exercise program when managing someone with knee osteoarthritis conservatively. So the background of it is the fact that, you know, exercise has always been a preferred treatment for clinicians. There's really well, good research out there looking at short term benefits.

That being said, the long term benefits of including these lifestyle modifications on top of an exercise program is still quite a recent theme and in line with various recent national medical guidelines. We just thought we would look into it a bit more and see how we can implement it in a clinical setting.

Thorlene 
Thanks, Adrian, and I'm really interested in that topic as well and I'm going to come back to that. But I think you've mentioned guidelines and I think that might have some connection with Ali's research. Is that right, Ali?

Ali 
Yes. So we recently published a systematic review looking at hip and knee osteoarthritis guidelines. Adherence to guidelines is generally pretty poor. Less than half of people generally receive guideline recommended care for hip and knee osteoarthritis. Part of that could be the so many guidelines. People just don't know which ones to follow and the quality of the guidelines is unknown as well.

So we appraise the quality of guidelines for all aspects of management. So lifestyle, pharmacological and surgical identified the higher quality guidelines using the agreed to tool and then applies higher quality guidelines looked at. Do their recommendations actually agree with each other or not? So we found they all were consistent in recommending exercise, education and weight loss if required for both hip and knee osteoarthritis.

And then after that, the only recommendation that was consistent was non steroidal anti-inflammatories. For hip and knee osteoarthritis and cortisone injections for knee were the only things that were consistently recommended in favour. Other medications, the recommendations were fairly inconsistent for surgery, none of the higher quality guidelines that we identified actually looked at arthroplasty. So there was no recommendations provided for those.

So there's a few gaps. And then the big gap is that they don't tell people how to actually implement the guidelines. So they say exercise, but they don't give any further details.

Thorlene 
So was that the conclusion of where your findings led you to think? Is that part of the problem is the inconsistency? And then the other part of the problem is that the guidelines don't give any guidance into how to deliver the recommendations. Is that right?

Ali 
Yeah, exactly. Yeah. Particularly for GP's and people who aren't as experienced or expert in exercise just saying you need to do exercise doesn't really help them with how they would then engage people in exercise or behaviour change.

Thorlene 
Thanks, Ali. That fits really well into what I've been looking into more recently, which is the education part of the recommendations in these guidelines. And we do know from a lot of qualitative and other types of research that what we're doing currently with education isn't helping and possibly is even doing some harm. So I know the guidelines say that we should educate and I think largely education is probably something that most clinicians would say that they do, but we don't really know a lot about the how and the what of the education.

And there's a real lack of evidence in to that area. And I also think that that overlaps quite a lot with the lifestyle part of what we deliver as physiotherapists as well. It's not just a matter of knowing what patients should be doing, but how do we support and empower them to do it. Do you have any thoughts on that, Adrian?

Adrian 
Yeah, absolutely. So from my review you're looking at, I guess so this so-called lifestyle modifications that can probably be split into four categories with advice and education being the biggest one, that can then be further split into disease education, just about the progression of knee osteoarthritis, pain, coping strategies, stress management as well as I guess diving into that whole pain science side of things.

And just from looking across papers, there are various different types that these interventions are implemented. But again, there just isn't really a structured guideline that we have at the moment and then are just touching on your research as well, just the language of these educational sessions and how they're run is a big issue as well.

Ali 
Thorlene I’ve read with interest, your work on some of the barriers that people have to getting access to care for osteoarthritis. So some of the work around GP's and patient education and things. Just wondering if you can tell me a little bit more about that.

Thorlene 
Thanks, Ali. Yes, we I have done some work with GP's on looking at ways we can get more people to receive the optimal care, and we did find that it was very challenging working, particularly in trying to get some behaviour change into GP practices. They’ve a lot of constraints that are put on them by the way, the systems and services are set up, a lot of demands on them and a lot of drivers that sort of influencing what they do in clinical practice.

So it is in our experience very difficult to get change. But I do agree with you that I think that that's where a lot of change needs to happen. What about you? Have you done some work with GP's?

Ali 
So at the moment we're just in the process of writing up a manuscript. So it's unpublished at this stage. Looking at GP's thoughts on managing osteoarthritis, in summary, they seem to know what the care should be, but for a lot of different reasons, I find it really difficult to actually get that care. Some of it can also be patient beliefs as well as the the system related factors. And like I say, addressing that behaviour change.

Adrian 
So speaking, I guess, the barriers of implementation. One reoccurring theme that I get in the clinic a lot is people coming in with an x ray report and on that report there's just all these big scary words about their knee, about the hip. And before you even start your consult or first thing they'll say to you is my knees gone, it’s bone on bone, there's no cartilage.

What can we do to address that? And what kind of educational intervention can we use to take that negative mindset away?

Thorlene 
Oh, thanks very much for that question, Adrian. That is right up my alley. I've been thinking a lot about this for many years and have now done a few studies in this space, and there's other people that have done some work in this space as well. There's some good work being done. Looking at the choice of words, you know, very specifically what words we use in the osteoarthritis and other musculoskeletal pain conditions as well.

And we are finding that words are important and can have an influence on people's self-efficacy and other cognitive and psychological factors and also their intentions for behaviour change. So it's a very interesting space to be working and my research recently has looked even beyond just the words and looked at trying to build behaviour, change techniques and even adult learning principles into some of our educational resources to see if that actually has a positive influence on people.

And I'm also particularly interested because people don't come to us as a blank page. People come with some preconceived ideas and beliefs about what osteoarthritis is and it's how to manage when we are delivering education via whatever format, whether it's videos or written information or 1 to 1, and you work clinically. So how does that play out in clinical practice in your experience?

Adrian 
Yeah, absolutely. So with the work I do at Gold Coast Knee group, we do offer quite a few services around knee osteoarthritis and one of the biggest change we are trying to implement is during the initial consult, assessing patients in a holistic view and not just looking at how clinically they're presenting, but at the same time in terms of the mental beliefs of the knee and even just going back to the basics with their sleep levels, stress levels and just their whole lifestyle habits, what we've found.

And I guess in line with my research as well as way in practice, take all those factors into account and not just traits on base and how they clinically present and not just hand them off with some exercises, but addressed to all those other deficits that they might have. People tend to pull up a lot better.

Thorlene 
Adrian that's fantastic. And I think that's an example of what Ali’s saying about implementing the guidelines and it's the guidance around how to implement is where the guidelines are generally falling short. Ali, do you have any comments on how Adrian is going forth and working on this implementation side of things?

Ali 
That sounds like a great model and I think that's where physios can get a lot, that the guidelines don't necessarily tell us what to do, but physios have a lot of that knowledge already of how to implement lifestyle behaviour, change, exercise. So I think that's where physios can add a lot of value to the care with osteoarthritis.

Thorlene 
Adrian How did you know what to do in terms of implementing guidelines?

Adrian 
A lot of it is I guess based around my research, knowing what type of lifestyle modifications seem to be the most common and what's most effective in terms of the types of lifestyle modifications to implement and how to implement. I'm just using a lot of resources that's out there already. So looking at going to the University of Melbourne website, doing those online courses and a lot of reading your work around the type of education type of wordings to use going to the pain science side of things and obviously with dietary modifications being a huge area as well at Gold Coast Knee group we're looking at I guess working an MDT style format and talking to a dietitian as well on how we can modify those things.

Thorlene 
And how are you monitoring the effect of the differences that you’re implement into your practice.

Adrian 
So what we do is we do regular, I guess, ‘testing sessions’. So just getting those clients or the patients coming in every couple of months, just going through a testing performed as well, using those same questionnaires, same measures and just kind of tracking along the way and see how that has changes. And based on that, we then kind of figure out what they’re still are lacking or what they might be doing. Well, and based on that, we can work around it.

Thorlene 
Do you have a story for us about a patient that's particularly memorable, a patient that came in with a two page MRI report with lots of scary words?

Adrian 
Yeah, absolutely. We do have a patient who I guess you could consider him relatively young. He's only in his early fifties. Unfortunately, there is a bit of crepitus in his knees with the clicking. And that report is quite full on given his past injuries with ACLs and MCLs. And he was very concerned that he was never going to surf again.

And at the same time, he's not sleeping well. His stress levels are through the roof and he's just scared to move. And I got him doing just some real basic high box squats. And once he heard the noise of that knee and he started quoting things from the MRI report. So I guess just taking the time to explain the anatomy of the knee of what arthritis is and just looking at the science of exercise and why it works, and then at the same time giving him handouts and just educating him on sleep stress levels that kind of calm him down a lot.

So, during the first, I guess a couple of weeks a lot was taking easy, just telling him you know less is more. Don't worry too much. We'll take it step by step. And then now he's very much into his exercises, sees a value in it and he's back surfing.

Thorlene 
And it's so great to hear the success stories. And I think that you raised a nice point there that even though my general advice is to avoid pathway anatomical language in education material, but that's not necessarily the right thing for every person. And there will be some people, depending on their need for cognition and their background, understanding whether they've got access to MRI reports, for example, that may need to have that anatomy fully explained to them. Ali, you work clinically as well. Do you have a story that relates to your research from your clinical practice?

Ali 
So the the service I work in is basically an orthopaedic screening clinic. We see people that are referred by their GP to see the orthopaedic surgeon, but instead of seeing the surgeon, they see the advanced practice physios, people that we're seeing all have to have imaging to be able to come to the service is one of the entry requirements.

They're all being referred for surgical opinion. So a certain percentage we find have just been told you need surgery, there's nothing else that you can do. So they haven't tried any of the other management. So the exercise, anything else. So they're quite surprised sometimes when you can say that yes, you do have obviously osteoarthritis changes on your X-ray, but there are other things that can help and can give you benefit and that you don't necessarily need surgery.

The other big question we get is, but I'll need it at some point, so why shouldn't I just get it now? And again, they're often quite surprised when explaining that in some people I was obviously does change over time, but not in everybody. And not everybody ends up at the point of needing or wanting surgery. So we've been really trying to push the message out to GP's patients, surgeons, everyone that there are other options apart from surgery.

Thorlene 
And education is hard. Like changing somebody's beliefs and thoughts about something, especially if it's quite ingrained and if it's connected to their identity in some way, it can be very difficult. I've got a story just last weekend talking to my father on the phone about his knee flare up and he's wanting an MRI.He has it in his head that he's got a meniscus tear and he needs the MRI and so on and so forth.

And so we had a long chat about what his expectations were. If the MRI does show, I meniscus tear and so on and so forth, the conversation went quite well. He still wants his MRI and that's fine. But two days later he tells me that I told him that he just has to suck it up. Oh, that just hurt.

Because in my mind I'd actually been saying something that was quite the opposite, that he should try some active management and that maybe his body would start stabilising things in his knee and that he wouldn't go down the path anyway. So education in is very difficult and there are some techniques that we can use to help check that people have heard what we were hoping that they heard.

But I think that we also need a lot of reinforcement and revisiting these conversations. What do you think about that Adrian?

Adrian 
Yeah, absolutely. I think the biggest part in practice, again is the education and reassurance. You do get patients who come in and they're terrified of the thought of surgery and yeah, some of them are  I guess coming in just to  really seek reassurance and a bit of guidance and then the other half are coming in thinking that they need surgery and they just want to get stronger before surgery.

So yeah, just working on the education side of things, taking the fear out of someone's mind and letting them know how capable their knees are is a big problem that we face. Another thing I want to touch on, Ali, was what you mentioned earlier about how when people come into your advanced clinic, they say to you, I'll be getting surgery anyway.

So what's the point of me trying conservative rout? And I think that's another big myth that we struggle to debunk every day that, yeah, actually need might not need surgery down the line of you manage your knee correctly now. So those are, I guess, constant challenges that we face, but we're definitely heading in the right direction. I think just a bit more structure and guidelines will go a long way.

Thorlene 
Yeah, I love what you said, Adrian, about letting people know how capable they are or how capable their Knee is because it speaks to the ICF notion that people are healthy as long as they're functioning. It's not really should be based on what path anatomical changes that their experience if they're functioning. Okay, that's an indication of health. And I think that approach is interesting and also very useful to us as clinicians.

Ali 
So yeah, there's been some work looking at the way people do talk about osteoarthritis and trying to shift it so that it's a participatory discourse rather than an impairment discourse so that you're focusing on their function and what they can do rather than the physical impairments. And it's something that needs fixing, but that can be a difficult thing to try and shift.

I just wanted to touch back over on the the lack of implementation in guidelines. So part of that is also there's a bit of a lack of evidence as well to be able to to say what should be done. So for instance, for exercise, there's not a lot of evidence to say all of those mixed evidence of whether supervised is better as an individual is better.

The group is better than home based exercise. There's not a lot of evidence to say that strength is better than Aerobic or is any different to different types of exercise. So some of the lack of detail of implementation guidelines is that there's just not the evidence to be able to say what people should be doing.

Thorlene 
So would that be your recommendation for where a lot of future research needs to be done?

Ali 
This is just my personal opinion. I've kind of got mixed thoughts on it because if any type of exercise works, then it doesn't really matter. You can then put it down to patient preference of what they're more likely to engage with and enjoy. So would you then need to spend time trying to research and say neuromuscular is better than aerobics, or aerobics is better than hit training, for instance. I’m just plain random examples.

Thorlene 
So maybe we need to understand a bit more about the mechanisms then and how exercise is working.

Ali 
And the other. I think implementation gap in guidelines is around the education and behaviour change, and that's possibly where they might be more detailed. They could give to look at how do you educate patients, what do you say to patients and that aspect of it.

Thorlene 
Yes, I think that we are heading in that direction with with some good research now. But we need we do need empirical research that can actually be put into the guidelines in terms of the very specific principles around education and around implementation as well. Where is your research going next Adrian?

Adrian 
So currently we're working on, I guess tapping on the theme of the addition of lifestyle modifications. This time we're looking at the pre operative side of things. So I guess looking at the population of those who are about to have surgery and looking at what we can do pre hab wise when it comes to education, stress management working on a sleeping patterns actually so similar but I guess on the different end of or different stage of knee osteoarthritis.

Thorlene 
That sounds very exciting. So thank you both very much for having this conversation with me. I have learnt a lot and I'm very inspired with where research is heading, the research that's being done by physiotherapist in this space. So thanks very much.

Adrian 
Thank you, everyone.

Ali 
Thank you.