Narrator:

Hello and welcome to the Talking Physio podcast. In this episode, Dr Christian Barton, from La Trobe University, and Associate Clinical Professor Jane Rooney, from Swinburne University, sit down with Professor Ewa Roos from the University of Southern Denmark, to share their experiences and successes with GLA:D - Good Life with Osteoarthritis in Denmark. Before we dive in, this episode has been brought to you by the Physiotherapy Research Foundation - supporting the promotion and translation of research - and sponsored by Flexeze, Australia's number one heat wrap. Let's get started. 

Christian:
Thanks for coming to Australia to meet with us Ewa and share your great wisdom. I'm wondering whether you want to share some of your research background with our physio community in Australia about some of the clinical trials that you did along the way at the beginning and then where you lead to in terms of implementing that? 

Ewa:
Thank you, Christian. We have had a long story of conducting clinical trials where we have compared surgery to exercise for a range of different conditions and in general, they have showed us that exercise is a lot more effective than you think, and that surgery rate may be not as good as we would like it to be. And that in comparison with doing, sitting on clinical guideline committees all over the world and really getting to know the evidence about exercise, that created a frustration for us when we could see that the clinical guidelines prescribing patient education and exercise were not implemented, in clinical care. So there would have been different pathways, or it's been different factors that has created a common pathway for me; our research, sitting on clinical guideline committees, building up frustration, having been a clinician for nearly 20 years, we need to do something. 

Christian:
Why do you think clinical guidelines are not changing policy and changing funding? Because this is a problem we have all around the world? Why do you think that's the case? 

Ewa:
That's a really good question. As a researcher, you think logically, and you think that good research, good arguments, should change clinical practice. But when you start on the journey that we did with GLA:D we realised that clinical or research evidence you need it, but it's not enough to change clinical practice because there are so many political, organisational and financial incentives that are barriers to changing healthcare system and actually for a change you need both energy and money, and healthcare systems have neither. 

Christian:
And for those listeners who may be unaware of GLA:D - many of them will be out there, but some may not be - can you explain exactly what GLA:D is for the audience? 

Ewa:
So GLA:D is based on evidence for treatment of osteoarthritis. So GLA:D targets people with knee and hip pain from osteoarthritis. And it's about educating patients about the disease, the different treatment options, of course with a focus on exercise, but on all treatment options, and about physiotherapist supervised exercise therapy for 12 sessions. That's twice a week for six weeks. And that dose is what we know is required to get a sufficient pain relief. 

Jane:
Can you share with us Ewa some of the outcomes of GLA:D so far that you found in Denmark? 

Ewa:
So basically what we find is that after attending the programme for six weeks, pain goes down with about 25%. You walk 10% faster. One out of three stop taking painkillers and that goes both for paracetamol insights and even opioids, and we can decrease days on sick leave in the year following GLA:D. What I find very encouraging is that we don't only see these results immediately after the programme, but they're actually maintained at one year after the programme. 

Jane:
Yeah that's interesting isn't it, because we know the effects of exercise don't last that long.  So what do you think contributes to that? 

Ewa:
And then I have to say that GLA:D is not a research study. GLA:D is a database building on clinical practice and what is delivered in physiotherapy practice all over Denmark, so we don't have a control group. So I can't really tease out what it is; what are the mechanisms? I can only share my beliefs or my hypothesis around it. And I would say that patient education is king. You need to inform patients about the disease and what they need to treat it and how they can self-manage it. And I think that in combination with having an exercise intervention that is long enough for them to actually experience pain relief, it creates a success, a feeling of success for them and that they have a new tool in their toolbox that can help them manage their pain. And I would think, and individual patients have told me that, they may not do exercise all the time because not everyone likes that. But that they know when they can feel the pain coming on, they use, they use exercise as a pain reliever. I don't know but that may explain part of it. 

Jane:
Do we know any of the Australian data yet? 

Christian:
Yeah, so we're going to present some of that a little bit later today at the conference and essentially we did some feasibility work with assistance from Ewa and Søren and you were part of that process Jane. And we trained up a number of physiotherapists, about 80 or so in a couple of courses in early 2017, and then we gave them a lot of support to try and implement the programme. And from that we know that awareness of clinical guidelines we significantly improved. We improved confidence to prescribe neuromuscular exercise, which we think is an important exercise option for people with osteoarthritis. But also people's confidence to have the discussion about weight management and physical activity and various other aspects about the osteoarthritis process. And from that they went back out to their clinical practice and we have some data from patients that they treated, which we somehow motivated at least some physios to collect some patient reported data on paper, and that tells us that we get similar pain reduction, similar joint related quality life improvements to what we've seen in the bigger data set in Denmark. We've then followed that on and developed an online database, which we have nearly 4000 people in now, and our outcomes are very similar to that initial 2017 data. So we're seeing pretty good alignment with what they've found in Denmark, but also what they found in Canada as well, which has been published literature. And so we're in the process of writing some of that up, and we'll hopefully share that more widely soon. And one of the questions that we have put into our data set, which I find really striking, is we ask patients about their surgery intentions. So do they feel they have so much hip pain or knee pain that they think they want have surgery? And it's interesting because about one in four patients that enrol in GLA:D will say 'yes' to that question at baseline and somewhere in the order of 60% or 70% of them change their mind at the three month stage, so that that seems to reflect what some of Ewa's work and Søren Skou's work has shown, in that if we do offer people good quality education and exercise, it does seem to have, at least a delay in that requirement or desire for some form of surgery, which is really nice. 

Jane:
That's very exciting and it's from a practitioner's point of view and also a business owner, it's certainly been a very easy programme to implement and you know it works even for our new grad physios who feel confident enough to prescribe and run a GLA:D programme. So it's been a great addition to our practice. 

Christian:
Yeah it's been great to see yourself and some of your colleagues embrace the programme so well, and that's allowed us from a research perspective to collect that data and we're having strong discussions with private health insurers now that might look at funding this programme, which would be great. So if any of them are listening, keep talking to us, that it's something you should be providing. I wonder Interesting, get your concept Jane around barriers to implement it because I'm sure there's physios out there who are there thinking about it and maybe they want to do it, they're not really sure. Are there any considerations that make it hard to implement or, or make it easy to implement. 

Jane:
Yeah, well, when I was the first private practice actually to implement it, as I understand in Australia, and some of the initial barriers that I came across was even trying to work out how to charge for it, especially because it was really including two sessions of education. And so there was really fourteen sessions and trying to work out what a reasonable fee was for that. And so I ended up sort of aligning it with our Pilates class charge, which was a similar time and a similar small group programme. Some of the other barriers that we came across were initially not having enough GLA:D trained physios to provide the programme, so I was the only one that could provide the programme. And obviously I couldn't provide five sessions a week for patients to have options. 

Christian:
We have the same problem at our clinic with myself. 

Jane:
Yes, so  um, my advice to  all practices when they send somebody for training, especially if they're regional, I say try and send two people, not just one. So they have options of, you know, if they go on holiday or there's options of class provision times. The third barrier was the space requirement. And although it's great because it has really minimal equipment required, you know, a few chairs and therabands and a few poles and slide boards or slide things. It's just having the physical space to enable to run a small group class and also a few exercise bikes, although you can do a warm up without exercise bikes, but we've found that a useful addition. 

Christian:
Just a quick one on the exercise bike, something we've embraced at our clinic and I'd encourage people to do, you can buy a set of pedals from Kmart for around $20 or $30 and so if you don't have space for  an exercise bike they could be used to do, even an upper limb warm up of doing some ergometry of your arms, but also it's very easy to sit on a chair and use those as well, so it's a nice space saving one. 

Jane:
Yeah that is good. And sometimes we’ve used a walking warm up as well around the clinic, surrounds or whatever, but it's about being creative, and I think some of the other clinics that I've come across have used their Pilates spaces to conduct GLA:D. So yeah I think it's um, as I said, there was a few barriers initially, but you just have to be creative and work through this and try and find a solution. Yeah, and the next barrier is obviously to market it to referrers. Word of mouth has started to really catch on and a lot of patients I'm seeing their friends, their brother, their uncle, that they're sending their colleagues to as well. So that's great. And we are starting to get a few surgical referrals as well, yeah. 

Christian:
And one of the things that I always considered around this around changing practice and implementing exercise within the physiotherapy profession is, we all have our different ideas and advice around what exercise programme should look like, so I'm wondering what are some of the aspects of the programme that you like Jane, and I'd be then interested to also chat to Ewa about why the neuromuscular exercise and why it developed? But maybe Jane first. 

Jane:
Yeah, well, I was very excited to see the neuromuscular part of the programme, being from an ACL background initially and doing neuromuscular exercises for a long time and also teaching them in Australia for at least 10 years. But really they weren't broadly adopted at all, which was disappointing because I thought they had such great utility. So the GLA:D programme's really enlightened a lot of physios to the benefits of adding in a neuromuscular training programme component, so, and also made it quite easy too. They've been trained in how to do that and how to progress it, so, and I think it's confidence. Physios have more confidence to know how to actually implement these and it's really good for patients. 

Christian:
And our data reflects that confidence too, because we do a test with every physio that does the programme before and we follow them up after. We follow them up 12 months and their confidence seems to grow, like the patient outcome seems to grow, which is nice. 

Jane:
And it's always really interesting to me as a physio that's running these groups and the support that I see from people within the group, to new members that come into GLA:D and the slide station, or the neuromuscular station, is always the station that they find most difficult to start with. And I love it when I hear some of the other participants say, 'Oh I used to hate that too. Just go with it. It gets better and it gets easier and look at me now. I can really do it well now'. So that's really encouraging because it means much more coming from a patient to a patient, then me saying it to a patient, I think. 

Christian:
So Ewa with your research and clinical hat on, there's lots of different exercise programmes reported in the literature to be effective at reducing pain, improving quality of life, a whole range of things. Why not just tell someone to go for a walk or do some strength training? Why start with this as a programme? 

Ewa:
I think that's a very good question because just as you say, there is really no evidence that one exercise programme relieves pain more than another exercise programme. Then I have to take my clinical hat on and say I think it is really important that the exercise programme is meaningful to patients and to clinicians. And it is meaningful to patients who have pain in the knee or hip, to have a programme that actually targets the hip and the knee, and where you use progression that depends on the status of your knee and how we can control these exercises. That is not to say that aerobic exercise and strength training is not important for people with osteoarthritis. It is. But we have found that it's a very good way to start to increase self-confidence, and knee confidence as well, in these people in how they move and then they can go on and do other things. For us it was also very important when you want to roll out a programme nationwide that it is safe. So we have for the first thing, had many years of clinical experience with this programme and then we have used it in a large number of research studies. And we have actually also used it in patients who have the most severe stages of osteoarthritis, who have what many patients would call bone on bone  osteoarthritis, and they have severe pain and they're waiting to have a joint replaced. And we tested the programme in these people and actually what we found was that they could perform 95% of the exercise sessions with safe pain, and that made us very confident that we can prescribe this programme to patients with osteoarthritis, regardless of their radiographic grade of osteoarthritis. And I think that's really, really important when you want to roll something out nationwide. 

Christian:
I agree and I think the confidence side of things I see in my patients in my clinical setting is a really important part of it. I think of one of my favourite cases that we had who started with GLA:D and this was a guy hadn't run for a number of years. He was 79 years of age. He had bone on bone osteoarthritis. He was offered joint placement surgery. Every time he tried to engage with exercise, he just flared up his pain. He couldn't do it and went through the progress of doing GLA:D and then actually he's progressed his exercise beyond that to aerobic exercise and strength. And that's allowed him to get back to running and he runs now 10 kilometres once every couple of weeks and does a park run on the alternate weekend. And so it's quite phenomenal and I think that confidence side of things was so, so important for him and I'm sure you've got some great cases as well Jane. 

Jane:
Oh yeah and also I think  too the confidence that the physios have, because there's some very clear guidelines, because they have to do a training programme in order to actually teach GLA:D. And there's some clear guidelines about how to progress, but also how to regress the exercises. And that's really important that if somebody does have a flare up, then you understand how to regress and try and find out what was it that flared them up and then you know how to regress. So that's really, makes it quite a good implementation. 

Christian:
One of the interesting things I find with the programme in our clinic is exactly that. They might have a painful flare and patients will ring up and try and cancel their appointment. They're not coming into the exercise class today because they're in pain. And so we always encourage them. No, no. This is your perfect opportunity to learn how to do exercise during a pain flare and they typically, if we can convince them to come in, which is sometimes challenging, but as long as they do, they come in and their pain is most often better after doing the session. And that's really empowering for a person to see that exercise isn't causing them damage, isn't making their pain worse, it's actually helping improve their pain. I think that's a really important thing. That's one of the things I really like about the programme is it can be done by anyone. You could have someone in aged care facilities who could do this programme and you can have someone who's maybe has a post traumatic knee injury and early osteoarthritis from an ACL injury, for example. So I think it's a great programme. 

Jane:
And we also use it after the early post-op phases of even a joint replacement, even though they're not in the register as such. The exercises are perfectly safe. We've found in our clinical group to use as rehab, particularly if they want a group setting to do that. 

Christian:
I think the private health insurance companies are very interested in that as a concept as well because they spend a lot of money on inpatient rehab and I think this is a programme that's something we should talk more about from a research perspective at some point Ewa, is using GLA:D as a post op programme and I think it could probably add value to what we do as physiotherapists and also save the health system money. So I think everyone can probably win from doing that. 

Dr Christian BartonI think we need to do some research on that first. 

Christian:
Yeah, agree, agree. Yeah it'd be quite interesting to look at. Do you have any questions for us about our experience in Australia, because you've done such a great job inspiring people around the world? 

Ewa:
I work in a country of 5.5 million people, and it's very small if we compare it to Australia and you work on this huge continent. So how do you tackle these issues? 

Christian:
It's actually a fascinating question and something we keep talking about. We've been looking at other options for delivery. So people are in rural and remote areas, they're not going to be able to get to a centre. And so we're developing a Telerehab option at the moment, which we're testing in a trial, and we will look and see whether we can produce similar outcomes using online. So for the physios out there, picture yourself sitting in your clinic room on a computer and you've got four patients in their lounge room doing an exercise programme. And so that's something we've been piloting and testing and it'll be interesting to see. So that's one of the things that we're trying to develop as part of the programme which I'm very excited about. I think the other thing we need to consider longer term is perhaps physiotherapists continuing to take leadership with the programme, but there may be settings where we actually can't get a physio to go and deliver the programme and particularly in rural and remote areas. I spent time in Darwin earlier this year and talking to Aboriginal health workers and so in that particular population, physiotherapists going into the communities is not really going to be an effective process to get them to engage with an exercise programme, but an Aboriginal health worker going into those communities and delivering something like GLA:D, which I think is feasible, might be something that we can start to look doing as well. So I think the answer to the question is that we have a lot, a lot of work to do. We have 2.1 million Australians with osteoarthritis at the moment and if we're going to try and deliver them education and exercise of some form, we're going to need to be very adaptable and I think it might take a number of years and hopefully the bottom up approach which you've inspired us to do will allow us to have some top down changes to make some of those things happen. But let's see how that goes. 

Ewa:
I have one more question for you that relates more to your healthcare system because in Denmark, GLA:D started in 2013 and I will say that now in 2019 the tide has actually turned. So now GPs and orthopaedic surgeons, they are referring to GLA:D and most in the healthcare sector working with MSK, they know what GLA:D is. So I just wondered Jane and Christian, what is your feeling in Australia? 

Christian:
Yeah so I think that it's definitely changing. And there's  some, I guess if you think about, I like the concept of bright spots and so there's some really big bright spots there where  actually I know of surgeons who won't actually see a patient until they've done GLA:D. So they actually get their receptionist to tell them to go and do GLA:D before they'll have a consultation with them. Now they don't always go and do that, but that's what they're kind of protocol is. So that's happening. Other GPs and rheumatologists and surgeons are routinely referring to the programme. There's also this barrier and resistance amongst some of other health professionals as well. And we've looked into this. We've actually interviewed them to ask them why? What are the barriers to referring, not just to GLA:D but to physio in general, and the biggest barriers that come up are around, 'We don't think the patient can afford it'. And this is ironic when there might be a surgical cost of multiple thousands of dollars ahead if they don't go into a programme. But that's one of the things that comes up and then the other thing is that accessibility. So they might refer them, but they don't feel like they'll be able to get to where the programme is for transport reasons and various other things. So I think from a cultural perspective in health professionals, it's changing. But it's slow and I think it's moving in the right direction, but from a healthcare perspective that top down idea, then we actually have a very broken system, in that Jane mentioned before about having to work out how to charge for education because actually, private health insurance will not fund a group education session, which would be probably high value to them, but they don't fund it. There's no code for that group exercise. They're cracking down a lot on try and actually reduce funding for group exercise in Australia at the moment, which has been a big problem for people who deliver a lot of Pilates sessions. And so I'm really interested to see what they're going to do with GLA:D because we've got the data. So if they start trying to withdraw funding for people delivering GLA:D that would be a really interesting publicity campaign that could develop as a result of that because I think it would reflect pretty badly on them. So it's just a word of warning to you private health insurers out there. And then, from a government perspective, there's these perverse incentives in our public health system, where public hospitals receive funds to deliver a joint replacement surgery. So let's say it's around $22,000. Now they might be able to deliver that surgery for $18,000 so that leaves $4000 on top. They then use that $4000 to fund allied health treatment so they'd fund their physio programme, so it's a bit of a perverse incentive to try and offer non-surgical care in place of surgical care. So there's a few things that government and private health insurance need to listen very carefully to. 

Jane:
Christian, can you talk us through how you actually, if you are interested in this programme and you think it might benefit your clientele, how you go about becoming a credited GLA:D provider? 

Christian:
Yeah. So we have a lot of resources on our website, which is gladaustralia.com.au, which talks people through the process they would need, so including equipment, space, the training required, etc. Why the programme is trademarked to keep the quality etc. There's a whole range of different information there. There's also links on that website to courses and links to enquire about courses as well. And so one of the biggest problems we've had is actually keeping up with demand. So we've trained 970 physiotherapists so far, but we actually also have about 1000 on the list that would like to do the course. And so one of the struggles we have is, when we announce a course it literally sells out. 

Jane:
It sells out quicker than an Adelle ticket. 

Christian:
Yeah our record, our record was four minutes for a course in Sydney, which was a bit crazy and a bit ludicrous. And so what I'd encourage people to do is to register themselves. There's a link on the website they can email and register themselves for information because we don't advertise the course. And then as soon as a course is announced, they'll be told when the registration will be open and then they'll have the opportunity then to log on and register people. As you suggested, probably registering a couple of people at a time. Now we are working as hard as we possibly can. We get complaints about not doing enough courses, but we can only do so many courses. We only have so much manpower and so much funding to do some of these things, because it's a not for profit. So I think simple thing is, get in touch and put your name on the register and you'll find out about the courses and then you'll be able to come and do it. Now the course itself goes for a day and a half. The cost is around $500 to $550 and that includes obviously all of good quality education. We do a lot of work shopping, so it's not just didactic lectures. It's lots of work shopping around, how to communicate with patients and educate them, and I think that's a really important part. And then obviously going through the exercise programme that is part of GLA:D and making sure you're really confident to go back to your clinic and deliver it. And then the funds that we require from the courses, that's quite novel, in that that's actually used to support you as a clinician to deliver the programme and used for policy and advocacy and various other campaigns that we're doing. 

Ewa:
There's actually one more thing that clinicians get to know how to enter data into your database. 

Christian:
100%. And that's a really important thing, and that's something we teach you to do. We've made it extremely easy for clinicians to do it because it's not part of our physio culture. And so we go through the registration process, which per patient takes about a minute or so. And there's some outcome measures that you need to take and as long as you do that, that allows us to collect the data to take to private health insurers, take to government and hopefully change what happens in terms of funding. 

Jane:
In fact, we've actually taught our receptionist to do that, so they register the patient and we just have to do the tests. And the other thing that we haven't talked about yet is the fact that you get an education package to actually educate patients about osteoarthritis. There are two sessions and you actually get supplied those PowerPoints, which are great because GLA:D actually supply that to you. 

Christian:
And I think along with that, too, Jane, some of the other things we've tried to put together is lots of other education resources that you can print off and share with patients. 

Jane:
As well, as the exercise sheets. 

Christian:
Yeah exercise sheets and there's a whole range of things that, actually the Danish group of lead and developed, which we've adopted and use. And then we've developed other things and we have GP seminar templates so you can actually go and provide a seminar to GPs to educate them about the program and osteoarthritis management. Or there's a whole range of different resources.

Jane:
In addition to the marketing materials, the standardised marketing materials, which been really helpful to us. 

Narrator:
That was Dr Christian Barton from La Trobe University, Associate Clinical Professor Jane Rooney, from Swinburne University, and Professor Ewa Roos from the University of Southern Denmark, and you've been listening to another episode of Talking Physio, brought to you by the Physiotherapy Research Foundation and Flexeze. Thanks for listening and make sure you catch the next episode of the Talking Physio podcast.