147. Knee osteoarthritis (OA) assessment, rehab & overcoming patient fears with Dr JP Caneiro

You're listening to Physio Edge Podcast Episode 147 with David Pope. Hey and welcome to the Physio Edge Podcast. I'm your host David Pope and Australian Sports and Musculoskeletal Physio. And on the Physio Edge Podcast I talk to the leaders in Musculoskeletal and sports injury management and get their experience and expertise in the latest research and give you lots of practical take home tips, techniques and strategies that you can use to help treat your patients more successfully. And on today's podcast we're talking all about knee osteoarthritis. When your patients have knee OA, they've often got a sensitive and painful knee and they're pretty reluctant to use it or exercising it, they're often worried that it's going to further just wear out the joint. So the question is how do you go about assessing and rehabbing your knee OA patients when they do have these fears and concerns? What are the subjective assessment questions you want to ask your patients? What are the objective assessment tests to identify what's going on with your knee? And then how do you go about treating it successfully? We're going to be diving into all that today on the podcast. This is a part two podcast on the first podcast we started to explore your patient's fears and beliefs and I wanted to take that further and really dive into that subjective and objective assessment and then further into the treatment with JP because he's got so much experience and knowledge around that area. So we're going to be diving into all that today and as I mentioned, this is with Dr. JP Canero. JP is a specialist sports physio based out of Perth in Western Australia. He also has his PhD and he's involved in teaching at Curtin University as well as working clinically. So we've got a ton of experience performing research around chronic pain and also around knee osteoarthritis and he also treats a lot of it clinically. So we're diving into all that today and we're going to give you lots of strategies that you can use with your knee OA patients. We've got a couple of free resources that go along with today's podcast and the first one is infographics that sum up the key points from today's podcast. The other great resource we've got for you today is your clinic-ledged free trial membership and in your clinic-ledged membership, you're going to get access to practical training that'll take you through how to assess and treat all sorts of musculoskeletal and sports injuries. We've got modules that are going to take you through how to assess and treat acute and chronic pain. So when your patient's coming with pain, how do you help them make sense of it without making them feel like it's all in their head? We've got a full module that'll take you through that pain, science and apply it practically so that it's not over-compacted, it's nice and simple and you know exactly how to explain your patient's pain to them. We've got a module on low back pain, how to go about assessing your patients with low back pain, what are the questions you want to ask them, what tests do you want to perform, what can you diagnose, is it all just non-specific low back pain, or can you actually be a bit more specific with a lot of your patients that do have low back pain. And then when you're identified, how do you go about treating it? So you're going to get access to all that with your clinic-ledged free trial membership. So go grab your access over at clinicledged.co/free trial and now let's dive into the podcast with JP. Hey JP, how are you? I'm good, David. Thank you so much for having me. Thanks for coming on. I really enjoyed our chat last time all about OAnees and there was so much that I wanted to explore with you that last time we got into some really practical stuff and exploring how you go about changing the narratives for patients and helping them to understand what's going on in their body and strategies that they can use to change and that you use with your patient. So there was so much that we got to explore, which was awesome, but there was a ton more that I thought would be fun to get on here and have a chat to you about. That sounds great. Yeah, the chat last time was really cool. Nice. But first I want to take you back and I want to ask you about growing up in Brazil. Right. Yeah, one of your favourite memories from growing up in Brazil. So many. I think the first thing that I think of is family and friends. I came to Australia when I was 25. So the friendships that you build at that age are a bit different to what you build growing up and I have a good group of friends since the age of four. So you've got some really good memories. Look, Brazil, it's a beautiful country. It's got a really cool culture. It's a very alive country. It's a, you know, music and dance and it's great and the food is very different and we have across the different states. Like in Australia, it's quite similar. There are some words that you may say differently in Queensland or New South Wales versus Spain. But in Brazil, every state has same language, but the accent is quite different. So it's very distinct. So there are lots of jokes around the different places that you're you're from. Everything's a bit different across Brazil. I'm from the South and region of Brazil. We like to think that we don't really cool state. But of course, the city is called Porto Allegri. Happy Port, but Rio de Janeiro and some Paulo, of course, are the big capitals and they get a lot of attention. So I've got phone memories of Brazil and but also it's a country that is very divided in terms of its economy and opportunities. So it's, you know, you might be walking down a server on one hand. On one side of the street, you have super expensive golf course and people drive Mercedes and on the other side of the server, you have people bagging on the streets. So the, the divide is really confronting and you grow up with that and you don't realize it until you come to a place like birth that you barely see someone on the streets and everything is pretty similar unless you go to the less half-fluent servers. And safety is probably one of the big things that I don't miss from Brazil. We tend to live in Brazil and feel like, yeah, it's fine. It's, you know, everyone talks that Brazil is not safe and actually when you, when you live here and you go back, you realize that you have to think a lot more about your actions when you're walking on the street and things like that. So I don't miss that side. I miss the culture, I miss the happiness of the people and it's just a different lifestyle. Any stories that spring to mind when you're growing up that sort of you fondly think back off when you think of Brazil? Stories. I've got a few firsts. I don't have a very good one that comes to mind. Maybe about family, you know, your family or any of those sort of things that give people a bit of a feeling for what it's like growing up in a family in Brazil and what sort of normal day-to-day life's like. Oh, I was, well, was Sundays on my grandmother's house. That's a very common thing. Presidents are very close to their family. You may say that we might be a little bit lazy in terms of how long it takes us for to leave our parents home. But that was one of the things that really called my attention when I came to Australia is that, you know, you turn 18, 19 and you get out of the house and you share an apartment and in Brazil that's not very common. So we tend to stay at home for longer. So that connection with your parents is it's quite strong and family is quite strong. Reminds me of my aunt when she was probably 18, 19. I was really young and she was bringing a boyfriend home and my grandmother had prepared just dinner and she asked everything to the guy like. And the guy, you really couldn't, didn't like eating fish. So that's exactly why my grandmother stood for him and just like pepped at him with questions and like it was a really funny dinner. But it was, the guy was feeling a bit under attack and she loved him, you know, it was great, but it was, that was just my grandmother's style. That's an awesome connection, yeah. And we, like I grew up, I've spent a lot of time with her and my grandfather. So they're really strong memories that I have. And in the summer, my mom's got a brother and a sister and all the cousins will get together and spend summer at a grandmother's house. And we did that across our entire life. So actually that's when my wife's parents met my grandmother. We went back for her 19. That is probably one of the best parties I've been to in my life. And I've got this great photo of my grandmother. She's turning 19 and it's 1/30 in the morning and she's like dancing on the dance floor with this red flag. That's awesome. And actually I had that picture in my room at the clinic. And when I had, you know, some 50-year-old, 60-year-old saying, "Oh, you know, I've got to move my hands and it's bad for you to move." And I'm like, "Look at this picture. Look at the timestamp. This lady's 19." And she's moving her arms and I'm petrified, she's got a roteca of 10. That is the age is not an excuse. But yeah, there you go. That's the memory that's sprang to play. Yeah, I think I love it. I love it. And I love that you get to use that, you know, even in your day-to-day life and you get to look back at it and then relate that to patients. That's awesome. Yeah, that's right. Great story. What a legend, day. 19 still dancing just down on the dance floor. She was good, man. She was good. I hope I've got some of those jeans. That's right. Appreciate you sharing that story with us and it's nice to understand to be able to connect with yourself and, you know, know, because a lot of these forces were shapers and what we do in the clinic and how we approach patients and all that sort of stuff. And I think that, you know, you can tie the way you've been able to tie in your background and that importance of family and then tie them up. Yeah, absolutely. Yeah, it's a nice connection. So we'll have a bit of a chat about NEOA. And you mentioned there that when people are getting older and they often think that they shouldn't lift my arms up or, you know, do whatever it is because I'm worried about hurting my body. There's a lot of myths and misconceptions around NEOA. And so tell us about some of those you commonly address or talk to your patients about. So probably one of the greatest misconceptions is that the more you use it, the worse you get. And that affects your day life and immediately tells you another system that you need to protect that body part. So this idea that you've got the generative disease that is getting worse no matter what. There is nothing you can do about it. The more you use it, the more it generates. So it's a very logical and plausible explanation that if you explain to anyone on the street, they would understand that. And because of that, it's a very sticky narrative. It's like the whole idea of, you know, why is my back sore because your joint is out of place. So what are I do about it. I'll manipulate your back and I'll put the joint back in place. Yeah, great. Give me 10 of those. So it's a very easy narrative to follow. We know that that's not the case. So there is this very negative understanding about neo-way where it's inevitable that you're going to go down the pathway or need a knee replacement and that there's nothing you can do about it and exercising or using the knee actually makes it worse. And there's quite a bit of research demonstrating that using the joint is actually good for the joint and this idea that we should be thinking of the health of the knee and the health of the person as opposed to the disease that is in the knee joint. If we think about this underlying inflammatory response that you have in the subchondrobone which kind of drives the disease of posterior arthritis, we have to think broadly as to what are the factors that can impact an inflammatory response. And some of the big factors are anything that affects your nervous system, right? So your immune system is linked to that. What is linked to that? So your sleep, your activity levels, your stress levels, your diet, how much you weight you carry, how you carry that weight. So some evidence to say that if you carry a weight around your abdominals, you tend to carry more of a fat content that is highly metabolic and has as a consequence a strong inflammatory response. Immediately with those factors, you can tell that it's not just about strengthening the quadriceps and it's not just about protecting the joint. It's about what can I do to improve my health and reduce this inflammatory response and take some control over this and reduce the sensitivity of the joint. And I think it's really important to make it clear that I'm not dismissing the biology that is changing in that need, but it's important to understand that we can make that environment a healthier environment and you can make that joint be more resilient and more tolerant to the demands of your daily life or to your job or whatever you need to do. So it's not a dismissal of the bio and just say, don't worry about it, everyone's got some of the generation just work on your sleep stress and weight and you'll be fine because it's not like that. And some people they're sleeping well, they're eating well, they're not carrying any extra weight. And they're trying to exercise and they've got a very sore knee, so that's another challenge. But it's important for us as clinicians to have a look at all those factors and say, hey, how's your health? Are you creating the best environment for this joint? When you look at that environment, it includes these factors that I mentioned. It includes how you carry the body part. Are you actually protecting it? And if someone is protecting their joint, I'm not just interested in changing it. I want to understand why you're protecting it. What is the belief underlying that behavior? It's very common that it's related to the fact that you don't want to cause more damage in the joint. A large proportion of the patients that I asked the question, so what do you think that makes the cartilage and the bone healthier? And they say, oh, I don't know, they don't have much of an idea. And they say, how about movement and graduated loading and having a trajectory that builds the capacity of that bone and that cartilage to tolerate load. And they go, oh, but I thought that actually loading the joint was worse for it. Everyone knows that running is bad for your knee. So, you know, that's another strongest conception that using that joint repetitively, you will make it worse. So I think that this idea that you're using the body when it's painful equates to more damage to the body part. Underpins the current narrative of New York's arthritis. Beautiful. So you're basically looking to identify within each individual patient, if there are some of those factors or which factors are influencing their pain experience, whether they do have any of those factors you mentioned, like their sleep, their health, their diet, whether they've got abdominal fat or whether they've got stress associated, they're avoiding it. And you're looking to identify the ones that are relevant for that patient, so you can address that throughout their treatment. Is that right? Yes, correct. And the patient's story is really important because I don't go into an interview to simply look for those factors and identify that three out of five are the key problems and I've got a little recipe to deal with them. I go into to listen to that story and go, why is your knee sore now? And it wasn't three months ago or six months ago. What's the difference? What's changed? And that line of questioning or the idea of curiosity, that's the word I'm looking for, gets the patient to reflect on their own story. I usually say, oh, nothing's changed. I'm doing everything the same and you go, right, so tell me what was happening in your life over the last six months. Many patients are taking back for that question and you give them a bit of a background and you say, just just give me an idea. You know, I don't know how you live your life, just tell me. And suddenly some of the things start to appear and it may be the logistics of the household. We've got a puppy and now I need to sleep downstairs. So when I sleep downstairs, I can't go for my running the morning, so I stop or I can go for my walk, whatever it is that they do. So I actually haven't done that walk for the last two or three months. So you immediately see that they've got less capacity and now they want to recover that and they increase their load. So that might be that all the other factors are fine. They might not be sleeping right because of the puppy. But they reduce their capacity and now they're trying to get it back and the knees long coping. Oh, but that wasn't a problem in the past. Well, but now it became sensitive and I don't try to completely understand as to why it got sensitive, but it is sensitive and now we have to deal with it. And the tricky thing is that once it becomes sensitive, you go down the track or looking for you're going to see a medical practitioner, you might see a GP, a physio, and you get an x-ray and depending on your age group, you will show changes in the knee. And that can drive the pathway immediately. That's the danger, I reckon. Because depending on your age bracket, like if you're over 50, you present osteoarthritic changes in your knee, especially if it's on one knee compared to the other. There's a high chance that you will be told that, look, you can try some physio or you can do some exercise, but you're just going to be going for any replacement in the future. And those words, it's like a sentence, I just say, you will need this as a matter of what you do. It can be quite, come quite an obstacle for that person to move forward. It's like you've been given a diagnosis that your knee is stuck. It's just getting more stuck over time. The only way of fixing is by replacing it. So a lot of people can forward that track and some people go, no, I don't own that. It might be in the future, but it's not now. What can I do about it? And they may be ready to engage in other forms of rehab. And I guess that's, if we go back to the underpinning belief that using the joint makes it worse, then you might go to practitioner and they say, you might need surgery in the future. Now, what do you need to do is to exercise your knee to make it stronger, and then go, but if I use it, it makes it worse. Why would I exercise it? So it doesn't make a lot of sense. It's degenerating, you replace it. Yeah, that makes sense. It's degenerating, and you use it to make it stronger. It doesn't make a lot of sense. And often patients will try. And I saw a lady yesterday, she said, look, I've tried physio in the past and I've done bunch of exercises and it just doesn't work for me. And I'm only here because my daughter saw you and she had a chat with you and she said you said some things that might be helpful. So I looked at the exercises she's done there, all knee-driven exercises. So she was doing hamstrings in quadriceps and really trying to load up the joint. And you know, after a couple of days, she was really sore. So she wasn't capable of doing those things yet. But you get her on a bike and she's going stationary bike at home. So I got her on a bike and I increased the resistance and there was no complaint. She didn't have pain doing that. And she's going, I quite like doing this. That's the way I used to exercise. And I don't understand how this is good. So for her, it was an explanation or, you know, she was really attached to the idea that the joint is degenerating. She's being given some really in-depth explanation of what happens with the bone and the bone deteriorates and the cartilage tears apart and it was a pretty horror story. And I said, right, it's all of that. But now, imagine that my hand is your cartilage, right? And then you lost a bit of cartilage here. You still have this bit. So what are you going to do about this bit? Are you going to let this bit take all the load and be an unhealthy part of your cartilage? So do you know what's going to make this bit better? Is if you use it. So cycling, for instance, you're using it repetitively. It's low load. You're repeating that action and cartilage, they love that repetitive, cyclic movement. And actually nourishes this. So what we need to do is not to worry much about that because we can't do much about that. But we can make this one a little healthier. And we can make this one more tolerable to accepting load. Like if you think about the story around tendinopathy, right? Why are physios so confident to make someone with tendinopathy exercise? Despite pain, right? You look at someone like Jewelcook and Craig Perdom, they push this message really strongly and now Ebony Rear is doing that. And they build this confidence in the physios of going, hey, it's okay to load the tendon. And once the story, you've got a healthy tendon, and then you've got a tendon that has a hole. You can have a hole, we can have some tear, whatever it is, it's not the same tendon. They don't worry about this bit. They worry about this bit, right? Isn't that the whole story? You make the rest of the tendon, the healthy part of the tendon healthier and stronger and more resilient. And I see cartilage in a similar way. The cartilage doesn't have the same properties of the tendin, so I'm not trying to, you know, compare apples with pears. But the story, in a way, it's similar that if you don't use that part of the cartilage and if you're protected and you don't move it, you won't be nourished, you'll be dry, you'll be stiff, and when you load it, it's more likely to suffer breakdown, whereas if it's unloaded in a graduated manner and is not getting pissed off every time you load it, It actually becomes healthier and we got to remember this idea and other when we talk about a whiny that is not just about the bone of the cartilage is about the whole joint structure, the synovial lining of a capsule, it's your ligaments, it's the whole story. So if I'm loading this and I'm moving that joint, the synovial response of that joint will be healthier. So actually movement nourishes the joint and one of the things the movement does, it increases the capacity of the proteoglycans in the cartilage to bind to water. And once they bind it to water, it means you've got more shock absorption. So that's kind of the chemistry behind it. So I wouldn't go into that with patience. But it's kind of for her was just say, don't worry so much about the bit that we can't do much about it. Let's worry about the bit that we can't. And that was the start for her and her whole exercise program was getting on the bike on a daily basis. And I said to her, this is your panadol, all right, you were taking a panadol a day, you're going to take a bike a day, non-negotiable, you've got to do it. And I said, the worst is going to happen, you're going to come back here, you're going to tell me a knee sore, but it's sore anyway. So let's see how you go. So I didn't give her a bunch of stuff, I'll see how she goes. But if we compare that to doing a bunch of knee extensions, knee flexions and single leg squats on that leg, what I gave her is way less provocative. And probably we'll achieve more in the short term or in the long term. And then I can start adding other exercises that will strengthen her leg. I agree with the other physios, she doesn't need a lot more quadriceps strength. But she can get a bit of that if she can use them without provoking the knee. It's that old story of, I want to exercise a body part and then you make it sore and then you hit the muscle and you keep chasing your tail. Whereas if you do something that is less provocative, you can build up some conditioning. It's a great way to get her to buy into the program. Yeah, she's experiencing that when she gets on the bike that she can actually perform the exercise doesn't stir up her knee pain and you know, yeah, actually like I say, it works like Pannadol for it to calm it down and get that nourishment to the rest of the cartilage that needs it and that can benefit from it and really focusing on that part of the part that you can help to improve within the joint. It's a nice way to get her really involved and engage in that exercise program. Yeah, an interesting thing too is that once I got her on the bike, she started asking all these questions. Isn't it true that, you know, if you do stuff like this or if you go for walks that it's worse for your knee and I said, say, what do you think that? Oh, because you're putting weight on the joint and going well, but you need to get used to that. You used to go for walks, but you're not walking any longer, so you got really the condition. When I looked at her walking, she was walking in a really stiff foot, which is a very common response if you want to protect your knee. So you don't want to bend and straighten your knee, so you fix the knee, you end up fixing your foot, you don't push off very much. So it's like it's a bit exaggerated and you can lead to a limp. And I said to her, that's not the right mechanics, it's like you're bracing your knee every time you put weight on it. So what do you think it's going to happen? Like you're pre-loading it and then you put weight on it. And she goes, wow, that's going to put more weight on the knee, more low in the knee and going, yeah, it's like putting a target in your knee. All the load will go straight there. But if you're using your foot, if you're taking a bit more of a relaxed walk, if you're relaxing the muscles around your leg, then that your body weight won't create the same load around the joint and that is something that you need to work on. So I said to her, it's not just about the task, it's about how you do it. And it makes sense that if you're concerned about doing it and you're protecting it, they will do it in a way that you feel like you're protecting it, but actually maybe you've provoked it. And that's part of our job in our objective examination to determine if what you're doing is helpful or unhelpful. Great. And I'd love to have a chat to you about the objective pretty shortly. You brought up some really good questions that within the subjective that helped to identify some of those health factors and some great follow ups. And I like that follow up where you mentioned there when you asked your patient, why do you think you've got it now? And they pointed out all patients go, I don't know, you know, you use that follow up question of telling me about your life and what's going on to I can understand. So great follow up question to get those details that are really going to help you clarify the situation for you. So are there any other questions within your subjective that really help you to identify some of those health factors or some of those other factors that are going to impact your treatment? I often asked about the different ways of asking, but one of the ways is brings to mind is, I want to get an idea of what it is to leave your life. And when you're wearing your shoes, well, my day looked like and they would say, oh, you know, wake up at 5 and I do this and I do that. And then I go from my walk and then I go to work and then I come back and I come home. And usually, you know, I stay on my phone until late hours of the night and then I go to bed and then I struggle to sleep. So immediately, I'm getting all this information. I'm going, so is that a snapshot of your week or is that a regular day? Weekends, yeah, usually I catch up with my mates on a Friday and I get drunk and I don't do anything on Saturday morning. So I'm getting all this information from a simple question or just tell me about what it is to be you. Because I'm interested in that because if I know what you do, then I know what are the demands that you need to meet. Right? If you go, look, JP, I just sit on my office all day, clicking on white and then I walk home and that's it. So you don't have great demands in your body. That may be the problem because you're not using your body as much. Or you might be someone that rides to work and it takes you an hour to get to work and you ride back and you go to the gym and lunchtime and you go running at night or you go on the weekend, you like to hike. Well, that's a different story. Or your job is to go up and down scaffolding every day. They are way greater demands than how do we meet those demands? Are you capable of meeting those demands? Or are you too sensitized that you can do it? It gives me an idea. So the idea of improving someone's health and improving someone's knee health. Principle may be the same, but how you achieve that will vary the opinion of the person's demands and goals and what they want to do. So if their goal is to run a half marathon, be a very different demand to the lady who just wants to go for half an hour walk every morning. So that idea, tell me about your lifestyle. What do you like to do? What are the things you like doing? The other question, too, is if you didn't have this knee pain, what would you be doing differently? And that question can often unleash your true self. They just go, I didn't have this knee pain. I'll be running every morning or be running three times a week for half an hour. I'll be hiking with my mates or I'll be playing with my kids and I'll be playing foodie again. And you just get this whole different perspective of the person that just told you that they will be happy to just go for a walk every day. And you go, right, so that's what you're telling me in your current situation. Can you see yourself out of this situation? And perhaps for patients that have a more persistent history of knee pain and here we don't need to think only about near way. You can just think of someone that rocks up with pain for a long time is asking the question, do you remember how it felt to walk or to run or to do whatever without this knee pain? Can you close your eyes and feel in your body? How was when you didn't have this problem? That can be quite a nice experience for patients because they go, they use the terminology and you usually can see that in the objective. They would say, I was three years, I was faster. I saw a guy last Friday. He was back pain, but he said, oh man, when I didn't have this pain, I was free flowing. I would just like, I'll look at videos of myself and I could see it was effortless and I felt effortless. And I saw a video of myself the other day and I looked like freaking Robocop trying to play tennis. It's like I'm super, super slow. And when I got him moving, he was exactly that. And for him, there was a big loss of identity because he goes, that's not me. And this is a young guy. He's like 35 and he's a firefighter. So it's really important. And for him was when I look at myself back, I could save anyone from a house on fire, whereas now my brain is thinking, am I able to do this? And I can't have someone's life depending on how I feel about my body. So that's really profound. And that came from the question, how he was to be in your body without this pain. And how would you feel if you woke up tomorrow and you didn't have all the different. So that's not for every patient, maybe asking that question, but for some patients, tapping into how he was and how he would feel, you can give you a really good insights about their relationship of their emotions with their body and the exceptional capability in the future or how they were capable and how they are not. And a lot of things come out, like I saw another lady yesterday who said, before this happened, I never thought of my age and she's 53 and she goes, and now I feel like I'm 65. So everything that I do, I just feel older, slow and grayer. So there, like the language that she used was gold, very negative, but was gold in the sense of it expressed her mood, it expressed how she feels about herself, it expressed her confidence. And expressed exactly how she moved, temptively, guided, slow, not committed to the movement, overthinking it, then you take all of that into your objective. And for her, was like, can you pick up that pan of the floor? Can you lift your shoe? She's a nurse. Can you show me how you would transfer her patient from the bed to the chair? She spent almost a minute preparing herself to do that. The interesting thing with her is that she didn't have pain anymore, but she was frightened of having that pain again and frightened of causing more damage. And look at her body chart. She had back and leg pain. She came in and she goes, that's what I had pain. I don't have it anymore. But I know it's there because I didn't fix it. What do you mean? It's only being time and me getting back to my life and taking a high dose of turmeric that changed it. I didn't have the surgery. I was told to have the surgery, but I didn't. So I know I haven't fixed it. So right there, she's telling you, she's thinking about the structure of the body and she's protecting it and she's frightened of going back to where she was. So let's talk about this biopsychosocial model and at times there is this idea that you can get a bit too psychosocial and you can get a bit too bio. I almost say, I don't see that white. You have to see it all. And in her case, she wasn't highly stressed. She wasn't highly anxious. She wasn't the patient. Well, it was affecting her mood about herself and this feelings of aging and she was frightened. That was the big factor for her. But she was like, you know, if you talk to her and I didn't ask those questions, it was like she was absolutely fine. So the psyche of her story is this fear of going back there. Is this perception that she's aged and that she needs to be. And it expresses in her behavior of protecting herself and slowing down and doing all of that. And all came down to a misconception that that's how you should behave with your back. Or giving different examples, but it's the same story. It is. And the great stories that demonstrate that point and the different way you can word questions to get that information that really does help you. And that was a really interesting story coming back to the bio fighter who felt like he was like a robot cop and pretty stiff in how he was moving and he didn't have that freedom and was worried about whether he could do his job and carry people out of a burning fire and that type of thing. So he would identify some really important factors for him. How did you then use that information in your assessment and your treatment and all those sort of things? How did that help you there? I got him to demonstrate some of the key things that he struggles with. They were far from being lifting a person from a burning fire. I was picking up his shoes and it was undoing his shoes, actually, undoing his shoe laces and taking his pants off, putting shorts on. So they're really basic strategies. And I said to him, "So when you're doing these things, do you feel the same? Do you feel like you changed?" And he goes, "Oh yeah, my wife mentioned to me that I'm granting that I'm protecting myself." And he goes, "I don't notice anymore, but I hate it. That's not who I am." So I said, "What do you notice in your body when you're doing that? What do you mean? Just do it again. Put your shoes on. Take your shoes off. What do you notice in your body? First thing he said, "I'm not breathing. I'm holding my breath." Right? Okay. So do you think you should be holding your breath? And he goes, "No, I'm just putting my shoes on. What else do you notice?" And he did it like six or seven times and he said, "I'm really bracing my stomach." So I'm here talking to you and he said that he was embracing, but he was already embracing. And then he said, "I go to move and the first thing that I do is I brace and I hold my breath." So I saw that, but I didn't tell him that. I asked him, "What do you notice?" Because at the end of the day, David, that guy is going to go home and he needs to change that. It's not me telling him how he changed. Well, I guide him how he changes. But if you notice it and he can't change it himself, then we are making change in his day-to-day habits. And then I said to him, "So what do you think that does?" Like you've got a sore back and you're tensing your belly and I palpate at his back when he did that. I said, "How does it feel in your back?" And he goes, "Well, it feels pretty hard." "Do you know what I'm pushing on?" And he goes, "Oh, my spine." And I said, "No, this is your spine, which is a sore." And he was sensitive, but not very sensitive. And then I went to his paraspinals and he goes, "Oh, yeah, that's quite sensitive." And he goes, "This is your muscle. You guys are bloody hard." So if you relax your belly and you breathe into your belly, how does it feel now? And the palpation changed. He wasn't as sensitive and he wasn't as tense. So that gave him two things. One was, actually, when you're pushing my spine, it's not that bad. When you're pushing my muscle, it's quite sore and he was jumpy. What happened was that once he relaxed his belly, he wasn't as tense or sore. So you change the sensitivity by changing your behavior that is controllable. So he's going, "Well, so my back is not as bad as I thought." And actually what I'm doing is not helpful. And I ask him, "What does that make you think?" Now, I push here and it's sore and hard and you relax your belly and it's not as sore, not as hard. He goes, "Oh, that tense in my belly is not good for me." Right? That's the message. You go, "Right, so how about we try to get your shoes on and off without bracing your belly?" And then he was frightened of doing that. And he goes, "No, I can't do that. Why can't you do that?" Because I feel vulnerable. Why do you feel vulnerable? Because I don't have a strong core to be able to do it. And I feel like my spine is going to bend in the wrong place. His strategy was lift his chest while he's trying to bend down. So I put the mirror on and go, "Look at that. What do you reckon? Does that look normal?" Like your shoes are down there and you lift your chest to the ceiling. It doesn't look very efficient. Right? And I was like, "How would you do it?" I'm going, "How about this?" So I demonstrated who my head down, chest down, went for my shoes. And I was, "Yeah, but your back is rounded." So in doing, in observing, these beliefs are coming out. Right? I had a hunch. He wasn't very keen on bending his back. And a lot of the rehab that he's done was around keeping a neutral spine, building his core, feeling strong. And this whole idea that my glutes don't activate. All right? If my glutes don't activate, that stresses my back. So he's doing a bunch of glute exercises and trying to keep his back. So the belief that flexing his back was bad for his back came on when he watched me running my back. And I said, "I understand where you're coming from. Why don't you try it?" So relaxing his belly and relaxing his head allowed him to bend forward. And then he came up and said, "How was that?" And he goes, "I wasn't too bad." So do it again. Do it again. Do it again. Do it again. Do it again. Then you can see that he like hogs are turning because he's going, "This doesn't make sense. This is not how you're supposed to move." Right? And that part, I think, is really cool. It's not something I didn't tell him about that. I didn't challenge his beliefs on economics. Or actually, I didn't challenge until right the end about the exercise that he was doing at the minute. And I didn't challenge any of that. I just collected information, got him through an experience, and asked him to reflect on it. And he's thinking. He's doing all the thinking. People maybe listening to this and going, "That would take too long. You can't do that." But in fact, he fast-tracked a lot. This guy didn't have any leg pain. He wasn't warranted for me to do a neurological examination on him. He had pain, but he could touch his toes. He was slow and guarded. Or not touch his toes, but he could go into the right side of his toes. He was sorry he's back. So it's not like I need to be doing a straight leg raise and doing a slope. So there's a lot of stuff that I got the information from getting him to do his daily tasks. So I'm gaining time on that. At the end of the objective, I asked him, "What do you think you need to do?" And he goes, "Oh, this may sound stupid, but I think I need to relax my body." And the way that I've been moving is not helpful. I'm going, "What do you think of that?" And he goes, "Well, it sounds a bit stupid because I'm doing it to myself." I'm going, "No, you can't think that." The habit, right? I feel like I've got to be careful that you're not judging someone's behavior. So when I got him doing those things, I had a hunch of what was going to happen. But I wasn't trying to box him in a little box of relax your belly to this to that. Because you can fall into a trap. He might be doing that and I'm going, "Actually, you're really sensitive. You're doing that because it's bloody sore and you don't have another strategy." And it's relaxing, it doesn't make any better. So they don't have to adapt and change it. And that's what I think is the cool thing about profession. Someone walks in the door, they say they've got back pain and you go, "Oh, what's going to happen here today? It's my number." Right? Or they've got Neo-Y or whatever it is. You're in for a challenge. And a lot of the story repeats itself. But the way you get there is different. At the end, this guy was asking me, he goes, "Oh, but what about my glutes?" Do you think they activate properly? And then I got him doing some fissom squats touching his fingertips on the floor and looking between his legs with no weights. We're just going down all the way down, coming up. And I said, "Just do a few of those." And I went and said that question for you. And after doing 12 repetitions or so, and I said, "So where do you feel in your legs?" And I feel my thighs and goes, "Funny enough, I feel my bum." Like my bum's work. And I said, "So is that similar to what you feel when you do your exercises?" And he goes, "Yeah, but I have to do a lot of them." So he was doing like clans and single leg bridges and grab walks. And he said, "Why do you think my bum is working?" I'm going, "Well, because you put yourself in a position that you don't give them an option. They have to work." And they have to work because your back is not working. But if your back is working, your bum doesn't have to work as much. And to be honest, my point wasn't to make his glutes work. My point was to make him understand that he could use his legs, get down and up without having to tense his trunk voluntarily. And the outcome of that was that he felt freer and he was moving faster as he was doing it. So I filmed him before on his phone, and I filmed him after. And so what's the difference? He goes, "Oh, it's easier." And I said, "So which one looks like you before this whole problem?" He goes, "The second one." So which one do you think you need to be moving forward with? He goes, "The second one." So it's making the person realize. But the big thing that made him realize was the experience. And my guidance during that process, there was no point in which I educated him. I just gave him snippets of knowledge. I'm going, "Do you know what happens if you bend forward and you plant your belly?" He goes, "No, this is what happens in your back." So you kind of just give some knowledge to move the person forward. Of course, if they get stuck in the ask for an explanation and you give them the explanation. But it wasn't like I went through an assessment or to identify all these impairments and held all that information to myself, went through my reasoning, set him down, educated him about pain, and then educated about all the things that he needs to fix. It was like life. As it's happening, we are reflecting, questioning, thinking about it, doing it differently. So his big job this week was to work on his habits to notice what he was doing. And if he was doing something with tension, notice if that was sensitive in his back, "Can I change my habit? Can I do it differently?" And try to look for comfortable positions and moving comfortably and closer to his natural pace, rather than guiding himself. So it's like, take the handbrake off. That was his first job, basically. And every patient asked, "What are your goals? "What are the things you want to achieve?" And at the end of that session, I asked him, "I want you to write down what would you like to achieve "in the next month or a couple of months? "What do you see as the obstacles?" And that's what we're going to work on the next time. So that's kind of a frames the session and the journey to the patient. I explained to him, I said, "Look, this is a journey. "The journey will end when you're achieving your goals "and you're living your life to what you want to do." And of course, you may have really long-term goals and you may have short-term goals. My job here is to help you identify these obstacles and guide you. in how to do that. And along the way, you're very likely to have flare-ups. And we welcome those flare-ups. You know, they're not great, but we welcome them because they will be a massive learning opportunity for you. When you have a flare-up, all your beliefs, all your negative chatter and the bad stuff comes up again. The habits come up again and you protect the body part and you question everything that you're doing. And that's an opportunity for you to go and say, "Can we modify what's happening now? You know, why did you have the flare-up? Let's look at the context." And then you help the person through that process, they get out of it, and then they go on and they may have another flare-up. We actually gonna give you a plug here. We actually gonna have a podcast with a patient. He was doing really well for two years and then he had a massive flare-up. And then he talks about that experience and he talks about how quickly he came out of it and what he learned about it. Flare-ups are a really interesting part of my job and I can think of myself as a young clinician that in my mind was, "If I gave you the right treatment, you shouldn't get pain again. That was my naive way of thinking." And when a patient had a flare-up, I automatically question the plan that we had and completely forgot that the patient had been doing really well up until that point. So there was something right and whereas now I look at it and I'm going, "Yeah, this is not great, but it's a great learning opportunity. So what can we do about it? How can we change it?" That was a conversation that we had. And that would be a very similar conversation to patients with near-weight, hip-weight, shoulder pain, neck pain, whatever. Absolutely. And you've really nicely adapted your assessment based on the issues that he was having trouble with or how he was feeling like he was moving when he was doing up his shoes or the movements that were important to him. And so when you're looking at your NEOA patients, for instance, obviously you're going to adapt that based on the issues that the patients are reporting to you if they're having trouble walking, like you mentioned before, and you're looking for whether they've got a stiff knee, stiff foot, those type of things or the movements that they're having trouble with. Are there any other aspects that will tend to stay within your regular objective assessment for NEOA that you'd perform on most NEOA patients? So I think it's really important to say that the behavior assessment is a strong part of it and then there is a thorough, more standard assessment, which will be palpation, palpation of the joint palpation, the muscles and identifying area pain. There's lots of patients that get offered a total knee replacement and they've got a patella femoral pain. It's not the actual knee joint. It's the patella femoral joint. So area pain is really important, palpation of area pain, range of motion in the knee. You know, can you actually flex this knee fully? Can you extend this knee fully? Do you have any restriction in this knee? Is this restriction because you're guarding your knee or is it actual limitation? You can't fully extend the knee. Depending on the history of the patient, do you have laxity in this knee that is quite significant laxity and because of that, you don't feel like you have a lot of control and that's why you stiffen this leg. So these would be like if I'm assessing a knee, I want to have a good understanding. Do you have good mobility in your hips? Do you have good mobility in your ankle? But I usually would contextualize that assessment based on the person's needs or difficulties. So, you know, I can't go downstairs. Why can't you go downstairs? Which is a very common functional problem for patients. What is it that you have trouble going downstairs? I don't feel sick or my knee gives way and then you look at the behavior and then you want to look at the the way they do it. They might have some stiffness or they might have a lot of guarding around their knee. So the examination of the body part that is sensitive, it's always done. The patient will back me. I'll light them down or pop it back or I'll have a few but it doesn't mean that I'm going to go through all my accessory movements and my physiological movements and there's a place for that but you vary with patients. So I saw a fellow with knee pain and he had general knee pain and he was like you couldn't really pain-point him and he had been offered a totally replacement. He was a story of significant changing weight, who was sleep and drastic reduction in exercise and actually here a minor like a sprain or like he was going downstairs and he slipped and he kind of hyper extended. It wasn't massively traumatic but he felt like it was a bite in his knee, right? He's like just hyper extending. I felt sharpish at the front and then maybe his knee becomes sensitized then because of that he kind of stopped exercising because when he tried to exercise immediately afterwards he was painful. Then the pain wouldn't settle. He popped some pain on the wall. He didn't settle. Went to see the GP, got an X-ray, he's 62 or 63 and had away in his knee. I'm sorry my four months down the track and when I examined his TBR femoral joint he didn't have sensitivity on for a patient but he was sensitive under his knee cap when he tried to extend his knee. So under load his knee cap was sensitized or if he was going downstairs his knee cap was sensitized. So he developed some sensitivity around the knee cap but not around the TBR femoral joint and for him was like the reason why his story comes to mind is that I asked him what do you think it's going to happen with the surgery? What do you think they do? They go well you know they take his point into his TBR femoral joint. They take this part here, they take the rubbish cartilage out and they put some nice titanium plate there and then you know that joint becomes a brand new joint it's like a bionic knee and it's going to crash okay so when I went to pulpit that joint that they're going to replace he wasn't sore so how does it work? This is not sore to touch and you got to replace it. Let's him make sense. He goes nah but surely this will be sore but why would it not? I was really pulping his joint and he wasn't sore. Then when I saw him going up and downstairs his pain was behind his knee cap. I pulpating the joint under the knee cap was sore but not the TBR femoral joint so for him that specific pulpation was really important to challenge his understanding of the problem of the concept and right at the end he's going I still can't believe that wasn't sore he goes ah I'm going to do this exercise I'm better this will get sore so I'm going what we'll see and he wasn't like his TBR femoral joint didn't become sore because he had a knee cap problem and he was a sensitive knee cap and he lost a lot of conditioning and to protect his knee he was walking with a slight knee flexion because he hyper extended right initially and so he didn't want to get there so he kept his knee in slight flexion which loads your knee cap massively so I actually I don't know if I was dealing with just the consequence of him walking like that and that's why his knee cap was sore but at that end of the day it doesn't matter the usual assessment is still present but I'm going into gather information I don't rely entirely on that to find impairments so let's say I did this whole assessment and I saw him walking with a slightly bend and going upstairs really slowly placing his whole foot on the step and coming downstairs sideways with his foot these are the key findings and then I go and examine him and I wouldn't be relying on his knee cap stiff or not you probably is stiff you're walking on a bend knee so being stiff or not didn't really would make a difference for him whereas I'm going yeah you can bend and straighten your knee looks like you're a bit stiff here but you can't do it when you do it actively and in a priced way it's sore then when you do it more relaxed and your sore on your knee cap right and you've got good hip mobility so let's go back to your behavioral tasks and see what we can change here and for him was like okay when you're walking why you're walking with your bent knee and when you're stopping why you're taking the weight off that leg and keeping that knee bent so it's like it's sore but you keep it on the load and then going upstairs he was going really slowly is that how he used to do it and he goes no I think I used to go a little bit quicker so let's try that instead of me stepping with your whole foot why don't you step with the front of your foot and you just go a bit more dynamic and they actually feel a bit better because he's engaging his foot engaging his calves taking the pressure off the knee I'm quite strong about assessing behavior and seeing if it's modifiable but you've got to make sense of it during your examination like your standard examination perfect and really nice way of tying those together too and helping him to understand that if he was going to get that knee replacement then it wasn't going to be actually replacing the path that we're actually painful or nose-exceptive so that's really nice and if people are listening in there thinking yeah I've got some patients like this and they're wondering about palpation tips that you could give them to help to identify these sort of patients that maybe are more tibia femoral-based or patellar femoral tell us about some of those things you you palpated on him and tell us about where you palpated how you palpated that help to guide that and help that patient to have that experience I tried to be quite systematic when I do this for patients and I tend to tell patients look and if you're doing yourself like you've palpated your medial tibia femoral joint it's usually sensitive around your MCL and posterior part of your joint it tends to be sensitive anyway and patients that have a sensitivity that is in the joint line you have like a bruise-like feeling so it would be quite acute and one of the first things I want to see you know do you carry a bit of effusion in your joint is it an intratricular effusion I often do a swipe test because that picks up on I prefer that than the patellar tab anyone because you know the swipe test usually gives you quite a good indication of how much effusion you've got I palpate around the soft tissue around the kneecap and like a medial and your lateral ligament to give you an idea is that this whole knee that is sensitized there is that really pinpointed and one area then I often would be having a patient in supine I'll be sitting on the table and I'll have their legs like in almost like figure four over my leg and that really opens up the tibia femoral joint and you can palpate along the joint and I go all the way from anterior to posterior helping the medial femoral con dial from the tibia femoral joint upwards helping the medial patellar femoral joint and around the peasant serine so you kind of like you have a good idea of how sensitive their area is and if the patient tells me they've got medial knee pain I'll spend a bit of time there just to identify exactly where it is. And that's same position that I'll have my other hands just with my index finger pulpen in the lateral tipia femoral joint. I find it that's a good way of getting a good idea of the whole joint. Then with the patient is supine, knees bent, you have really good access to the femoral condyle in both sides of the kneecap. And the pulpation is telling me you know what looks like you're quite sore in the joint, right? It's in your medial femoral condyle and it's like I'm not touching much and you're quite sensitive and then I'll look at their skin and they might have a bit of activity dimmer or they've got significant changes on that side. So it's telling me that that region is sensitized and I'm going yep that makes sense. So you're sore on that spot in your skin so that's telling you that that region is highly sensitized now. So the biology there is quite strong and what do I do in giving this person activities or exercises to do if they are having some discomfort that is tolerable it's not impacting on their daily activities on that day or the next day keep going as part of the process. If they're doing a task and it progresses they're getting worse or they're limping after loads or they're really having to protect the leg that tells me that the task that we've given it's a bit too provocative. So you don't need to be completely pain-free when you're doing activities but you don't want to be constantly provoking the joint with the goal of trying to make their legs stronger. And at times if someone has an active bone marrow dimmer on their femoral condyle for instance and they're highly sensitized they get pain with knee excitation, they get pain and pulpation, they get pain with loading. Then what you might do is get them to exercise like if they can get on a bike or if they don't have access you might get them to exercise around their lower leg, get to exercise their hamstrings get to exercise their hips. If they have weakness around that region to build a bit of conditioning in that region while that knee is settling. So it kind of you're making more of a hip target, a lower leg target, a rehab and then you go back to the knee to strengthen the thigh and as needed. The pain on the patient or they will have really specific exercises like you know they have really weak hip rotators for instance and they're constantly loading up like they have a dynamic bulgues and they're sensitizing their medial patellar femoral region let's say. It could be just soft tissue but once they have been stronger they're not falling into that same position and it's not so sensitized. And here I'm not talking about correcting biomechanics of everyone that walks in the door but if it's someone that they are going downstairs and they have a bulgues that they don't have on the other leg and they have a clear weakness around their hip and they're sensitizing the medial femoral region and when you load their leg in a less vagus manner they are not sensitive. That may be a link and what can happen is they send them off, get them really strong, you test them, they're really strong, they are not sore anymore and you look at them coming downstairs and they might still have the virus and back in the day I'm going oh shit you know didn't help this patient probably going to have this problem again. So nowadays I'm going okay you got stronger you're now probably capable of tolerating that bulgues and it doesn't sensitize any that's how I think now. So that's just an example and probably kind of overstating the idea that you need to do some targeted assessment and you may need to deal with impairments or weakness around the hip rotators or thigh muscles or the calf to assist this patient to be able to change their function on the end of tasks. So that gentleman for instance the 62-3-year-old that asked him to go up the steps more on the edge of the stairs and going a bit quicker. In doing that he goes well I can really feel my calves working and when I tested his calf on that leg he wasn't very good at all. There was a 10 repetition discrepancy between the two and on the non-painful leg he was quite springy on the painful leg he was really sluggish and slow and was kind of as the calf fatigued he was kind of bendy and straightening his knee. So that showed me that is it weakness is it conditioning? Don't know that but what it tells me is that you're not very good at using a foot on that leg and you're not habituated to do it. So let's train you to do that and you know at times between a week or 10 days patient comes back and they can do it so you didn't get stronger in those 10 days you just access the muscle you just created a pathway there you go oh yeah that's how I use my ankle and that's it. So you kind of going I want you to change a habit or a behavior. Do you have the capacity to sustain this new behavior and if you don't then you need to be provided some exercises to facilitate that. Exercises are a mechanism to train a new behavior right or a new movement pattern or whatever we want to call it or to deal with specific impairments of muscle weakness muscle conditioning that's how I see you know they rehab for education. Beautiful and you're really addressing their goals you've identified with some of those really nice questions before where you were trying to identify what they'd like to be able to achieve in the next couple of months you're getting them to identify their obstacles to achieving that and sounds like tying that into their treatment about making sure they're achieving their goals and working towards with specific whether that's identifying those fears that are associated with it and then working through that to give those safe experiences and that sort of thing within the clinic. Is that right? Exactly. Beautiful. Well I think that's a fantastic place to wrap up this podcast. You've shared so much fantastic information with people out there about how they can approach whether Neo-A any persistent pain like a really thorough bias social approach that really identifies those individual components within each patient that are important. How you might go about helping them to come up with the solutions or with the experiences that really change their beliefs and their habits so that you can make those long-term changes for them and then how to deal with it when you know they have those flare-ups and I think there's been a ton of gold in here and I think it's one of those podcasts where people are going to want to go back and listen to it you know a number of times to pick up all those little facets so I really appreciate you coming on and sharing all that with this JP. It's a pleasure David thank you so much man I hope you enjoyed it. Yeah it's been a lot of fun. Probably a paper that we published last year it's an editorial in the British Journal of Sports Medicine. It touches on this idea of kind of pain is pain no matter where and the name of the paper is it's time to move beyond body-region silos it's like this idea that we treat shoulder pain differently to neck pain differently to hip pain and when we look at the risk factors for persistent pain they are shared across pain anybody region and when you look at the biopsychosocial principles the idea of coaching someone to achieve their goals and enabling them to do that in terms of education they're very similar principles so that may be an interesting read for the listeners to get a good idea of that and a good excuse as to why we talk a lot about back pain in the Neo8 podcast. It's sure and we'll have links to that in the show notes for the podcast and also some of your other recent research that's been fantastic to read as well so people been going and grab that from the podcast show notes so where can people find out they need to go listen to your podcast as well so where can people find your podcast and yourself on twitter that type of thing. Right we have a little bit of information in the bodylogic.physio website forward slash podcast that's the the name of the podcast is empowered beyond pain you know stutter off has been bitter as hell on myself and driven by the super tech savvy high tech Kevin Wally finishing off his PhD now so he's very busy he's doing a fantastic job in moving that forward and the idea of the podcast is to get information translated to clinicians and patients and get patients to share their experiences as well that's what we're coming from. Nice the bodylogic.physio/podcast to go check out your podcast and then you're on twitter what's your twitter handle. @jpcanearo C-A-N-E-I-R-O Awesome so go tell JP what you've enjoyed about these podcasts and check out his podcast as well so thanks JP for coming on and sharing all that awesome information I really enjoyed chatting to you. Thank you so much David and thank you so much for all the work that you've been putting over the years it's been fantastic man thanks. Thanks JP. Thanks JP that was awesome I hope you enjoyed that podcast you've got lots of good ideas about the type of questions that you want to ask your neo-a patients how you can explore their beliefs and help to overcome them your objective assessment tests which tests to perform how to identify what's going on with your patients neo-a and then how to go about treating it. So if you enjoyed today's podcast let us know on twitter so give JP a follow and let him know what you enjoyed and I'm also on twitter as well at David K-Pope. We're also over on Facebook we've got lots of Facebook lives and resources there that you can enjoy and that's over at facebook.com/clinicaledge remember grab your free resources we've got your infographics that sum up the key points from today's podcast and also your free trial membership over at clinicaledge.co/free trial So you have a great week and I look forward to catching you on the next Physio Edge podcast.