Musculoskeletal pain and osteoarthritis with Imran Sajid

[Music] Welcome to Deep Breath In, the primary care podcast from the BMJ, sponsored by medical protection, that tackles the everyday challenges of being a GP. It's said that musculoskeletal problems form 20% of presentations to general practice, but there have been a lot of changes in recent years that have made consultations a bit harder than they used to be and might have left some GPs feeling a bit de-skilled. Patients are increasingly encouraged to self-refer to physiotherapy-led community services, and what we're emphasising now when it comes to management has also shifted. This is highlighted in the recent draft nice guidelines for osteoarthritis, which seem to be accelerating the move away from pharmacological intervention to a much greater emphasis on self-management. But what's driving those changes? And what exactly does that mean we should cover in a consultation? In this episode we're hearing from Imran Sadjid, GP and Northwest London CCG Musculoskeletal Clinical Lead to find out how he approaches osteoarthritis and chronic pain and to get his top tips in a consultation. I'm Navjoy Ladder, a GP in London and a clinical editor for the BMJ, and today I'm joined as ever by Tom Nolan and Jennifer Razzanathan. Hi Navjoy, yeah I'm Tom Nolan, I'm a clinical editor at the BMJ, also currently a low-come GP. Hi Navjoy, I'm Jenny Razzanathan, a family medicine doctor and clinical editor for the BMJ. Well welcome both of you and as I said this week we're talking about musculoskeletal pain, osteoarthritis and all of that stuff which supposedly is like 20% of what we see in medicine so hopefully something that is really clinically common for all of us. My impetus for wanting us to focus on this for this week was from when the new draft nice guidance was published in the UK around springtime and there was a lot of attention to it because it was focusing much more on non-pharmacological management, much more about exercise, there are a lot of medication options that were taken out from the guidance with only really parasitimal left as an option and it just made me wonder as GP's this is something that we see so often what sort of left in our toolkit now really to manage these patients who often come and see us and really struggling with pain, with the limited function and that sort of thing so I thought this would be a good good thing for us to discuss and I don't know in your experience how you tend to approach particularly osteoarthritis I think which is what the nice guidance is about. I don't know Tom, do you feel like it's an easy consultation for you or challenging? Yeah definitely challenging, I love that you know the 20% thing, have you noticed how pretty much everything is like 20% of our GP? Yeah I think dermatology is 20% as well isn't it so that's like already 40% that's dermatology and musculoskeletal. So I always love to pour my cynical yeah I think you're right to be skeptical. To be skeptical. Anyway but no it is common, interesting like like is it as common now that we've got first contact physios and a lot of people go directly to physios or other healthcare professionals to see people and I wonder how much I get de-skilled by the comfort of being able to say right that's very, I will give you that my consultation style but you can come and see a physiotherapist tomorrow and have a more detailed assessment etc. So I wonder about that, worry about that but I also quite like it, I like all this stuff but I think we're going to hear about today which is trying to think about osteoarthritis differently from that you know where I would try to give it too much away but where and tear and you know need to see the x-rays and all that so I'm looking forward to talking more about that today. Yeah no definitely and I think I think what we'll hear coming up is perhaps challenging some of our for me anyway kind of quite outdated approach to assessment and management of people who come in with you. You still get an x-ray for everyone after are you that person getting back x-rays? I don't think I'm that person but I think I don't I probably don't I definitely think about imaging probably more than I should be and I'm definitely I think my the sort of options that I present to patients probably are a bit narrower than they should be which you know we'll heal more about coming up but before we do that Jenny I mean how do you tend to approach osteoarthritis or what's your experience? I think pretty similar to tons to be honest I mean I find these consultations personally difficult because I think the ability to refer to physio and to have a kind of allied health care provider pretty accessible has resulted in some deskilling on my part but also I just feel helpless in terms of strategies and treatments that I can provide. I often end up with a feeling that people come in and they have pain and the remedies they've tried which are often within the scope of the guideline aren't working and then I feel like there's nothing else to do and so particularly in New York it was the process of getting them in to see a physio hoping that the waiting time wouldn't be too long and hoping that they would be able to help and in New Zealand it was more an issue of you've gone to see physio and it hasn't helped and now what? Isn't that so interesting that like we're sort of pinning all of our hopes on physiotherapy and it seems like what else can we do? That that's something we're definitely going to talk about with our guests this week in Maran Sagitt who is a GP with an interest in expertise in musculoskeletal medicine and pain management. I did my GP training within Maran which is how I know him and he's definitely someone who's really taken a deep dive into a lot of these issues so thinking about sort of broadening the kinds of management that we think about and also about how we approach taking a history as well and how we approach talking about pain and I think I certainly found our conversation really informative and there were lots that I took away to that I think you know is and will change my practice so hopefully there'll be a lot for us to sink our teeth into so why don't we have a listen to the first half of our interview with Imran and that's coming up after a word from our sponsor. 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To find out more visit medicalprotection.org Thanks for having me. I'm a GP, I spend about a third of my week in clinical practice. I love all general practice but I've got particular interest in MSK so I started off more around sports and excise medicine and general MSK but concurrently I've done a lot of psychiatry and psychology training and accreditation so that kind of naturally led me into pain medicine. I'm also qualified personal trainer and more recently I'm doing my complete my case accreditation as an MSK sonographer. So lots of interest in how we clinically manage MSK pain. So in round with your background and interest you are steeped in thinking about musculoskeletal conditions and osteoarthritis and pain and how we can get better at managing those things in primary care and beyond. I just wanted to start by asking you what are the some of the concepts that guide your approach to management of a patient presenting with the more dare I say straightforward musculoskeletal conditions say something like an uncomplicated osteoarthritis. I mean I guess I always start with it's I think it's useful for clinicians to have a good understanding of what these conditions are. I know that certainly in my journey, one of the kind of light bulb movements was when I started to realize that there's a lot more going on in a lot of MSK conditions and just some clear structural phyomedical cause of someone's symptoms. I think if the clinicians in the system start to understand that, then we can get better at really supporting patients. I think there's a really key principle that I think probably if particularly coming from an evidence-based perspective, I think would be sobering and useful for most clinicians to know that anything that we tend to do when it comes to MSK pain, when people get better, that's largely not the treatment that we did. So a lot of the time when patients come back and say, "Oh yes, this thing that we did really worked," a large part is actually probably natural history of the condition or regression to the mean and maybe a small part of contextual effects. So I think it's important to recognize that as a clinician that there's lots of things that we can do. There aren't that many magic silver bullets that are just suddenly going to fix everything. Everything that we do has a different kind of risk or opportunity costs associated with it. And I think we have to be particularly careful within MSK because sometimes you can do something or the patient might do something. And just because of all the biases we have, we think that that treatment we did help them, but then we get this belief reinforcement that we think that injection or that medication helped. And that's not always a bad thing, but I think when you've got people really relying on treatments or interventions which maybe reduce their ability to self-manage that make them more reliant on other people, sometimes I think we have to be a bit careful about that, that we might be removing people's locus of control to be able to help themselves and make people maybe excessively reliant on others for things that they probably can manage themselves. And that fits in with a lot of the discussion about the draft Nice Guidelines for osteoarthritis that recently came out, which has more of a focus on self-management. I mean the nice guidelines came up recently, I think. A lot of it isn't necessarily new, there were I think a few bits of it which raised a couple eyebrows in terms of can primary care deliver and do all these things practically. Again, I think with osteoarthritis, again, I think it's useful for clinicians to understand what is arthritis. I think a lot of people think of arthritis in very different ways. I mean there's a very basic kind of advice that how you diagnose it, people who are over age 45, activity related pain, no prolonged morning stiffness, you don't necessarily need imaging as much as it's intuitive. A lot of people with most MSK conditions think that they need some imaging. We know that it depends on the study you look at, but whether it's x-rays or MRIs, above the age of 40, maybe 40, maybe some studies half of people above the age of 40 will have some arthritis changes on their knee joint. Most of those people have no symptoms. So like most things in MSK, the correlation between structural changes and actually people's symptoms is really poor. And so it's useful to try and provide that education to patients, try and help people understand what arthritis is. So you mentioned that the explanation is an important part of setting expectations and future trajectory, if you like. How do you explain what osteoarthritis is? I know, we often use the word wear and tear. We all do it. It's easy. People can kind of understand it. If you're in a, you haven't got much time in the Constitutions, it's very easy to kind of say that and people kind of get what you're saying. It's probably not really accurate. We kind of having a better understanding of what's going on. It is probably some level of inflammatory condition, maybe not as inflammatory as kind of historic kind of rheumatology, kind of rheumatoid arthritis and so on. But there's some level of information going on. If you're going to use any way to describe it and try and tell patients it's aware and repair process, then you know joints are metabolically active. They are responding to the pressures and loads that we are putting on them. A lot of the changes that we see on X-rays, we're seeing a repair process. So when people have osteophytes cortical irregularities, that's remodeling. That's a healthy, healthy part of repair. It's just sometimes that repair process kind of goes into overdrive as such, and it can cause debilitating symptoms. I know one of the things that the nice guidelines suggest is that you don't necessarily routinely need to do X-rays, which I think is a challenging conversation. We don't always have time to explain to patients why it doesn't necessarily change management. But we do often see that the correlation between what you see on X-rays when people's pain isn't particularly strong. I think we have to be careful about the verbiage that we use when we see people's X-rays that we describe their condition to them because if we start saying things like, you've got a degenerative joint, you've got bone on bone, this can have quite enduring effects on people. So it can affect their perception of their condition. It can affect people's perception on what type of treatments may or may not work. It might ramp up their avoidance behaviors. People might think, especially if you use a word degenerative, people might think, well, it's just going to keep getting worse and more activity might progress it further. It's even possible that by changing people's perception of their condition, you might even affect their pain signaling and actually increase their pain directly. So we have to be careful, I think, about what we understand of arthritis and how we explain it to people. It's really interesting to hear you talk about the way you approach consultation or approach these ideas about what is osteoarthritis and actually how much of what we do in an average MSK consultation. It's certainly in terms of interventions actually makes a difference. I think that is quite sobering. Now I was going to say, I'd really recommend that there's a guy called Professor Tony Dickinson in years, I think I'd been a GP for one or two years and I stumbled upon one of his lectures and he's just incredibly articulate explaining this wealth of neuroscience in terms of how the neuroe emotional circuitry, which really ramps up and drives our pain experience. And it's just not straightforward at all. These no-susceptive neurons in our system, they kind of feed into this complex system of signal amplification and then inhibitory down regulation and then there's this interplay between our emotional limbic system and our higher cortical regions and your body generates this value judgment of what these signals mean and that's what pain is. It's just this value judgment around a perception of threat and it's really inaccurate, especially when it comes to kind of persistent pain. You can have horrendous life-threatening tissue injury and have no pain, you know cancer for example. Or you can have a horrendous pain from absolutely minimal tissue injury and there's all these changes that we increasingly understand in terms of changes that happen in the peripheral nervous system, the central nervous system and that can be very largely influenced by lots of things in our lifestyle and things that we can potentially influence as a GP. It's just it's not easy to necessarily get that across and there's all this debate about how useful it is to actually provide that detailed pain neuroscience education to patients. But I think it does help as a clinician to broadly recognize and I think like I said most clinicians kind of recognize this, they might not recognize just how significant it is but particularly with persistent pain, you've got these physiological structural causes which might be you know no-susceptive tissue drivers like joint changes or deconditioning. There are neurological dysfunctions which might cause people to have kind of hyperalgesia or allodinia so that's things like you know radiculopathy's or neuropathes and then you can get this so-called kind of nocy plastic or central sensitization changes which I was just talking about where pain signals are just are transmitted at much lower thresholds and they should be and the nervous system can get really sensitized and all those things drive pain but there's all these personal factors which drive pain and they really drive the disability around the pain. So that's people's mood, their expectations, their belief, their perceptions, their self-epicyccy. A lot of these things drive kind of avoidance behaviors where people start avoiding things and we can all do that if something starts hurting, we just start avoiding doing things and it's really interesting that when you're taking a consultation of all the things that you might look for in the history and examination or even imaging for a lot of the high volume stuff that we see whether it's back pain, shoulder pain, probably even for knee pain. One of the most prognostic things that you can find out is what people's perceptions, what do they think is going on, what do they think is going to happen, what do they think about movement, how long do they think this is going to take to recover. Those things are probably more impactful and everything else that we ask for and like you say we hang on to a lot of the kind of the red flags because obviously there are medical legal reasons that we need to do that but perhaps, you know, back pain for example, I think the average practicing GP will see one true quarter of a corner in an entire practicing lifetime, right? But yeah, we ask about those symptoms in every single consultation and maybe we don't have enough time to actually ask people, you know, they're moved. What do they think this pain represents? What do they think is going to happen? What are their thoughts around movement? What are the environmental factors around their employment, their workload, their job satisfaction, their stress as anything else, legal going on in the background, treat the pain. My general view is if you're just trying to treat the pain using just the medical model, it'll work with a very limited degree. So when you're taking that history, you know, you need to have a really good understanding of the whole pain journey that person's been on. Now what initially triggered that pain, what movement patterns or activities bring it on, what things that they found helps, you know, positions or medications, what is that pain stopping them actually doing, what would they like to get back to? I often say to people, if you were not in pain tomorrow, what would you be doing more of? Because that might help tailor some of the goals you might try and figure out how they can slowly get back to, and always asking them, you know, what do they think might be going on? Is this happening over multiple consultations? Yeah, and this is a tricky thing. I think, yes, I think you're right that you can't often do all of this in a single consultation, particularly if they're coming with lots of problems. And it may be a case that you do a little bit of understanding one consultation and then you have have to do, you have to have a bit of a framework where you're gonna do little bits. So there we go, that's the first half of our interview with Imran and I think lots to kind of chew on there. You know, we were in our initial conversation we were talking about how you know we immediately think of physiotherapy and what that conversation made me realize is actually I'm probably really short-changing the patient and not talking them to them enough about their pain or having enough of a conversation about what osteoarthritis is and definitely not mentioning where all tear. What did you guys think Jenny? Oh for sure, you know, one of his initial points that if you know the interventions were prescribing decrease the patient's own self-management or feeling of self-efficacy then and we're removing that locus of control from them then we are doing a disservice. And I thought that was really interesting and that's not to decrease the value of physio. I mean I think a lot of us turn to it because there is evidence for it in many conditions but that piece about kind of self-efficacy and self-management and their own perceptions. I thought was really important especially because their perception of what this is, what it's coming from and what is gonna help it. At least thinking of a couple examples of people I know including my curmudgeon of a father will often dictate what they're willing to do and how much they're willing to engage in any kind of self-management or treatment efficacy. Yeah, I mean it's fascinating is it I mean I find that all really compelling the kind of patient benefit and the sort of benefit to management from approaching a consultation in that way and I must say the other thing I was struck by is actually it gives the GP their sort of a locus of control as well if we're feeling that you know we're this is all about access to physio whatever actually here something sort of practical and tangible that we can do. What were your thoughts Tom? Yeah, I'm just glad to hear like the phrase locus of control again because I can tell you both like it because you've heard for a piece. I remember what a very GP theory kind of type of expression is that a psychiatrist when I first heard of it a psychiatrist wrote to me and saying that she felt my patient had an external locus of control and I want to try and say I think she's say stop trying to fix all their problems and. Yes, yes, yes, I thought the way I'm terribly I think I've started saying where repair that I liked the additional bit of describe or maybe not these words but the joint is metabolically active because I think you do have this vision of a joint being this kind of. You know our Atlansky with nothing happens it's like so I like that maybe that will help to make that where repair idea stick a bit more because I feel it doesn't really go I don't know I think I need to improve my delivery. I agree with you I also thought it was a useful kind of reminder to kind of really be clear on the poor correlation between the symptoms and the x ray findings and that's a really useful piece of information we will say you know 40% or whatever percent of people. At this age will have some abnormal x ray findings and to point out you know that just because you have this doesn't mean this is where your pain is coming from because I think there's a real temptation even perhaps on our part to say look and ask you a fight that explains it. The generative change but I mean I was thinking about that term because that's quite a hard place to start a follow up consultation is you know because I like to be very. I like to give the the as much of the report as I can in the word and then try to sort of decode the wording but if you're starting with the term degenerative change. Which seems to be on every x ray that you say Jenny it's quite hard to let an uphill battle and wonder if the radiologist could do as a favor by coming up with a better term. Yeah yeah I mean it is interesting to kind of reflect on how much of a difference that language might make and what actually is being absorbed and what messages that sending to patients. I mean the point about whether radiologists could think about their reporting language I mean one of the things this should be even be even be requesting a lot of that imaging in the first place to even have had that report. Just coming back to the point about where and tear I think it does still sneak into my it's just so like in my parlance although I have tried to switch I think I've tried to switch I read an editorial a BMJ editorial earlier this year. Where they used flair and repair and thinking of you know again sort of picking up or what in my mind was saying about you know perhaps this is there is a level of sort of inflammatory process going on. Does it have to learn with where they're going? You can only have words that rhyme you can't that that's quite limiting but yeah that they're the only words that are allowed but I'm just going to read a bit of this editorial out to you that says the conclusions of this study that the paper was commenting on. Should mark the end of discussions about where and tear with patients or anyone else the where and tear model was negatively framed is inconsistent with evidence and advice on physical activity and is woefully inaccurate reinforcing expectations of inevitable decline and reduced quality of life so just to reiterate that message and I guess if there's one thing perhaps that we could all come away from this episode with its let's stop saying where where and tear. Did you think a little bit of what Imran was saying and kind of drawing on Tony Dickinson like if I was thinking and as I was listening. If I tried to explain this to a patient you know about perception and how different nerves maybe are getting it wrong and that they're kind of overreacting or being inappropriately triggered or. And you know if I was worried that it would sound to a patient like I was saying this was in their head or that not that that they were kind of making it up in a way or that it wasn't real or legitimate but maybe the future of MSK is neuromodulation. Yeah well there's a great book called pain is really strange which is a it's like a graphic novel type thing that's written for the public and it explains pain in terms of the so neural pathways and and all that stuff. I need to read it again to remind myself of what it all is but yeah we had one of those of the practice and somebody didn't bring it back but I thought that was a good one to be my tip for. But I mean that sounds like a phrase that you know I could see myself using like the start of an expression well you know pain is really strange but like you know an on from there and I think it's pain we I mean certainly for me I feel like there's a lot I don't understand about pain you know we think a lot of it is you know. One plus one equals two and it just isn't it just you know there's there's so much so many inputs that I think we don't understand. And I think I think there is value in sort of sharing that sort of with patients that you know there could be all sorts of things I don't know if it's helpful or not helpful but I think certainly this idea that you know I have pain I'm going to take a pain kilo you know we know that that's that's not how it works so I'm like I guess. Most patients know that too. Well so we've talked a lot about the sort the kind of I guess history taking approach to consultation explanations and one of the things I was really keen to discuss with Imran was also about kind of management options really and particularly if there is going to be this. If we do want to move towards more of a focus on self management and moving away from medications and a kind of medical model what is some of the things that we can offer so that's what I spoke to Imran about in the second part of the interview so why don't we take a listen. When we talked earlier you were telling me about the neuroscience and psychology which is an important part of patient experience and in presentations of osteoarthritis and pain and can we talk a little bit more about that and how we might better cover those issues in a consultation. And the problem is we have this very linear approach where and we're really time pressured so you know they come and it's like okay well I'll prescribe something because that's the easiest and quickest thing to do and you know there's all sorts of problems in terms I think how we prescribe drugs and pain and often the effect is much lower than we might hope it to be and then they come back and then okay well let's refer to physiotherapy but there's huge weight times a physiotherapy at the moment which is a big problem. Another big problem with physiotherapies. have completely different expectations of what they think physiotherapy might be. Clinicians, physiotherapists and patients, they all think it might be something different from exercise to massage, so it can be kind of useful to understand what do you think physiotherapy is and what's it going to do for you. I mean, people come back because physiotherapy didn't work, because either they didn't get many sessions, it wasn't what they expected it to be, or it's quite hard to do. A lot of people, you know, it's not easy, physiotherapy's behavior change, it's not really easy to do. So we might send them for imaging, and like I said, imaging, it's a diagnostic or at least therapeutic yield. How often will imaging change your manager? It's pretty rare. It's often just a holding thing we're doing, just because action bias won't do something, then we might try an injection. That doesn't work, so we might think, okay, well, now I'm going to refer you for procedural intervention or to secondary care. And it's kind of, I think we need to move away from that linear approach. This is fairly, let's go into this. It's not a ladder that you're just going up. It's more of just, there's a whole buffet of options that you can think about in terms of managing someone. And there's a lot we can do in terms of just whole person management and primary care, which does the research so that tends to be effective as anything else. And is that the emphasis in the new draft and ice guidance for osteoarthritis, I should say, is that it does seem to be trying to step more towards that kind of enabling self-management in patients, maybe moving away from more of the drug and imaging that we tend to go for. Can you take us through what some of that buffet of options is? Absolutely. I think this is, it's always, guideline committees always have this, in some amateur terms, trying to come up with one-size-fits-all coaches. We know there's all the inherent limitations around guidelines. But clearly, nice is doing what many institutes around the world have been trying to do is try and course correct from just a biomedical approach and make us think a bit more about other psychosocial interventions. And also try and get us moving towards an idea, particularly with persistent MSK pains, often it's about living with the pain rather than completely being able to cure it. And two of the things that the nice guidelines, particularly focused on, was this idea around weight loss and then also excise movement. And I think these are some of the areas that maybe kind of raised a few eyebrows in terms of the pressure that we are under in primary care. How can we pragmatically and practically do that? So it might be useful, just I can share some of my tips and thoughts on that. Yes, please, that'd be great. So I mean, if we start with weight loss. And this is, I think, one of the ones that a lot of people kind of thought, oh, this is quite challenging. There is some nuance to this that we know there's lots of observational data. Higher BMI does seem to increase people's risk of developing new arthritis and also perhaps doing worse with it. Going from that point of it's a risk factor, then treating weight loss in order to actually treat pain is a little bit more nuanced. We know that most people, and I'm not an expert in terms of weight loss, but this is just my my understanding of the evidence, particularly when it comes to MSK. We know that most people are trying to lose weight themselves, can usually lose about 2% in the short term. The benefit that you're going to achieve from conservative weight loss programs is relatively small. We know that if you are able to get more to that 5, 10%, which not necessarily everyone can do, the effect size of that is around 0.3, which is quite small. You're talking about a 5 to 10 point reduction in pain on 100 point scale. So that's just about the minimal clinical and poor difference that's noticeable. The patients might be able to notice. It's not even clear if that's necessarily just the weight loss. It might also be metabolic changes. It might be that as people lose weight, they become more physically active. So it's definitely something to pursue. Yeah. And from what you're saying, it sounds like they would need to lose a proportion of weight that is, you know, from studies, is quite challenging to not only lose, but then also sustain. My general perspective is, yes, it's something to bring up, but I tend to focus a bit more on getting people moving for various reasons, which I'll talk about. And just figuring out what's the person's goals? Because people with persistent joint pains or any kind of persistent MSK pain, there's lots of, you know, they can often be a loss of identity, poor sleep, loss of fitness, loss of social environment, impact on their work study. I try and figure out, look, where, how are all these aspects of your life going? And what are the goals that you want to get back? Should we talk about movement then as well? Because that seems to be like an avenue where potentially there is more that we can be doing. Absolutely. You know, I kind of think, again, I scrutinize everything in equal measure. So exercise, if you actually look at the actual average effect size of exercise, it's not a panacea. It's just, it's, there's so many reasons that we might encourage exercise more than other. If we say that we've got all these interventions, there's a reason we might gravitate towards exercise. And that's because, you know, it's very attractive that it's very safe, you know, fine, you've got a risk of maybe some injuries, but if people are doing exercise sense, but you can manage that. There's all these kind of pliotropic other benefits of exercise in terms of people's well-being, reduced disability, improving their self-efficacy, cardiovascular benefits, blood pressure, changing fat composition. There's so many reasons why it makes sense to encourage exercise. And it's, it's attractive because it's achievable. Almost everyone with the right support can't get into a bit of exercise. The actual, if you, again, if you go into the actual effect size of exercise, Bob placebo, it's probably only about five to ten points on a zero to one hundred scale, but it's not, and really, you know, you can fairly say to patients that, you know, with osteoarthritis, people who just focus on exercise, maybe with some as required pain relief, the majority by that, I mean, more than 50%. We'll do well. They'll find that their pain and function improve. And going back to what I said earlier, a lot of that may well be natural history and regression with a bit of contextual effects, but there are so many benefits of exercise. And it's such a generally safe thing to do that. It seems like a very good starting point. We know that there is a decent evidence that there's lots of beneficial effects on joints and cartilage from loading, again, while I was saying earlier that these are active joints. They respond well to activity. The whole kind of user or lose it, analogy. Same thing with the muscle. If you don't use your muscles, they'll get weak. And if you're not applying some load to your joints, they could, in a way, kind of you could describe the, the joints becoming weak or less able to tolerate load. It's really important to make people realize that activity, the right kind of activities on joints, won't make your arthritis work. And they are, it is probably going to help them in long term. If someone's willing to kind of get going with some movement, I often don't say exercise, because exercise might make people think of something really athletic that is just out of reach. Yeah, it makes me think of PE. Yeah, it turns into a bit of a chore, or something. Exactly. So it's sometimes useful just to say like some movement, some upgraded activity, just to get your body moving, get your conditions, your tissues, your tissues' restondition. And sometimes I feel it can be a bit of a chicken in egg situation, though, because patients with osteoarthritis and pain often feel unable to exercise because of their pain. And what do you tend to suggest in those situations? It's always really, really helps to give some preparatory education, the whole, let people know just because something hurts, doesn't mean that you're making it worse, doesn't mean it's harming the joint. You've got to kind of reduce some of that anticipated threat level that you might experience, because exercise, it's stress, right? It's positive stress on the joint. People's joints are much more robust than they often give them credit for. And you've got to try and help people experience that their joints can respond well. They need to be exposed to them. They need to have that experience to recognize that exercise can be a pain relief, and not just a pain cause. And I always tell people that, especially if you're getting into exercise, it might hurt. It might even be quite bad afterwards. Generally, you can, a pain of up to about three, maybe up to four out of 10 is normal, and that's okay. If you're doing more, that's probably a bit too much too soon, listen to your body, but you need to also have adequate rest. So, again, particularly people with persistent pain, understandably they're just in a constant pain state. They get really fatigued. So I often tell people, you might start with 10 minutes, the first time, and you might be wiped out for the whole day or the next day. So you need to give yourself adequate rest after exercise as well. So, when we've talked about kind of self-management, we've talked about weight loss, we talked about exercise. Where does our kind of traditional toolkit of anti-inflammatories, x-ray imaging, where does that come into the equation? Yeah, and so there's absolutely a role for the biomedical approach. I'm not saying we should complete a ban on it. It's just that by itself, it's usually not going to be enough, unfortunately. So, use all those tools and they will enable people to move more and they'll enable people to address the other areas that they might need to address in their lifestyle and diet and weight. But just be sensible. So we know, and the nice guidelines have said the same thing. So, with anti-inflammatories, see if you can start with with topicals rather than going to oral anti-inflammatories. With opioids, generally we know that opioids in the long term really, there's a lot of research now that outside of cancer pain, they're really not that effective to use particularly potent opioids in the long term. So you've got to be really careful about which patients that you use opioids and try to use them in the short term. And then of course, there's all sorts of other agents that sometimes out of desperation we might start trying to use, whether it's things like neuropathic agents or try to cycle anti-depressants and they all might have a role. Particularly when it comes to persistent pain, I normally use the rule of third. This is not accurate, but just very, very crudely. I tell people, look, when you're in persistent pain, drugs might help reduce symptoms at best by about a third, around a third of the time for around a third of patients. So they're there, use them, always, always be checking how effective are they for drugs, not working, stop it, always try and use the lowest effective dose and ramp up slowly. And just keep it under regular review, because we see so many patients who are just popping pills quite long-term, and if you ask them, it's probably not actually helping them, they just continue taking it. So that's, they all have risks, and NSAIDs probably put, I think, if I'm right, NSAIDs put more people into hospital and road traffic accidents in the UK, there's a lot of political kind of awareness of opioids. I think the opioid issue is variable depending on where you are in the UK. We probably don't have the same level of issues as North America for various systemic reasons, but there's still, there is definitely an issue of lots of patients being over-prescribed opioids of any strength, where it's probably not doing much for them. And there's also big issues with gabapentinoid prescribing as well, where not only is the effect not very substantial, but there's also issues with dependency. So drugs have a role generally try and keep them short-term, and any long-term medication keep under regular reviews, it really helping the patient, because sometimes they're on so many pills and you'll find actually, if they recognize, it's not clearly as a helping, and you can slowly get them off those medications, sometimes people feel better just by being off the plethora of drugs that they're taking. And the imaging, imaging is tricky, so I could talk endlessly about imaging. For all these speaking, there's not masses of evidence that shows that imaging in primary care will very regularly change your management, because a lot of the time, the nasty stuff, you'll often identify it from the history. X-rays, they perhaps have less potential harm because you're not going to have so many cascades from X-rays. Ultrasound and MRI, I think they do have some risks in primary care, because they're such sensitive modalities that you're going to pick up so many things that are just incidental. And if you consider kind of misdiagnosis, misreferral to surgical pathways that someone doesn't need, delayed to appropriate care, if you consider all of those things as patient harm, a lot of advanced imaging in primary care has a very, very high rate of patient harm. And like I was saying earlier, it can really change people's perception if they start being told they've got this, that, and if you look at the epidemiology, most of the things that we see on imaging, they're just normal for your age. Yeah, so when would you tend to request imaging in someone with straight forward, what sounds to you like relatively straightforward osteoarthritis? In terms of my management, it's pretty rare that I think I need imaging to know what to do, because the most people know that you want to try and get them moving, use some analogies as required, address all that, like I said, the social aspects of their lifestyle. That to me is what primary care should be doing. If patients need more than that, they need to be in a specialist setting, whether it's a community setting or a hospital setting, because it's very hard for primary care to do more than that. So again, lots I think we could potentially pick up on there. Tom, I think the message about imaging and avoiding over diagnosis will be music to your ears particularly. Yes, yeah, I do go on about that a bit much, don't I? But yeah, because you see it a lot, don't you? I feel like I see it all the time. The follow-up appointment to discuss an MRI result, which shows something unexpected, probably normal, but not something you've seen before, that kind of thing. So yeah, and I see what he's saying there about the X-rays. It's less potential for those cascades, which is true, isn't it? So yeah, no, I very much enjoyed that, yes. Indoor that message. I mean, it is interesting. I find imaging one of those things quite interesting in that, we started this episode by talking about the kind of limited array of options that we sometimes feel that we have in primary care. And imaging is one of those options. And I know certainly I don't necessarily approach every imaging request thinking, okay, these are the potential things. This is how it's going to potentially change my management. Sometimes, I mean, I'm low to admit this, but sometimes it can feel like a bit of a holding measure, or it feels like, well, the patient will be expecting this or wants this. So, and I don't really have time to get into a conversation about how this isn't really needed. And so I'm going to do it anyway. But I think just everything we've heard and spoken about in this episode, from everything from, you know, actually there are more options that we have beyond imaging and medications, but also this awareness of how these things can all subtly change a patient's pain perceptions. And actually the trajectory of their experience of, you know, their condition. I think that but has hopefully sunk in with me. But let's see. Just on the imaging there, I think it feels to me that often if I look back on what my consultations probably look like, you know, plan A is you go with this approach that Imran's suggesting and then you kind of can quickly pick up on whether that's going well or not. And I think then sometimes, you know, and then it's 10 or 15 minutes later and, you know, you kind of have to bring up the imaging. Don't you? And then they go, yes, that's what I want. And then, you know, that's what it feels to me like sometimes. There is in New Zealand, at least in the Auckland District Health Board, there's pretty active gatekeeping on radiology. So anytime a GP requests any imaging study at all, a radiologist has to review their request relative to the clinical information and relative to the clinical guideline pathways. So it was actually quite challenging to get an X-ray in the public system. And to be clear, I think that's a good thing, right? Like it is really good to have that check where you're being forced to really consider what are you looking for? How is it going to change your management? And I think it makes a lot of sense in light of some of the kind of thinking that Imran shared with us today. Yeah. I think it's important to flag. I mean, the conversation that we had with Imran and this conversation that we're having now, we are, I think we're talking about patients with what is a fairly obvious kind of osteoarthritis. Obviously, if someone has signs of, you know, an inflammatory process that perhaps does need X-ray or whatever it is or blood tests, then I think those are not the patients we're talking about. These are patients we've already assessed. And that's so interesting because I feel like what you said, Jenny, about the kind of gatekeeping to imaging. Because I feel like there was certainly more of that when I was training like 10 years ago, but it feels like the sort of imaging request pathways have changed. And there's a lot, to me, it feels like there's a lot more that is available now to the GPs. There's a line though, right? So all of the GP practices in New Zealand are private. So you're also always thinking about patient satisfaction. And if people have private insurance and they're not just covered financially from the public health system, then they can just go around you basically. In some cases or go around that radiology gatekeeping, meaning in some cases and get the X-ray anyway. So there is a balance there. You know, people who are really clear on wanting X-rays want their X-rays. The tide is, is that the right expression that the tide against us or swimming against the tide? That's the one. Because there's so much in the, I guess, media and policy level, which is about promoting better access to imaging, you know, mostly to do with cancer, but there's a, there don't seem to be many voices urging caution over that, at least in that kind of mainstream media. I really liked what Imran said about joints responding well to exercise and the kind of preemptive guidance around possible soreness or pain after exercise. And I thought your question about that was such a good one, Navjoite. I mean, you know, for people who are experiencing joint pain to think about moving, is this level of barrier that, I mean, I, I've been grateful to not have to encounter much, but I can't imagine how hard that would be to kind of go to your doctor and hear that you need to get moving and then just know what's going to make your pain worse. And I think some of that reassurance would be really helpful. Yeah, that's definitely been again, something I've taken away from that conversation which has changed my practice in just making sure that yeah, I'm not just saying, do a bit of movement, you know, there is a conversation there about how much the, how it might affect pain perception to take rest alongside it. So yeah, I found that really useful as well. Because as you say, it had always come up as a bit of a catch 22 for me, but you know, maybe it isn't so much of that. And what did you think about the, what we spoke about on weight loss? Because I found it really interesting to frame that as thinking about the kind of minimally, minimally important clinical difference that you can achieve through that, which actually is quite useful framework when thinking about, you know, where to focus your, your energies. And yeah, I found it quite compelling, you know, in my hands take that she may be thinking about moving might be a bit more sort of useful, but what did you by think? I thought that was really important and in particular because framing it as weight loss and talking only about that could lead someone to like work on their diet, for example, and not get moving at all, or to want a weight loss medication or to feel hopeless. I think that actually framing it as getting your body moving and using those joints and that your joints respond really well to that was a much more positive, potentially agency boosting approach. But I thought that was really good night, feel bad for a particular consultation where I probably stressed the importance of weight loss more than what the evidence orance. I think we've all been there, Jenny. I definitely filled it. I've done a lot of that. Also, I just feel bad for patients who, again, get caught in this catch 22 of wanting to be considered for other treatments or surgeries, but they wait prevents them from doing, you know, it just feels like there's a lot of obstacles for people where their weight is an issue, but you know, it often can be preventive in terms of accessing some some kind of healthcare. So that anything I think that is more enabling. And as you said, agency boosting. And also, I think that point about setting things in in the context of people's own goals as well. I think that's that's all a really important part of that kind of equation. Yeah. Well, I mean, there was loads, there was loads there. And as I said, I feel like I've learned a lot from speaking to in-ran. Thanks so much to in-ran, Sajid for that really extensive update. And thank you so much to my co-host. See you next time, Tom. Thanks. See you next time. And bye, Jenny. Thanks, Navjore. Bye for now. We'll be back in a fortnight with another episode. So subscribe on all major podcast apps, and that episode will be delivered directly to your phone. If you're enjoying deep breath in, please rate and review us. It really helps new listeners find us. Or you can tell your friends and colleagues about the pod too. If you've any topics that you'd like us to find out more about and discuss on the pod, then we'd love to hear. Do drop us an email at [email protected] and we'll endeavour to bring it to you. So until next time, I'm Navjore Ildar. Thanks for listening and bye for now.