Clinical Edge - 146. Knee osteoarthritis (OA) rehab. Shifting patient beliefs & narratives with Dr JP Caneiro Clinical Edge - 146. Knee osteoarthritis (OA) rehab. Shifting patient beliefs & narratives with Dr JP Caneiro

146. Knee osteoarthritis (OA) rehab. Shifting patient beliefs & narratives with Dr JP Caneiro

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David: Hi JP, how are you?

JP: I'm very well, thank you. How are you David?

David: Yeah. Great. Thanks. It's great to have you on the podcast. I've been reading a lot of your research recently and you've been putting out a ton of great stuff. It's been fantastic to see what you guys have been getting out and the info in each of your articles has been awesome.

JP: Thank you so much for having me, it's a pleasure to be a part of this.

David: Fantastic. Well, tell us a little bit about yourself. Where are you based and what do you get up to?

JP: So I'm a physio, I'm a clinician, and researcher. I work in Perth, Western Australia. I'm originally from Brazil and have been living in Perth for the last 15 years. I graduated in Brazil, did a Master's in biomechanics and decided to come to Australia to develop my clinical skills. So I came over, did the Master's at Curtin University. I did a Master's in sports. And soon after that, I started working with high-level athletes and started traveling with Rowing Australia. That was a great opportunity, and it was a really cool sport to work with rowing, because it kind of spans across the acute pain presentations to more chronic ongoing, persistent pain problems. And back pain plays a big role in the career of rowing athletes.

And that initiated my interest in pursuing my research career in that sphere. As I started working with Peter O'Sullivan and we've been working together for the last 10 years, 12 years, and we now co-direct Body Logic Physiotherapy in Perth.

We work three days in the clinic and two days at the university. So I've got a postdoc fellowship at the university where I'm part of two NHMRC projects.

So, one is a large multicenter trial for people with disabling back pain, testing cognitive functional therapy. The other side of my post-doc is part of a center of research of excellence for patients with hip and knee osteoarthritis. And a specific strain that we work at is looking for non-surgical alternatives for patients that have been offered a total joint replacement. So, that's kind of the space that I work at. So, working in the clinic with patients the majority of the time and having a position at the university to try and make sense of the literature and how to integrate that into clinical practice.

David: Awesome. I'm looking forward to exploring some of that and particularly the clinical implications of your research and how people can incorporate that into their clinical practice. So, that's going to be awesome to explore. I mean, you've got a great team surrounding you at Curtin and also at the practice there as well by the sounds of it, which is always a really nice working environment when you've got people that you've got lots of similar interests and also support that sort of thing. But coming back to Brazil, tell us about, when did you get over here from Brazil?

JP: So, it was 2005. I came over with a good friend of mine, a resident physio, Roberto, and we did the master's together and first got here and we had to learn the language to start with and save some money to do the master's. So, in 2006 we did the master's and in parallel to that, I went through the process of doing the exams to accredit my diploma in Brazil. And that was a pretty grueling experience going back to neuro, cardio and all of that.

David: I'll say.

JP: Oh man, that was tough. Then doing theoretical and practical exams. So, once I finished the master's, I passed that exam as well and I registered as a physio in Australia. It was a life changing moment because the original plan was to come over, study for a couple of years and go back to Brazil.

But I seem to have missed my flight back and it's been fantastic man. And I've been really privileged to be working along people that have always mentored me and people that, they want to see people around them growing. As you said before, I'm surrounded by, well, I'm part of a big team of people with big hearts and huge minds, much bigger than mine, that are really keen on progressing other people.

So, I feel very privileged to be working with the team at Curtin. And having mentorship is so important. There are different levels of mentorship. Some people come to your podcast for mentorship and guidance and some other people have that and have access in the clinic to someone guiding them and not only in academia, but also in clinical practice. And that's something that we strive for in the practice, is to support clinicians to develop along the way. So, one of the things that we do in the clinic is we encourage sharing patients and doing combined sessions with patients.

So, if I have a tough patient that I'm struggling with, or it's a bit complex, or it's not going where I think the patient could go, I'll do a session with Pete, or I'll have another colleague that might be struggling with a patient and I'll join in and sit in with them. And it's a very constructive scenario where we have providing feedback, but the patient is the centered goal of that session. And in that way, we share knowledge. Patients love that idea that you're kind of going beyond your expertise and asking for support. And at times those sessions are simply to reassure what you're doing. And at times it takes a slight different direction and also encourage clinicians to sit in with each other.

So, it's a great way of learning and so, we have this very community view in the clinic. It kind of does three things. It progresses each individual, helps patients, but also creates this common narrative in the practice where you might walk into the gym and you see a physio explaining something to a patient, and it just resonates the same message that you're giving to your patients. And that I think patients really value that. So, that's kind of an aspect that we take from our own journey of being mentored and guided along our journey to take that into the clinic as well.

David: Definitely. And that's great that you've got clinicians that you respect and that respect you and do you know what I mean? That you can support and provide that unique insight and independent viewpoints when you got tricky patients, that's a massive help in developing your own skills, but also like you said, really helping the patient. So, it's fantastic.

JP: Yeah. And to look at a process like the specialisation that the Australian College encourages clinicians to go to. And that was probably one of the biggest things from the specialisation process was this peer review, and just seeing patients in front of other clinicians and getting feedback and meeting roadblocks and seeing how other people work out those problems and reflecting back on how you work with those problems. And so that's probably, again, as the mentorship and that process of self-reflection on your mistakes and your achievements, I think it helps clinicians to develop themselves.

David: Absolutely. And you mentioned there about your narratives and from the sounds of it, you've got a number of different clinical interest areas, but from the sounds of your research, you're really quite interested in that sort of chronic conditions, particularly around low back pain and then hip and knee OA. When you're looking at those sort of narratives that you mentioned there before with having themes with your narratives running through what's, the education you're providing to patients, let's focus on knee OA and talk a little bit about some of those narratives, and then how we go about the practicalities of implementing that with your patients, your hip and knee OA patients and particularly knees. So, tell us about some of the key sort of themes to start with, a bit of an overview with the narratives for knee OA before we start to dive into some of the details.

JP: Sure. I think that there is an overriding narrative in musculoskeletal pain, which is this perception that the body is vulnerable and it's easy to harm. And that varies in terms of the intensity of that narrative across different body parts, but it's a very common narrative for people presenting with pain.

And this idea that when you have pain it's an accurate measure of tissue damage. So, if you hurt, it means there's something wrong. And traditionally that's how we've been trained in looking at the source of the pain and understanding how we can improve the healing of that tissue and how can we impact that process with our hands or through exercise.

And for many cases, that is probably one of the key causes of a person's pain experience. But the more we research and read about pain, especially pain that persists beyond what is expected to be a normal healing time, what we tend to see is that there are several factors that can influence a person's pain experience, and the knee is no different. The difference with the knee probably is that the biological narrative is really strong, and is something that cannot be disregarded. Not that you can disregard biology in any pain presentation, but in the knee it's quite a strong part of the narrative, because the definition of osteoarthritis is this structural change within the joint that can be associated with pain.

Can is probably the key word in that sentence, because we can have radiological features of osteoarthritis in a person with no pain or disability. They may present some movement restriction, but they can go on about their lives, they can reach their goals and they don't have a problem. How many times were you in a physio lab practicing your colleagues and you find out that someone has a hip that doesn't move as much as the other one? They never had hip pain and they go on about life.

And so you can have those changes and it may adjust your own mechanics. But as people develop changes in their structure and they have the right contextual factors, those, that joint can become painful. That biology is part of it. It's part of it in a way that in the current narrative is perceived as being a very negative thing, where if you have structural changes, therefore that joint is doomed. The only way of fixing it is replacing the joint. And the tricky part of knee osteoarthritis is that surgical procedures to fix the joint or replace the joint are in fact quite helpful.

People that go for a hip and knee replacement, 80% of people, they'll have a change in their life trajectory and they will have really good results.

I saw a patient yesterday that came in and she said, "Look, I've been told to come here and get some exercises for my knee. But my 82 year old sister, she just had a knee replacement and she wasn't able to walk and get off a chair. And now she's walking 5Ks. So, why wouldn't I do that?" So, there's quite a lot of really positive stories around the knee. So, it's a very strong narrative. You get a skin, you've got changes in the skin, your knee hurts, you can't do the things that you want. You have a surgery that is mostly successful and you get better.

So, to shift that narrative is really difficult. It's probably a little bit different to the back pain narrative, where patients come in and although many may perceive that pain equals damage, or they might just avoid doing things because it hurts, a lot of people know that surgical procedures are not as efficient in the back. The narrative of fixing the structure is not so strong in the back.

So, people come in with mixed beliefs around the back, and at times you can really shift that narrative upside down. The structural changes become a very small part of the story. Whereas in the knee or the hip, or with osteoarthritis in general, that biology might still be a strong part of the narrative. But looking from a positive perspective, structural changes can change again to a healthier joint. I think our job is to identify what are the factors in this person's physical lifestyle and social interactions and work demands that can be modified to improve the health of this joint.

So, if we look at osteoarthritis as an underlying inflammatory response of the joint structure, we can live in a very inflammatory context in lifestyle. So, we can be eating poorly, we stack on a bit of weight around your abdomen. You become less active. You're under stress of work, you're not sleeping very well. And that creates this physiological environment that is quite pro-inflammatory and can sensitise the joint structure. So, you look at that structure in his skin, it doesn't look right.

You look at that context, it looks like a very pro-inflammatory context. So, are you going to be able to change the joints? Probably not, but you're potentially able to modify that context to shift it from a pro-inflammatory context to more of an anti-inflammatory context, and build the person's capacity to meet the demands of their work or social interactions or whatever is that they want to do. And with that, you may see a shift in a person's pain experience.

Now, if we look at the physiology of the joint, we know that we can't grow cartilage, but we can change the health of the existing cartilage, right? So, we can make a joint healthier if you are putting appropriate load in that joint. If you're supporting the joint with strong and reactive muscles versus very weak and braced muscles around the sensitive joint. Or if you change someone's movement habits in a way that they are shifting load, instead of taking on load straight into that joint, you are shifting load. So, an example of that would be gait analysis of people with knee pain for instance, where, if you're over striding or if you're landing while walking or running, you're landing ahead of your center of gravity, so you have a longer stride length, your tendency is that you will land on your heel and you kind of shoot the load through your knee. And then the knee would be the first joint to take on the most of the load versus if you're landing with your foot more underneath you, under your center of gravity, and you're pushing the ground behind you, so you're engaging your ankle and your calf, and you're sharing the load between the lower leg and the knee and the hip. So, it's still the same action, it's still walking, but potentially the way you are performing that activity could be less helpful than what you could be doing. And some people may not be able to do that because they don't have the physical capacity. So, they can't actually push the ground because they don't, they wasted their calf. They'll be walking on a stiff ankle because they're protecting the knee for instance.

Perhaps part of their rehab journey is to create a bit more power in that calf, build the capacity of that muscle, so then they can change the way that they're walking. So, that's kind of an example of something where, yes, the biology is there, but the way you're using that biology is probably not very helpful from a mechanical perspective, but also there are all these other factors which are psychological in the sense of how you perceive that joint and how you're protecting that joint.

And also the lifestyle factors of the fact that you're working really hard and you don't have time to exercise or you exercise and you do one week boot camps and then you're sore and stiff for two weeks. And then you don't do anything for two or three weeks. And then you go back in and do it in the same intensity. So it's like this boom-bust loading approach that is not very helpful. And so people, when they come into the practice, they come in with this story and traditionally, we will look at the story of the knee and we go, "Right. So, where does it hurt? Okay. So, that's more tibiofemoral. This is more patellofemoral, right. How about your muscles? Are you strong enough? Are you tight? Are you stiff in the joint? Okay. Your hip and your ankle play a role in this. Great."

So, you're looking for the impairments, but how about their lifestyle? How about the context in which they live in? Do they have capacity to exercise? Are they young, free and have plenty of time to do whatever they want, or they care for sick parents and they have two or three kids and they're not sleeping and they can't exercise much? So, taking all those factors in consideration makes the management really individualised and considerate of several factors. I think that complexity of pain actually increases the clinician's capacity to work. So, we go from being able to work on a joint, to actually being able to impact change in a person's lifestyle and social interactions and assist them to achieving their goals.

David: There's so many areas within that that we can explore, but this is a really nice overview of the factors that are influencing the patient's pain experience, their beliefs, oftentimes they're coming in and they're thinking that they've got to have a knee replacement because they've got these changes on OA and your describing to them how you can change the health of the healthy cartilage and change the load that's going through the knee, as well as addressing all the other factors that are involved in their lifestyle and their stresses and that type of thing as well. So, that's a fantastic overview and with lots of details within that as well.

So, and you mentioned as well within that about, sounds like those lifestyle and beliefs are important. And before we dive into some of the biology, looking at some of those beliefs, if patients are thinking that this is a very positive outcome for having a total knee replacement, they're thinking why would I go through all this effort to change my walking style and strengthen everything when I can just go in and have surgery? How do you address those type of beliefs?

JP: Yeah, it's interesting. I guess probably a step before that is to understand people's perception in terms of why would I exercise a sore joint? And there's some beautiful work from Sam Bunzli and Ben Darlow, looking at qualitative perspectives on people with knee osteoarthritis, and also Bea De Oliveira from Curtin, she did some really cool work, quality work on people with hip OA or with persistent hip pain that presented to surgeons with a variety of clinical diagnosis. And the narrative there, is that, if we think of a framework, like the common-sense model, where it's the way that people perceive illness and in MSK probably pain presentations.

So, probably the first question is when someone presents pain is, “What is it this time? What's the identity of this problem?” In the hip and knee OA space, the perception is that it's bone on bone, right? There's not much you can do because it's bone on bone. And what caused that? What caused that is wear and tear over the years. So, it's the fact that I'm aging and my bones are deteriorating. It's the fact that I did too much sports when I was young or I did too much jumping or I run or whatever it is.

So, there's this association between using the joint and wearing the joint. That kind of puts people in this perception that, well, I can't change the past and I can't change the fact that I'm getting older. So, there's not much that I can do. So, it's this inevitable decline of the health of their knees or their joints in general. And as a consequence of that, how do you try to save that joint for the future? You stop using it, you stop exercising, you stop running, you stop walking or whatever it is. And you start protecting that joint. For some people, that may occur even in the absence of pain, because they know that with time their joints will deteriorate.

But for people that present pain, that's a very strong part of their story. And as a consequence of that, if you do have pain and you stop exercising and your knees still hurt, what is the only solution? Why would I exercise if loading my knees is going to cause more wear and tear? So, the only solution is to fix the thing, is to replace it, resurface or clean up or whatever it is. Some of the quotes in the quality work is saying, kind of I'm doing physio, but it's kind of just postponing the inevitable, right? It's not going to fix the joint. Fixing the joint is replacing it. That is kind of an average narrative of people with hip and knee OA, but each person walking through the door may have a slight different take on that.

They may say, "Look, I actually tried exercising. And every time I tried to exercise, my knee got worse." So, they may have tried to break that cycle, but they couldn't. So, that underlying perception that using the joint will make it worse, lends itself very well to thinking that replacing the joint will make it better. And in a lot of cases, it does make it better. But when we look at research, there's over 50 randomised control trials demonstrating that if you do exercise plus or minus education and weight loss, compared to not doing anything or taking a surgical approach, it's very effective to exercise a knee that has got OA. And it's very effective in reducing pain and disability.

And as such, it should be the primary thing that is offered to these patients. And you would think that given the, I think the first RCT was in 2002 I think. So it's 18 years of hammering the same evidence that people would know that. But in fact, over 40% of people that do receive a total joint replacement have never been offered guideline recommended care. They have never been offered an education program or weight loss or an exercise program. And if they have been offered an exercise program, it wasn't of the right dose. So, it was a session a week, presets of 10, not progressive, if you feel pain, just scale back.

So, it kind of just reinforces this idea that if you use it and it's sore, kind of step back, don't go forward. So, that is a problem, right? And if a person comes in and they have those beliefs and they're thinking of going for surgery, my job is not to go straight away and say, "Look, that's not what the evidence says, and you should exercise beforehand." It's probably reflecting more and saying, "So, tell me about the things you've tried so far." Because I can understand. If you think that putting weight on the joint will be painful, why the hell would you do? It makes total sense. Right? So, and they may say, "Look, I tried these exercises and it didn't work and it got sore." "Right, so when you got sore, what did you do?" "Well, I stopped them and then I tried again." So, you can see that there's on and off, right? As opposed to modify it, pain is okay, keep going. Pain is tolerable, acceptable, it doesn't interfere with your day-to-day activities the next day. I'm sorry, but that's where we're going to have to keep going. Right?

So, it's like pain is okay to feel. Now, there's research that demonstrates that a vast majority of people that start on exercise programs with hip or knee OA, have an increasing pain in the first few weeks of the program. Right? But that pain that they feel is within their acceptance, it's tolerable. And once they stop exercising, it kind of goes back to the usual achy feeling and the next day they can either do the exercise again, or they can just go on about their lives. But over time, that pain reduces and their function increases.

What we are trying to build here is that, I can't really think of a patient lately that I would say during my interview that you should exercise and not go for a knee replacement. I would raise those discrepancies in their story, I would question their beliefs and I would say, "Right, let's have a look at how you're doing this." And they might say, "I couldn't even get up from the chair because my knee hurts." I'm going, "Oh, so that's why you're putting your weight on the other leg."

"Yeah, because I don't want to cause any more damage." "So, what happens if you actually put weight on both legs equally?" And they say, "Oh, it hurts." "Okay, right. So, what about if you change the way you're doing that, and you actually engage your foot when you're getting up from the chair?" "Well, it hurts less." "Right. So, go back to the way you were doing before, with no weight on the leg." "Oh yeah. That's a bit sore." "And when you put weight on the leg, but you use your feet?" "It's pretty much the same."

"So, if you look in the mirror, which one looks more like a normal movement that you would have done if you didn't have a sore knee?" "Well, the second one." "Right. So, you're telling me that if you do this normally, you get as much pain or maybe a little less than when you avoid using the leg?" "Yeah. That's pretty much it."

So, straight away they have an experience that either reduces their pain or is the same pain. So what we're trying to do without telling them is, have a think about this. You told me that putting weight on the knee is worse for the knee. But actually when you do it, it's either better or the same. If it's the same, but it looks normal and it gives you a chance of using that leg and conditioning that leg, which one do you think your knee will like better over time?

So, you're kind of guiding people to have an experience that those behaviors may be unhelpful. So as you're doing this through your examination, when it gets to the end you say, "So, what do you think about this idea that using the leg is worse for it?" And they may say, "Well, I can see how there is sense in it. But today we used the leg and actually I'm feeling better or I'm feeling it's not any worse, but my leg feels tired." So, and you look in the mirror and your leg is not very strong. "So, do you think that'll be smart of you going ahead and having a surgery with these habits and not having a very strong leg?"

So, if it's someone that is really stuck with the idea that they need surgery, and they're just ticking that prehab box, you roll with that and you say, "Look, you've got prehab for the next six weeks. So, let's see how you go." Halfway through that or at the end of that, they may be questioning themselves if they need it. And some people, they still need it and they're happy to go, but they're going in a much better position. There is evidence as well of people that went through a prehab program, they're pulled off wait lists and they went through this program of going, "Look, your joint is damaged. You're going to fix it anyway. Why don't you just exercise and see what happens?"

I think it was 76% of those people went on to forego the surgery at the end of it. And you look at an exercise program like [inaudible] for instance, that will be two years down the track, a big chunk of people are still foregoing surgery. For those that, I think it was [inaudible] who published a paper in 2015, where he compared doing a prehab program, an exercise program, versus going straight to surgery. And the outcomes after having surgery of the group that had the prehab was actually a better outcome.

You don't need to shift people away from wanting to do surgery. You present them with the facts, you take them through that journey and then they make their decision. And if they want, they say, "Look, I'm okay for now. I'm not going to go for surgery. I'll see you in a year and see how it goes." The least that we've done is we made that leg more capable. They might be able to do more. They have less pain and they have a healthier joint, plus or minus lifestyle. And that has to be beneficial in case they go forward to have surgery.

David: So, you're saying they're engaging their foot and their pain's about the same and they're standing up and it looks more normal. Then, if they have a belief that pain is equal to damage or they're thinking, well, yeah the pain is about the same, but I'm actually putting weight on it and that's going to be doing more damage to my knee. How do you identify those and then sort of how do you address it, when, as you're going through that process?

JP: I guess it's the experience that they have in the session. If they tell you it's getting sore as I put weight on this joint…I had a lady yesterday that she has been avoiding using that leg for a couple of years, because she was walking most days 5Ks. And she was okay. So she had pain, but she was okay. She had to go into isolation because of COVID, and she stopped walking, and then her pain increased. And she couldn't really see the fact that she stopped and that's what led to her pain increasing. In addition to that, over the couple of months of isolation, she'd put on five kilos, she wasn't having any social interactions. So, there was a lot of other factors that influenced that pain presentation as well.

So, for her, it was, "I've done my time of exercise and now the only solution is if I replace my knee." She had a lot of trouble getting out of the chair. When she was trying to get out of the chair, despite all of the changes that I was trying to offer her, she was getting quite a bit of pain. So, she had a highly sensitised joint. I could barely touch her joint line and she was very sensitive. And she had a heightened pain response across the whole leg. It was like her nervous system was really warmed up.

I didn't keep trying to force her to use her leg. I took a different approach, and I said, "Look, we're going to have to take a different approach here and try to exercise that leg in a way that is not provocative. She’s got a stationary bike at home and she goes, "No, I haven't even thought about doing that." So, I took her to the gym, got her on the bike and did very light resistance and just kept moving that knee. And after doing that, getting up and down the chair with her usual strategy was less painful. That to her was quite powerful. She said, "Look, I would never dream of trying to do the bike, because it puts weight in the joint. My muscles feel they're working. But it actually feels better when I'm doing this." So, she's going to go home with a sit to stand that forces it to normalise that behavior. She went home with a little graduated program of jumping on the bike on a daily basis a couple of times a day for short periods. I think that will be the in to her system, where she's doing something and she's improving the health of that joint.

That's an example of someone that I couldn't really modify the behavior, but I could provide her with an activity that will be good for that joint, and I gave her some exercises that made her leg work really hard and were not provocative for the knee. What we need to do then is instead of trying to change the behavior straight away, is to find a way where we can make them use that leg, build up the capacity, reduce the sensitivity, and then work on the behaviors. That's probably how I would deal with that. And the worst thing that could happen is if I put in my head that I need to change the way that that person is doing a task and we just butt heads in the session. That cannot happen, because she's going to become defensive. It's like I'm trying to find a single solution for that patient.

Whereas what we have to do is to adapt and say, "Look, this will be good for you, but not right now." So, maybe I will be targeting those behaviors, maybe she comes back next week and she goes, "Well, my knee feels freer and it feels better." And she might herself be getting up differently or she might just wouldn't expect get a flare up in that knee. Because interestingly, at the end of the session she was saying, "So, can I go for a walk? Can I try going for a walk? Would that be bad for my knee?" And I'm going, "What's the worst that could happen if you went for a walk?" And she goes, "Well, my knee's going to get sore." "Entirely up to you."

So, it's okay. I wouldn't recommend you go for your 5K walk because you haven't done it in three months now. And she goes, "Oh, but if I just went to the shops?" I'm going, "Yeah. Go for your life." So, it was interesting that by the end of the session, having had that experience, it gave her a perception that maybe she could do a little more. And I think that's the power of getting someone to reflect and taking them through an experience, where it's guided and they have to think basically, and it challenges their beliefs and what they're doing.

David: And was she afraid of getting on the bike or did you have to sell that to her in some way? Or how did you approach that, her getting on the bike to start to desensitise that area?

JP: Well, she said, "Look, I'm not sure if this is a good idea because I haven't done it in a while. In the past when I did it, I would last only a couple of minutes and it would get really sore." And I said, "Look, you'd be surprised of how people sit on a bike. So, that may be the way you're doing this that might not be a very helpful. Do you mind if I have a look?" She goes, "Oh, okay. Sitting on a bike is just sitting on a bike, isn't it?" So, she sat on the bike and she was sitting on that bike taking the weight off one butt cheek, sitting really upright and pedaling with her feet fixed.

I'm going, "Look in the mirror. Does that look like a comfortable way of riding a bike?" So, I sat on the bike next to her and I go, "How do I look?" And she goes, "You look lazy on the bike." I'm going, "Yeah. I'm relaxed. And I'm using my legs, I'm not using my whole body." And so that was an experience where she had to go, "Right, so maybe that's not the way." So it's okay for me to sit here and relax. So she put the weight on the seat, she relaxed a bit her posture and she started. I said, "Use your feet when you're pedaling, because that loosens up your ankle." And she goes, "Oh yeah, that feels less strenuous."

And I wasn't then looking for, how is your pain? Is your pain reducing? Is your pain increasing? So, how does it feel? Does it feel good? Does it feel comfortable? Do you feel safe doing this? How would you feel if we did this for five minutes? And she goes, "Ah, I don't know." And then we got talking, at the end of six minutes, she goes, "I can really feel the burn in my thighs." I say, "How is your knee?" And she goes, "Well, it's okay. It's no different." "So, what does that tell you?"

"Well, it tells me that if I do it this way, maybe it's okay." She goes, "Oh, we have to see it tomorrow." I'm going, "Your knee is no different. Your thighs are sore. Which bit of your leg do you think will be sore tomorrow?" She goes, "Well, my thighs." "Yeah, very likely. And if your knee's a bit sore, it's normal because you haven't done anything like this." And then make it really clear that we're not telling people to just push through pain. No pain, no gain, that's not the idea. The idea is to understand that changes in symptoms, they can occur and it's normal for that to happen, given the context. And as long as that doesn't interfere with your day-to-day activities, it doesn't progressively get worse. It's okay.

And if that does happen, then I want you to send me an email and if you are unsure of what to do, we'll have a chat before our next session. It's pushing, but being there to support. That's the way you tend to see this behavior experience within the session.

David: So, you were there encouraging her to just give it a go, just sit there to start with was kind of your way in, from the sounds of it. And then just getting her to reflect on how she was doing it and finding a strategy that felt comfortable and talking through it as you went.

JP: Probably an important aspect is, if I reflect on my earlier days as a clinician, maybe I would have taken that person to the bike and I would be using a language that is like, "Let's just give it a try, see what happens. If that doesn't work, we can do something else." So, it's almost like I'm preempting that it might not work, versus what I tend to do is, "You've done it in the past, right? But that's different. We've just tried using your knee and you bend your knee and you straighten it and it actually felt good when you're moving it versus keeping it straight. So, what is the likelihood of doing this? There's no weight here." So, it's like questioning and guiding with confidence. "I want to look at how you're sitting here and see if the way you're doing this is helpful or it's unhelpful."

People, I think they feel confident that you're not just trying and seeing what happened, you're guiding them towards something that you have confidence that it's probably going to be helpful for them. And as she's going and feeling okay, you can give some experiences of patients that, saying, "Look, knees love to be moved. They love to be moved with some resistance. That really engages the muscles."

One of the things that, you said when you're sitting there that your knee was really stiff, do you know what lubricates the knee? And she goes, "I don't know." "Okay, well, movement lubricates the knee, because it creates more water within the joints. And even though the shift of water within the cartilage makes the cartilage more healthy." So, you kind of go back to the biology, and especially with patients that are really stuck with that idea of the joint, if we think of the biology of the cartilage, what happens over time is that the ability of the proteoglycans to bind to water reduces, right?

So, when you get a load in the joint, water is kind of dissipated from the joint. If it's a healthy joint, the water gets reabsorbed and the joint builds up again. So, that's how the cartilage kind of accommodates load. Over time or with a joint that is more, that's got significant structure changes, their ability to bind and reabsorb water is reduced. So, one of the things that we know is that movement increases that capacity.

So, that's one of the things we were talking about before in terms of increasing the health of the joint. You're providing a strategy that can make that environment healthier.

David: And so she went home having felt a thigh burn and her knees coped okay and she was finding it easy to get in and out of the chair. How'd you go about talking about the next day, did she ask about how she was going to be feeling the next day? You mentioned that, where do you feel it now? And she's like in her thighs, and you mentioned that she's likely to feel it. Was there any other sort of discussion about the next day and sort of post-treatment sort of effects or any of that type of thing?

JP: Not specifically with her because she was kind of settled when we talked about, when I challenged her that way and I gave her a way out. I said, "We've got an appointment in a week. Here's my email address." That's one of the things we tend to do is I wanted her to read some good credible information about knee osteoarthritis. So, I gave her a link to have a read of that. So I sent her, at the end of the session, I wrote an email and I said, "Here's the link of what I'd like you to have a read, feel free to respond to this email either with feedback questions or if you have any concerns."

So, that gives the patient a way out in between appointments, so they don't have to suffer for the whole week. If they are getting worse, they can contact you and you might give them a phone call or bring them in earlier. But one of the things that I did say to her is, "Don't get discouraged if you have some pain in your knee. It's normal and what we need to find, and we're going to have to work together here. We need to find what is the right dose for you at this stage, given that you haven't put any load through that knee or any exercise load through that knee for basically three months."

And that's when she came up and said, "Look, I put on about five kilos over the last three months. And that's because I haven't been walking." I said, "Did you change your diet as well?" And she goes, "Yeah. I'm just sitting around at home, I'm eating a bit more stuff that I shouldn't." "So, is that something you could work on and change that?

Do you understand the link between carrying on extra weight, especially that is rapidly put over the last couple of months and inflammation?" And she goes, "No, I know that being heavier puts more weight in your knees."

I said, "Well, that's one factor. But the other factor is that we know that the fat content that you hold, especially around your waistline is highly inflammatory. It's a metabolic response. If you lose a bit of weight and you change that physiology, it may be less inflammatory. And then I linked back to the examination where I said, "Look, I'm barely touching your joint and it's quite sensitive. We do a few things and you're quite irritable in that joint." And that was probably the other thing that was strong for her, that when I was trying to get her to do stuff with the knee, she was guarded, she was protective and she was highly sensitive. And on the bike, once she relaxed and she was just cycling away and talking to me, she wasn't guarded anymore.

So, I used that as a comparator and I said, "So, it doesn't look like you're guarding your knee, and you're telling me that it's not making it any worse. So, actually using your knee when it's not guarded, it feels better." Giving those insights and these are key messages that I'll be writing in her management plan. And the management plan probably will be a diagram demonstrating the factors that influence her pain experience, how she's responding to that, the effects of that response, and then the things that we did in the session that targets some of those factors and how she responded in the new way.

And then looking at things like diet and for her sleep as well, in which she could make some changes herself and how that would be helpful. And the link that I gave to her speaks about these confluence of factors influencing someone's pain experience. So, it's almost like the message that I'm giving the patient is then reinforced by a text that they read at their own time and they're not being bombarded with information in a session. So, she's got cognitive knowledge, she's got experience in the session, and then she can think about that. They are the things that I'll be questioning in the following session. David: Excellent. And I'd love to get, we might even put it in the show notes some of the links to some of the resources that you might send to patients to get them to read. We sort of think that if we can have some resources that clinicians can send to their patients after, I think that's a pretty handy thing to, like you say, incorporate those cognitive elements. It sounds like you're fairly strong on having an experience within the treatment session to build their confidence and to address a whole lot of those sort of psychosocial elements.

JP: Yeah. There's some study around the fear literature that if you'd simply try to tell someone to do something that they are concerned about, you don't tend to get a change in their behavior. You might get a change in their knowledge and their conscious response. So, if you ask them, is pain equals damage, they might tell you it's not because they learned that it's not. But when they have to do the task that they're concerned about, then that belief may be different.

I saw another patient that I saw yesterday. He was the first follow-up. I saw him for the first time last week, really fit guy, 52 years old, does CrossFit, really strong and developed back pain over the years. He used to be a cyclist and developed pain, then stopped cycling, went to the gym, was going okay, developed pain in the back and then kind of gradually stopped exercising and started just exercising the upper body and his back just got worse.

So, reduction of exercise or just upper body exercise made him feel worse. And when I questioned him around his beliefs, he told me straight up that he wasn't fearful of using his back. He goes, "I'm not fearful. I'm doing all this stuff. I know that pain doesn't mean that my back is damaged. I don't think like that." When I was taking him through an examination, everything was fine until I asked him to bend over and pick something up from the floor. It was only a two-kilo weight. Straight away he kind of stopped and his breathing changed. I said, "Does that concern you?" And he goes, "Yeah. Because I know that that's the thing that's going to set me off for the next few days."

When he was exposed to something that is threatening to him, his response was different. And then I said, "What do you think is going to happen when you get this flare up?" And he goes, "I don't know.

I think I'm damaging my back more." So, the very belief that he'd told me explicitly that wasn't something that he thought about, it came up. It's like a core belief that emerges when you are exposed to the task that worries you. In his case, then it was using that to challenge that belief and looking at how he does it and what is his body reaction?

It is the body-mind relationship when you are doing something that you're concerned about. If you're trying to do something and you anticipate that it's going to be painful, you anticipate that you're going to be in trouble, then your body responds in relation to that. Now is that modifiable? That's part of the job to try and change that. David: It's interesting to see the conflict between the beliefs when you're talking about it and when you're actually doing it. So, how did you address that with your patient there where he was fearful? And I know we're drifting off knee OA, but it's quite an interesting topic to explore. So how did you talk through what was going on with him and address those with him?

JP: Well, we're not drifting off that much. Because he had been told he had OA in his back. So, he had the generation of his back. In principle was similar to what I described before, but with him was, "We've done a few tasks so far and you've been fine. Now, I'll ask you to pick this up. What do you feel in your body when I ask you to pick that up? You're not going to pick it up right now, but in a second we're going to pick it up. So, how does it feel for you? What do you notice in your body?"

And he goes, "Well, I'm kind of tensing up a bit." "So, can you pick up and show me how you do it?" He did it and I said, "What did you notice when you're doing that? Were you breathing?" He goes, "Oh, I guess not." And then he tried again and he goes, "Oh, I'm tensing my belly." "Do you feel any weight in your legs? Are you using your legs when you're doing that?" And he goes, "No, my weight is around my core and my back."

I said, "So, what are you doing with your core?" And he goes, "Well, I learned that I need to engage my core to do so." So, I asked him before about if he actively engages his belly and he said he doesn't. When he had to do it, it happened. And he goes, "Right. So, that's what I'm doing. So, what should I do?" And then with him, we used an example that we tend to use it quite commonly like, “Imagine you have a sore wrist. If you move a wrist like this versus clenching your fist and trying to move it, which one do you think will feel better in that wrist?” He goes, "Well, probably the first one." And I go, "So, if you look in the mirror, which one are you doing? You're kind of bracing and you're worried about it. So you're pre-tensed and then you're using your belly to bend. And so, how does that feel in your back?" "Well, it's pressure and it's uncomfortable."

And so, I suggested strategies and said, "How about we kind of take a bit more weight into your legs and how about we breathe as we're doing this, and don't tense your core. Shift your weight as you're bending down." He did that and the first time that he did it, he goes, "Oh, that was painful but I tensed my belly." So, his struggle was to relax his belly and then it became really clear to him. He goes, "I'm really struggling with this, of relaxing my belly." I guided him but he took over the process because he was cognitively curious about that fact that he couldn't relax it. And so, he was trying to relax it and when he managed to relax, he goes, "Actually it feels better."

And he did four, five, six and then he felt pain and he goes, "I tensed up again." And then he kept going. And then that repetition of doing the very task that he was concerned about, it was reinforcing that if he did it in a different way, it didn't have the same negative outcome. And that's kind of the principle of exposure, where you put someone to do a task, they anticipate an outcome, which is usually catastrophic around the back or the knee. And then they are taken through that experience and they actually don't have that negative outcome. So if we talk about safe memory and fear memory, so your fear memory is quite big, and if you do that repetition once, that's your safe memory. It's very small, but if you keep repeating it, keep repeating it, keep repeating it, even in a session, now you have a safe memory that is almost as big as the fear memory.

And then, you tell the patient to go home and integrate that habit. So, in the first session that we did, his biggest exercise, he was taken through some strategies to help him relax before he exercised, then he had to basically rehearse through every time he was picking something up, putting his shoes on. That was probably the biggest thing is in the morning, putting his socks and shoes on, putting his jocks on. So, I used that as the exercise. Every time you're doing this, you're going to have to do it in the new way. And if you feel pain, it's a reminder that you should try and change it. And so that was the habit, and integrating to daily life means that you are trying, and you're not getting the negative outcome. You're building this safe memory to the point where the safe memory is quite much bigger than the fear memory. And it becomes like, "Well, I've done this a thousand times and it hasn't happened."

So, it's almost like you're squishing that fear memory. The interesting thing though, is that if we look at the fear literature, especially phobia, but also fear of pain, the fear of memory never goes away. If you're fearful of spiders, you'll never forget fearful of spiders. You will never like spiders. But your safe memory, if the treatment was successful, is much bigger. So, the chances of this resurging are smaller, because this is getting bigger and bigger. But you don't forget about it.

So, what does that mean? It means that a couple of weeks or in three months or whenever, when he probably will have a flare up, because it's very common to happen, that memory, it's going to resurge. And with that memory comes the behaviors, comes the beliefs, then it's like this whole pain schema resurges and that's where it's really important to be there for the patient. If they come in or they contact you via email, you can see that these old beliefs come back and you can see the bracing coming back and you can see the avoidance of the leg coming back. And then you've got to work through those through a very similar process, but now they already develop that safe memory, so it's a bit easier to tap into that.

Then they had this flare up and they managed to create this association again. So it's like you had the resurgence of the fear, but you squished it with a new memory and you go, "Oh yeah, that's what I have to do. I have to relax my belly and use my legs, et cetera, and bend over this way," and integrate today.. [inaudible], then the next flare up, the tendency is that the fear memory doesn't resurge with such intensity because people will start developing this strategy where they can control themselves.

And I think for persistent pain conditions, such as osteoarthritis, back pain, neck pain, it's really important that the pain flare ups are used as a learning opportunity because that helps patients to develop an ability to self-manage. So, they start recognising triggers. They start recognising their responses and what they have to do. So, nobody found yet a cure for back pain or knee OA and probably there won't be a cure for it… or maybe in the future, who knows? But there are ways of managing the condition, and just symptom relief and impairment based therapies don't give people ability to self-manage. Whereas, if they learn how to manage flare ups, it means that if you track them over a few years, they still have episodes of back pain, but they might not be seeking care as often. They might not be taking time off work. They might not be distressed. They might not be disengaging from social work and physical activities. So, you're kind of minimising the impact that pain can have in someone's life.

David: On that note of flare ups, when there's kind of the short term, if we're looking at the patient on that initial session and they haven't had a chance to build up that repertoire or the amount of memories of performing it safely and not having a flare up, how do you go about finding that level of what they can do in that first session? So say, let's take that guy for instance, when he had trouble lifting that two-kilo weight, or had to believe he wasn't contracting his core when he's doing it. And then he felt that he actually was when he went to perform the task right. So, then you were like, "Okay, relax your core. You're doing it, take your weight into the legs," and it sounds like those were some of your key cues you used with him.

So, let's just imagine that he did it five times and then he started to flare up or he had a flare up the next day or whatever. So, we have another chance to build up that memory. How do you go about finding that right level to build those safe memories?

JP: That's a tricky question and I think that's the tricky position that clinicians get put in, as you know yourself. Probably my take on that, if it was flaring up in the session, given that in this particular case was the fact that he couldn't relax, then probably I will dial down the exposure, get him relaxed again, expose him again to the same task if he had completely relaxed or something similar to that. Now, it's important to kind of finish the session in a strong note. You don't want to flare up the patient and say, "See you later, and we'll fix it next week." It's not going to work.

So, some people, you just got to be mindful of that. And I had patients that had a flare up and I can think of a lady that had significant apprehension for a patellofemoral dislocation, massive traumatic history, mental and physical. She was going okay and then in a session, when I asked her to do some one-legged tasks, and then she was a bit fatigued and I pushed her and she had this big flare up. She had this perception that her kneecap was going to dislocate. She freaked out, almost had a panic attack.

My response to that wasn't like, "Oh shit, what do I do now?" It was more like, "Okay, this is the time where we have to settle," because this will happen outside. So, I calmed her down, brought the attention back to things that she could take control of. So, back to the breathing, regulating the breathing, calming, weight bearing on two legs, getting and shifting the weight to that leg and went back to the very task that gave her the flare up, and repeated several times without the flare up. I said to her, "I want to hear from you either tonight or tomorrow, and I want you to tell me what was that experience like for you?"

And she sent me an email saying that it was a very frightening experience, but she was very glad that we went back to it because that helped her to feel like she developed control over it, as opposed to going, "Right, let's just call it a session," and then the patient leaves frightened. Because it's almost like, "Yeah, I really can't do this." That was a successful story, but it doesn't always happen like that.

You might got a patient that might have a flare up at home. But I think that keeping that contact via email, being accessible to the patient, especially the patients that you know that are vulnerable, and at times you might not be able to get someone to bend and lift and twist in the first session, and you might have to dial down and take them more gradually because they're steps behind.

Whereas someone else you might go, "You start with two kilos and you finish with 15 kilos in the session." There was a lady the other day who goes, I was seeing her for hip pain. And she was doing well, it was the fourth session. She said, "Look, I'm doing really well. I don't think we need to continue this." And I said, "Right, so is there anything you're avoiding?" And she goes, "No, I'm doing everything. I'm going upstairs. I'm walking, I'm going back to Pilates and I'm riding my bike." I was like, "Anything you're avoiding?" She goes, "I'm just not silly. I'm not trying to lift my grandkids."

I'm going, "Okay. How important is it for you to lift your grandkids?" And she goes, "Very important." "So, can you get by life without lifting your grandkids?" She goes, "No, I miss it." I'm going, "Right. So is that something you need to be able to do?" She goes, "Yeah, that's something I need to be able to do." Right. So, the rest of the session, we were doing lots of lifting. Her granddaughter was 15 kilos, so by the end of the session, she was lifting 15 kilos of weight repetitively to embrace a habit of doing it in a way that she felt confident. And now part of her management was to go and pick up her granddaughter and develop that confidence. And then I saw her for a couple of more times to manage how she responded to that.

But, I guess what I'm trying to say is the management approach is not only… or it shifted from finding impairments and giving exercises to fix those impairments, to looking at what are the person's goals, and demands of those goals. Are they capable of meeting that? And developing strategies to help them achieve those goals.

And a lot of times, the exercises the patients are given, they actually are a mechanism to build a new habit of how to lift the granddaughter for instance, or they are exercises to build capacity or they exercise the very habit. It might be tying their shoelaces, it might be sweeping the floor. It might be using the vacuum cleaner, and confronting those activities with a new behavior. And that helps them integrating those tasks into daily life.

If a patient comes back to me and say, because I tend to ask them at the end of the session, "When you go home, what would you tell your wife or your partner, or what are the takeaway messages from today?" If they tell me that they've just been given a bunch of exercises, then I'll have to make them reflect on the session and reinforce some of the ideas. Because if they leave the session thinking they just got to do three sets of 10 of sits to stands to fix their problem when they actually have a bunch of other factors, then I've failed in transmitting that message. And if they say, "Look, you told me that my problem is this. I might feel some pain. There's lots of things that I need to change. I need to change my diet, I need to go to bed earlier, I need to get more active and you gave me some exercise to support me in that way."

"Yeah, that's it. So, that's correct." So, kind of checking if the session went to the same direction as you thought it went, to see if your beliefs align in terms of the session. So, I think that's quite important for learning as well.

David: It's really important too, as you mentioned there, to recap, find out if the patient is taking on those key messages and throughout the session, it sounds like you're helping them to experience new ways of moving. You're building up their feelings, that they can perform that movement safely and you're addressing their particular goals, like finding out if the patient can lift their grandkids, and then specifically addressing those goals within your treatment session. So, when they come away from that treatment session, they are feeling confident to go about and have strategies to go about improving their ability to do it.

JP: That's right. Look, there are cases where I remember a younger lady, she was 48. She had hip pain. She had tried some exercise, but not consistently. Had this idea that when she felt pain, she should stop exercising. And so when I saw her, she had movement restriction. So, I've taken her through a graduated exercise program. She made some changes in her lifestyle, but she didn't have any other major things to change. She had a good diet, she was on her weight and she was trying to be active. She had quite a lot of mind pain, the restriction in the hip didn't shift and there was restriction to flexion and rotation. It was really impacting on her ability to actually putting her clothes on. As she exercised, she just wasn't getting better.

She tried for six months in doing that and she ended up having, she decided to go for a hip replacement at a fairly young age. But you look at her history, she had Perthes growing up. So, she had significant structural changes from a young age. She had a trauma to that knee growing up. So, she had an ACL tear, wasn't reconstructed. So, she carried a lot of deficiencies in that leg that led to significant changes in the hip. And she was struggling, she was limping. So, it was almost like you would offer them good dose of exercise. And she went through a pretty good program of twice a week of exercising in the clinic and then another two times at home and cycling. But at the end of the day, her function didn't really change and she was struggling with pain and she had the hip replacement and she did really well. And interestingly, once she had the hip replacement, then to strengthen her knee and to build the stability of the knee was easier because she could engage the leg more, she was more active, she was sleeping at night. So you got to look at each case and see what happens. And I just think we can't settle for someone that comes in and say, "Oh yeah, I tried exercise. It didn't work for me." Go, "Well, what exercise actually works?" And the other thing is there's some research demonstrating from Michelle Dowsey and Peter Choong at University of Melbourne, looking at some predictors of poor outcome after surgery. And if you go in to have a hip replacement and you don't have significant changes on your structure of your knee or hip, right?

So your X-ray doesn't look that bad. And you have factors such as social isolation or depression, your mental health is not great. You're overweight and you're inactive. They're not very good predictors that you'll respond well to surgery. So, having those factors and going for surgery, the tendency is that you may still present pain afterwards. It varies between 10 to 25% of people that go for a knee replacement for instance, that may not have a positive outcome. Whereas if you lost some weight, you got yourself active, you engaged in physical activities, your mental health is on check and if you have a crappy looking scan, so if your structural changes are quite significant, you're more likely to have a positive response.

So, it's not clear cut when I talk about those predictors, but looking at people that went through and looking at the factors that were related to their outcome, these are some of the factors that we tend to look at. And that may help clinicians with making that decision. So, when I saw this lady, she's really young, she shouldn't have a hip replacement. But when you look at the scan, there was some significant changes with physical restrictions that did not change to exercise, and she had good mental health, good social support and good lifestyle and she was active.

Despite all of that, the only thing she hadn't tried is an adequate dose of exercise. And she went through that for six months, didn't get better. And she was actually progressively getting more discomfort at night. So, she was a good candidate for it and she did well. Probably two key messages that are really important to come across when we talk about OA, one is that biology is important, is relevant. And we can't say that, "Oh yeah, it's all psychosocial," and forget about the structure. Because it's not the case for everyone. And for a lot of people, the structure plays a role.

And the second aspect is, our job is not to shift everyone for surgery. Our job is to get people to have conservative care or surgery at an appropriate time. If you're going down the pathway of surgery, try to get guideline recommended care, which is exercise, weight loss and education.

Actually, prior to all of that, understanding the condition, understanding the triggers, understanding the modifiable factors that influence someone's pain experience, going through an exercise program that is adequate and then making a decision at the end of that. But it's a shared process where you inform the patient, "We go through a journey and then we make a decision as we are going along." And I think we have to be quite good at adapting by the way.

David: Excellent. And there's so much, so many great takeaway messages from within what you've just shared. You wrapped it up really nicely there. And I think we had a lot that I'd keen to cover, but I think there's so much in one podcast here that I think that'd be a great place to leave it, but I would love to get you back on the podcast and have a chat about some of those other areas, like common presentations and questions that people can ask, and the subjective and objective tests and well, those type of things would be great to cover as well.

But I think this podcast has contained so many great take home messages for people that I think that'd be a fantastic place to wrap it up. So, are you interested in coming back on JP and having a chat again about it?

JP: Absolutely man, it would be a pleasure.

David: Excellent. All right. Well that really wraps it up nicely, those take home messages. Anything else you want to add before we ...

JP: I guess the biggest take home is to listen to the patient, try to understand how they understand their condition and make sense of their behaviors and see if there are factors that can be modified. See if their behaviors can be modified and empower them to self-management. I think that's the biggest thing with patients with persistent pain conditions. David: Perfect. And where can people find out more about yourself, are you on Twitter?

JP: Yeah, I'm on Twitter, @JP Caneiro. So that's C-A-N-E-I-R-O; On the website; and at Curtin University. I guess you'll put my email on the show notes if you like, and I'll be happy to answer any further questions. So, they're probably the three key places.

David: Fantastic. And you're also recently been releasing a podcast from the clinic there. So, tell us what's that podcast and where can people find that one?

JP: All right. So Body Logic is creating a podcast, which is run by Kevin Wernli and Peter O'Sullivan and myself. So, three clinician-researchers, our goal is to translate science to patient community, but also to clinicians. So, we're trying to present important messages that are translated to both sides of the story, and also give patients a voice as well, to share their concerns and try to address some of those key questions. So, the name of the podcast is Empowered Beyond Pain, and you can find that at

David: Great. And that's on iTunes and Spotify and all those places as well?

JP: Yeah, all the common places, as well at Empowered Beyond Pain.

David: That's on Twitter as well?

JP: Yes.

David: Excellent. Thanks JP, everyone jump on Twitter and let JP know what you liked about these podcasts and we'll be getting JP on to have more of a chat about knee OA because he's got tons to share obviously. So JP, thank you very much for coming on the podcast and sharing all that with everyone. We really appreciate it.

JP: Thank you so much for the opportunity David and congrats on this initiative. It's been running for a number of years and it's reaching a lot of people with some really good knowledge.

David: Awesome. Thanks very much.

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