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

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

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David: Hey, JP, how are you?

JP: I'm good, David, thank you so much for having me. David: Thanks for coming on. I really enjoyed our chat last time, all about OA knees and there was so much that I wanted to explore with you that, last time we got into some really practical stuff and exploring how you go about changing the narratives for patients and helping them to understand what's going on in their body and strategies that they can use to change and that you use with your patients. So there was so much that we got to explore, which was awesome, but there was a tonne more that I thought would be fun to get on here and have a chat to you about.

JP: That sounds great. I loved our chat last time. It was really cool.

David: Nice, but first I want to take you back and I want to ask you about growing up in Brazil. What are your favourite memories from growing up in Brazil?

JP: Oh, there's so many. I think the first thing that I think of is family and friends. I came to Australia when I was 25. So the friendships that you build at that age are a bit different to what you build growing up and I have a good group of friends since the age of four. So you've got some really good memories. Look, Brazil, it's a beautiful country. It's got a really cool culture. It's a very alive country. It's music and dance and it's great. And the food is very different and we have across the different states, like in Australia, it's quite similar. There are some words that you may say differently in Queensland or New South Wales versus Perth, but in Brazil, every state has same language, but the accent is quite different, so it's very distinct. So there are lots of jokes around the different places that you're from.

Everything's a bit different across Brazil. I'm from the southern region of Brazil. We like to think that we are a really cool state, but of course the city is called Porto Alegre, happy port, but Rio De Janeiro and Sao Paulo of course are the big capitals and they get a lot of attention. So I've got fond memories of Brazil, but also it's a country that is very divided in terms of its economy and opportunities. So you might be walking down a suburb, on one side of the street, you have super expensive golf course and people drive Mercedes and on the other side of the suburb, you have people begging on the streets. So the divide is really confronting and you grow up with that and you don't realise it until you come to a place like Perth where you barely see someone on the streets and everything is pretty similar. And unless you go to the less affluent suburbs. Safety is probably one of the big things that I don't miss from Brazil. We tend to live in Brazil and feel like it's fine. Everyone talks that Brazil is not safe and actually when you live here and you go back, you realise that you have to think a lot more about your actions when you're walking on the street and things like that. So I don't miss that side. I miss the culture. I miss the happiness of the people. And it's just a different lifestyle.

David: Any stories that spring to mind from when you were growing up, that you fondly think back of when you think of Brazil?

JP: Stories, ah, I've got a few. I don't have a very good one that comes to mind.

David: Maybe about your family or any of those sort of things that give people a bit of a feeling for what it's like growing up in a family in Brazil and what sort of normal day to day life is like.

JP: It was Sundays on my grandmother's house. That's a very common thing. Brazilians are very close to their family. You may say that we might be a little bit lazy in terms of how long it takes us to leave our parents' home. But that was one of the things that really caught my attention when I came to Australia is that you turn 18, 19 and you get out of the house and you share an apartment and in Brazil, that's not very common. We tend to stay at home for longer. So that connection with your parents is quite strong and family is quite strong.

Reminds me of my aunt when she was probably 18, 19, I was really young and she was bringing a boyfriend home and my grandmother had prepared this dinner and she asked everything that the guy liked and the guy didn't like eating fish. So that's exactly what my grandmother cooked for him and just peppered him with questions and it was a really funny dinner, but the guy was feeling a bit under attack and she loved him. It was great, but that was just my grandmother's style.

David: That's awesome.

JP: That connection. I grew up spending a lot of time with her and my grandfather. So they're really strong memories that I have. And in the summer, my mom's got a brother and a sister and all the cousins will get together and spend summer at grandmother's house. And we did that across our entire life. So actually that's when my wife's parents met my grandmother. We went back for her 90th. That is probably one of the best parties I've been to in my life. And I've got this great photo of my grandmother. She's turning 90 and it's 01:30 in the morning and she's like dancing on the dance floor with this red dress. It was awesome.

And actually I had that picture in my room at the clinic and when I had some 50 year old, 60 year old saying, oh, I can't move my arms, it's bad for you to move. And I'm going look at this picture, look at the timestamp. This lady is 90 and she's moving her arms and I bet she's got a rotator cuff tear. Age is not an excuse. But yeah, there you go. That's the memory that's sprang to mind. David: Perfect and I love it. I love it. And I love that you get to use that even in your day to day life and you get to look back and then relate that to patients. That's awesome.

JP: Yeah. That's right.

David: Great story. What a legend. Ninety and still dancing, just getting down on the dance floor.

JP: She was good, man. She was good. I hope I got some of those genes.

David: That's right. Appreciate you sharing that story with us and it's nice to understand, to be able to connect with yourself, because a lot of these forces sort of shape us and what we do in the clinic and how we approach patients and all that sort of stuff. The way you've been able to tie in your background and that importance of family and then tie it into.

JP: Absolutely. Absolutely.

David: It's a nice connection. So we'll have a bit of a chat about Knee OA and you mentioned there that when people are getting older and they often think that, ah, I shouldn't lift my arms up or do whatever it is because I'm worried about hurting my body. There's a lot of myths and misconceptions around knee OA. And so tell us about some of those you commonly address or talk to your patients about.

JP: So probably one of the greatest misconceptions is that the more you use it, the worse you'll get and that affects your daily life and immediately tells your nervous system that you need to protect that body part. So this idea that you've got a degenerative disease that is getting worse, no matter what, there is nothing you can do about it, the more you use it, the more it degenerates. So it's a very logical and plausible explanation that if you explain to anyone on the street, they would understand that. And because of that, it's a very sticky narrative. It's like the whole idea of, why is my back sore? Because your joint is out of place. So what do I do about it? I'll manip your back? And I'll put the joint back in place. Yeah. Great. Give me 10 of those. It's a very easy narrative to follow, but we know that's not the case.

So there is this very negative understanding about knee OA where it's inevitable that you're going to go down the pathway of needing a knee replacement and that there's nothing you can do about it and exercising or using the knee actually makes it worse. And there's quite a bit of research demonstrating that using the joint is actually good for the joint and this idea that we should be thinking of the health of the knee and the health of the person, as opposed to the disease that is in the knee joint.

If we think about this underlying inflammatory response that you have in the subchondral bone, which kind of drives the disease of osteoarthritis, we have to think broadly as to what are the factors that can impact an inflammatory response. And some of the big factors are anything that affect your nervous system. So your immune system is linked to that. What is linked to that? So your sleep, your activity levels, your stress levels, your diet, how much weight you carry, how you carry that weight. So some evidence to say that if you carry your weight around your abdominals, you tend to carry more of a fat content that is highly metabolic and has as a consequence high, strongly inflammatory response.

Immediately with those factors, you can tell that it's not just about strengthening the quadriceps, and it's not just about protecting the joint. It's about what can I do to improve my health and reduce this inflammatory response and take some control over this and reduce the sensitivity of the joint. And I think it's really important to make it clear that I'm not dismissing the biology that is changing in that knee, but it's important to understand that we can make that environment a healthier environment, and you can make that joint be more resilient and more tolerant to the demands of your daily life or to your job or whatever you need to do.

So it's not a dismissal of the bio and just say, ah, don't worry about it. Everyone's got some degeneration just work on your sleep, stress and weight, and you'll be fine, because it's not like that. And some people they're sleeping well, they're eating well, they're not carrying any extra weight and they're trying to exercise and they've got a very sore knee. So that's another challenge, but it's important to, for us as clinicians to have a look at all those factors and say, hey, how is your health? Are you creating the best environment for this joint? When you look that environment, it includes these factors that I mentioned, it includes how you carry that body part. Are you actually protecting it? And if someone is protecting that joint, I'm not just interested in changing it. I want to understand why you're protecting it. What is the belief underlying that behaviour?

It's very common that it's related to the fact that you don't want to cause more damage in the joint, a large proportion of the patients that I ask the question, what do you think that makes the cartilage and the bone healthier? And they say, oh, I don't know. They don't have much of an idea. And I say, how about movement and graduated loading and having a trajectory that builds the capacity of that bone and that cartilage to tolerate load? And they go, but I thought that actually loading the joint was worse for it. Everyone knows that running is bad for your knee. That's another strong misconception there using that joint repetitively, you will make it worse. So I think that this idea that using the body when it's painful, equates to more damage to their body parts underpins the current narrative of knee osteoarthritis.

David: Beautiful. So you're basically looking to identify within each individual patient, if there are some of those factors or which factors are influencing their pain experience, whether they do have any of those factors, you mentioned like their sleep, their health, their diet, whether they've got abdominal fat or whether they've got stress associated, they're avoiding it. And you are looking to identify the ones that are relevant for that patient. So you can address that throughout their treatment. Is that right?

JP: Yes. Correct. And the patient's story is really important. Because I don't go into an interview to simply look for those factors and identify that three out of five are the key problems and I've got a little recipe to deal with them. I go into to listen to that story and go, why is your knee sore now and it wasn't three months ago or six months ago? What's the difference? What's changed? And that line of questioning or the idea of curiosity, that's the word I'm looking for, gets the patient to reflect on their own story.

They usually say, oh, nothing's changed. I'm doing everything the same. And you go, right, so tell me what was happening in your life over the last six months, many patients are taken aback by that question and you give them a bit of background and you say, just give me an idea. I don't know how you live your life. Just tell me. And suddenly some of the things start to appear and it may be the logistics of the household. We've got a puppy and now I need to sleep downstairs. So when I sleep downstairs, I can't go for my run in the morning, so I stopped or I can't go for my walk, whatever it is that they do. So I actually haven't done that walk for the last two or three months.

So you immediately see that they've got less capacity and now they want to recover that and they increase their load. So that might be that all the other factors are fine. They might not be sleeping right because of the puppy, but they reduce their capacity. And now they're trying to get it back and the knee's not coping. Oh, but that wasn't a problem in the past. Well, but now it became sensitive. And I don't try to completely understand as to why it got sensitive, but it is sensitive. And now we have to deal with it. And the tricky thing is that once it becomes sensitive, you go down the track of you're going to see a medical practitioner, you might see a GP, a physio, and you get an X-ray and depending on your age group, you will show changes in the knee and that can drive the pathway immediately. That's the danger I reckon. Because depending on your age bracket, like if you're over 50, you present osteoarthritic changes in your knee, especially if it's on one knee compared to the other, there's a high chance that you will be told that, look, you can try some physio or you can do some exercise, but you're just going to be going for a knee replacement in the future.

And those words, it's like a sentence. Just say, you will need this, it doesn't matter what you do. It can become quite an obstacle for that person to move forward. It's like you've been given a diagnosis that your knee is stuck. It's just getting more stuck over time. The only way of fixing it is by replacing it. So a lot of people can fall on that track and some people go, no, I don't own that. It might be in the future, but it's not now, what can I do about it? And they may be ready to engage in other forms of rehab. And I guess that's, if we go back to that underpinning belief that using the joint makes it worse, then you might go to a practitioner and they say, you might need surgery in the future. Now what do you need to do is to exercise your knee to make it stronger and they're going, but if I use it makes it worse. Why would I exercise it? So it doesn't make a lot of sense.

It's degenerating, you replace it. That makes sense. It's degenerating and you use it to make it stronger. It doesn't make a lot of sense. And often patients will try. And I saw a lady yesterday, she said, look, I've tried physio in the past and I've done a bunch of exercises and it just doesn't work for me. And I'm only here because my daughter saw you and she had a chat with you. And she said, you said some things that might be helpful. So I looked at the exercise that she's done. They're all knee-driven exercises. So she was doing hamstrings and quadriceps and really trying to load up the joint and after a couple of days, she was really sore. So she wasn't capable of doing those things yet, but you get her on a bike and she's got a stationary bike at home.

So I got her on a bike and I increased the resistance and there was no complaint. She didn't have pain doing that. And she's going, I quite like doing this, that's the way I used to exercise and I don't understand how this is good. So for her, it was an explanation of, she was really attached to the idea that the joint is degenerating. She's being given some really in depth explanation of what happens with the bone and the bone deteriorates and the cartilage tears apart and was pretty horror story. And I said, right, it's all of that, but now imagine that my hand is your cartilage, and then you lost a bit of cartilage here. You still have this bit. So what are going to about this bit? Are you going to let this bit take all the load and be a unhealthy part of your cartilage? So do you know what's going to make this bit better? It's if you use it.

So cycling, for instance, you're using it repetitively, it's low load. You are repeating that action and cartilage, they love that repetitive cyclic movement and actually nourishes this. So what we need to do is not to worry much about that, because we can't do much about that, but we can make this one a little healthier and we can make this one more tolerable to accepting load. If you think about the story around tendinopathy, why are physios so confident to make someone with tendinopathy exercise, despite pain? You look at someone like Jill Cook and Craig Purdam, they push this message really strongly and now Ebonie Rio is doing that and they build this confidence in the physios of going, hey, it's okay to load the tendon.

And what's the story? You've got a healthy tendon and then you've got a tendon that has a hole. You can have a hole or you can have some tear, whatever it is. It's not the same tendon. They don't worry about this bit. They worry about this bit. Isn't that the whole story? You make the rest of the tendon, the healthy part of the tendon, healthier and stronger and more resilient. And I see cartilage in a similar way. Cartilage doesn't have the same properties of the tendon, so I'm not trying to compare apples with pears, but the story in a way, it's similar that if you don't use that part of the cartilage and if you're protect it and you don't move it, you won't be nourished. You'll be dry, you'll be stiff. And when you load it, it's more likely to suffer breakdown. Whereas if it's under load in a graduated manner and it's not getting pissed off every time you load it actually becomes healthier.

And we got to remember, this idea now that when we talk about a way that is not just about the bone and the cartilage, it's about the whole joint structure, the synovial lining of your capsule. It's your ligaments. It's the whole story. So if I'm loading this and I'm moving that joint, the synovial response of that joint will be healthier. So actually movement nourishes the joint. And one of the things the movement does, it increases the capacity of the proteoglycans in the cartilage to bind to water. And once they bind to water, it means you've got more shock absorption. So that's kind of the chemistry behind it.

I wouldn't go into that depth with patients, but for her, it was just saying, don't worry so much about the bit that we can't do much about it. Let's worry about the bit that we can. And that was the start for her and her whole exercise program was getting on the bike on a daily basis. And I said to her, this is your Panadol. You were taking a Panadol a day, you're going to take a bike a day. Nonnegotiable, you got to do it. I said, the worst that is going to happen, you're going to come back here, you're going to tell me your knee is sore. But it's sore anyway, so let's see how we go.

So I didn't give her a bunch of stuff. I'll see how she goes. But if we compare that to doing a bunch of knee extensions, knee flexions, and single leg squats on that leg, what I gave her is way less provocative and probably will achieve more in the short term, well, in the long term, and then I can start adding other exercises that will strengthen her legs. I agree with the other physios, she does need a lot more quadricep strength, but she can get a bit of that if she can use them without provoking the knee. It's that old story of, I want to exercise a body part and then you make it sore and then inhibits the muscle and you keep chasing your tail. Whereas if you do something that is a bit less provocative, you can build up some conditioning.

David: It's a great way to get her to buy into the program. She's experiencing that when she gets on the bike, that she can actually perform the exercise, doesn't stir up her knee pain. And it actually, like you say, it works like Panadol for her to calm it down and get that nourishment to the rest of the cartilage that needs it and that can benefit from it. Really focusing on that part, the part that you can help to improve within the joint. It's a nice way to get her really involved and engaged in that exercise program.

JP: Yeah, and interesting thing too, is that once I got her on the bike, she started asking all these questions. Isn't it true that, if you do stuff like this, or if you go for walks that it's worse for your knee? And I said, so why do you think that? Oh, because you're putting weight on the joint. And I'm going well, but you need to get used to that. You used to go for walks and you're not walking any longer. So you got really de-conditioned. When I looked at her walking, she was walking with a really stiff foot, which is a very common response if you want to protect your knee. So you don't want to bend and straighten your knee. So you fix the knee, you end up fixing your foot. You don't push up very much. So it's a bit exaggerated, it can lead to a limp.

And I said to her, that's not the right mechanics. It's like you're bracing your knee every time you put weight on it. So what do you think is going to happen? You're pre-loading it and then you put weight on it. And she goes, wow, that's going to put more weight on the knee, more load on the knee. I'm going, yeah, it's like putting a target in your knee. All the load will go straight there. But if you're using your foot, if you're taking a bit more of a relaxed walk, if you're relaxing the muscles around your leg, then your body weight won't create the same load around the joint. And that is something that she would need to work on.

So I said to her, it's not just about the tasks about how you do it. And it makes sense that if you are concerned about doing it and you're protecting it, they will do in a way that you feel like you're protecting it, but actually may be provocative. And that's part of our job in our objective examination to determine if what you're doing is helpful or unhelpful.

David: Great. I'd love to have a chat to you about the objective pretty shortly. You brought out some really good questions that within this objective that helped to identify some of those health factors and some great follow ups. And I like that follow up when you asked your patient, why do you think you've got it now? All patients go, oh, I don't know. You used that follow up question of finding out, tell me about your life and what's going on so I can understand. That's a great follow up question to get those details that are really going to help to clarify the situation for you. So are there any other questions within your subjective that really help you to identify some of those health factors or some of those other factors that are going to impact your treatment?

JP: I often ask about the different ways of asking, but one of the ways that springs to mind is I want to get an idea of what it is to live your life or wearing your shoes. What would my day look like? And they'll say, oh, I wake up at five and I do this and I do that and I go for my walk and then I go to work and then I come back and I come home and usually I stay on my phone until late hours of the night and then I go to bed and then I struggle to sleep. Immediately I'm getting all this information. I'm going, so is that a snapshot of your week or is that a regular day then on the weekends? Ah, yeah, usually I catch up with my mates on a Friday and I get drunk and I don't do anything on Saturday morning.

I'm getting all this information from a simple question of, just tell me about what it is to be you, because I'm interested in that. Because if I know what you do, then I know what are the demands that you need to meet. If you go, look JP, I just sit in my office all day, clicking away and then I walk home and that's it. So you don't have great demands in your body. That may be the problem, because you're not using your body as much. Or you might be someone that rides to work and it takes you an hour to get to work and you ride back and you go to the gym at lunchtime and you go running at night or you go on the weekend, you like to hike. Okay that's a different story. Or your job is to go up and down scaffolding every day. They have way greater demands. Then how do we meet those demands? Are you capable of meeting those demands or are you too sensitised and you can't do it?

It gives me an idea. So the idea of improving someone's health and improving someone's knee health, the principle may be the same, but how you achieve that will vary depending on the person's demands and goals and what they want to do. So if their goal is to run a half marathon, be a very different demand to the lady who just wants to go for half an hour walk every morning. So that idea of tell me about your lifestyle, what do you like to do? What are the things you like doing?

The other question too, is if you didn't have this knee pain, what would you be doing differently? And that question can often unleash their true self. They just go, oh, if I didn't have this knee pain, I'll be running every morning. I'll be running three times a week for half an hour. I'll be hiking with my mates or I'll be playing with my kids and I'll be playing footy again, and you just get this whole different perspective of the person that just told you that they would be happy to just go for a walk every day and you go, right, so that's what you're telling me in your current situation. Can you see yourself out of the situation? And perhaps for patients that have a more persistent history of knee pain and here we don't need to think only about knee OA, we can just think of someone that rocks up with pain for a long time is asking the question, do you remember how it felt to walk or to run or to do whatever without this knee pain? Can you close your eyes and feel in your body, how it was when you didn't have this problem?

That can be quite a nice experience for patients because they use the terminology, they usually can see that in the objective. They say, I was freer. I was faster. I saw a guy last Friday, it was back pain, but he said, oh man, when I didn't have this pain, I was free flowing. I would just like, I'll look at videos of myself and I could see it was effortless and I felt effortless. And I saw a video of myself the other day and I looked like freaking Robocop, trying to play tennis. I'm super stiff, super slow. And when I got him moving, he was exactly that. And for him, there was a big loss of identity because he goes, that's not me. And this is a young guy. He's like 35 and he's a firefighter.

So it's really important. When I look at myself back.. I could save anyone from a house on fire. Whereas now my brain is thinking, am I able to do this? And I can't have someone's life depending on how I feel about my body. That's really profound. And that came from the question, how it was to be in your body without this pain. And how would you feel if you woke up tomorrow and you didn't have it? What would be different? So that's not for every patient they'd be asking that question, but for some patients tapping into how he was and how he would feel, it can give you a really good insight about their relationship of their emotions with their body and the perception of capability in the future or how they were capable and how they're not.

And a lot of things come out. I saw another lady yesterday who said, before this happened, I never thought of my age and she's 53 and she goes, and now I feel like I'm 65. Everything that I do, I just feel older, slower and grayer. So there, the language that she used was gold, very negative, but it was gold in the sense of it expressed her mood. It expressed how she feels about herself. It expressed her confidence and expressed exactly how she moved. Tentatively, guarded, slow, not committed to the movement, overthinking it. Then you take all of that into your objective. And for her, it was, can you pick up that pen off the floor? Can you lift your shoe? She's a nurse. Can you show me how you would transfer a patient from the bed to the chair? She spent almost a minute preparing herself to do that.

The interesting thing with her is that she didn't have pain anymore, but she was frightened of having that pain again and frightened of causing more damage. I look at her body chart, she had back and leg pain. She came in and she goes, that's when I had pain. I don't have it anymore, but I know it's there because I didn't fix it. I'm going, what do you mean? And she goes, it's only been time and me getting back to my life and taking a high dose of turmeric that changed it. I didn't have the surgery. I was told to have the surgery, but I didn't. So I know I haven't fixed it. So right there, she's telling you, she's thinking about the structure of the body and she's protecting it. And she's frightened of going back to where she was.

Now we talk about this biopsychosocial model and at times there is this idea that you can get a bit too psychosocial and you can get a bit too bio. Honestly, I don't see it that way. You have to see it all and in her case she wasn't highly stressed, she wasn't highly anxious, she wasn't depressed. Well, it was affecting her mood about herself and this feelings of ageing and she was frightened. That was the big factor for her. But if you talk to her and I didn't ask those questions, she was absolutely fine. So the psyche of her story is this fear of going back there. Is this perception that she's aged and it expresses in her behaviour of protecting herself and slowing down and doing all of that. It all came down to a misconception that that's how you should behave with your back or I'll give you different examples, but it's the same story.

David: It is. And they're great stories that demonstrate that point and the different way you can word questions to get that information that really does help you. And that was a really interesting story. Coming back to the firefighter who felt like he was like Robocop and pretty stiff in how he was moving and he didn't have that freedom and was worried about whether he could do his job and carry people out of a burning fire and that type of thing. So you've identified some really important factors for him. How did you then use that information in your assessment and your treatment and all those sort of things? How did that help you there?

JP: I got him to demonstrate some of the key things that he struggles with. They were far from being lifting a person from a burning fire. It was picking up his shoes and it was undoing his shoes actually, undoing his shoe laces and taking his pants off, putting shorts on. So they're really basic strategies. And I said to him, so when you're doing these things, do you feel the same? Do you feel like you changed? And he goes, oh yeah, my wife mentioned to me that I'm grunting, that I'm protecting myself.. and he goes, I don't notice anymore, but I hate it. That's not who I am. So I said, what do you notice in your body when you're doing that? He goes, what do you mean? Just do it again. Put do your shoes on, take your shoes off. What do you notice in your body?

First thing he said, I'm not breathing. I'm holding my breath. Okay. So do you think you should be holding your breath? And he goes, no, I'm just putting my shoes on. Okay, what else do you notice? And he did it like six or seven times. And then he said, oh, I'm really bracing my stomach. So I'm here talking to you. And he said that he wasn't bracing, but he was already bracing. Then he said, I go to move and the first thing that I do is I brace and I hold my breath. So I saw that, but I didn't tell him that. I ask him, what do you notice? Because at the end of the day, David, that guy is going to go home and he needs to change that. It's not me telling him how he change... Well, I guide him how he changes, but if he notices and he can change himself, then we are changing his day to day habits.

And then I said to him, so what do you think that does? You've got a sore back and you're tensing your belly, and I palpated his back when he did that. I said, how does it feel in your back? And he goes, wow, it feels pretty hard. Do you know what I'm pushing on? And he goes, oh my spine. And I go, no, this is your spine, is it sore? And it was sensitive, but not very sensitive. And then I went to his paraspinals and he goes, oh yeah, that's quite sensitive. And going, so this is your muscle. He goes, it's bloody hard. Yeah, but if you relax your belly and you breathe into your belly, how does it feel now? And the palpation changed. He wasn't as sensitive and he wasn't as tense. So that gave him two things. One was actually, when you push on my spine, it's not that bad. When you push on my muscle, it's quite sore and he was jumpy.

The other thing that happened was that once he relaxed his belly, he wasn't as tense or sore. So you change the sensitivity by changing your behaviour. That is controllable. So he's going, well, so my back is not as bad as I thought and actually what I'm doing is not helpful. And I ask him, What does that make you think that I push here and it's sore and hard and you relax your belly and it's not as sore, not as hard. He goes, oh, that tensing my belly is not good for me. Great. That's the message. Then I go, right, so how about we try to get your shoes on and off without bracing your belly? And then he was frightened of doing that. And he goes, no, I can't do that.

Why can't you do that? Because I feel vulnerable. Why do you feel vulnerable? Because I don't have a strong core to be able to do it and I feel like my spine is going to bend in the wrong place. His strategy was lift his chest while he's trying to bend down. So I put the mirror on him going, look at that. What do you reckon? Does that look normal? Your shoes are down there and you lift your chest to the ceiling. Doesn't look very efficient, right? He goes, how would you do it? I'm going, how about this? So I demonstrate it. Put my head down, chest down, went for my shoes. He goes, yeah, but your back is rounded. So in doing, in observing these beliefs are coming out. I had a hunch he wasn't very keen on bending his back. And a lot of the rehab that he's done was around keeping a neutral spine, building his core, feeling strong. And this whole idea that my glutes don't activate. If my glutes don't activate, that stresses my back.

So he is doing a bunch of glute exercises and trying to keep his back. So the belief that flexing his back was bad for his back came on when he watched me rounding my back and I said, I understand where you're coming from. Why don't you try it? So relaxing his belly and relaxing his head, allowed him to bend forward. And then he came up and said, how was that? He goes, that wasn't too bad. So do it again. Do it again. Do it again. Do it again. Then you can see that his cogs are turning, because this doesn't make sense. This is not how you're supposed to move and that part I think is really cool. I didn't tell him about that I didn't challenge his beliefs on ergonomics or actually I didn't challenge until right the end, about the exercise that he was doing at the minute. And I didn't challenge any of that. I just collected the information, got him through an experience and asked him to reflect on it.

So he is thinking. He is doing all the thinking. People may be listening to this and going, well, that would take too long. You can't do that. But in fact it fast tracks a lot. This guy didn't have any leg pain. It wasn't warranted for me to do a neurological examination on him. He had pain, but he could touch his toes. He was slow and guarded well, not touch his toes, but could go in the direction of his toes. You saw his back. So it's not like I need to be doing a straight leg raise and doing a slump and...

So there's a lot of stuff that I got the information from getting him to do his daily tasks. So I'm gaining time on that. At the end of the objective, I asked him, what do you think you need to do? And he goes, ah, this may sound stupid, but I think I need to relax my body. And the way that I've been moving is not helpful. I'm going, what do you think of that? He goes, well, it sounds a bit stupid, because I'm doing it to myself. I'm going, no, you can't think that. The habit. I feel like I got to be careful that you're not judging someone's behaviour. So when I got him doing those things, I had a hunch of what was going to happen, but I wasn't trying to box him in a little box of relax your belly, do this, do that.

Because you can fall into a trap. He might be doing that. And I'm going, actually you're really sensitive. You're doing that because it's bloody sore and you don't have another strategy and relaxing it doesn't make it any better. So then I'll have to adapt and change it and that's what I think is the cool thing about the profession. Someone walks in the door, they say, they've got back pain and you go, whew, what's going to happen here today? I don't know. Or they've got knee OA or whatever it is, you're in for a challenge. And a lot of the story repeats itself. But the way you get there is different.

At the end, this guy was asking me, he goes, oh, but what about my glutes? Do you think they activate properly? And then I got him doing some, just some squats, touching his fingertips on the floor and looking between his legs with no weights, but just going down all the way down and coming up and I said, just do a few of those and I'll answer that question for you. And after doing 12 repetitions or so, and I said, so what do you feel in your legs? He goes, I feel my thighs and funny enough, I feel my bum, like my bum's worked. And I said, so is that similar to what you feel when you do your exercises? And he goes, yeah, but I have to do a lot of them. So he was doing like clams and single leg bridges and crab walks. And he said, why do you think my bum is working? I'm going, well, because you put yourself in a position that you don't give them an option. They have to work and they have to work because your back is not working. But if your back is working, your bum doesn't have to work as much.

And to be honest, David, my point wasn't to make his glutes work. My point was to make him understand that he could use his legs, get down and up without having to tense his trunk voluntarily. And the outcome of that was that he felt freer and he was moving faster as he was doing it. So I filmed him before on his phone and I filmed him after and I said, what's the difference? He goes, oh, it's easier. And I said, so which one looks like you before this whole problem? He goes, the second one. So which one do you think you need to be moving forward with? He goes, the second one. So it's making the person realise. But the big thing that made him realise was the experience and my guidance during that process. There was no point in which I educated him. I just gave him snippets of knowledge of going, do you know what happens if you bend forward and you clench your belly? He goes, no, this is what happens in your back. So you just give some knowledge to move the person forward.

Of course, if they get stuck and they ask for an explanation, then you give them the explanation. But it wasn't like I went through an assessment to identify all these impairments and held all the information to myself, went through my reasoning, set him down, educated him about pain and then educated about all the things that he needs to fix. It was like live, as it's happening, we are reflecting, questioning, thinking about it, doing it differently. So his big job this week was to work on his habits to notice what he was doing. And if he was doing something with tension, notice, if that was sensitive in his back, can I change my habit? Can I do it differently and try to look for comfortable positions and moving comfortably and closer to his natural pace rather than guarding himself. It's like take the hand break off. That was his first job basically.

And every patient I'll ask what are your goals? What are the things you want to achieve? And at the end of the session, I ask him, I want you to write down, what would you like to achieve in the next month or a couple of months? What do you see as the obstacles? And that's what we're going to work on the next time. It frames the session and the journey to the patient. I explained to him, I said, look, this is a journey. The journey will end when you are achieving your goals and you're living your life to what you want to do.

And of course you may have really long term goals and you may have short term goals. My job here is to help you identify these obstacles and guide you in how to do that. And along the way, you're very likely to have flareups. And we welcome those flareups. They're not great, but we welcome them because they will be a massive learning opportunity for you. When you have a flareup, all your beliefs, all your negative chatter and the bad stuff comes up again, the habits come up again and you protect the body part and you question everything that you're doing. And that's an opportunity for you to go and say, can we modify what's happening now? Why did you have the flareup? Let's look at the context and then you help the person through that process, they get out of it and then they go on and they may have another flareup.

We actually got to give you a plug here. We actually got to have a podcast with a patient. He was doing really well for two years. And then he had a massive flareup. And then he talks about that experience and he talks about how quickly he came out of it and what he learned about it. Flareups are a really interesting part of our job. And I can think of myself as a young clinician, that in my mind was, if I gave you the right treatment, you shouldn't get pain again. That was my naive way of thinking. And when a patient had a flareup, I automatically questioned the plan that we had and completely forgot that the patient had been doing really well up until that point. So there was something right. And whereas now I look at it and I'm going, this is not great, but it's a great learning opportunity. So what can we do about it? How can we change it? That was a conversation that we had. And that would be a very similar conversation to patients with knee OA, hip OA, shoulder pain, neck pain, whatever. David: Absolutely. And you've really nicely adapted your assessment based on the issues that he was having trouble with or how he was feeling like he was moving when he was doing up his shoes or the movements that were important to him. And so when you're looking at your knee OA patients, for instance, obviously you're going to adapt that based on the issues that the patient's reporting to you. If they're having trouble walking, like you mentioned before, and you're looking for whether they've got a stiff knee, stiff foot, those type of things, or the movements that they're having trouble with. Are there any other aspects that will tend to stay within your regular objective assessment for knee OA, that you'd perform on most knee OA patients?

JP: So I think it's really important to say that the behavioural assessment is a strong part of it. And then there is a thorough more standard assessment, which will be palpation, palpation of the joint, palpation of the muscles and identifying area of pain. There's lots of patients that get offered a total knee replacement, and they've got patellofemoral pain. It's not their actual knee joint. It's their patellofemoral joint. So area of pain is really important, palpation of area of pain, range of motion in the knee. Can you actually flex this knee fully? Can you extend this knee fully? Do you have any restriction in this knee? Is this restriction because you're guarding your knee or is it actual limitation? That you can't fully extend the knee depending on the history of the patient. Do you have laxity in this knee that is quite significant laxity?

And because of that, you don't feel like you have a lot of control and that's why you stiffen this leg. So these would be like, if I'm assessing a knee, I want to have a good understanding of, do you have good mobility in your hips? Do you have good mobility in your ankle? But I usually would contextualise that assessment based on the person's needs or difficulties. I can't go downstairs. Why can't you go downstairs? Which is a very common, functional problem for patients. What is it that you have trouble going downstairs? I don't feel safe or my knee gives way. And then you look at the behaviour and then you might look at the way they do it. They might have some stiffness or they might have a lot of guarding around their knee. So the examination of the body part that is sensitive, it's always done. The patient with back pain, I would lay them down or palpate their back, but it doesn't mean that I'm going to go through all my accessory movements and my physiological movements and there's a place for that, but you vary it with patients.

I saw a fellow with knee pain and he had general knee pain was like, he couldn't really pinpoint it. And he had been offered a total knee replacement. He was a story of significant changing weight, poor sleep and drastic reduction in exercise and actually he had a minor, like a sprain. He was going downstairs and he slipped and the knee kind of hyper-extended. Wasn't massively traumatic, but it felt like it was a bite in his knee. Just hyper-extended it, felt sharpish at the front and then made his knee become sensitised then because of that, he stopped exercise, because when he tried to exercise immediately afterwards, it was painful.

Then the pain wouldn't settle, he popped some Panadol, didn't settle, went to see the GP, got an X-ray. He's 62 or 63 and had OA in his knee. I saw him like four months down the track. And when I examined his tibiofemoral joint, he didn't have sensitivity on palpation. He was sensitive under his kneecap when he tried to extend his knee. So under load, his kneecap was sensitised, or if he was going downstairs, his kneecap was sensitised. So he developed some sensitivity around the kneecap, but not around the tibiofemoral joint. And for him, the reason why his story comes to mind is that I asked him, what do you think is going to happen with the surgery? What do you think they do? He's pointing to his tibiofemoral joint and he's going, oh, they take this part here, they take the rubbish cartilage out and they put some nice titanium plate there. And then that joint becomes a brand new joint. It's like a bionic knee.

I'm going great. Okay, so when I went to palpate that joint, that they're going to replace it wasn't sore. So how does it work? This is not sore to touch and you got to replace it. Doesn't make sense. He goes, no, but surely this will be sore. I'm going well, it's not like I was really palpating his joint and he wasn't sore. Then when I saw him going up and downstairs, his pain was behind his kneecap. By palpating the joint line of the kneecap was sore, but not the tibiofemoral joint. So for him, that specific palpation was really important to challenge his understanding of the problem, of the concept. Right at the end, he's going, I still can't believe that wasn't sore. He goes, oh, I'm going to do these exercise, I'll bet you, this will get sore. So I go, well, we'll see. And it wasn't. His tibiofemoral joint didn't become sore, because he had a kneecap problem and it was a sensitive kneecap and he lost a lot of conditioning and to protect his knee, he was walking with a slight knee flexion, because he hyper-extended, initially. So he was, he didn't want to get there. So he kept his knee in slight flexion, which loads your knee cap massively.

So actually, I don't know if I was dealing with just a consequence of him walking like that and that's why his knee cap was sore, but at the end of the day, it doesn't matter. The usual assessment is still present, but I'm not going in to gather information. I don't rely entirely on that to find impairments. So let's say I did this whole assessment and I saw him walking with a slight knee bent, going upstairs really slowly placing his whole foot on the step and coming downstairs sideways with his foot. These are the key findings. And then I go and examine him and I wouldn't be relying on, is your kneecap stiff or not? It probably is stiff. You're walking on a bent knee. So being stiff or not wouldn't make a difference for him. Whereas I'm going, yeah, you can bend and straighten your knee. It looks like you're a bit stiff here, but you can do it. When you do it actively and in a braced way, it's sore. Then when you do it more relaxed and you're sore around your kneecap. You've got good hip mobility, so let's go back to your behavioural tasks and see what we can change here.

And for him was like, okay, when you're walking, why are you walking with your bent knee? And when you're stopping, why you taking the weight off that leg and keeping that knee bent. So it's sore, but you keep it on the load. And then going upstairs, he was going really slowly and going, is that how you used to do it? And he goes, no, I think I used to go a little bit quicker. So let's try that. Instead of you stepping with your whole foot, why don't you step with the front of your foot? And you just go a bit more dynamic and that actually felt a bit better because he's engaging his foot, engaging his calves, taking the pressure of the knee. I'm quite strong about assessing behaviour and seeing if it's modifiable, but you got to make sense of it during your examination, like your standard examination.

David: Perfect. And really nice way of tying those together, too, and helping him to understand that if he was going to get that knee replacement, that it wasn't going to be actually replacing the part that were actually painful or nociceptive. So that's really nice, and if people are listening and they're thinking, yeah, I've got some patients like this and they're wondering about palpation tips that you could give them to help to identify these sort of patients that maybe are more tibiofemoral based or patellofemoral. Tell us about some of those things. You've palpated on him and tell us about where you've palpated, how you've palpated that helped to guide that and help that patient to have that experience.

JP: I try to be quite systematic when I do these for patients. And I tend to tell patients, look, and if you do it yourself, like you palpate your tibiofemoral joint, it's usually sensitive and around your MCL and posterior part of your joint it tends to be sensitive anyway. And patients that have a sensitivity that is in the joint line, you'll have like a bruise like feeling. So it would be quite acute. And one of the first things I want to see, do you carry a bit of effusion in your joint? Is it an intra-articular effusion? I often do a swipe test because that picks up on... I prefer that than the patella tapping one, because you know, the swipe test usually gives you quite a good indication of how much effusion you've got. I palpate around the soft tissue around the kneecap and like your medial and your lateral ligaments to give you an idea is that it's the whole knee that is sensitised. So is that really pinpointed in one area?

Then I often will be having a patient in supine. I'll be sitting on the table and I'll have their legs, like in almost like figure of four over my leg. And that really opens up the tibiofemoral joint. And you can palpate along the joint. And I go all the way from anterior to posterior, palpate the medial femoral condyle from the tibiofemoral, joint upwards, palpate the medial patellofemoral joint and around the pes anserine. So you have a good idea how sensitive that area is and if the patient tells me they've got medial knee pain, I'll spend a bit of time there just to identify exactly where it is. In that same position then I'll have my other hand just with my index finger palpating the lateral tibiofemoral joint. I find that that's a good way of getting a good idea of the whole joint.

Then with the patient in supine, knees bent, you have really good access to the femoral condyle in both sides of the kneecap. And the palpation is telling me, looks like you're quite sore in the joint. It's in your medial femoral condyle and I'm not touching much and you're quite sensitive. And then I would look at their scan and they might have a bit of active oedema or they've got significant changes on that side. So it's telling me that that region is sensitised and I'm going, yep, that makes sense. So you're sore on that spot in your scan. So that's telling us that region is highly sensitised now. So the biology there is quite strong and what do I do in giving this person activities or exercises to do. If they are having some discomfort that is tolerable, it's not impacting on their daily activities on that day or the next day, keep going, it's part of the process.

If they're doing a task and it's progressively getting worse or they're limping afterwards, or they're really having to protect the leg, that tells me that the task that we've given, it's a bit too provocative. So you don't need to be completely pain free when you're doing activities, but you don't want to be constantly provoking the joint with the goal of trying to make the leg stronger. And at times, if someone has an active bone marrow oedema on the femoral condyle, for instance, and they're highly sensitised, they get pain with the extension, they get pain on palpation, they get pain with loading.

Then what you might do is get them to exercise. Like if they can get on a bike, great. Or if they don't have access, you might get them to exercise around their lower leg, get to exercise their hamstrings, they get to exercise their hips if they have weakness around that region, to build a bit of conditioning in that region while that knee is settling. So you're making more of a hip targeted, lower leg targeted rehab, and then you go back to the knee to strengthen the thigh and as needed.

Depending on the patient, they have really specific exercises. Like, they have really weak hip rotators for instance, and they're constantly loading up, like they have a dynamic valgus and they're sensitising their medial patellofemoral region, let's say. It could be just soft tissue, but once they are a bit stronger, they're not falling into that same position and it's not so sensitised. And here not talking about correcting biomechanics of everyone that walks in the door. But if it's someone that they are going downstairs and they have a valgus that they don't have on the other leg and they have a clear weakness around their hip and they're sensitising the medial femoral region. And when you load their leg in a less valgus manner, they're not sensitive, there may be a link.

And what can happen is they send them off, get them really strong. You test them, they're really strong. They're not sore anymore and you look at them coming down the stairs and they might still have the valgus. And back in the day I'm going, oh, shit. Did I help this patient probably going to have this problem again? So nowadays I'm going, okay, you got stronger. You're now probably capable of tolerating that valgus and it doesn't sensitise your knee. That's how I think now. So that's just an example and probably kind of overstating the idea that you need to do some targeted assessments and you may need to deal with impairments of weakness around the hip rotators or thigh muscles or the calf to assist this patient, to be able to change their function on daily tasks.

So that gentleman, for instance, the 62- 63 year old that I asked him to go up the steps more on the edge of the stairs and going a bit quicker. In doing that, he goes, well, I can really feel my calves working. And when I tested his calf on that leg, he wasn't very good at all. Like there was a 10 repetition discrepancy between the two. On the non-painful leg he was quite springy, on the painful leg he was really sluggish and slow and as the calf fatigued, he was kind of bending and straightening his knee. So that showed me that is it weakness? Is it conditioning? Don't know that, but what it tells me is that you are not very good at using your foot on that leg and you are not habituated to do it. So let's train you to do that.

And you know, at times between a week or 10 days, patient comes back and they can do it. So you didn't get stronger in those 10 days, you just accessed the muscle. You just created a pathway. There you go, oh yeah, that's how I use my ankle. And that's it. So you're kind of going, I want you to change a habit or a behaviour. Do you have the capacity to sustain this new behaviour? And if you don't, then you need to be provided some exercises to facilitate that. Exercises are a mechanism to train a new behaviour or a new movement pattern or whatever we want to call it or to deal with specific impairments of muscle weakness, muscle conditioning. That's how I see, the rehab for each patient.

David: Beautiful, and you're really addressing their goals that you've identified with some of those really nice questions before where you were trying to identify what they'd like to be able to achieve in the next couple of months. You're getting them to identify the obstacles to achieving that. And sounds like tying that into their treatment about making sure that they're achieving their goals and working towards with specific, whether that's identifying those fears that are associated with it and then working through that to give those safe experiences and that sort of thing within the clinic. Is that right?

JP: Exactly right.

David: Beautiful. Well, I think that's a fantastic place to wrap up this podcast. You've shared so much fantastic information with people out there about how they can approach whether knee OA, any persistent pain, like a really thorough biopsychosocial approach that really identifies those individual components within each patient that are important, how you might go about helping them to come up with the solutions or with the experiences that really change their beliefs and their habits so that you can make those long term changes for them and then how to deal with it when you know, they have those flareups. And I think there's been a tonne of gold in here. And I think it's one of those podcasts where people are going to want to go back and listen to it a number of times to pick up all those little facets. So really appreciate you coming on and sharing all that with us, JP.

JP: Yeah, it's a pleasure, David. Thank you so much, mate. I hope our listeners will enjoy it.

David: Yeah, it's been a lot of fun.

JP: And probably a paper that we published last year, it's an editorial in the British Journal of Sports Medicine. It touches on this idea of kind of pain is pain, no matter where. And the name of the paper is, It's Time To Move Beyond Body Region Silos. It's like this idea that we treat shoulder pain differently to neck pain, differently to hip pain. And when we look at the risk factors for persistent pain, they're shared across pain, any body region. And when you look at the biopsychosocial principles, the idea of coaching someone to achieve their goals and enabling them to do that in terms of education, they're very similar principles. So there may be an interesting read for the listeners to get a good idea of that and a good excuse as to why we talk a lot about back pain in the knee OA podcast.

David: For sure. And we'll have links to that in the show notes for the podcast and also some of your other recent research. It has been fantastic to read as well. So people can go and grab that from the podcast show notes. So where can people find out where they can go listen to your podcast as well. So where can people find your podcast and yourself on Twitter, that type of thing?

JP: We have a fair bit of information on the The name of the podcast is Empowered Beyond Pain. It started off as being Peter Sullivan, myself and driven by the super tech savvy high tech, Kevin Warley finishing up his PhD now. So he's very busy. He's doing a fantastic job in moving that forward and the idea of the podcast is to get information translated to clinicians and patients and get patients to share their experiences as well. That's where we're coming from.

David: Nice. So to go check out your podcast and then you're on Twitter. What's your Twitter handle

JP: @JPCaneiro, CA-N-E-I-R-O.

David: Awesome. So go tell JP what you've enjoyed about this podcast and check out his podcast as well. So thanks JP for coming on and sharing all that awesome information. I really enjoyed chatting to you.

JP: Thank you so much, David. And thank you so much for all the work that you've been putting over the years. It's been fantastic, mate.

David: Thanks JP.

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