so often times the uncertainty around Healthcare provides a lot of anxiety for people living with various diseases including osteoarthritis and one great way to demystify this and to reduce anxiety is to get a little bit forewarned and forearmed about your experience with Healthcare today's episode of The Joint action podcast is really trying to demystify the first part of your clinical Journey specifically engaging with healthc Care Professionals going through and telling them your story of living with this disease having a physical examination and ideally from there formulating an appropriate individually tailored management plan that suits and
is made in a shared way targeted towards your goals so those first parts of the history your story of living with Osteo arthritis are really important for you to think about in advance of that Health encounter so that you can go along and and ideally provide answers that would be reflective of your living with this disease the impact it has on you and ideally share meaningfully in the formulation of goals for the management of the disease from there after a detailed holistic history has been taken ideally a tailored physical examination is then done to try
to determine where your symptoms are coming from and the functionality of your joint it's only then typically that you would then move on and formulate a management plan uh that ideally again is a shared one where you as the person living with ostearthritis share that development of the management plan that's targeted towards your goals with the health professional that's looking after you so it's those details that ideally you should go along to the health encounter for armed and forewarned with so that you can get as meaningful encounter uh done as possible and we're privileged to
have today two wonderful physiotherapists Melanie Holden and pip Nicholson to talk through this really important topic this is on the back of them along with Leticia deisa contributing to the development of a module to help train healthc Care Professionals in uh communication related to history and physical examination for osteoarthritis hello Mel pip welcome to the show hello David and I should have not I should have not said Mel pip I should have said Mel and pip but that's okay I'm sure everybody will understand by the time we get to this end of this conversation exactly
what's going on but in the first instance Mel if that's okay can you just share with the listeners a little bit more about your background and what a typical day looks like and it this will be an old question for you because I've obviously asked this the time you before on the joy action podcast but some of the listeners may have forgotten your answer so go ahead yeah so I'm a physiotherapist by background and I work at Keel University now in the school of medicine I'm a professor of muscular sceletal Rehabilitation and I do lots
of research focused around osteoarthritis and how best to treat people with osteoarthritis mainly through non-drug treatment wonderful thank you for sharing that again and pip how about you I'm also a physiotherapist by background I trained in New Zealand worked solely clinically for five years in New Zealand the UK and then in Australia and then I moved into a research role firstly at the University of Melbourne and then undertook my PhD and then I've been here at the University of Oxford in the nfield department of Orthopedics Rheumatology and muscular skeletal Sciences for almost six years now
and similarly my research is focused on hip and KN ostearthritis both non operative treatments but also trying to optimize outcomes after joint replacement and Joint revision surgery as well wonderful and obviously you're in the UK now and before we got on and started having the recorded conversation you mentioned something about the brilliant weather that you're experiencing given you're from Paradise would you have been better off staying in Paradise namely New Zealand before you moved to the UK or you happy oh it is something that I that I contemplate particular when when it's raining and I'm
cycling up their Hill to work but no I'm very happy to be able to visit it's a little bit T and- cheek because I know obviously both Mel and pepper are both in the UK at the moment and I'm sure loving the experiential component of the weather that the UK provides everybody very very generously but before I digress too much further obviously today we're talking about a critically important part of the patient Journey that of the encounter with health professionals and specifically what health professionals ideally should do in engaging with people living with ostearthritis and
in typical pilant you know often times that encounter is divided up into the story of your Osteo what we might call a history subsequent to that typically there's a tailored physical examination so you know there may be laying on of hands to try to determine exactly what's going on within the joint that are involved in other parts of the body and then from there potentially there'll be a need for further investigation and hopefully ideally the shared management plan is developed but the first part of that particular encounter is identifying your story so you're really working
out what your history of ostearthritis is so I guess in the first instance Mel why is that important yeah so it's really important for a health professional to to ask the person lots of questions to really understand what's going on so for example if someone came to see the healthc care professional and they were a certain age and they're presenting with knee pain well that knee pain could come from lots of different sources so it could be osteoarthritis but it could be something else so it could be a sprained muscle it could be a torn
ligament and so we really don't know and so that's really one of the reasons why we start asking a person lots of question questions to really work out what's going on what's causing the pain so it's important to know what the pain is it's important really to rule out if there's anything else that's more serious going on as well so for example if there's a fracture there if there's a tumor there it's those questions that will really start to to unpick that so there'll be lots of questions asking about symptoms that might feel relevant but
some might not be but again those questions will be really good to working out what's going on but also to get to know that person as an individual rather than just the symptoms so you might find that you get asked questions about your sleep about your mood about your your kind of social activities and we're really asking that again just to to help understand the impact that the pain and the symptoms can have on your life but these things are really kind of interl so the symptoms might be causing issues with with how you're feeling
in terms of your mood but also mood can affect the symptoms so that's why it's really important to get a kind of holistic assessment and so get to know the person and that can help then tailor that individual treatment for that person so it's the right treatment for the right person wonderful and with within that obviously you might go on and look at further aspects of uh the history taken in that holistic assessment what aspects uh you you've touched upon some of this in terms of that being a holistic assessment but what aspects of that
history taking other than that holistic assessment are important to cover there and I guess I'm particularly wanting you to expand on aspects related to the impact that has on a person the goal setting pieces and how that might lead into subsequent management plans without leading you too far yeah no that's fine so so obviously be asking about the the kind of symptoms um so that the history of the symptoms what people are doing to try help but there'll also be your questions around other health care conditions so other health problems that somebody might have because
that might affect and particularly around medications for example that might influence What treatments you can have thinking about somebody's moods thinking about their confidence their attitudes and beliefs so what they feel is going on with their knee problem what they think about potential treatment so how they feel about an exercise program or a weight loss program for example how they're sleeping um because that can be important so pain can affect sleep but sleep can also affect pain so it's it's it's really kind of thinking about all of those quite broad things really to get that
overall kind of picture of that person and and when a health professional does that ideally what type of communication style should they adopt that would uh allow them to get the best information from this yeah so so really we're trying to encourage a kind of a person centered approach to communication so being an active listener so really listening to what someone's trying to tell you trying to focus on open questions um try not to lead people and because if you say oh you know for example well you take pain at night time don't you so
that person will probably say well yes I do but rather than so it's around the style that that gets the most information out of somebody but as well as that kind of verbal questioning we're also looking for non-verbal cues as well so how people are are kind of looking in their face and that can give away a lot as well so it's again it's really focusing on both the verbal and the non-verbal yeah and you know obviously an important part of that conversation coming back to the comment that you made about this being person centered
is trying to identify the goals that a person may have related to their condition how as far as as the story is concerned how do we go or how rather should health professionals go about doing that in a way that is truly person centered rather than just uh what the clinician wants that goal to be yeah so it's it comes back to that communication style that kind of active listening and then it's working together with the with the patient to work out what they want so what they expect out of treatment what they want to
do so it might be for example that they um they can't take part in an activity that they they like to do like gardening for example or bowling or dancing so then it's saying okay that's your goal now how can we achieve that goal what can we do to to get you back and it might be some strengthening exercises it might be some of increasing physical activity or or pacing of activity so it's really working out what's valued to the the patient and then working out as a therapist well okay what are the tools that
we can use to help you achieve those goals I think when it's when thinking about goal setting we tend to think about them in terms of smart goals so they're quite specific measurable so they know they can be measured and we know how well we're doing with those goals um achievable relevant for that person and timely so so it's been very specific about the goals but a goal that's important to the patient yeah and I think that's obviously key because at the end of the day for a person with ostearthritis uh engaging in a management
plan that may involve important changes in their behavior motivation is often difficult particularly if it's a goal that they haven't set themselves so that's obviously a really key and essential Point Mel is there any other really Key Parts about that first part of the history that you think it's important that we cover off no I I don't think so I think we've covered most of it but I would just say know even if the questions don't feel relevant so they're not specifically about your symptoms they they still are important and so it's just kind of
going expecting to to answer a wide range of questions about yourself just for the reasons that we've talked about really yeah no I I think as you say it's really important that that be holistic and cover a whole lot of elements that in the first instance you may not necessarily think are immediately relevant to the management of your condition but hopefully all helps in building a really important story about your experience of living with that disease the impact it has on you and hopefully that helps to inform some shared decision making and goal setting between
the person who's living with ostearthritis and the clinician who's caring for them now pep moving to you if that's okay what I might get you to okay is tell us about the next phase of that Journey with the clinician specifically around the physical examination why do we need to do a physical examination in diagnostic purpose for Diagnostic purpos in ostearthritis so the physical examination really allows us to build on on the history on what we've been told what the person has said about their symptoms what they have trouble with so doing a physical examination it
means that we can actually look really closely at the specific elements of that and it's just really important to to clarify something that people sort of common misunderstanding is that to diagnose ostearthritis that that you need to go for an x-ray that you need to have an x-ray to be able to diagnose that's not the case anymore uh we know that we can we can accurately diagnose ostearthritis from a a really good history and the physical examination we really can break the the physical examination down into four parts um and the the clinician might first
of all look at at you at you moving at you moving specific joints but also just at how you're how you're standing how you're sitting how you walk in an of the of the room and then they might move on to feeling perhaps The Joint so looking at the Joint specifically um and they're looking there they're looking for for tenderness or or bony enlargements or or heat anything that might indicate some uh some changes within the joint and then the the two other parts are looking at at you at you moving uh and and measuring
as well so we're looking when we say moving we're looking at at how far you can move that joint but also also the joints either side and similar to the history uh within the physical examination uh there might be some parts that you think oh but it's my it's my knee that's sore it it's not my hip why are you looking at my at me moving my hip but it is really important that we look at the whole body to see so that we can actually really see a a good picture of of what's happening
so the physical exam will include sort of multiple different parts and the um the measuring part that I mentioned might involve you doing some some specific tests so so what we call functional tests so things like perhaps standing up from from a chair multiple times we might ask you to to walk up and down some stairs we might also look at your muscle strength and muscle length uh and also some joint specific tests so there are some some tests that we might do that are are specific to the to the perhaps the knee joint itself
that we're looking at that's a tremendous explanation and really just to emphasize a couple of key points and I'll I'll ask both pip and Mel to comment on this but in the first instance one thing that you said pip there is really just emphasizing the fact that it is a clinical diagnosis so um this is a diagnosis of a disease based upon the history that Mel explained and and the examination that pip just explained and we don't need Imaging in the vast majority of instances to make this diagnosis unfortunately a lot of health professionals have
a prodction to get Imaging but often times that's not necessarily helpful in the grand scheme of things I guess another point that Mel that you made and pip that you explained is that there are a lot of sources of pain in and around the joint that are not ostearthritis and without a proper examination you will not necessarily know that they are there and so there I'm particularly thinking about sources with pain like a bositis a tontis particular muscle muscle problems in and around the joint that you may get an inclination from a good history that
that could be the case and then that's reinforced by a tailored physical examination that that's the case but in the absence of doing that properly if you went off and for example did an MRI in the first instance you may make completely the wrong diagnosis based upon an image where you hadn't taken a decent history on physical examination but you know in in the worlds that you work in um Mel I might just get you to comment first if that's okay is that a frequent occurrence that a person goes off and gets Imaging done they
get LED down a path it's not necessarily relevant to the symptoms that they're experiencing I think I think yes I think that x-rays are still commonly done and then like you said we don't we don't need to now but I wonder if that's in part driven by by patients wanting to have an x-ray as well so it it is just making the point that you don't you don't need it we can and get the information that we need from history in the exam and and what you were alluding to David is that even on the
X-ray sometimes there might be symptoms on an X-ray or some changes on an X-ray even if someone didn't have any pain so so they don't always kind of marry up and the changes on the X-ray particularly in the in the kind of earlier stages of osteoarthritis it wouldn't change the management plan anyway so so so we really don't need to have that x-ray to make that diagnosis and to inform the management plan and particularly when we're thinking non-surgical treatments yeah and pip I'm obviously have a strong predilection towards favoring physiotherapy as a as a muscular
practice so I'm going to start with that at the outset for this particular question but you know I think as far as learning about these specific techniques whether it be the history or the techniques of physical examination it takes time it takes practice in your EXP experience you know how long did that process take for you and all your colleagues you don't necessar have to mirror it based upon yourself but for your colleagues um and you know for for most health professionals is that an experiential learning process is it something you learn in a textbook
is it something you learn by listening to this podcast or watching your Atlas modules that you've just created how I mean what's what's the best way to do this I think it's a it's a real combination of of those factors I think certainly when you when you undertake your physiotherapy training you learn all of the tests all of the steps that you should take but it's through experience it's through seeing patients that you're able to refine that combining the history and the physical exam and really learning to to pick up on things within the the
the history within the discussion you might have with the patient that you then can focus your your physical exam I certainly recall myself when I first graduated I would do every single test that I possibly could because you didn't want to miss anything um and I think the more experience you have with patients and and the more confidence that you have uh and that may come through doing perhaps additional training um or just just seeing more and more patients that you're able to refine that down so that your physical exam uh very closely links to
to what someone has said in that history and links to what their their goals are and what they want to be able to achieve yeah and you know I think what you've explained is typically what I think for most health professionals they they generally experiences so in the first instance they're very uh recipe based and they follow a spe specific order about the way they do everything but you know over time hopefully with a with greater experience and greater understanding of particularly the common presentations but at least efficiency as well you may tailor that more
um but I guess a a key point and you've both emphasized this uh through tonight's discussion is that everybody who presents is an individual and they present differently and it's really important that you know the I guess the recipe based approach to a history taking and physical examination over time ideally molds itself according to the way a person is presenting both in their history and their physical examination so that you can fully understand truly how that unique individual has discrete elements that just pertain to them so Mel is there any one piece of advice knowledge
or wisdom that you'd like to give for people living with ostearthritis I think really just reflecting on some of the conversations that we've had today is just just that kind of reinforcing the fact that a healthc care professional doesn't need to have an x-ray to be able to diagnose yeah well it's a really good and valuable point and hopefully more people sit up and take notice pip any wisdom from you I'm sure there's lots to share just as as Mel said reflecting on on what we've been discussing around the fact that the health professional will
be asking lots of questions my advice to to a person with osteoarthritis is do ask your questions ask them questions ask um what any con questions concerns feel free to ask the health professional why they are doing a particular test or or what they're looking to find out from doing that so I think um you you'll be asked to answer lots of questions but also do make sure that you ask your questions yeah definitely be proactive in that engagement and hopefully learn a lot from that and be more empowered as a consequence of that now
Mel pip thank you so much for your time for your valuable contribution both to the atlas modules but obviously also to this podcast and the invaluable contributions you're making to ostearthritis as a whole the community of people that we serve thank you very much for having us it's a pleasure so really an important topic today one that I hope you've gained a lot from and that will help your journey of living with ostearthritis particularly as it relates to getting a truly informed and engaged healthc care professional to provide U meaningful management for your disease that
will be shaped and formed based upon the information you provide in the history and ideally telling them about the impact that this is having on your life whether that be your work your social roles your relationships and identifying with them goals that are meaningful to you this could be anything you know it might be a health related goal it might be something around activities that you like to do participation in the community that you might have but it should be ideally tailored towards what your preferences and values are and done in a way that is
truly person Ed and from there a tailored physical examination would occur that ideally respects your dignity and your comfort and is done in a way that's tailored and targeted towards finding out specifically what is wrong with the joint and where your symptoms may be coming from and to better understand the function of the joint itself so again these elements we're sharing today because they're truly an important part of your journey of living with osteoathritis and the more forewarned and forearmed you are about that particular Journey the better informed and empowered you will be so I
hoping you found today's episode helpful again huge thanks to Mel and pip for sharing their insights and to letia uh for their valuable contributions to the outlas module that they've created really hoping that this was uh informative for you and again thank you for your continued support of the join action podcast and we'll look forward to seeing you hopefully again in the not to distant future but between now and then please do take good care of yourself thanks for listening to Joint action with David Hunter if you like our show and want to know more
visit www.join action.in if you have any questions you can email us at hello joint action.in and follow us on Twitter at joint action org this podcast was hosted by David Hunter edited by Vicky dwang music produced by Jordan Hunter the information posted on this podcast is not intended to diagnose treat cure or prevent disease anyone seeking medical advice should consult a health professional [Music]
