[Physio Explained] Knee osteoarthritis: exercise, education, and better care with Dr Allison Ezzat

In this episode, we discuss Osteoarthritis and exercise. We explore: 

• How can we improve GP referral pathways
• Telehealth and management of knee OA vs in-person care
• Mindset Shifts for High Quality Care
• Value of Education in the treatment of Knee OA

Want to learn more about knee osteoarthritis? Allison Ezzat recently did a brilliant Masterclass with us called “Knee Osteoarthritis Essentials: Practical Strategies for Clinicians” where she goes into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial:
https://physio.network/masterclass-ezzat

Dr. Allison Ezzat is a physiotherapist and Implementation Scientist at the BC Injury Research and Prevention Unit, BC Children’s Hospital Research Institute, and a Clinical Assistant Professor at the University of British Columbia, Canada. Her research uses theory-driven implementation science to reduce the short- and long-term burden of musculoskeletal injuries, with a focus on addressing gender disparities in sport injury prevention and improving outcomes such as knee osteoarthritis. She completed her PhD at UBC, undertook postdoctoral training at La Trobe University, has held leadership roles within the GLA:D program in Australia, and now serves as the National Lead for GLA:D Canada while maintaining clinical expertise in knee injury management across the lifespan.

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Our host is @Sarahyule from Physio Network

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Transcript

SPEAKER_01 0:05

For people in Australia, you have the Royal Australian College of GP ostearthritis guidelines, which again are guidelines for GPs that again recommend exercise therapy, exercise education, and weight management as that first-line approach. So sometimes being able to share those resources, even if it's something they might read later on their own, can be really helpful.

SPEAKER_02 0:29

Have you ever found yourself giving clear, evidence-based advice? Yet perhaps nothing seems to shift. Or perhaps you felt that you're saying all the right things in your consults, but the behaviour change isn't happening. If that sounds familiar, today's episode is going to land deeply. We're diving into the topic of communication for better outcomes with Dr. Alison Sim, osteopath, educator and researcher specialising in pain management and early intervention following injury. Alison has worked clinically for over 20 years and teaches communication and behaviour change skills to allied health professionals across Australia. Her research focuses on distress, risk screening, and recovery-in-compensable injury settings, giving her a uniquely practical lens on how communication shapes outcomes. She's incredibly passionate about improving clinician-patient interactions and helping practitioners integrate evidence-based communication strategies into everyday care. And she has created a masterclass with Physio Network titled Beyond the Symptoms, Communicating for Better Outcomes, which we'll be unpacking today. You're going to love today's episode with plenty of clinical gems. I'm Sarah Yule, and this is Physio Explained. Well, welcome to you, Alison. Thanks so much for joining us today on the podcast. No problem, great to be here. Now, the first talking point that we've got to dive into today is about GP referral pathways. And we know that education and exercise are consistently recommended as first line of care for neosteoarthritis. Yet many people still perhaps aren't accessing physiotherapy early. And I know you led work to co-develop an intervention with GPs to increase referral to exercise and education. And I'm curious, what did that process teach you about how physios can better support GPs and influence referral behavior in what's a realistically a time-pressured healthcare system?

SPEAKER_01 2:20

Yeah, no, thanks. Thanks for the question. It was a really interesting study. I felt like I learned a lot. I sort of, I think, grew my appreciation for the role and the challenges that GP has GPs have. I think first is to take a step back, I think of how why we did this study is as you said, many people with knee osteoarthritis are being referred for surgery or even having knee replacement surgery without trying any sort of first-line care. So as you said, exercise education and weight management. And again, that's a huge missed opportunity there. And so we do know, again, from the research that GPs getting a referral from a GP to try exercise is a facilitator for many people. But that being said, there's lots of challenges for GPs to make that referral. And I think one of the main messages that came away from me in doing this work was I had, again, a new appreciation for just the caseload of patients that GPs see is they have many, many people who are not interested at all in exercise. And I think as a physio myself, all the people who come to see me, even if they're not super athletic or have a lot of exercise background, they've at least made that appointment and come in. They're willing to talk to a physiotherapist who they typically know is going to do something to do with exercise. Whereas GPs have many patients who have never exercised in their life and have no interest in exercising ever. And so for that GP who might have a short five to 10 minute appointment, for them to try to convince that patient that they need to go and do exercise can be, can be really, really tough. And then you also throw in some of those barriers in that GPs aren't always fully knowledgeable in what should be the first line management for neostearthritis. Or even if they are knowledgeable, they don't know where to refer or where they can send that patient to get good quality exercise. And so that was really why we set out to do this study how can we try to bridge that gap between knowing that that GP referral can help patients to access that first-line care, but finding a way to support GPs to do that. I guess back to your question and that what can physios do to try to support GPs in their neighborhood, I think one of the things we learned in co-designing the intervention was that not unsurprisingly, GPs are very diverse and they have lots of different sort of learning preferences. And it's not necessarily going to be a one size fits all for how do we improve those GP referrals. So we did develop with them sort of a multi-component intervention that included doing an interdisciplinary workshop that was about 90 minutes held online. Again, that was their request to do it, do it online in the evening, again, to make it more accessible. They didn't have to drive anywhere, come in. So we had that workshop. We also gave them an electronic referral template. Again, the idea was is we provided them with some addresses of local physios in their neighborhood that then they could use this template to easily refer patients. We gave them essentially an online toolkit with again some different patient resources and handouts that, again, they really asked for. We gave them some different posters and flyers about the GLAD program and about again the benefits of exercise for neoostearthritis. What ended up happening is we got really good feedback about the workshop, first of all, is that they all really liked the workshop. We did some pre and post-workshop testing about their knowledge and their confidence. So the workshop was really well received. Interestingly, that electronic referral template that we gave them, despite them saying that they wanted that, it didn't really get used hardly at all. And so again, that really said to me that we have to make it as easy as possible for them to do that referral. That even having that extra step of, you know, we were trying to get this template directly embedded in their EMR system, but even just trying to work with their office staff to do that. Again, I'm not 100% sure that that was successful. That was, again, a real challenge. But what was interesting was a resource that we showed them that was pretty basic, that was essentially an online map on the GLAD Australia website where anyone can go and you put in your address or your neighborhood and it will just pull up for you on the map where the local locations are that offer the GLAD program. That was a big hit. They loved that. And to them, again, some GPs talked about doing that with their patient, showing them how to sort of find their own way there rather than them doing more of a direct referral of the GP to the physio, but instead working with the patient to find a local clinic and then writing down the address and making the patient a little more autonomous and in control over that, that they really liked that map. But the other thing that, again, really specific to, I guess, people listening to this is that GPs really are more likely to refer to clinicians that they have a relationship with in the community as well. And we certainly heard that from the GPs in our study. I think if we were going to repeat the study again, instead of us as being a central leadership group delivering this workshop and doing everything with GPs, we would partner with local clinicians and have them deliver the workshop and build the relationship with the local GPs in their neighborhood. Because I think that again would make it more successful rather than sort of us being this middle person in doing the workshop.

SPEAKER_02 7:40

So it sounds like the takeaway there for the clinician and the community, there's great merit in reaching out to your local GP to highlight this online resource on the Glad Australia locations. And probably what we've known for a long time, and it's nice to have it supported by research, is that the relationships with the referrist is so important.

SPEAKER_01 7:58

Yeah. And again, it's not, I'm not saying it's easy to build those relationships with GPs because they are certainly busy, whether that's just going in, bringing them a lunch, doing a lunch thing again, they're all so different, was what we found is that some GPs seem like, yeah, we'd love to have someone come in with some lunch and teach us something. And other ones were like, nope, we don't do that anymore. Not gonna work. So it really, I think, depends on your local GP and your local situation. But I would say that yeah, building that local relationship, it does take time and effort, but it probably is worth it because if they can trust that local person, they're gonna be more likely to send their patients there. Some great takeaways there.

SPEAKER_02 8:35

Let's move on to talking about telehealth and the management of Neo A. Of course, since COVID, telehealth has opened up plenty of new possibilities for access to care, but I think there's still perhaps a lot of hesitation around whether it's truly effective for exercise-based conditions like Neo A. And I know you evaluated the GLAD program delivered via telehealth in Australia and found outcomes comparable to in-person care. What were the key findings from that work and what do they tell us about what really matters in knee OA management?

SPEAKER_01 9:05

Yeah, you're spot on there in that COVID happened and we all said, oh, let's try this telehealth thing, or not all of us, some of us did. I know in Australia and Canada, we had similar, actually in Canada we had even more strict restrictions initially where we weren't really allowed to do any in-person care at all as a physio in private practice. But what this research found is again a good thing, is that when we compared the patients who did GLAD by telehealth, either fully by telehealth or in sort of a hybrid model where they did part in person and part by telehealth, the outcomes when we looked at their pain, at their quality of life, at their functional tests, the chair stand test, were really comparable in those looking at in-person pre-pandemic compared to by telehealth during the pandemic. And so again, I think one of the challenges we found with doing this paper was that physiotherapists are sometimes hesitant to do telehealth. And maybe it's not always our preferred method of working, but we did qualitative interviews again with adopters and non-adopters of telehealth to and try to sort of understand what are those sort of barriers and facilitators to physiotherapists doing it. And I think, yeah, most of the people, even the adopters, did say they sort of prefer in person, but they saw again the value to being able to offer this telehealth because, again, there's patients who may not live close to a clinic or they may not be able to drive, or they may have caregiving responsibilities for an aging parent or for a young child, where, you know, to have to come into the clinic to say do a one-hour exercise program like GLAD is just not feasible for them. And so if they can do this program by telehealth, then yeah, that's amazing. We can have the confidence that they can still improve just as much as in person. And I actually find, or again, this is not an evidence-based thing, but I actually think physio said this in the interviews that patients being able to set up all their exercise equipment in their own home when they were getting ready for the telehealth sort of session, it's really again a way to sort of promote that patient autonomy. And that again, if they do the GLAD program where they have those, say, 12 supervised exercise sessions, they're much better equipped to be able to continue on exercising. They've already been setting up in their house, they know how to do it, versus if they're used to coming into the clinic every week and then all of a sudden they're not coming into the clinic anymore. It's a little more of a jump for them to be able to do it independently. So that's in some ways, I think almost a hybrid approach of where maybe in an ideal situation, you would do a couple of weeks where you're doing twice a week in person, and then you could transition to be doing some by telehealth as well, so that people can get used to setting it up in their own environment.

SPEAKER_00 11:43

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SPEAKER_02 12:10

Yeah, fantastic. You're almost able to problem solve in real time and overcome barriers of setup. So for the physios listening who might feel unsure about delivering really high-quality knee OA care via telehealth, what do you think are the key mindset shifts that we need to deliver high quality effective care remotely?

SPEAKER_01 12:30

Yeah, great question. So obviously, you're gonna be a bit limited in your ability to do a hands-on type assessment. So it does require a little bit of an adjustment in how you're gonna do that assessment. And I think really, as per any assessment, doing a very thorough sort of history and subjective assessment is that's always critical. But I think with telehealth, you definitely wanna be very thorough with that. And then yeah, it does take a little bit of creativity. It does sometimes mean, you know, making sure the patient is has enough space to be able to potentially move around if you're wanting to watch them do some different functional movements, like let's say a chair stand test, which as a side note, that 30-second chairstand test has been validated to be to be valid to do by telehealth. So that's again a really easy test where it's essentially how many chair stands up and down the person can do in 30 seconds. And so that's a really good one that of course you want to make sure the person is safe, whether that's having the chair supported behind them or however, but that's a really good test as an example that you can do just as good in person or by telehealth. So yeah, just being a little bit creative with potentially how you're getting them to move or how you're getting them to adjust their camera if that's needed. And there is a little bit of a learning curve. So I would say giving yourself a little bit of extra time, for example, if you're if you're new at telehealth. But yeah, I think really as far as exercise, obviously again, like the hands-on manual therapy treatment is not going to be very not going to work by telehealth. But as far as exercise, which is really again that bread and butter treatment for knee osteoarthritis, then I think there's a really good opportunity to provide that exercise, be able to provide the feedback again, as long as they're making sure they're adjusting their camera, they have the right space set up, it's really quite, again, I would say easy to be able to provide that feedback for different exercises and to tailor it to that person.

SPEAKER_02 14:28

Great. And then I suppose the next component being the role of education in knee OA management. And I'm curious, do you feel like education is often undersold in knee OA management and we could increase our potency of impact with our education?

SPEAKER_01 14:45

Yeah, yeah, for sure. And I think as a new grad physio many years ago, I think I was probably guilty of, you know, wanting to do this, these fancy hands-on techniques and didn't appreciate, you know, really the value of just being able to provide education to people, especially in something like knee ostearthritis, where probably people have either read something online or they've talked to a family or a friend, someone who's had a knee replacement, or people hear stuff on the media or through word of mouth that's, you know, not always true. And so I think we have a lot of potential, you know, again, it very empowering for patients to be able to provide them with yes, this is the actual evidence of what works. And so I think it's it is a skill though, at the same time, in that if you just all of a sudden like spew all the information you know about knee osteoarthritis at somebody, especially if, you know, maybe they have a few myths or a few, a few things that they're that are incorrect about osteothritis management, if you just all of a sudden tell them their GP is wrong and that you're gonna tell them how it is, it is a skill as well to be able to provide that education. And so one thing that I often find is being able to share different resources with them so that it's not always just me telling them, no, this is how it is, because if I'm, again, completely different than what they've read or what they've heard, that can be a bit challenging for them. But, you know, whether that's sharing some online resources, like a toolkit that I was part of developing that I'm sure you can share the link. It's called the My Knee Toolkit, which has tons of information about neostearthritis. It's co-designed by physiotherapists and patients. It's got some interactive quizzes, it's got infographics, it's got lots of information on there. That can be one resource. But even something else that I will do is again to pull up some actual clinical practice guidelines. Again, this is going to depend on your population that you work with. And I work with a fairly high-educated, high health literacy population, where the ones I use, because I'm based in Canada, I will pull up the American College of Rheumatology guidelines. And it's a research article. So I say you don't need to read this, but when you scroll down and I can show them, there's some tables that are green, which is the type of recommended treatment, and then they have red. And so again, this is the American College of Rheumatology. So it's not just Allison telling them something. This is a credible source. And so for people in Australia, you have the Royal Australian College of GP osteoarthritis guidelines, which again are guidelines for GPs that again recommend exercise therapy, exercise education, and weight management as that first line approach. So sometimes being able to share those resources, even if it's something they might read later on their own, can be really helpful. And just knowing that it can take time, that again, sometimes you just need to start slowly and that multiple sessions or multiple weeks before people might start to sink in some of the messages. But I think, yeah, as physios, when we have sometimes these longer times with patients compared to, say, GPs, we have this great opportunity to be able to provide this education. You're so right.

SPEAKER_02 17:55

We've got that ability to plant the seeds and just water it with each session, don't we? Fantastic. Well, Alison, thank you so much for joining us. Your work really highlights how much impact we as physios can have when we think beyond just those individual sessions and use the resources that are available to us and the systems available to us in the community. So for those that are listening, if you'd like to dive deeper into this topic, Alison has recently delivered a masterclass with us on NIOA, which the link is available in the show notes. And as always, we'll also link the key papers and resources discussed today in the show notes because those will be fantastic to use in the clinic tomorrow. So, Alison, thank you so much.