Latest / The STA Clinician Podcast / Ep200: 'Managing Tendon Pain' with special guest Dr Ebonie Rio

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Ep200: 'Managing Tendon Pain' with special guest Dr Ebonie Rio · The STA Clinician Podcast

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You're listening to the Sports Therapy Association podcast, putting evidence
0:04
back into soft tissue therapy.
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Music.
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Hey people, how are you doing? We're
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live. Welcome to the Sports Therapy Association podcast, episode 200.
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200 my name is matt phillips creative one chat live.com and
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yes you heard it right 200 episodes in a
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row every week pretty much one or two
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i was on holiday but pretty much every week and it
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all started in covid as we were coming out of covid because we realized at the
0:40
sports therapy association that there was a need therapists suddenly had loads
0:44
of questions and actually therapists realized actually i should be talking to
0:48
the person down the road my competition now rather than just trying to compete
0:51
with them because I need to know about the same things.
0:53
So we had loads of episodes on things like returning to work during COVID,
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use of PPE, personal protective equipment, how to utilize online consultations.
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And it was a beautiful time we were sharing.
1:01
And then it turned into, well, let's get some guests. And we did.
1:05
And by Christmas that year, back in 2020, we'd already started delving into
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the wonderful world of female and male pelvic health, strength and conditioning
1:12
for your rotation, working with elite athletes, neck and head injury, and so much more.
1:16
And then four years later, down the line, 200 episodes later
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thanks to our wonderful guests experts from health
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fitness and health care it means that our podcast for example is
1:25
being used at universities across the uk on first
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degree physiotherapy courses and also sports therapy degrees um
1:31
so first of all just thank you to every to all of our guests who probably can't
1:35
hear me at the moment and i'll listen to the podcast but it's a massive thank
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you to everyone who's given up their free time to join us for the podcast and
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also those who've managed to get along to therapy expo which is obviously coming
1:46
up this November and speak there in our STA theatre.
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And also everyone who's joined us live. Thank you very much.
1:53
Because the same with One Chat Live, I just love live.
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I couldn't do this if it was just pre-recorded. It just wouldn't have the same buzz.
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So everyone who comes and joins us live, thank you so much.
2:01
And obviously everyone who comes and downloads the podcast, that makes a massive difference as well.
2:06
It's just gone up and up and we love that. We do want to break kind of where
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we are at the moment, and that's going to involve more regular pleas from me
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to you to please just leave reviews.
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If we have 3,000 downloads, there should really be at least 1,000 reviews,
2:20
and I think we're at about 50. So do please leave a review.
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If you listen to the podcast now, click pause, especially on an iPhone. You've got no excuses.
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IPhone, you've just got a native app. Just go in there and leave a review,
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please. Five star, obviously.
2:33
But yes, so thank you very much, everybody involved. involved and
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if you are listening to the podcast and you like the idea of joining us live
2:39
and didn't realize that you could then just head along to the sports
2:42
therapy association youtube channel or facebook depending which
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you like normally at eight o'clock uk time but the last three episodes because
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all my guests are in australia we've done it nine o'clock uk time that's six
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o'clock in the morning in a lot of places there so that's why we're an hour
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later but if you do want to come along join us that'd be great for example when
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you do join us live then you can come in and you
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can leave questions with the guests and i can bring it up on the screen for example
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sir glenn murphy mbe is in the house and
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he has said congratulations all 200 wow i know um
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it is indeed a monumentous occasion brian huxley is here as well saying good
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evening my followers my followers i know my fellow followers thanks brian i
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thought it was very big of you and gary benson is here as well founder of the
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sts congratulations gary on reaching the big 200 cecily hislop has come in as
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well and people are just coming through the door now to join us on our 200th episode
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cecily says evening all the tennis is on i've got a cuppa and i'm listening
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to this podcast what a good night cecily i love the way you live your life there
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we go right so there we are episode 200 and what better way of celebrating it
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than once again with an amazing guest for those of you who aren't aware we've
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been having a series of a three-part series on tendinopathy.
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And tonight in part three we've got once again another hugely respected name
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from the world of tendon research and education dr ebony rio who will be joining
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us very shortly dr ebony rio is a Senior Clinical Research Fellow at the Australian
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Ballet La Trobe University,
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a sports and exercise physio at the Victorian Institute of Sport.
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And like I say, joining us from Australia at something unearthly like six o'clock
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in the morning. So thanks people.
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Remember, this is a huge chance for you of joining us live to ask questions.
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The topic tonight is going to be in episode 200 of the Sports Therapy Association
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podcast, Managing Tendon Pain.
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And I shall now bring up my special guest for episode 200, Dr. Ebony Rio.
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Music.
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Hey, Dr. Ebony Rio, how are you? I'm great. How are you? Happy 200.
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Thank you so much. So excited. And I mean, it is great.
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I'm hoping, I always say this, I'm hoping some people have not heard of your
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name before, because I always worry about this echo chamber and we're all just
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sharing names and people we know. But I'm really hoping people haven't heard you.
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Obviously, I know you and a lot of people do. And it's just thank you so much
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for giving up your time because yourself and Alison Grimaldi and also Pete Maliaus,
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it's just Just an absolute honour to have you on our little show. So thank you very much.
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Oh, that's a pleasure. Thanks for having me. Especially six o'clock in the morning, Australia.
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This is a question which we haven't quite got to the bottom of yet.
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What is it about Australia and the production of Tendon Specialists?
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I mean, you've got yourselves, the three being in the show. You've got Jill Cook, Bill Vincenzino.
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What is it? Must be something in the water. We're just so far away from everyone else.
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We just had to kind of, you know, do something. And I think a lot of us landed on Tendons.
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There we go. I'm pleased to have massive spiders and tendon
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specialists that's great we've done well so yeah
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thanks very much for joining us tonight it's been a wonderful couple of episodes like
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I say with Dr Alison Maldon professor Peter Maliaras
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and tonight we're going to focus on managing tendon pain and
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what I'm going to do I've pre-warned you now I'm going to take you a little bit back
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in time and make you realize how long you've been dedicating yourself to
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research and you're going to feel old I'm sorry you don't
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look at all obviously but it's gonna I have to warn you
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because i've seen what the effect it's had on our previous two guests
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so and also to show our listeners if you listen to the podcast you can't see
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it but i'm bringing up images on the screen just from research gate because
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it's a it's an easy way to look up all of our guests who are involved in research
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and see the papers they produce dr emily real like i say is is a huge name in
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tandem research and i'm looking at the at the research gate now 116 publications.
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106 273 reads 2559 citations and if you look at the skills and expertise just
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think of any Any word you can stick on the end of neuro and it will be there.
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That's where the expertise is. That's the easiest way to describe it.
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So what I'm going to do is we are going to go back, not to your first papers.
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Actually, before we look at those.
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The earliest papers, I think, were probably around 2013. I think I saw – no, it was before then.
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I think we went back to 2006, just to make it even worse. And it was all about Australian football.
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So were you playing at the time, or how did you end up with looking involved
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in Australian football, first of all?
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So actually, Matt, that was my honours back in 2003, 2004, or maybe earlier, actually.
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And I was finishing
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off physiotherapy and Jill Cook
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was my honours supervisor and we decided
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to track an intervention study in Australian football and
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it was super interesting and you know the intervention group had no ACLs and
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I thought oh this is this is pretty cool like we can actually do stuff that's
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you know important and I got to the end of physio and Jill goes you know have
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you ever thought about doing research like ongoing and I said I don't want to do research.
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I want to help people. I want to be a physio.
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And she said, and I've never forgotten this. She doesn't even remember saying
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it, but it had a profound impact on me.
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She said, if you are a therapist, regardless of our training,
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if you're a therapist, you help the person in front of you.
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But if you're involved in research, you can help many.
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And I didn't go straight into research, but it sort of stuck with me.
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And so I finished physio and I still work as a physio. I'm still very hands-on.
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I'm half clinical and I love it.
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But that little kind of appetite for a more broad impact definitely landed.
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Amazing. I think it was Professor Peter Maliaus who said that one of the things
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that drew you together and probably had an effect on a lot of Australian research
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was Professor Jill Cook.
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So, yeah, you mentioned that, yeah, definitely you worked with Jill.
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And we'll probably see her name on quite a few of the papers that come up shortly.
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I'm interested back then.
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I love bringing up research and looking at time because one of the things we've
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talked about a lot on the show is particularly with sports therapists and sports
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massage therapists and sports rehabilitations, because they're not allied health professionals.
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They're not kind of part of, I was going to do quote marks elite. I have done it.
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They are regarded often as the elite allied health professionals because you
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can work in the NHS in the UK and you just, a lot of people will see you as
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top tier and everything else is kind of underneath struggling to become that,
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which we've talked about loads of times here.
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But there is a danger of some sports therapists and massage therapists shying away from the research.
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But one, I love it because we get to see the name behind the research like you.
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We can see here that you're human.
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You're not some kind of monster or somebody who's got absolutely no emotional
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intelligence or social skills. You know, you're smiling.
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We have to think these researchers are these academics who just never go out.
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So I think that's really healthy. And just to just to show how things change.
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So I'm interested back then, because tonight we're talking about managing tendon pain.
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What was your understanding or experience of pain back when you did start working with tendons?
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For example, like 2013, there was the relationship between compressive loading
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and ECM changes in tendons.
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I don't know whether you were already interested in tendons then,
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but we're looking at kind of over a decade ago now.
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So what was your understanding or interest in pain back then?
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So every kind of research project that I do or have done in the the past has
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actually sprung from a clinical question.
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So it's always the person that didn't get better or why did this work or why
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didn't this work or why do tendons hurt?
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And so I think my real interest in tendinopathy really came from when I was
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up at the Australian Institute of Sport and I was working with Craig Purdom,
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Professor Craig Purdom, another amazing tendon giant.
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And one of the sports I worked with was basketball. And if a coach,
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if we had a stress reaction or a a stress fracture, I could really confidently
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say to the coach, here's the amount of time this person's going to be out.
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Here's our reload program.
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We've got this. And everyone felt very clear.
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Same with the muscle strain. I felt like most of our injuries,
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we had some pretty good timeframes.
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And despite the amazing work that's been done in tendons, it just felt like
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we're kind of going, oh, we'll try and keep them going.
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And should we do gym in season or should we be resting them?
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I felt like we still had all these great clinical questions.
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So, and I say to my students now, your research question is the one that keeps you awake at night.
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And that's what we should go and research, something you're really passionate
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about, that your brain is kind of churning over.
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So back then I had a super mechanical kind of understanding of tendons.
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I don't think we did tendons very well in undergrad physio, to be honest.
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And so I definitely didn't appreciate how complex they were,
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but also, So, you know, as we were saying before we started the chat,
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you know, biopsychosocial, I think was a throwaway line when I went to uni.
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It certainly wasn't appreciated.
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It's so nice to hear that because it's
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just one of the things that happens again and
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again in order to put confidence into therapists and for them
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to have confidence most people who want to work
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in health care are not doing it for the money i'm not sure what it's like in australia but
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you're not doing it for the big bucks you're doing it because you like to make a
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difference because those thank yous are the best way of being paid
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whether it's the patient or the patient's relatives or whatever so but to
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do that you need to have the confidence and you need to you need to
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feel that you are making a difference otherwise you can go down some really dark holes
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so it's really nice to hear from specialists and.
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People with your with a high degree of respect
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that people have for you to hear that you know you didn't know
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things back then you were just doing stuff which you look back now and think maybe
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it's the best we had at the time but we were going down some long you know
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rabbit holes there so it's really helpful helpful to know
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so the idea tonight then with you in
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the house is because you've managed to change a lot of these myths and misconceptions
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thanks to the research you got involved in and the first thing
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i want to talk about i'm going to bring this paper up just a little bit bigger so
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people who are watching on youtube can see this this
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was like i said 2013 so we are going back 11
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years now a little bit gosh we don't need to count yeah
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sorry a few years uh there's so
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i mean there's 119 papers i could have picked from here but i've just
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put some brought some up which i think will be interesting to talk about this
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was where the word compression i saw first of
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all it's relationship between compressive loading and ecm changes in tendons
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and and a lot of people are still talking about compression and there's a lot
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of backwards and forwards debate as always on social media but can we introduce
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could you introduce the the relevance of compressive loading particularly when
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we're talking about tendinopathies.
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Absolutely. So Matt, I think understanding tendon loading, for me,
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if you understand load, you actually really get tendons.
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So if you're a tendon, you can see up to four different types of load.
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So the first load is tensile load. And for it to be really high tensile load
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or high tendon load, it has to be fast.
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Tendons are about rate of loading. So immediately we can say,
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is our patient or our athlete talking tendon?
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Are they describing an activity where they're using their tendon as a spring
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to store and release energy. So it can help us with diagnosis.
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The second thing it can help us with is by definition, anything slow or static
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is easy for a tendon because tendons are about rate of loading.
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So we can immediately say, well, we can apply safe start loads.
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We don't need to ever rest a tendinopathy.
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The second load is compression. So compression is where your tendon is squashed
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against a bone, normally near the insertion.
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So So you think of the Achilles, it squashes, it goes into dorsiflexion.
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That's why people with insertional Achilles prefer to be in a shoe with a heel
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because they don't get into compression as early.
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They don't do well with the Alfredson program off the step. They're better from
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flat ground and they don't like stretching.
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Alison would have spoken about gluteal tendinopathy and when women cross their
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legs and they adduct, they compress their tendons. and almost all of our tendons involve compression.
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So the hamstring tendon, even tip posts, the compression is the point of pathology.
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It's a long way from the insertion, but that's where we see the pathology.
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So my first tip is if you tell most people not to stretch in the early stages,
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it's going to be really helpful.
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It's not that people have to be scared about compression and avoid those activities
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forever, but as a pain reducing step, it's really, really helpful.
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Now our third load so we've got spring load tensile load we've got compression load,
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which is where we squash it. And our third load is combination and combinations
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where you're asking your tendon to store and release energy like a spring,
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but from a compressed position.
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So it's what our tendons are designed to do. So it's the most provocative load,
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but it's what we have to get people back to.
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And for me, this is a great reminder that we should never say,
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oh, should we do isometrics or eccentrics?
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That's the wrong question. We need both of those and actually neither of them
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are a complete rehabilitation strategy when you look at what our tendons need to be able to do.
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So we shouldn't be saying, is this better than this? Or manual therapy or no
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manual therapy, that's so reductive.
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We should be saying, what role does this have in the timing for this person?
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But also where do I need to take them to?
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And our fourth load is a load of differential diagnosis.
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It's where we're sliding and gliding the outside sonovial layers.
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So the outside sheath or peritendin layers over the tendon.
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And an example would be someone that's going for a bike ride or they're cycling
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or they're swimming where they're getting lots of repeated plantar flexion and dorsiflexion.
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So there's lots and lots of repetitive movement, but we're not asking the tendon to act like a spring.
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And that is a different clinical presentation. It's a different pathology.
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And when you think about it, we need to manage them differently because someone
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with a peritendin issue in the Achilles is going to do terribly with calf raises.
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And even they don't like, they actually don't like a heavy isometric because
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it bunches up the peritendin.
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So I think Sir William Osler said, if you listen to a patient,
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they'll tell you what's wrong. And if you really listen, they'll tell you how to get them better.
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And I love that for tendons because people give us the information.
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We just need to really piece it together.
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So compression is a really important load in tendons.
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It won't give you tendinopathy. so no one's going to get
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hamstring tendinopathy listening to the podcast tonight but if
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you already have tendinopathy compression is a
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load that we can take away to really help manage people's pain
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that's that's really interesting and it's
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it's an amazing quote which we've had a couple of times before because it's
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so relevant so good it's it's brilliant and and also what i've taken from what
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you've just said is there's again there's a trend in our industry sadly and
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i'm sure i don't know i have i did live in australia actually for a year but
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i don't know that was like back in, God knows where, a long time ago.
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But I don't know what it's like over there, but over here, there's still courses,
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which still treating therapists or building therapists up to be kind of like operators, fixers.
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You kind of spend a minimum time listening and then you just think,
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well, I'm going to do some cross-fiction here. I'm going to do some of this.
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I'm going to do some of that. I'm going to give you this exercise.
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And there's still not enough listening to the patient.
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So one of the things I really enjoy and I have really enjoyed about listening
17:46
to you guys about tendinopathy is I think it really, really shows how much you
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do need to listen to the patient because there's so many things they could be
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doing which are irritating this.
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And regardless of the incredible things and the ways you could bring down pain
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and that patient could walk out feeling like, oh, it's gone.
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On are you amazing have some money if they go back and
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like you say they're spending their lot of time doing
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something which involves deduction at the hip or if they are dorsiflexing and
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therefore annoying the insertion for the achilles then you're not helping them
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so it's really nice to hear something which does involve i mean it's always
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the case but yeah listen to the patient and they'll tell you what's wrong listen
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to more and they'll tell you how to fix them,
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and i think we're in a really privileged position in our professions because i think people.
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Feel safe that's one of the really important
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you know the therapeutic alliance is really strong and
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I think that gives us a really privileged position because I
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think our patients do feel in a
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position to share and so we don't often have the traditional we often have longer
18:48
with our patients than some of our medical colleagues and people might take
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some time to get into it so at the start if we're sitting there doing our subjective
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we might get this much and then as As we're moving through the appointment and
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working with that person, they just keep layering on the information.
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So actually, the data they're giving us goes for the entire time.
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And I think we're in a very lucky position compared to some of the other professions.
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So we get a head start, I think, Matt.
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When you say we, like you get longer, why is it you get longer than other physios
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then? What's the deal there? Because you're private practice?
19:20
No, actually, I'm not private practice. I just choose to take longer.
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So I just schedule longer. So I work at the Victorian Institute of Sport and
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I work at the Australian Ballet and I just take longer.
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And then if I'm asked to see someone privately, I just take longer because I
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think that's really valuable.
19:37
That's great. And you did, you nailed it on the head. It's true.
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I mean, a lot of, a lot of our sport, because sports therapists,
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some sports therapists now they can get into NHS and they can work with other
19:48
allied health professionals, but the majority of it is private practice.
19:51
And there's some get really frustrated with that, but they forget the fact that
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they're being given a patient who is going to come for an hour.
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And they probably have been let down by a long list of 15 minute visits because
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you can't get that alliance. And so a lot of our listeners, I believe,
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are super privileged and haven't even quite realized yet.
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But the skill is not spending an hour of doing massage. It's not all the time.
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It might be a session for that.
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It's going to be spending that time listening, like you say, peeling off the layers.
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It's a big power to have. It's exciting, especially we mentioned this before as well.
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If you are somebody who spends, who does increase maybe that therapeutic alliance
20:27
by putting your hands on someone, because that whole primal grooming thing,
20:30
that's a massive connection. It's almost prepared to take their clothes off
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in front of you, lie down, not even see you and just say, yeah, fine, go for it.
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That's like, you've already got a massive alliance there. So a lot of trust.
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Absolutely. Isn't it? It's huge.
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And that's why we get the criers, people. We've all had them,
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massage therapists you've taught, and it really does happen because you are
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allowing people to peel off those layers and then start telling you what's really
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going on and what could be. Yeah. So fascinating.
20:55
So, yeah, the compression, you mentioned some great examples there of where
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people could be potentially delaying recovery.
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And you also kind of mentioned, I want to go into this as well,
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because there's a lot of debate about this.
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You mentioned that we bring this up on the big screen for people who have given
21:08
their time to join us live.
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This one, this one, which we said off air, I mean, it's down here on ResearchGate.
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It's Best Paper, which I thought was very big of you all.
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You're the number one author there. So I find it hard to believe that that wasn't
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your title for the paper.
21:21
Best paper exercise to reduce tendon
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pain a comparison of isometric and isotonic muscle contractions and
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efforts on pain cortical inhibition muscle strength so yeah
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isometric and isotonic you kind of mentioned it there but
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what is this role of isometric and isotonic
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is there an order people should be following with tendons or what's the research saying
21:40
about that i just want to clarify five that i
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did not like your number one
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also on there so i mean maybe someone else
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so yeah this best paper you did yeah what did you find from it okay so when
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we think about tendon load and we've got our you know our spring load and our
22:00
compression our combination and then our friction load we then go okay that's
22:04
how we listen to our patient about whether or not we think they've got tendinopathy,
22:08
it gives us an opportunity to provide some really good advice about removing provocative loads.
22:13
So every time you see someone with a tendon injury, and that word's deliberate,
22:18
we can get to that in a minute.
22:19
Every time you see someone with a tendon injury, I want you to give them two
22:23
pieces of advice to remove their provocative load.
22:26
So for gluteal tendons, you know, not crossing your legs.
22:31
For Achilles tendons, not stretching, getting them in a shoe with a nice high
22:36
heel, just really thinking through two simple things you could give them to
22:41
do that supports your treatment and their treatment plan.
22:46
Then when we go, okay,
22:48
that's the provocative load as i
22:51
said the the kind of reverse of that is what safe
22:54
loads can they start with if someone has tendinopathy that
22:57
can actually immediately start with either isometrics or
23:00
isotronics or both because they're both completely safe start loads because
23:04
anything slow or static is easy for a tendon so if someone has insertional achilles
23:09
or mid-portion achilles i might start them on an isometric calf raise out of
23:14
compression so that would mean
23:16
matt for of the insertion that I'm up quite high into plantar flexion.
23:19
And I might look at what they can do. Can they do it on two legs holding on?
23:24
Can they do it on one leg holding on? Are they quite athletic and I need to
23:28
add some additional weight? Or can I just start them on calf raises?
23:32
And giving them the confidence that these are safe start loads really supports
23:37
them that exercise is the best management for them, which is the evidence that we have.
23:42
And it gives them the confidence to get going.
23:45
So often get asked, do you have to start on isometrics? Of course you don't.
23:49
No one's going to come around and hunt you down.
23:51
It's actually about what's the best exercise that gives that person the confidence
23:57
and empowers them to get going.
23:59
And for some people that are really kinesiophobic or really worried about exercise
24:03
or might've had a bad experience, that can be a nice start point.
24:07
But isotonics can be started immediately for tendinopathy.
24:12
So by isotonics just in case people don't know i mean
24:15
concentric eccentric so for a calf raise
24:18
that would be from flat ground going up you
24:21
know keeping the middle of your ankle joint over the middle of your second
24:23
toe so a nice good quality calf rise but the up
24:26
and the down we don't separate out the eccentric only
24:29
that's again that's so nice to hear because
24:32
people do worry that they're doing the wrong thing not all
24:35
therapists some therapists just jump straight in which is the other side of the
24:38
coin which is just as bad but people do worry are they following and the
24:41
right protocol but you've just kind of again you've laid it out say
24:43
well see what your patient's happy with you know look at the person let
24:46
them decide which exercises necessary things the
24:49
best exercise it's just the exercise that suits the patient in that
24:52
kind of period of time so that's interesting to know but again people watch
24:56
out because in social media which i'm growing i'm going through a really anti-social
25:00
media phase at the moment i'm actually starting to i used to follow people who
25:03
annoyed me just because i wanted to hear what they were saying i wanted to challenge
25:07
my biases and i thought it was really healthy and i told other people to do it.
25:10
I've got to the stage now where if people talk in a certain way,
25:13
I just start following them because they get me down.
25:15
So on social media, there is this always polarised debate and people say,
25:19
oh, no, the research has just shown that isometrics makes no difference between
25:22
isometrics and concentric because we've shown this in this study. But.
25:26
Why do these arguments exist? It's about the patient in front of you, isn't it?
25:31
Correct. And, you know, so for me, I'm very simple.
25:36
If someone has tendinopathy, which means they're provoked by rate of loading
25:40
and their pain is quite focal, then the definition of that is that they can
25:47
do isometrics and isotonics safely.
25:49
And neither of those are enough. We need to build them up and restore their
25:52
spring and get them doing faster work.
25:54
But if someone has diffuse pain or
25:57
pain that gets worse the longer you go so i gave you the
26:00
example of cyclists and swimming but the other the
26:03
other dead giveaway for a peritendin condition or a
26:06
peritendinitis or a peritin on they're all the same thing the sheath is that
26:11
they get worse the longer they go so just say matt you have a runner that starts
26:15
running in the beginning their calf is kind of coping and they're kind of quasi-isometric
26:20
as they fatigue they start to overload the peritendin.
26:23
And so the runner that doesn't get pain until they're five kilometers in,
26:27
that's not tendinopathy. That is peritendinitis.
26:30
And they need to be managed differently because they do terribly with heavy
26:34
isometrics. They do terribly with isotonics. So for me.
26:39
The more heterogeneity or the worse we are as researchers at including an absolute,
26:45
licorice all sorts of patients into a study, the more we're going to read stuff
26:50
where some people got better, some people got worse.
26:53
Some people say the same, more research is needed.
26:55
I mean, kill me now, better research is needed.
26:58
So I feel really passionately about that. The first thing I do when I'm reading
27:03
a study is I go to their methods section and I look at how they diagnose tendinopathy.
27:07
And if it's rubbish, you know, if I'm reading a study on patellar tendinopathy
27:13
and they have a big cohort of women, I'm immediately skeptical because it's
27:18
actually very uncommon in women.
27:20
If they have, you know, very few volleyballers and people that do like running,
27:26
running's not high patellar tendon load.
27:28
So I'm immediately skeptical that they actually just have a whole lot of people
27:32
with patellofemoral joint pain who hate heavy leg extension.
27:36
So, of course, you then conclude, oh, you know, it doesn't, you know, it didn't work.
27:40
It's all about understanding tendons. And I think clinicians do it better than researchers.
27:48
Very interesting. That's quite a big statement there. We're going to cause some
27:51
outrage on Twitter. But yeah. Well.
27:55
Which you avoid now, I just had to add. I'm not on Twitter. No.
28:00
No, no, no. Anyway. Anyway. I don't remember the question.
28:04
We won't lower ourselves down to that no but yeah the
28:07
the fact that it's yeah it's the patient
28:10
in front of you who decides what you give them and the and the more
28:13
you move away from that then probably and the more
28:15
you're going to move away from the solution for this person in front of you
28:19
so yeah it's really cool to hear that from the horse's mouth as it were so you
28:23
kind of started talking then about um recognizing tendinopathies because one
28:28
of the things we mentioned that was discussed in the other ones was this i think
28:31
i talked to peter about it was the this It's...
28:34
I think he was really laid back. He's so laid back, but he was like,
28:37
he nearly fell off his chair at one point, but it was like,
28:41
I was kind of saying, you know, often we're kind of read and taught that one
28:46
of the potential factors to consider during the subjective is,
28:49
is, oh, it feels better once I start warming up.
28:51
This kind of warm-up reaction isn't there where tendons start
28:54
and if that happens then your ears need to pick up a little
28:57
bit and start looking at everything else you've talked about and maybe that could be it
28:59
but what are the just for tendinopathies what
29:03
other things should clinicians be looking out for to
29:06
to actually not misdiagnose or kind of go down
29:09
the wrong wrong hole great question so you
29:12
need to hear what is their provocative load so their
29:15
provocative load for tendinopathy should be something that involves you
29:18
know speed or rate of loading that's the first thing the second
29:21
thing is their pain remains really focal in the
29:24
lower limb it doesn't move or spread regardless of
29:27
the length of time of symptoms the exception would be gluteal
29:30
tendinopathy where you have you can have some referral down
29:33
the leg usually not past the knee but that can be more diffuse and then the
29:39
third thing is that tendon pain behavior that you mentioned so tendons warm
29:43
up but they're worse the next day so we see that clear mechanical link that
29:48
even though people can have persistent pain,
29:51
it actually remains quite clear for tendons.
29:56
But the things to keep a lookout for, either the differential or the systemic drivers.
30:02
So if we consider the differentials, it would be when someone has.
30:06
You know, the kind of where people feel their pain's a bit random or they feel
30:10
that, you know, it's a bit diffuse or it's kind of hard to pin down or sometimes
30:14
it warms up, sometimes it doesn't, or it warms up a little bit,
30:17
and then it gets worse the longer I go,
30:19
you know, that can hurt at night, that is peritendin.
30:22
So tendons don't hurt at night, again, aside from glutamate because of the compression.
30:27
So if you have someone with night pain, your antenna needs to be up for some
30:31
sort of other differential.
30:32
And the classic is knee pain, sleeping in a bit of knee flexion,
30:36
you get a really achy patellofemoral joint, that's not your patellar tendon.
30:40
So listening to all those other cues, you know, if you've got knee pain, does it swell?
30:45
Because because the patellar tendon is extra articular. It's outside the joint.
30:49
So if you've got swelling, it's not patellar tendinopathy.
30:52
It's something inside the joint. So just putting together all those little clinical
30:57
cues that people come up with.
30:59
Then the classic for peritendin is also the one that gets worse the longer they
31:06
go, either the runner or the swimmer or the cyclist.
31:10
So spending some time on differential is critical. So they've got that morning
31:14
pain and stiffness. The systemic drivers...
31:17
The kind of non-load-induced tendinopathy. So Paul Kirwan has a fantastic infographic called ScreenDom,
31:26
and you can run through those questions with your patients, and it just gives
31:30
you a high index of suspicion to refer them to someone for follow-up.
31:34
So it's things like whether or not people have psoriasis, because that can be
31:39
linked with psoriatic arthritis, uveitis, so a lot of our inflammatory conditions.
31:45
But a really nice screening question or a really nice one to start with is whether
31:51
or not someone has more than 30 minutes of morning pain and stiffness.
31:55
That's a systemic driver as opposed to just a really grumpy tendon.
32:01
Even your grumpiest tendons warm up within 30 minutes.
32:04
So while morning pain and stiffness is a hallmark of Achilles tendinopathy,
32:08
really prolonged symptoms, it's likely to have a non-load induced presentation.
32:14
The reason that's important is people need their disease process managed before
32:19
we can do any rehab or any intervention.
32:22
It's not saying that they won't need some sort of exercise or advice,
32:27
but they actually really need non-load induced strategies first and they do
32:32
worse with load unless their kind of disease process is managed.
32:38
Hey there, Matt Phillips here. Sorry to interrupt the podcast.
32:42
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33:39
Doesn't include already discounted bundles i mean
33:44
normally i wait to the end but there's there's so much you said there i'm
33:47
going to put it in here now if people are interested in
33:51
doing courses and spending time like online
33:54
stuff where they can work through it themselves because there's an awful lot
33:56
of information we're saying you know clinicians need to be informed to be able
34:00
to help people tendinopathy and and all sorts of things but tendinopathy in
34:03
particular what have you got out there at the moment where where you think it
34:06
would be worth people tapping into course wise So I did a course for Physiopedia,
34:12
which I think its birthplace is the UK.
34:14
And so that was on pink flags. And pink flags, the flags we don't really learn
34:20
about, but they're the ones that actually promote a kind of positive behavior.
34:26
So we hear about, you know, red flags and yellow flags and all those flags are important.
34:30
Pink is the really good one. So pink flags are the ones that empower people.
34:34
And so I talked about how we can harness pink flags in tendinopathy by,
34:39
you know, promoting exercise, but actually educating people about different tendon loads.
34:44
So I quite like that one because it's very practical.
34:47
I've also, you know, completed some lectures for Physio Network and LearnDot Physio.
34:52
So there's definitely some out there, depending on how deep people want to dive.
34:56
But I'm also told by my kids that there's plenty on YouTube.
35:01
So I reckon just listen to different people and try and put it all together.
35:08
The challenge I think we have, Matt, we've actually just published a paper that
35:12
looked at what people Google when it comes to tendons and where they end up.
35:17
And the terrifying thing for me is that people end up in four different countries,
35:23
we did, and we did every tendon and the questions that they enter and the places
35:28
they end up is Wikipedia and YouTube.
35:31
Now, there's some great content on YouTube, but it is also a platform that anyone can upload to.
35:37
So what I would say is, you know,
35:40
google the person you're listening to and make sure they have some sort of authority
35:44
as well that you can start to discern the kind of the information that they're saying,
35:51
and beware the person that gives you you know this will cure everything like that's rubbish.
35:57
Yeah yeah any one size all approach doesn't really work with humans does it
36:01
cars maybe but not humans doesn't work not that clever yet and that's really
36:05
great advice and we'll make sure the the links which you mentioned um all in
36:09
the show notes people as well but i think i like to think that not just us but
36:13
once you know i think podcasts can be really useful because some,
36:17
podcasts they want to associate if their thing is
36:21
evidence informed but not too evidence informed if they've got
36:24
like a an identity which they want to establish then they're
36:26
going to obviously pick their guests to maintain that identity podcast owners
36:29
like having that you know it's their their reputation as well
36:32
so for example that's true actually you know what i mean i
36:35
hadn't thought about that but that's a really good point yeah yeah
36:38
that's what
36:41
we try and do here i mean every guest i've had on here i've sometimes
36:44
i think about let's get someone on who i really don't
36:48
agree with sometimes we've had some people on talking about certain things i'm
36:53
not going to talk about which i've been a bit skeptical but it's interesting
36:55
to have that sometimes but most of the time i've got people on the show because
36:59
i know that they're going to educate our listeners in a way that I believe is
37:03
conducive to their future and the business and in all their clients.
37:06
So that may be a way of doing it. One thing you said that I really loved is
37:11
evidence informed. So...
37:14
You know, we had a great conversation about language before we went on air,
37:18
but what people need to remember is you can't like take the next paper that
37:22
comes out and goes, I'm going to disregard everything that's come before it.
37:25
What we need to do is think about how we layer it on. And I'm going to give you an example.
37:29
So I do isotonics or heavy, slow resistance or whatever we'd like to call it,
37:34
but I don't do the Kongsgaard protocol in the patellar tendon or the Bayer protocol
37:38
in the Achilles because they're double leg.
37:41
And we also know from other research that people are
37:44
asymmetrical and what we need
37:46
to do is actually use cross-education so exercise both sides but also bring
37:52
our tendinopathy side up to where we need to be and so if we're doing double
37:57
leg we actually never address the asymmetry so be evidence informed and say
38:03
yeah I'm going to do heavy slow resistance but I'm going to do it single leg,
38:06
I'm going to do it each leg and challenge each side.
38:09
So that's three different pieces of information, you know, heavy,
38:13
slow resistance, the asymmetry and cross-air in neuroscience.
38:17
And that's how you be evidence informed rather than kind of recipe based and
38:21
saying, oh, Ebony's just done a new study on isotonic, so I'm going to do that.
38:26
Just take it with, you know, the context of all the other great research that's out there.
38:32
And that can be a challenge but i think that's how we
38:35
should be operating that's great advice and it's
38:38
so nice coming from one of the researchers like yourselves this is a
38:40
researcher saying don't just follow the latest thing i've done you
38:43
know but be informed that's why i kind of like i
38:46
love words as well and and in my own
38:49
mind i like the distinction personally between evidence-based and evidence informed
38:52
i think for me there's quite a difference between the two words i like it you
38:56
know rather than being based everything is about evidence now because we wouldn't
38:59
be doing much if we just did everything we'd be doing nothing no we do not much
39:02
at all so yeah informed but again it's it's yeah language is a beautiful thing
39:06
but i think that's a good distinction.
39:08
Right then. People, you're very quiet. There's lots of people commending us.
39:12
Thank you for your comments.
39:13
And Gary Benson here, founder of the STA, said so many takeaway clinical reasoning
39:18
nuggets so far. There are an awful lot.
39:19
There's a huge amount here. We'll try and make sure they're all signposted.
39:23
I do spend quite a lot of time, people, putting timelines for all our podcast episodes.
39:28
Actually, I'm lying. AI does it all now. I'm going to be honest with you.
39:31
But I do twiddle them so that you can see the most important things in a list.
39:35
So you don't have to listen to the a whole hour to get
39:38
everything you can just find the nuggets on there so what are
39:40
the emojis that steffa has steffa here
39:43
the emojis let's bring this up steffa i think they're happy ones let's
39:46
bring it up oh hold on great info from brian and
39:49
steffa there has got they're not tears are they i hope
39:53
not oh i think no no i think it's a blowy thing it's like
39:55
a celebratory birthday thing no don't worry
40:00
everyone suffers from imposter
40:03
syndrome people there's a classic example there dr ebony rio thought that
40:05
somebody was crying what she'd be saying she thought there she
40:08
is what's going on no it's celebratory and
40:11
thank you also mike grice is in the house hey
40:14
mike how you're doing this is happy 200 episode matt thank you very kind but
40:18
if you've got any questions people please do put them in the comments then to
40:21
attend this is your chance what else have i got on my list of things i wanted
40:25
to bring up we've covered so much already oh yeah you just it's not down here,
40:32
but you mentioned that cross-training thing,
40:33
which kind of blew the mind of a lot of our listeners when Alison mentioned
40:37
it, the comment section suddenly woke up.
40:39
And you are very much into the neuro side of stuff.
40:43
In fact, there's another paper selection I wanted to bring up here,
40:46
which I'll bring on the screen for people who have joined us live.
40:50
I was interested in, was it that one? Oh, no, actually it might be the next one.
40:56
Oh yeah, tender neuroplastic training. The whole neuroplastic thing is something
41:00
which which some people might have dipped into a little bit when we first started
41:05
talking about it a while back.
41:07
But you are taking that and still very much into it. Yeah. So maybe could you
41:12
help? Imagine people don't understand what neuroplastic means.
41:15
Let's take it from there. And what's
41:16
the relevance of neuroplasticity with tendinopathy and pain management?
41:20
Okay. So Professor Laura Mimosley describes us as a changing clump of cells.
41:27
So every cell in your body is actually capable of
41:30
change until the day you die so all of us
41:33
are incredibly plastic so plastic just means change so when we say neuroplastic
41:39
we just mean the cells in our nervous system so our particularly our central
41:42
nervous system so think of your brain your brain is incredibly changeable with
41:47
uh with injury with use so you think of a pianist and the representation,
41:53
of their hands and the dexterity on their sensory and motor cortex.
41:57
So your sensory and motor cortex is just the representation of you in your body.
42:03
So it's a little version of Matt that.
42:06
Depending on how much you use something, will be, you know, bigger or smaller.
42:10
So our hands are really well represented in our sensory cortex and our motor cortex, actually.
42:15
But so are our legs. They're just represented at a different scale.
42:20
And it's like a little backflip. So your feet and your knees are kind of down
42:24
the center, and then it goes in an outward direction.
42:27
And so what we can do is look at the neuroplasticity or the changes to your
42:34
motor cortex with tendon pain or tendinopathy.
42:38
And that's where I started. And my hypothesis was that there would be no change
42:44
in the motor cortex because I started with people, I started with young male
42:47
elite athletes, jumping athletes with patellar tendinopathy.
42:51
So patellar tendon pain at the proximal insertion.
42:54
And because they weren't in pain while I was testing, because they were just
42:58
doing a sustained leg extension, I thought they wouldn't have any changes because
43:03
Because the research that had come before it was experimental pain.
43:07
So I figure, yeah, while you're kind of, you know, testing someone and they're
43:11
in pain, they're likely to look different in terms of that information.
43:16
But I was completely wrong.
43:18
So because I was wrong, I was like, well, that's interesting.
43:21
I need to learn more about it.
43:23
And so the research that I got into with Dawson Kitchell, who was one of my
43:28
supervisors, was really probing how the motor cortex works. and the motor cortex works like a car.
43:35
So we're a little bit like a car. It's a bit, it's a fancy car,
43:38
but a little bit like a car when it comes to our movement.
43:41
So everything we do is actually a balance between our excitability or our accelerator and our brake.
43:50
So you might hear the terms corticospinal excitability, cortico,
43:54
brain, spinal, spinal cord, that's the tract,
43:57
excitability, just think accelerator and cortical
44:01
inhibition so that's literally the brake the neurons
44:04
that synapse onto that motor cortex to kind of
44:07
calm it down so we've got this balance with all
44:11
of our movements whether or not it's something fine motor or whether or not
44:14
we're you know bench placing 200 kilos we have this balance between our brake
44:20
and our accelerator and we can actually look at how the brake and the accelerator
44:25
works for different movements so So that's what I did as part of my PhD.
44:30
And we found that people that had patellar tendinopathy had changes to both
44:33
their brake and their accelerator.
44:35
So then the clinician in me said, okay, well, how well does our current treatments work?
44:43
Address the brake in the accelerator. So if we look at the deficits or the changes
44:48
in someone that has tendinopathy, we know they have pain.
44:51
We know they have changes to kind of strength and capacity, but what about kind
44:56
of motor control or motor drive or, you know, the brake in the accelerator?
45:00
So then I started kind of categorizing our different interventions.
45:04
And if you take something like blood injection or PRP injection,
45:08
we can then evaluate it. We can and say, well, does it do anything for pain?
45:12
The research would say no. Does it do anything for strength?
45:15
The research would say no. Does it do anything for motor drive?
45:18
No. We can't be surprised it doesn't work because it doesn't actually address
45:22
the deficits of the person in front of us.
45:25
So, okay, let's take something like exercise.
45:29
There's evidence that it helps pain short and over time.
45:33
There's evidence that it helps strength, but actually in its current form,
45:36
If we just send someone off to the gym and get them to do the exercise,
45:40
it actually doesn't change motor drive.
45:42
But if we pair that exercise with something like a metronome or some sort of
45:47
skill-based constraints, we can actually change our brake and our accelerator.
45:53
So that's where the metronome training really came from.
45:56
It's from neuroscience and it's got a ton of research in the neuroscience space.
46:02
It also helps cross-education. as you mentioned it actually augments cross-education
46:06
so neuroplasticity is just.
46:09
The the art and the science of our brain changing over time and with use but
46:14
it's actually something that we can change in real time as therapists which
46:19
is kind of cool very cool and it's and a wonderful uh commend you it's a fantastic
46:25
way of explaining as well it ties in maybe this
46:29
obviously this will the the role of neuroplasticity and
46:32
everything kind of all ties in i think with things
46:35
we've already talked about like the relevance of language we use and all
46:37
the sensory input because that can all cause changes and
46:41
blur things and clear things up in in the brain as well
46:44
so because that kind of ties in also
46:46
like cecily here has asked a
46:49
question here which kind of ties me with what i want to say so what can massage therapists
46:52
do to help tendinopathies and i'm not going to mention cross-fiction thank
46:55
you cecily thank you much because a lot of our
46:58
listeners are massage therapists then the
47:01
role they can have through massage if like a modern therapist like cecily realizes
47:05
she's not probably having any effect through mechanotransduction or anything
47:09
by doing cross-fiction she's not stimulating you know restoration of that matrix
47:14
or anything but what could she be doing up here with with regards to what you've just been saying.
47:19
Yeah i think i think.
47:22
Number of things. So I think advice and education around removing the provocative
47:28
load is really powerful because if people go to the internet,
47:31
they'll be told to stretch and ice and neither of those things are helpful.
47:35
In fact, stretching is potentially provocative. So don't underestimate the value
47:39
of listening to your patient and the provocative load and giving them some strategies
47:44
around how they might remove it,
47:46
whether it's removing stretching for your postmenopausal
47:50
a woman with gluteal tendinopathy giving them some advice about sleeping
47:54
positions can be really valuable so the you
47:58
know the ability to listen and then provide
48:00
some strategies is really really important I think
48:04
for me manual therapy and I still do manual therapy
48:07
where manual therapy fits is as an
48:10
as an intervention it can help
48:13
people because they can feel better and it can support them to do their
48:16
exercise program it doesn't cost a lot of money and it
48:19
doesn't do any damage each so for me that sort
48:22
of intervention fits nicely as
48:25
an adjunct to exercise therapy so good advice
48:28
treatment that allows people to do their exercise but also positive language
48:32
around exercise and you know we produce some infographics actually for just
48:38
trying to support people so even helping people to access good quality resources
48:44
so the just resources matt would you
48:47
know, if you have Achilles tendinopathy and you don't particularly want to be elite,
48:50
but you want to self-manage, when should you listen to your tendons?
48:54
What should you kind of avoid in the short term? And what are some safe start points?
48:59
You know, something like that could really support your treatment,
49:02
Cecily, to empower your patient and support what you're doing,
49:06
but also give good quality information.
49:08
And don't underestimate the value of removing the terrible information.
49:15
You know, they get so much noise and sometimes just helping them distill it
49:18
down into, okay, remove this, add this because it's safe. And here's how I want you to self-monitor.
49:24
So just teaching people to listen to their tendon 24 hours after their load.
49:28
And I did a bit more, I was a bit more sore.
49:30
No problem. Continue with your calf raises. They're super safe.
49:34
Keep going. And then next time you do that exercise, just back off a little
49:39
bit and see see how you pull up the next day and you can really empower people to manage themselves.
49:45
Great. Excellent answer. Thank you so much. I mean, I hope that helps you out, Cecily.
49:51
Yeah, I mean, I champion so much the power that massage therapists and anybody
49:56
through the power of touch can have on education, on breaking those barriers
50:01
that, you know, just get people to listen and go, really?
50:03
Do you really think I should stop
50:04
that stretching, even though the whole Internet is saying I should do it?
50:08
In this particular case, I don't want to get bad mouth for stretching.
50:11
Can be really useful i'm not well easy tigers get those
50:14
fingers off your twitter buttons i'm just saying in this case for example
50:17
for them to change that it's all about behavior
50:20
isn't it it's some people it's really not easy changing someone's
50:23
behavior and if people especially if they're in pain even more difficult so
50:25
yeah behavior change not for everybody not
50:28
everybody likes being touched not everybody will will need that
50:31
if they've come to you and they know that what you do as profession is
50:34
touching other people make them feel good then wow you could
50:37
educate them so much either not and not
50:40
just before i think we talked about this with somebody else on the show it
50:43
doesn't it's not a case of just in the subjective while you're massaging them
50:46
what a great time to actually say you know what i read the other day
50:49
on on this podcast you know i was talking about the sta podcast this
50:51
lady a lovely lady australian i think she was and dr
50:54
ebony ria she was saying and that person just like a sponge going oh i should
50:58
try that that's so interesting you said that because bam and then they tell
51:01
you something else which they haven't told you in six months and you go that
51:05
is why we're not recovering that's why so you need to change that and do that
51:08
so huge power cecily especially people like yourself who who are sponges and and and not.
51:14
Angry at the thought that a lot of what you have been
51:17
taught originally needs tweaking a bit you know so yeah
51:20
brilliant i'm glad you asked that question cecily i hope that helped it's
51:23
a great question it's a great question where are we 956
51:26
in the uk oh i think i might go to bed soon sorry not
51:29
rubbing it in you've got a whole day in front of you haven't you what's your daily like what
51:33
have you got oh it's it's pretty busy i've got a i'm starting
51:36
with a dentist appointment for my youngest who's got a sore
51:39
tooth and then off to work and then i've got basketball tonight
51:42
but are you going to tell your youngest that the pain is just all in her head
51:45
and she just has to kind of man up or is that a bit of a is that not the right
51:49
message i don't i don't reckon that's a good way to finish that i thought that
51:54
was the message from laura mostly i thought that i thought that had all been
51:56
dismissed now and he was nothing anymore now i've been reading twitter,
51:59
no great great message so right so links if
52:02
people do want to follow you you are i admire the
52:05
fact you're not all over social media and that's why i think i'm being a bit
52:08
cynical with social media you because so many of your knowledge i respect the
52:12
fact that you're not over there the whole time but if people do want to contact
52:15
you then your email address i will put in the link is that okay people want
52:20
to yeah that's fine can't guarantee it'll be like a quick response but.
52:26
Yeah no yeah you have to send a carrier pigeon to australia i'm old school,
52:32
yeah so we will put that into the it's or it's e you
52:34
can listen to it now if you want but e.rio at the trobe.edu.au but we'll put
52:40
that in the links and then we will put links to courses which were involved
52:43
in in various places including physopedia with rachel low i think in the uk
52:50
so we'll make sure that goes in there as well as with the other people you mentioned.
52:53
I didn't pre-warn you but we'd like to try and finish the show with a dance
52:59
no not really a dance with a putting putting theory into practice i mean you've
53:04
already given so many things but,
53:07
But if you could, I'm going to give you a minute now to think of this while
53:09
I tell people who next week's guest is, but just kind of the top three,
53:14
if you like, things which you think people should be aware of.
53:17
And you might have already said them, but just to end on this,
53:19
in terms of managing pain with tendinopathies and that tendon pain,
53:23
three things people should really
53:24
take home and start doing maybe tomorrow when they go to clinic. Okay.
53:30
Meanwhile, whilst Dr. Ebony Rio is thinking of which to choose and the many
53:33
things which he says so far.
53:34
Just to let you people know that next week, next Tuesday, back at the normal
53:38
time, at eight o'clock UK time, we're going to have the wonderful John Scriven
53:42
of Move Well from Jersey.
53:45
He's going to be with us. Some of you may be aware of Johnny from Therapy Expo.
53:50
He was there, part of the Hands on the Hub team with Anna Marie Mazzieri,
53:53
a lovely guy and really just a genius when it comes to explaining what he calls physical literacy.
54:00
And it's a lovely way of putting it. And actually, no, it's not here.
54:03
Is he'll be the first one to say that's not his wording but he goes into explaining
54:06
what physical literacy is so it's going to be yeah move well at eight o'clock
54:09
next tuesday which you've listened to podcast um it's going to be the 11th of june,
54:15
Yeah, 11th of June, next Tuesday, 8 o'clock UK time, Move Well Physical Literacy
54:20
with special guest John Scriven of Move Well.
54:23
Check him out, his website, and then you'll have a little idea of what that's about.
54:27
Right, Dr. Ebony Ria, what are people going to take away from this?
54:30
What are they going to put into practice?
54:32
Okay, now your diagnosis. So do you have someone with tendinopathy,
54:37
focal pain, it warms up, it's provoked by high tendon load, so rate of loading,
54:42
speed, spring? bring? Or do you have peritendinitis?
54:46
Diffuse pain, doesn't warm up, a little bit random in terms of its presentation.
54:51
If you have tendinopathy, then what you need to do is remove the provocative load, but not all load.
54:57
So remove the compression, just bring their loading down a little bit,
55:00
but don't take them off everything.
55:02
They're safe to start, isometrics and isotonics.
55:06
If you have peritendinitis, you need to remove their movement load so you can't treat them the same.
55:11
So my top tip would be remove the provocative load with tendinopathy, but not all load.
55:16
Don't rest people. You'll actually just reduce their capacity.
55:19
My final thing to finish on is when I try and frame education for a patient,
55:26
I think of Laura Mimosley's four questions of self-efficacy.
55:29
So people want to know what's wrong with me, what can I do about it,
55:33
what can you do about it, and how long is it going to take?
55:36
So work out which aspects of those four questions you can be part of and answer
55:41
and work out who else you need to bring into their team to support that person
55:45
to be able to move well and to get back to what they want to be able to do.
55:51
That's brilliant. Can you say those four again?
55:53
So people want to know. So this isn't mine. This is Loz's.
55:57
What's wrong with me? What can you do about it?
56:02
What can I do about it? And how long is it going to take?
56:06
That's a lovely way of putting it. That's great. yeah that should be on and that's
56:08
how i always think i'm like right people want to
56:11
leave with some sort of idea around diagnosis they will
56:15
they they want to know what can i do about it
56:17
and what i can do about it might be helping them with
56:20
their exercise supporting them with manual therapy giving them good advice around
56:24
removing the provocative load what can they do about it here's their safe start
56:29
loads here's the things to avoid in the short term how long is it going to take
56:33
can be a little bit trickier but what you're really looking at what's the difference
56:36
between where they are now and where they want to be.
56:38
And we know that if they've got big strength deficits and that's going to take
56:42
a few months, it's going to take a bit longer.
56:44
So you don't have to give an exact number there.
56:46
It's more giving people expectation management.
56:49
Oh, I'm going to fix you this week is quite different to actually tend to take time.
56:54
You've had pain for a long time and you've been unloaded. It's going to take
56:58
us some time to build you back up, but you're going to do really well.
57:01
Pretty so empowering your patients
57:04
are so lucky that's great amazing i love those four things that's so
57:07
much for people to think about even write down on your kind of like that you
57:11
know that board the patient can't see just have it there at the top written down
57:13
and that'll be your new guide it's a lovely way of looking at it to make
57:16
sure you don't leave any of those out fantastic right is 902
57:20
like i say here thank you so much people joining us live cecily
57:23
his hub has come back saying great advice thank you very much brian huxley
57:26
has said i'm just bringing these messages up on the screen if you listen
57:29
to the podcast and thank you ebony excellent episode to celebrate the 200th it's
57:32
true they would we we couldn't have celebrated it without
57:35
you thank you ebony for showing your expertise and experience with our valued members and
57:38
listeners says gary benson founder of the sta so yes
57:41
indeed and thank you as well i mustn't let you go without saying
57:44
thank you to the other people who are involved in this series
57:48
so we had part one episode 198 with professor
57:51
peter maliaris which was tendon treatment what the research says
57:54
all these available obviously on youtube if you want to watch the
57:56
visuals or if you want to listen to it just find it on any popular podcast
58:00
app in part two a couple of weeks ago we
58:02
had episode 199 which was understanding tendinopathies
58:06
of the hip and pelvis with the wonderful dr allison grimaldi which
58:09
again you can listen to in your own time and then tonight you
58:13
have had the pleasure of spending an hour with in part
58:16
three episode 200 was managing tendon pain with special.
58:19
Guest my guest tonight dr ebony rio so it's
58:21
been an absolutely fantastic it feels longer than
58:24
a month or three weeks because there's been so much information but i
58:27
do thank you ebony really thank you for giving up your time really
58:30
appreciate it thanks for having me not always
58:33
at all i'm going to shut the live lounge down now ebony if you cannot
58:36
touch any buttons i just want to say thank you to again once more once everybody
58:38
that's it hands up well i can see them but we can tell you got kids kids put
58:42
your hands there that's it don't move yeah i'm going to say thank you to everyone
58:45
who's joined the live lounge and again just once again thank you everybody who's
58:48
got us to episode 200 we wouldn't do it if there was no downloads and obviously
58:51
what's the point but we we thank Thank all your feedback.
58:54
And we know we're making a difference. We thank all the educational staff who
58:57
have sent us emails saying thank you as well.
58:59
That means a load to us knowing that the information from our amazing guests
59:02
is getting put out there because that's what it's all about.
59:04
It's all about disseminating this information for free and obviously giving you opportunities.
59:09
If you want to go down a path of spending some money for some quality CPD,
59:12
then hopefully we're giving you a selection of choices as well for you to choose
59:15
freely from without shoving it down your throat and giving you the link to something
59:20
which also makes us money.
59:21
We don't do that not on the sta we are a non-profit organization and
59:24
we're just here to support soft tissue therapists impartially and
59:28
without any biases so there we go right that's it thank you very much hopefully
59:32
some of you have used the podcast you can join me next tuesday eight o'clock
59:36
uk time for move well physical literacy with john scriven of move well but to
59:40
end tonight thank you again once again to dr ebony rio thank you very much.
59:45
Music.