Podcast Outline Overview

I had a wonderful discussion with Alex Murray the rehab Podiatrist which ebbed and flowed and covered a range of topics related broadly to clinical reasoning and decision-making.

I really feel like recent graduates and students will get a lot out of some of the topics including really learning how to tailor assessment and treatment to the individual and their own Values. This is in contrast to what we are often taught through universities and we tend to come out with set plans, procedures, protocols etc. Whilst these are still useful as Alex says, it’s important to know when to deviate from these and how to be a little bit more fluid within your sessions with patience.

Alex’s Journey and Evolution as a Clinician

Alex shared:

• What inspired him to pursue podiatry and later become a clinical educator and mentor?
• Key moments or influences that shaped his approach to clinical reasoning and decision-making.
• How his background in strength and conditioning informs his clinical practice.

3. Clinical Reasoning and Diagnosis

Alex shared:

• The systematic approach he uses to arrive at a diagnosis or differential diagnosis (DD).
• The importance of constantly reviewing and updating the diagnosis.
• How and when to integrate imaging results into clinical reasoning.

4. Treatment Selection and Management

Alex discussed:

• Method for selecting appropriate treatments or management strategies for patients.
• How he monitors progress and updates treatment plans if necessary.
• The role of outcome measures in informing and adjusting treatment strategies.
• How he incorporates clinical evidence into his treatment choices.
• The balance between clinical experience, patient preferences, and research evidence.

5. Philosophical Approaches to Clinical Reasoning

• • Discussed the hierarchy of evidence, with meta-analyses and systematic reviews at the top.
  • Explored the concept of evidential plurality and dispositionalism.
  • Challenged the traditional view that higher forms of evidence always trump lower forms, highlighting the value of various evidence types in different contexts.

More details

Alex really dived into the importance of communication and provided some fantastic insights into how to communicate clearly with the person in front of you to improve your appointments and outcomes.

We discussed the common trap that clinicians fall into. I’ve just trying the next thing when something fails. Rather than getting into this trap of just trying treatment after treatment Alex encourages clinicians to pause and reflect with the patient what it is that they really want. This shows that treatments and treatment outcomes are really tired back to the person’s goal or desired outcome.

Our discussion also touched on patient entered Care and how this doesn’t mean that we need to always have the patient take the lead. There are certain individuals who come to us much prefer the clinician to lead the process and even potentially decision-making process. It comes back to a much more individual approach to treating each person rather than, this dogmatic approach where we consider patient had Care as just reflecting everything back and asking them what they think.

Alex said his process of coming up with a diagnosis and even differential diagnosis and how he tries not to hold too fairly onto these especially initially until he has collected more data. 

He also shares how he approaches treatment and really informs the patient through the process how this treatment works and why it should work for this particular diagnosis that is the latest working hypothesis. 

There are a lot more clinical gems in this podcast and I really hope you enjoy this episode.

Please leave a review

If you do enjoy this episode or any of the episodes, I would really appreciate you taking the time to leave a five star review as it helps the Podcast reach more people and hopefully help spread more evidence informed information within healthcare.

Where can you find more about Alex?

Socials: https://www.instagram.com/therehabpodiatrist/

Education website: https://education.therehabpodiatrist.com/free

Website: https://therehabpodiatrist.com/

Introduction:

• Welcome back to the Be Strong Physio Podcast!
• Today's guest is Beau Walker-Tyrrel, known as The Stress Fracture Physio, who is an expert in Bone Stress Injuries.

Interview with Beau Walker-Tyrrel:

• Beau shares his journey into specialising in bone stress injuries and discusses his passion for the field.
• He explains what bone stress injuries are and the importance of understanding them, including the continuum from bone stress injuries to fractures.

Key Topics Covered:

• Explanation of Bone Stress Injuries: How they occur and their impact on runners.
• Clinical Presentation: How bone stress fractures typically present in a clinical setting.
• Risk Factors: Identifying factors that increase the likelihood of bone stress injuries.
• Importance of RED-S: Beau discusses Relative Energy Deficiency and its significance in bone health, along with screening methods.

Clinical Management:

• Screening Techniques: Methods used to screen for bone stress injuries.
• Imaging Requirements: Types of imaging necessary for diagnosis and monitoring.
• Risk Stratification: Strategies for differentiating between high-risk and low-risk patients.

Conclusion:

• Thank you, Beau Walker-Tyrrel, for sharing your expertise on bone stress injuries!
• For more information and to connect with Beau, find him on social media here [Link to Instagram].

Stay Connected:

• Visit [Be Strong Physio website] for more information about Geoff Ford Physio including if you would like to book an appointment.
• Follow us on [Instagram] for updates and discussions.

On this episode it was a privilege to have Physiotherapist Kevin Wernli on the podcast. 

Kevin is physiotherapist, has completed his PHD on low back pain at Curtin University and is a great communicator. 

This is a great episode to listen to if you currently have low back pain or help people who do.

We covered the 10 facts about low back pain which are:

1. Persistent back pain can be scary, but it’s rarely dangerous. 
2. Getting older is not a cause of back pain. 
3. Persistent back pain is RARELY associated with serious tissue damage. 
4. Scans rarely show the cause of back pain. 
5. Pain with exercise and movement doesn’t mean you are doing harm. 
6. Back pain is not caused by poor posture. 
7. Back pain is not caused by a “weak core”. 
8. Backs do not wear out with everyday loading and bending. 
9. Pain flare-ups don’t mean you are damaging yourself. 
10. Injections, surgery and strong drugs usually aren’t a cure. 

We then took a deep dive into posture and movement and their relationship to low back pain and how they change as pain improves. This was the subject of Kevin's PHD research and included some fascinating examples of people's lived experience both with disabling back pain and then after the treatment, reflecting how how their movement and posture and fear levels had changed. 

Ten Low Back Pain Facts – VIDEOs (most shared resource with patients)

Back to basics: 10 facts every person should know about back pain

From Protection to Non-Protection (Mixed Methods)

Does Movement Change When Low Back Pain Changes? A Systematic Review

The Relationship Between Changes in Movement and Changes in Low Back Pain: A Systematic Review of Single-Case Designs

Movement, posture and low back pain. How do they relate? A replicated single-case design in 12 people with persistent, disabling low back pain

Systematic literature review of imaging features of spinal degeneration in asymptomatic populations

Empowered Beyond Pain podcast

Empowering you to manage pain

RESTORE back pain information page

Becoming confidently competent: a qualitative investigation of training in cognitive functional therapy for persistent low back pain

On this episode I spoke with Frances who is a Sports & Exercise Physiotherapist who has a special interest in bone health. 

On this episode we dived into all things bone health and what we can do to optimise it, particularly from a physical activitiy perspective. 

We discussed why you should care about your bone density.

We clarified terms like osteoporisis, osteopenia, and what the consequences of these conditions are. 

We then went through what you can do about your bone health no matter what stage of life you are.

Resistance training - and specifically what types of exercises and how intense they need to be.

Impact training - multi-directinoal and why bones become deaf to repetitive loading.

On this episode of the podcast, I was incredibly excited to be joined by Adam Meakins to discuss his back injury and how he recovered from it.

The aim of the podcast was to provide people who might be in a similar situation with acute, severe low back and possibly leg pain an example of how a Physio was able to self manage and get back to full health and fitness without anything fancy.

It's my hope that this episode is a resource for clinicians and people in pain alike. When you are severe pain it is normal to have fear and concern but I hope this episode can provide some hope of the amazing ability of the body to heal.

If you want to check out Adam's original back injury video you can do so here: https://twitter.com/AdamMeakins/status/1557775099721293825

All of the videos are great to watch and you can find them on Adam's Instagram if you scroll back to August 2021: https://www.instagram.com/adammeakins/?utm_medium=copy_link

More details about what we chatted about follow.

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We dived into a great discussion about what happaned as well as the reocvery process he went through.

Some of the recovery principles that came up include:

• Stay active but also allowed to rest 

• Do movements that feel good - do you need to push into pain to restore eg extension 

• Analgesics and sleeping medication 

• Hot baths / water bottles 

• Patience 

Criticism he copped

• Should see a physio, get scans etc 

• Manual therapy 

• Specific exercises (McKenzie) 

• Self blame - technique 

Evidence about specific treatments / exercises

• What does the evidence say about whether any specific treatments are superior to others? 

• Do people need to get manual therapy for acute back pain? 

• Does this mean they shouldn’t get manual therapy just to anticipate a common strawman argument? 

• Is this negative or does it provide people more choice?

If people want to see a physio

Advice for members of the public who might want some guidance from a healthcare practitioner, what should they look for and what should they be wary of?

Why did he get injured?

Upon reflection with the aid of hindsight, what factors do you think might have contributed to your injury? Can we take any lessons from this?

• Technique? Evidence

• Programming - RPE, Training history with COVID

• External factors that could have placed a stress on your system?

• Shit happens?

Fear avoidance - deadlifts

How hard was it to get back into deadlifts? Do you still have any residual fears or concerns in the back of your mind? 

I really hope you enjoyed this episode. If you did I would be incredibly grateful if you could please leave a review on your favorite viewing platform. 

Geoff Ford from Be Strong Physio 

On this podcast I was excited to have Neil Meigh, AKA the Kettlebell Physio on to discuss his research known as the BELL Trial. 

We dived into:

• The outcomes from the paper which were phenomenal. 
• The exercises the participants performed. 
• The question of how important is technique.
• How much forward force is really produced by a hardstyle kettlebell swing.
• Practical tips and takeaways for people who want to learn kettlebells as well as clinicians looking to include them in their practice. 

Neil papers:

Meigh, N.J., Keogh, J.W.L., Schram, B. et al. Effects of supervised high-intensity hardstyle kettlebell training on grip strength and health-related physical fitness in insufficiently active older adults: the BELL pragmatic controlled trial. BMC Geriatr 22, 354 (2022). https://doi.org/10.1186/s12877-022-02958-z

Meigh, N.J., Davidson, A.R., Keogh, J.W.L. et al. “If somebody had told me I’d feel like I do now, I wouldn’t have believed them…” older adults’ experiences of the BELL trial: a qualitative study. BMC Geriatr 22, 481 (2022). https://doi.org/10.1186/s12877-022-03174-5

On this podcast I chatted to Jono Steedman who is a dietitian and nutritionist about:

• How people can optimise their nutrition if they are trying to recover from an injury
• Are there any specific things that he recommends for different types of injuries
• Are there any vitamins or supplements that he recommends people take to optimise thier health
• Once people have recovered from their injury and have returned to the gym, what should people be looking to include in their diet to optimise their gains in the gym and long term health?
• Are their any specific diets he recommends
• Sufficient v adequate protein intake

You can find Jono on Instagram at jonosteedman (https://www.instagram.com/jonosteedman/?hl=en)

Steve is a Physiotherapist and Strength and Conditioning coach who is passionate about helping healthcare professionals improve their critical thinking skills as well as practical skills to apply to make them better clinicians.  

In this podcast we discussed applying principles rather than methods in both physio and strength and conditioning. 

We talked about common example you see of how healthcare practitioners might be guilty of following a method rather than applying principles.

What counts as knowledge in healthcare

In 1996 David Sackett commented upon a simplified framework for considering EBM. This framework consisted of the best available external evidence, clinical expertise, and patient values/circumstances to help guide the clinician.

Steve, do you use this framework or something similar, and do you have any tips on how young clinicians can utilise it to guide their decision making process?

You can listen to Steve's RPE podcast here: https://podcasts.apple.com/au/podcast/the-rpe-podcast/id1662487686

Steve's instagram: https://www.instagram.com/steve_coach_physio/?hl=en

Some articles Steve referred to:

Hegel's Thesis-Antithesis-Synthesis Model 

https://link.springer.com/referenceworkentry/10.1007/978-1-4020-8265-8_200183

Blooms Taxonomy

https://www.frontiersin.org/articles/10.3389/feduc.2020.00107/full

On this episode I spoke to Kieran Richardson who has a special interest in Non-surgical Management of ACL injuries. 

We dived into a bunch of exciting topics including:

• Do early ACL reconstructions lead to better patient outcomes?
• Are ACL reconstructions necessary to return to sport?
• Do ACL reconstructions help prevent further knee damage?
• Do ACL reconstructions reduce the chances of osteoarthritis?
• Can ACLs heal?

I would really appreciate it if you liked the episode, please leave a 5 star review because it really helps more people find the podcast.

I hope you enjoy it.

Geoff. 

Daniel's story to becoming an evidence based Sports Chiropractor and Strength and Conditioning Coach. 

People and events that have influenced his practice.

Some of the stigmas and false beliefs around him being a Chiro.

Changes he would like to see about the way Chiropractic is taught.

Whether he thinks we will see a combined musculoskeletal healthcare profession one day.

Tips and advice for new gradautes in healthcare.

On this podcast, I spoke to physiotherapist Andrew Wild about his story to becoming a physio and strength and conditioning coach. 

We discussed how he moved away from a strongly passive focus towards providing more active interventions that people could then implement themselves away from the physio clinic.

Andrew shared what a typical initial appointment is like at Wild Physio Fitness including the Wild Walk and Talk Method (patent pending). 

We discussed some common myths and misconceptions around back pain.

Andrew also shared some great tips for those at uni and recent graduates. 

I really hope you enjoy the first episode of the Be Strong Physio podcast!

What's wrong with osteopathy

This episode was based up on the paper What's wrong with osteopathy (link here)?

We explored some of the topics within the paper including 5 key problematic areas for osteopathy:

1. Its weak theoretical basis
2. Inherent biomedicalism 
3. Mono interventionism 
4. Practitioner-centredness
5. Predilection for implausible mechanisms 

You can find Dr Oliver Thomson on Instagram here.

You can find more of his papers here.

Today I welcomed Dr. Tom Cross and Andrew Wild. Today we discuss the Cross Bracing Protocol (CBP), recent CBP research updates, how some ACL ruptures can heal using the CBP, the MRI classification system of ACL injuries that has been developed by Tom and his team, how to manage an acute ACL rupture, criticism of the CBP and Tom’s response to this criticism and much more.

Heal ACL Website: https://healacl.com/

On this episode I sat down with Cameron Faller, physical therapist and educator to discuss some of the shortcomings of the current approach to evidence-based practice and how a move to process based therapy may be the answer. 

We went through the following topics:

Q 1: To begin with, do you mind if we dive into some of the issues or shortcomings of evidence based practice as we know it?

Shortcomings of the current approach to therapy (biomedical model)

• Focussed on biology 

• Has saved lives 

• Struggles to capture the interplay between biological, social and psychological 

• Reductionist problem solving 

Mechanistic world view 

• View body like a machine 

• The focus is on fixing isolated parts 

The idea that we can understand individual trajectories by understanding normal and the

 deviation from normal. They thought that between subject variability was a good estimate of within subject variability. 

• Falsely homogenized group and situationally decontextualised individual units 

• The Bell Curve of the collective only to decontextualized individuals (which is no one) 

• Normative concepts may not be applicable to specific individuals (as they are non-ergodic) 

• It's a kind of individualism but not related to a real individual 

Question 2: Issues with the application of the biopsychosocial approach to clinical practice

Question 3: What is process-based therapy?

What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed? 

Process based therapy approach: 

• What creates the problem for the individual 

• What historical factors may have contributed 

• What are the factors that maintain the problem 

• Create a network of nodes of possible factors [network functional analysis] 

• What strategies can we use to perturbate this complex system? How can we introduce healthy variation or retention?” What treatment kernels do we have available to us to do this in the particular context?

• We are aiming to perturbate the system to turn it from maladatpive to adaptive.

• This has to be done in the right context. 

• What is the network in the process that you are targeting?

• Use data to track progress and to test hypotheses. 

• Adjust as needed.

ACT - incorporates functional contextualism - what works (functions) in a given situation or context. 

• Unique to the individual 

• Does this work in this moment? Is this moving us towards the type of life we want to have? To reduce suffering and engage in our values

Q: How does it address some of the issues with the current approach to therapy? 

Q: Does a systems based approach bastardize Evidence-Based Practice? Does it come down more to clinicians appreciating the evidence then being able to skillfully apply it to the person in front of them and their individual context? 

Q: To help me and any of the listeners understand how it is actually applied, do you have any examples we could run through? 

Q: Example of a network analysis? Eg thought of keeping back in neutral when bending. 

Q: What can we do with this information from a network analysis to create positive change of an individual ? 

Q: For listeners who want to learn more about process based therapy - what can they do / where can they go to learn more?

You can find out more about Cameron here: https://www.instagram.com/camfallerdpt/?hl=en

You can find out more about the Human Rehabilitation Framework here: https://hrfhome.com/

On this episode I spoke with Jeff Morton who is a physiotherapist Advanced Lower Limb Practitioner in the NHS in the UK and shares some great content on social media around movement science, biomechanics and complex systems theory with some cracking memes. 

You can find Jeff here: https://www.instagram.com/jmortonphysio/

We dived into a discussion about ecological dynamics, which considers the body as a complex system that interacts with its environment. 

Jeff shared some great insights including how he uses ecological dynamics in the clinic as well as some great examples of how he uses constraints to target key areas such as the quadriceps during ACL rehah. 

An outine of ecological dynamics follows:

Human movement can be viewed as the emergent result of the interaction between the athlete and its surrounding context. 

The athlete performs in a context that is shaped by three types of constraints 

1. Individual constraints 

2. Environmental constraints 

3. Task constraints 

Individual constraints 

• Height 

• Weight 

• Strength 

• Limb length 

• Fatigue 

• Anxiety 

Environmental constraints 

• Terrain 

• Light 

• Weather

• Boundaries of the field 

Task constraints 

• Goal of the task 

• Any rules such as for a sport

• Objects or rules that specify or constrain the athletes response dynamics, eg actions of other players 

Movement is not produced by an athlete in isolation, but emerges from a dynamic coupling between the athlete's characteristics, the stimulus-rich environment, and the desired actions (ie tasks). 

There is a non-linear relationship between changes in constraints and the produced movement. 

Self organized movement, perception and action are inherently coupled and cannot be studied in isolation. Expert athletes aren’t just proficient movers, they excel at perceiving information from the environment and executing actions accordingly. 

I really hope you gained as much from this episode as I did! 

Geoff. 

On this episode I had Ben Darlow to discuss the impact of what clinicians say on their patients and how we can work with patients to find solutions and make sense of their pain. 

Ben is a prolific researcher and has produced some papers that have had a huge positive impact on the way that clinicians practice, particularly how they consider the impact of their narratives on patients. You can find more of his articles here.

An outline of our podcast follow:

What are some common negative beliefs that people in pain have?

How have they developed these beliefs? 

What is the impact of these beliefs? 

• Unhelpful beliefs about LBP are thought to underlie many of the psychological factors that are associated with pain and disability. 

• Belief that the back is fragile and needs protection - associated with higher levels of pain related fear and avoidance behaviors. 

• May lead to conservative management such as taking time off work and bed rest 

Finding solutions with patients 

We discussed the opportunity to explore patient narrative and the sense they make of their pain to help them find a solution. 

Ben shared some great clinical pearls about how he applies the leanrring from his research in clinical practise. 

If you found this episode helpful, please consider sharing a 5 star review on your favourite platform so more people can find it!

You can find Ben on Twitter @BenD_NZ

Geoff

On this episode I was joined by Dr Stephanie Filbay to discuss all things ACL rupture.

Dr Stephanie Filbay is a physiotherapist, and Senior Research Fellow at Univeristy of Melbourne and is a leading researcher in knee ACL managment including emerging research on ACL healing. 

The following is an outline of our chat.

Reminder: if you enjoyed this episode please consider leaving a 5 star review so that it appears higher in the charts and therefore more people can find it and have access to up-to-date healthcare information. 

QUICK FIRE QUESTIONS 

1. Do early ACL reconstructions lead to better patient outcomes?

2. Are ACL reconstructions necessary to return to sport?

3. Do ACL reconstructions prevent further knee damage?

4. Do ACL reconstructions reduce the chances of osteoarthritis?

5. Are there currently too many ACL reconstructions performed? 

6. Can ACLs heal?

Cross bracing protocol 

• What is the cross bracing protocol including rationale for it?

• Study and results.

• Shortcomings of this study and what future research do we need?

• What are the implications of this research?

Decision making aid 

Decision making aid for patients and clinicians in light of this new research.

• What are the consequences of ACL rupture?

• What are the objectives of management - 

• Restore knee function

• Address psychological barriers 

• Prevent further injury and reduce risk of OA

• Optimise long term Quality of Life

• What management options do people who have just torn their ACL have? 

• Do outcomes differ depending on what management approach is chosen?

• Knee laxity and functional instability 

• Return to sport

• Does early surgery prevent additional meniscus and cartilage damage - what does the evidence we have say about this belief?

• Preventing further knee damage and long term OA

• Discussing management options and expectations for someone who has just torn their ACL - Steph what do you wish someone had told you when you first tore your ACL? 

• Eg all patients of 181 expected to have normal knee function after ACLR and 91% expected to return to sport - is this realistic? 

• Are there any practical steps that people can take after injury if they want to consider participating in the Cross Bracing Protocol?  

• Are there any less extreme options open for people who want to help their chances of healing but don’t want to have their knee in a brace for 12 weeks? 

You can find Steph on Twitter (@stephfilbay).

Today Oliver Crossley (Yogic Physio) and I discussed allostasis as a model to better understand and treat pain. 

Allostasis potentially helps us to better understand how apparently disparate things like psychological stress and social pressure can place a cumulative load on our bodies and ultimately combine with other stressors to produce or enhance pain, using principles more in line with a more recent understanding of pain such as neuro-immune-endocrine factors that can lead to nociception. 

Oliver included some great examples along the way to better illustrate and explain the model and also included some great tips and takeaways about how he uses allostasis to help people with persistent pain. 

Outline

What is Allostasis?

What is the Allostasis model and how can it help us to explain or understand pain?

What are the possible mechanisms of allostatic load and pain?

• Stress can produce a paradoxical response within the immune response within the immune and nociceptive systems. 

• Acute stress - analgesia

• Chronic stress more variable and can produce stress-induced hyperalgesia

Top down of central governance of stress response

• Brain determines what a person perceives as threatening or stressful in a particular context, influenced by past experiences and beliefs.

• For example muscular strain during lifting could be perceived as threatening or non-threatening depending on the person’s expectations and previous experiences. 

• If person has negative beliefs - your inhibitory responses may be lost and you experience a stress response in the absence of tissue trauma. 

Multiple dimensions possibly contributing to, and interacting in pain presentations:

• Central and peripheral nociceptive processes

• Movement

• Psychology 

• Social 

• Genetic + Epigenetic factors 

• Health + lifestyle

Oliver Crossley 

https://www.yogicphysio.com/

Exercise within. biopsychosocial approach.

On this episode I sat down with Dr Mitch Gibbs to discuss the role of exericse in a biopsychosocial model. 

We had some nuanced discussions about what exercise does and doesn't do. Mitch provided some great tips for listeners who are in pain as well as healthcare practitioners. 

Dr Mitch has authored some really interesting research and it an incredibly clear communicator. It was a real pleasure to sit down and chat to him about this fascinating topic. 

Biomedical v biopsychosocial approach

We went through what a biopsychosocial approach is and contrasted it with the more reductionist, biomedical approach or model which has been the foundation for most of the research that has been conducted in this area. 

Shortcomings of the biomedical approach to exercise

Mitch then outlined what exercise look like under a biomedical v biopsychosocial approach. He went through some examples of how the biomedical model has informed research and what the outcomes of this research have been. 

Applying an individual approach to interventions

How to apply this research be applied. Rather than there being an opitimal intervention for back pain, instead can we explore what the best form of exercise or best approach is for the person in front of you.

Social media

We finished with some tips on how to navigate social media including how to identify whether your favourite influencers is viewing exercise from a biomedical lense.

If you enjoyed this episode PLEASE consider leaving a 5 star review so that more people can help find the podcast and help us all spread more evidence informed information. 

Geoff.