#19 Mastering Clinical Decision-Making: Insights with The Rehab Podiatrist, Alex Murray

On this episode I was a guest on Noah Mandel's Forward Physio Podcast (Noah's podcast) This episode runs through the whole Cross Bracing Protocol and acts a stand alone resource to help you understand what is involved when you brace your knee to try to heal your ACL.  If you have torn your ACL and want to book an appointment, click here: Online bookings Thank you for listening and if you enjoyed it please consider leaving a 5-star review. Geoff 

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/  

Be Strong Physio Podcast Show Notes 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.

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: Its weak theoretical basis Inherent biomedicalism  Mono interventionism  Practitioner-centredness 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  Individual constraints  Environmental constraints  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  Do early ACL reconstructions lead to better patient outcomes? Are ACL reconstructions necessary to return to sport? Do ACL reconstructions prevent further knee damage? Do ACL reconstructions reduce the chances of osteoarthritis? Are there currently too many ACL reconstructions performed?  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/