Transforming Knee Osteoarthritis Treatment Through Implicit Belief Analysis

[00:01:34] Brian Pulling: So why would that be? Why are people telling us that physical activity is good for them and yet not doing enough physical activity? And so we thought maybe it's not what they're telling us Explicitly, maybe it's what they're believing

[00:01:49] Mark Kargela: welcome back to the modern pain podcast you just heard from this week's guest, Brian polling sharing the big questions that inspired the study we're diving into today. This research takes a closer look at why so many people with knee osteoarthritis avoid physical activity. Even though we know it's one of the best ways to manage their pain and improve how they move and feel.

This research looked at something called implicit threat associations.

These are subconscious beliefs, the ones people aren't even aware they have. That can make them associate movement with danger. The researchers used a tool called the implicit association test or IAT to dig into these hidden attitudes. They studied over 550 participants, including people with painful knee osteoarthritis. People with other lower limb pain and pain-free controls. What they found was really interesting.

People with knee osteoarthritis had much stronger subconscious [00:02:34] associations between movement and danger compared to the other groups. And here's the twist, these hidden beliefs. Didn't always line up with what people said when asked about their pain activity or fears and self-reported questionnaires. This mismatch highlights a big gap between what patients consciously believe and what might be driving their behaviors under the surface.

I sat down this week with the lead author, Brian and discussed his unique story that had him drop out of his physical therapy training here in the states and move his life across the world to study pain.

So on my lunch break one day, someone put a copy of Lorimer Mosley and David Butler's Explain Pain in my hands, and I read it voraciously. I just flipped through it as quick as I could to try to inhale all of this new information that I'd never seen. I'd never heard of pain science education or really pain science in the first place.

And a lot of what I was reading Sometimes directly contradicted what I learned in school,

Society is full of information that feeds conceptualizations, that physical activity is not safe for knee [00:03:34] osteoarthritis.

[00:03:34] Brian Pulling: We've got these sort of complex conceptualizations all throughout the community, even among people without knee pain, that doing too much activity or doing the wrong kind of activity is harmful for knee OA

[00:03:48] Mark Kargela: Another big problem out there is that clinicians managing the pain with patients often hold these very implicit and explicit associations.

[00:03:55] Brian Pulling: I do think that there probably are too many people practicing who also hold these beliefs that are not necessarily aligned with contemporary evidence for how we think knee OA works.

[00:04:08] Mark Kargela: Brian. And I spoke about ways we can engage patients in conversations around their beliefs to help them shift them in a more adaptive direction.

[00:04:14] Brian Pulling: Based on your score to this test, it seems like implicitly, deep down, you have this knee jerk reaction to associating physical activity with danger. Why do you think that might be? Let's talk about that, and let's see if we can investigate that further, and that might help someone who's not gonna have a eureka moment, [00:04:34] they're not gonna have a lightbulb moment where everything just clicks all at once

[00:04:37] Mark Kargela: We'll unpack what all this means for us clinicians. Y addressing these hidden attitudes might be key in helping our patients move more and how this research could change the way we approach chronic pain in practice. Stick around. This is an episode you don't want to miss. Now onto the episode.

[00:04:52] Announcer: This is the Modern Pain Podcast with Mark Kargela.

[00:04:57] Mark Kargela: Brian, first off, thank you for joining us in the podcast. And before we went on, Brian told an interesting story. I had no idea. I looked at Brian's LinkedIn and I'm like, is Brian a physio or is Brian not a physio? I'm like, I know he's a high level researcher. Obviously he's pushing out some great research that we talked about, but I'd love if you could share with the audience, Brian, a little bit of your journey of how you ended up in Adelaide, Australia

[00:05:19] Brian Pulling: yeah, sure thing. Thanks for having me, Mark. It's great to be here. It's a, an interesting story. I, yeah, like you said, I originally planned to be a physio. I grew up in New York. So I went to a small liberal arts college in New York and I, [00:05:34] yeah, I was studying aging and orthopedics and I was really interested in chronic pain.

I really wanted to understand. How to help people with persistent low back pain, for example, or chronic regional pain syndrome, fibromyalgia, things like that. So I went and I was doing, I finished my undergrad, I was doing my first clinical rotation in a an orthopedic outpatient. rehab clinic, seeing a lot of people with knee pain and back pain.

And around 70 percent of our patients did really well. They responded really well to treatment. We did a lot of manual therapy, a lot of pretty straightforward orthopedic rehab, but there was still that proportion of people that just weren't really responsive to treatment. And I found that really challenging because I was still in school and I didn't really, have that expertise to know what to do for these people.

[00:06:21] Mark Kargela: So on my lunch break one day, someone put a copy of Lorimer Mosley and David Butler's Explain Pain in my hands, and I read it voraciously. I just flipped through it as quick as I could to try to [00:06:34] inhale all of this new information that I'd never seen. I'd never heard of pain science education or really pain science in the first place.

And a lot of what I was reading Sometimes directly contradicted what I learned in school,

[00:06:49] Brian Pulling: which I found really challenging. So I started to reach out and try to learn more reading research papers and watching video lectures on YouTube. And I was realizing that there's this whole world out there about pain science that extended well beyond what we were learning about basic orthopedics.

And I found that really exciting. The path winds and one thing leads to another, and I didn't end up finishing my PT degree. I decided, what I really want to do is research this. I want to study how pain works and how it affects people and how people experience pain throughout their lives.

I was really interested in aging and aging over the lifespan and how people adapt to changes in their [00:07:34] environment. How do I actually do that? That was the real question. So I started to reach out to people and I. I thought, you know what, Lorimer Mosley is the big name in this field. He's probably getting a lot of emails on a daily basis.

He might not be so keen to reply to an email from some guy in New York. But Tasha Stanton out in Adelaide is looking for students, and she works with Lorimer, and she's done some really cool research, and I've seen her online talking about what she's done in pain and perception research, which I found really interesting.

And so she might be able to respond to an email and just, answer some questions, point me in the direction of some cool research papers, that sort of thing. So I remember sending her a paper, sending her an email and asking for some ideas. And she got back to me and said if you really want to study this, if you really want to learn about this, you should just come here and do a master's degree.

And I was right at that point in my life where I was naive enough and adventurous enough to hop on a plane and move my whole life to the other side of the world. [00:08:34] And that was about six or seven years ago. And I've been here ever since. So I did my master's degree here in Adelaide. And then I went back to the States briefly to do some work at Boston Children's Hospital and Harvard Medical School, which was really interesting.

And then Got back on the plane right before COVID took off and started my PhD. So I'm now Dr. Brian Pulling. I finished my PhD last year and I'm working as an epidemiologist at the South Australian Health and Medical Research Institute studying aging and using big data to understand how people experience the aged care sector.

[00:09:08] Mark Kargela: Just an interesting story of how it seems like I talked to more and more people and they have that like existential crisis or that aha moment, especially when it comes to pain, when you get some of this literature, Louis Gifford stuff was a big one for me. Definitely Lorimer and David's book explained pain was a big kind of change moment for a lot of clinicians out there.

So it's always fascinating. I don't know if how many of them have moved across the world like you did for it, but I mean, kudos to you and kudos to you for crossing the finish [00:09:34] line on a PhD. Yeah, no, that's. an immense amount of work and a massive undertaking. So congrats for that. I'd love to talk because a lot of what we're going to talk today probably is a result of a lot of the hard work you put in your PhD.

, the study were lead author on spoke to implicit threat assumptions and this development of an implicit association testing for osteoarthritis and to check the differences between, if there was some predictability of this with, and I'll let you get into the details of it, but I'd love if you could lay the groundwork of what inspired this look at an implicit associations and implicit threat associations in this work.

[00:10:09] Brian Pulling: Tasha Stanton, my mentor, has been doing a lot of work on knee osteoarthritis and trying to help people recover from knee osteoarthritis or get back to what they enjoy doing. And what we know Probably more than anything else for people with painful knee osteoarthritis is the thing that really helps the most people is physical activity.

Everybody stands to benefit from doing physical activity when they have knee [00:10:34] pain, and that is a complicated belief because a lot of people have a strong belief that physical activity is damaging to the knee. Because of these narratives around wear and tear and bone on bone ideas about how And and so we've got these sort of complex conceptualizations all throughout the community, even among people without knee pain, that doing too much activity or doing the wrong kind of activity is harmful for knee OA.

And that's really complicated, and there's a lot to that. But the main thing is that. In the clinic particularly among physios, their goal is to get people moving. And people with knee OA get them moving through walking programs and strengthening programs and things like that. And there is some fear and avoidance and concern among patients and people with with painful knee OA to engage with physical activity.

So the question then is how do we [00:11:34] provide the right information, the necessary information to help people feel confident and safe to move so that they can benefit from this this tool? evidence based and guideline recommended treatment. And so we, we turn to things like pain science education and we teach people about why it's okay to move, why it's good for them to move and how it'll help their pain and their their knee recovery in the longterm. And that works for some people. And that's really great to know. But it doesn't work for everybody. And I will say that not everybody has these explicit beliefs that that physical activity is bad for their knee or harmful for their knee, but it is fairly common. So we thought perhaps we were coming up against people who would tell us straight up.

Exercise is the best thing for me. Exercise is great for money. Use it or lose it. Have to move while I can and it will help me either put off surgery or maybe even avoid surgery. together, which is great to hear. And yet, [00:12:34] even among those people, the majority of people with knee OA aren't meeting guideline recommendations for the amount of physical activity that they should be doing over the course of a week, for example.

So why would that be? Why are people telling us that physical activity is good for them and yet not doing enough physical activity? And so we thought maybe it's not what they're telling us Explicitly, maybe it's what they're believing implicitly, non consciously. And so then we turn to the implicit association literature, and we look at what research has been done in the past to look at what people believe deep down in their belly.

And one way of doing that is through implicit association testing. And this has been done for many years. It's a relatively old field of study. To evaluate. Associations that aren't explicitly reported to evaluate what people believe. But don't stay. And so this comes out, when people [00:13:34] are being asked questions about really sensitive topics.

So most of the research has nothing to do with health or physical activity or anything like that. It comes from areas of psychology that look at things like racism and ageism and political beliefs or stereotypes around gender and sex. And the, there are the topics that are really hot button issues that people.

might say what they think the researcher wants to hear. And we call that a response bias. Now, when you're in the clinic, and particularly when you're in a research based clinic, when you're working with people who have volunteered for a research study that they hope will decrease their pain in the long run, there is a risk of response bias.

And by response bias, I mean an a non conscious desire, I guess you could say. to tell the researcher what you think they want to hear. Now, it's not that they're lying. It's not that they're they're faking anything like that. It's when people go into the [00:14:34] clinic and they want to get better and they want their clinician.

to be successful because that means that their treatment is working and that means that their pain will decrease. So it's intuitive. It makes sense. And it makes surveys very difficult because a survey lends itself to a response bias. You give someone a survey where they're ranking questions from, Strongly agree to strongly disagree or zero to 10 scales, things like that.

And they're want, they're going to want implicitly to give scores that improve over time throughout the course of the treatment or throughout the course of the research study. So we turn to the implicit association test, and they're pretty popular and common. You might have done one. I first took one in psychology 101 at uni mostly for fun, because they're kind of interesting.

And essentially, they're a categorization task. So if you imagine you've got your keyboard, you're sitting in front of the computer, and on one side of the screen is a word and on the other side is an opposite [00:15:34] word. So for our study, it was safe on one side and danger on the other. And you've got you put your hands on the keyboard, and basically you're using opposite keys to assign an image or a word in the center of the screen to one of those two categories.

So you look at a photo and you say, is that photo safe or is that photo dangerous? Or you might even go more basic than that and say, is that photo active, an activity or rest? So no activity. And the goal is to assign this, these images or words as quickly as possible. And the idea is, if you're doing this really fast, and we're talking like milliseconds, blink of an eye really focusing on knee jerk reactions, if you'll pardon the pun, the idea is that you're bypassing conscious deliberation over what you think the right answer would be.

So if you're looking at an image of a knee in a mid squat and you want to give the [00:16:34] right answer to your physio who's doing a physical activity study about the safety of physical activity, then you might be more inclined to say, Oh, that image, if I think about it, that must be safe because the whole point of this study is that physical activity is safe. But we want to know deep down in your belly, do you really think it's safe? Or do you have an implicit bias or an implicit association between physical activity and danger? And so it's really, it's quite straightforward. That was the goal, to see if we can use this relatively straightforward and, uh, evaluated methodology in a new context. This has been done before for back pain and lifting. By JP Caneiro one of my collaborators on this project, he developed an IAT and implicit association test to see if people thought bending, like doing deadlifts and, or lifting boxes with a round back or a straight back was either dangerous or [00:17:34] safe. that study found, yeah, definitely people think lifting with a rounded back is dangerous. Lifting with a straight back is safer. And there is conflicting research over whether or not that's actually the case. He's found evidence with Peter O'Sullivan that actually lifting with a round back is not particularly riskier than lifting with a straight back.

So there's a whole thing about that. That's a whole other area of study. But at least in the context of knee pain, we were just interested in whether moving at all is safe or dangerous. That was our main question.

[00:18:05] Mark Kargela: Yeah. It's as you spoke to that too, and as I was reading the study, it was interesting because it. My question is always like these, like we use the WOMAC in clinic. And sometimes I just wonder like our patients, cause you'll see times where people score like very high yeah, nothing, no problems.

I'm doing great. And then you see when they're in the clinic and how they behave and do things. And it's just diametrically different where I thought this was a pretty interesting design and these types of tests. I can see like [00:18:34] a, some significant clinical utility as far as having tests that really bypass.

This response bias that you spoke to and really get into the people's deep down, maybe implicit beliefs that don't let them get into that rationalizing kind of conceptualizing way where they're trying to think of what, what does this. Clinician or researcher want me to say, or what would look best as me developing through this study or this plan of care, I'm wondering if you can speak to what you found with that testing and what you saw is compared to, because you had three groups.

You had the lower extremity that were not maybe Neo, a related lower extremity pain, a control group, and then osteoarthritic knee group, but I'm wondering if you could speak to a little bit of the results of what y'all found with that.

[00:19:16] Brian Pulling: Yeah, so whenever anybody is developing a study, particularly designing a new assessment tool that's never been used before really what we hope for as a PhD student, what we hope for is just to meet the bare minimum sample size requirements. We were trying to recruit people to do this test. In the middle [00:19:34] of COVID.

It was initially we had these grand plans. People were going to come in and do an intervention and try the test and it was going to be beautiful design. We had a really hard time recruiting people to do this test. And we were very fortunate that people were so gracious with their time and and willing to do this test because it's all online.

It's very straightforward. You can administer this type of implicit association test in about seven minutes. It's quite quick. And. I'm, I really couldn't be happier with the results just because they're so easy to interpret if you look at the, if you look at the charts and the figures in the paper like you said, we had three, three primary groups.

We had people with knee OA pain people without pain just from the community who are willing to do this test. And we did have an age matched sample. And then we had people with lower extremity pain. that was not knee pain. So that's mainly hip pain or foot and ankle pain. And what we found is that by [00:20:34] far, dramatically, people with knee pain had the implicit association that physical activity is dangerous.

That knee movement is dangerous. And so that on the other hand, rest is safe. And That was a significant difference to people without pain, even in the age matched sample and people with non knee lower extremity pain. Now, across the board, most of the people who did the test had some implicit association that Physical activity is dangerous, but the differences in the magnitude of that association were pretty dramatic, and that's really important because if you think about the way this test is scored is on a scale from negative two to positive two, where zero means no association. I don't know why. There's a whole algorithm. That's what they've settled on. I don't ask those questions. The the strongest associations were among people with. Knee pain, and they had a in the direction of positive [00:21:34] one was their association. Everybody else was much closer to zero, meaning no association or, if an association, fairly minor.

And that's really compelling information, because it means that something happens, psychologically, for people with knee pain, that leads them to this implicit association. Now, I don't know where that is. I don't know what it is that makes that occur. It may be somewhere in the process of their treatment or their diagnosis or just in the experience of having that pain that helps them develop this implicit association.

We know that in the community there is this idea that knee OA means wear and tear and bone on bone. That's what it means. People without pain have that experience and have that understanding Perhaps from media, perhaps from friends or relatives who have gone through the process of treatment for knee OA I think pretty much we all know somebody who's had a knee replacement or a hip replacement.

The magnitude of [00:22:34] that difference is important and we can see absolutely people with painful knee osteoarthritis. implicitly believe that physical activity is bad for them is dangerous. Which asks it, it brings up some really important questions about now what do we do about this? How do we treat this more effectively?

Because these are the same people who will say openly physical activity is great. Physical activity is the key ingredient to my recovery. So there's this, like you said, this dichotomy, this discrepancy in They're explicit and implicit beliefs, and types of incompatible beliefs are fundamentally what make misconceptions.

Now, that's one way to look at them as misconceptions. I think there's another, perhaps more optimistic way to look at these. Um, the core direction that all of this came from was educational psychology, if you can believe it. I do have a background in health science and that was where I [00:23:34] started all, started this journey from, but really everything that we're doing for people with pain is some level of health education.

And now some, sometimes it's very structured. It's pain science education. It's a specific intervention to help people understand the science of pain and how it works and how it affects them. There are different ways to do that, but sometimes it's very straightforward. But generally, whenever we're working in the clinic with people with pain, and that might be the research clinic, or it might be, an outpatient clinic or a hospital clinic, we're trying to teach them about their pain and their self management of their conditions so that they can.

live the type of life that they want to. And so we're asking researchers and clinicians across the board to become educators. And that's a big ask. Education is difficult. It's not formulaic and standardized. It requires a deep and complex understanding of how people learn. And so I turned to learning theory.

There's a, there's, [00:24:34] 100 plus years of research on educational psychology and how people learn across their lives. And there's a whole lot of really interesting literature on misconceptions. And how people form really strong beliefs that are fundamentally untrue and cannot be true. And the main way that these misconceptions arise is when there is a bit of it that is true.

That there's a fundamental core concept that fits well within their understan within an individual's understanding of the world. And this other piece kind of globs onto it, and the individual doesn't notice. a person doesn't realize that they have these two incompatible beliefs that need to be reconciled in order for them to comprehensively understudy understand the nature of the true concept.

So we're talking about knee pain. We're talking about knee osteoarthritis and that physical activity is safe. So they have this belief. [00:25:34] Physical activity is good for me. Physical activity helps me retain my independence and mobility and quality of life. But, knee OA is caused by wear and tear, and the state of my knee is bone on bone.

These both cannot be true. Until that person can reconcile those two incompatible beliefs, They have a synthetic conceptualization. I just think that sounds better than misconception, but it wasn't my idea that comes from the literature.

[00:26:01] Mark Kargela: Sure, and it makes me think with JP Caneiro and Peter O'Sullivan's work where they. Cause it's tough. Like I've, I find, I don't know, David Butler's got deep into learning theory and how do we, get into like educational and really looking at learning theory as we try to become educators in the clinic.

But I sometimes wonder, and I'd be curious what your thoughts are on cause in cognitive functional therapy, obviously more geared towards low back pain, but would make sense to have translations to other joints in the body. They talk about behavioral experiments, right? Where [00:26:34] you have this person with this belief in this behavior around, like, where they have to, brace their core and keep their back in lordosis.

And don't dare bend it yet. When they, when you create clinical situations where they can challenge that belief, because I just sometimes wonder, and I'd be curious what your thoughts are around the fitting of like behavioral experiments in this population, where all the pamphlets and infographics and things that we can put out, which are great.

I'm not saying they're bad. They just. Sometimes that just, it's hard to translate to the real world where as a clinician, I think we have a unique opportunity to create clinical situations where that patient with knee OA can show themselves that activities better, or you can unpack because it's always fascinating to me because I talk, we'll have knee OA patients regularly where.

They'll say, yeah, what, how does it feel when I first walk, it gets better. If you keep walking or no, when I first get up and move, it's kind of stiff and it's achy and it's pretty bothersome. But the more I walk, the better I feel. And but yet they still carry these beliefs of it's, I'm wearing my joints out, I shouldn't walk.

[00:27:34] And we'll get into some of the. where these societal and cultural narratives come from. But I'm curious what your thoughts are on, and maybe you all are looking at studying this type of thing. I can imagine that's maybe a question down the road of like, where, how do we shift these implicit beliefs in clinic where, sometimes the education and speaking to it, and of course we still educate and I tell people, all the things about arthritis and statistics and the normalcy of it.

I, my joke with patients are it's like calling degenerative joint disease is like calling my head degenerative scalp disease. Usually gets a good laugh out of the patients, but I'm wondering how you, what you, where you think like clinically shifting these implicit kind of associations may fall.

Do you think behavioral experiments have a place here?

[00:28:17] Brian Pulling: Yeah, absolutely. And cognitive functional therapy is a great example. Peter O'Sullivan's work has absolutely shown that there is a way that you can guide someone through this re conceptualization about the strength and Stability [00:28:34] or strength of their body particularly for, cases of low back pain, where people have these really strong narratives, compelling narratives, that they are frail, they are fragile And I think that's something that needs a lot of attention.

The fear avoidance model is a way of looking at how people, how these narratives are reinforced, self reinforcing where a person gives feedback to themselves about the state of their body. And and that can feed these misconceptions and these narratives. So I think there is a degree of that, which is absolutely present for some people, not all people.

We're making generalizations, but for people with. painful knee OA. I will say there are, it's really, it is, it's really difficult to guide people through these reconceptualizations or this conceptual change. It happens slowly. It happens much more slowly than we'd like. And there's a lot of expectation that it should happen quickly in a [00:29:34] certain way if we do things Nicely and and sometimes we see these sort of eureka moments, lightbulb moments in the academic or in the education literature, they call it a gestalt type shift where in a moment, in an instant, you can see it happen where a person relearns a complex topic.

In this case, they relearn very quickly that physical activity is safe or that it's safe. bending is okay. It's rare and not because the physio is doing anything wrong. Not because the patient is unable to take that on, but because that type of learning is fundamentally rare. People don't tend to learn something dramatically in an instant.

Rather this type of conceptual change is slowly, it does happen incrementally over time to the point where the individual might not even realize that it has happened. They just suddenly, not suddenly, they slowly [00:30:34] Our living life differently because all of these different factors have piled up. So I'll give you the example.

Really what happens in order for this conceptual change to occur. Three things must be true. First the learning process must be important to the learner, or in this case, the patient, the person who has these incompatible beliefs Needs to think that learning about them is going to be important and a lot of people don't a lot of people don't see the value in any type of clinical education and I'm not limiting to an intervention.

I'm not saying this is true specific to pain science and education or therapeutic neuroscience education or even cognitive functional therapy. But generally speaking, throughout the world, learning has to be important if this individual is going to reconcile incompatible beliefs. The second thing is that the source of the new information, the source of the education, has to be compelling to the learner.

So they have to have trust, and sometimes faith, [00:31:34] in their physio. Or in the source materials that you're giving them to read, in those brochures, or books, or websites, or whatever it might be. That, again, is difficult and raises the importance of developing therapeutic alliance and rapport with patients.

Fundamentally, that's why that's important, because they're not going to take on new information if they don't trust the person providing new information. This isn't shocking, but it is evidence based. And the third thing is the hardest thing. In order for a person to, To reconcile incompatible beliefs, they have to care enough, they have to be bothered enough to notice that they exist in the first place.

Stella Vosniadou, who's one of the pioneers in this area of educational psychology it's broadly, it's termed conceptual framework theory. So Stella Vosniadou says that students should be bothered by conceptual inconsistencies. And [00:32:34] that research comes from learning about maths, physics, things like that.

In the context of health, patients should be bothered when information that they've learned and their experience don't match up. If a person isn't bothered by this idea that exercise is really good for me, and my knee pain is caused by wear and tear, Then they're not going to, they're not going to learn, they're not going to have that conceptual change, they're not going to have that shift that's going to allow them to really engage in physical activity or whatever therapy to the extent that it would be useful.

Cognitive functional therapy is a great example that you raised because it gives people really compelling evidence pretty quickly that That they are safe to move because they're just put in a position where they have to move or they have to question those preconceived notions or narratives about what is safe and what isn't.

It's very difficult to replicate in randomized controlled trials [00:33:34] because it's different for everybody and those gestalt shifts are pretty rare in the community generally. The academic literature on that subject is nuanced. I know our lab has been looking at interventions that use pain science education and physical activity interventions.

Really fairly straightforward interventions, but that have been targeted to knee OA. So the content of that education isn't generally about, pain neuroscience. It's specific to the experience of people with knee pain. And I think that's really where we're seeing a shift. We're seeing a shift away from just having people memorize facts.

Memorizing facts about pain has a very limited benefit. It has some benefit, not enough to be satisfying. I mean, I think if we're talking about assessment tools, so you mentioned WOMAC, that's a great tool. There's also, there's some knowledge assessment tools. We've got the revised [00:34:34] neurophysiology of pain questionnaire.

We've got recently, Ben Darlow developed the, osteoarthritis knowledge scale these tend to be more about the facts of pain science. that's important, and we need those, as researchers in particular, we need those, because they give us important information about what a person knows about pain.

But there's a lot more to these broader conceptual frameworks than just knowledge. Beliefs matter. Experiences and expectations matter a great deal. I, frankly, I would argue that there aren't that many things in a person's life and experience that don't matter to the way that they experience pain.

So we need more. Validated assessment tools that maybe not more assessment tools, but we need assessment tools that are comprehensive, that, that evaluate the complexity of the experience of pain. The WOMAC does that as it relates to knee pain for [00:35:34] pain, stiffness, and function. Which is fairly comprehensive for an objective assessment for for a physio.

But there are a lot of other complexities once you start considering things like implicit associations. What about what a person believes that they can't express verbally? What about the things that a person is able to express verbally but that might demonstrate contradictions? So things like exercise is good for me, but my knee is caused, my knee pain is caused by wear and tear.

One of the other projects that I've been working on, and I'm very glad to say will be published hopefully in the next few months, is called the Osteoarthritis Conceptualization Scale. And it's intended to be a comprehensive assessment of the conceptual framework held by people with painful knee osteoarthritis.

So it asks questions about how people think about the importance of learning in their recovery, which is important if we're thinking [00:36:34] about conceptual change treatments. It also asks about how a person understands the physiology of their condition and the knowledge underpinning how pain works and how osteoarthritis works.

It asks questions about what they believe and expect for their future treatment. What do they think is the maximum benefit they could get if they go to physio? What do they think is the long term prognosis for their condition. Do they know that they're going to need surgery regardless of what they do?

And that's going to influence the way that they engage with their physio and the way they prioritize different treatments. So we've tried to use really innovative methods in psychometrics and statistics to model how people understand their condition comprehensively in a way that hasn't been done before.

And we're really excited to see how that will be hopefully useful to physios who really don't have a whole lot of time to go through the [00:37:34] long evaluations that we might be able to do in research, but aren't practical in a 10, 15, hopefully 30 minute session, but often not. But if I can give a physio an assessment.

And the implicit assessment takes around seven minutes. Maybe I could give another assessment at the first appointment that takes, sort of 10 minutes or less but gives a really complex picture of a person's experience that might be useful to a physio who's trying to make treatment decisions.

but doesn't really have any idea about where this patient is starting from comprehensively in the way that they think about the OA. These are big issues that don't have quick answers, I'm afraid, but hopefully we can use assessment to improve the Or at least give physios an improved understanding of how people are experiencing their condition and where they're starting from.

[00:38:27] Mark Kargela: No, I can definitely see the value in something like that, where it gives us a little bit more of a comprehensive picture of where somebody's at, [00:38:34] maybe beyond just a traditional pain, stiffness and function type measures, like you said, WOMAC being good, but doesn't really get into some of the nuts and bolts of what we spoke to already, thinking back to what you were initially speaking about of those three key concepts of things, I think learning process needs to be important to the patient.

And this is where I, as a clinician, I think. Okay. You need to get to the nuts and bolts of how, why it matters to that unique person in front of you. And that's where I think the unique therapeutic alliance you spoke to of being able to see how is this, Affecting your unique life, how's it affecting the things that matter to you?

And if we think of even from an acceptance and commitment therapy perspective, really keying in on somebody's values, what do they value? What's what really truly matters deep down inside that this is interfering with and I think cognitive functional therapy too, is, kind of aims to push that out as far as bringing that front and center when you talk through it and making sense of pain and different things.

And I can definitely see how, when you create clinical scenarios that. Hopefully where they see that what they've learned in their experience in the clinic [00:39:34] they're having with you as a clinician isn't compatible. You even ask them, does this bother you? That what's your, what do you make of that?

I mean, it's often where I have, I put patients in this like mental tug of war from time to time where you can see that's just a very much, this is everything I've been told and everything I've seen on YouTube and everything I've seen on Instagram University. And this is what I'm seeing in front of me behaving, how my body's behaving front and center.

So I think. What you said makes complete sense with what we see clinically, and I'm definitely interested to hear and we'll definitely push that study out when we, when it comes to be published sounds like here in the near future. I would love to know, obviously this measurement tools can be awesome.

What other questions do you think are lingering out there that we need to answer or kind of see? And even before I do that, cause this is one question I almost forgot about. Have we done something like these implicit assessments? I know I've seen it in different. I don't remember if it was around Neoway, to be honest with you, but I know clinicians often hold implicit, beliefs and things too that it [00:40:34] affect how they educate, affect how they, and I've worked in some pretty, Mayo Clinic, great place, loved it.

But I would see some of the, primary care physicians doing the most unguideline based behaviors when they'd get back pain, let's image it, let's inject it, let's do all these things that the guidelines say, because they're humans that freak out about their condition too, but I'm wondering what your knowledge is on clinician beliefs. Have we had studies that have looked at that as far as when it comes to knee OA?

[00:40:59] Brian Pulling: Yeah. That's a really great point. And you're right. Like we will talk about, contemporary pain science or the most recent advances in, orthopedics or rehab or pick a topic. And. Because you and I have interest in this, we're talking about studies that came out in the last few months but the reality is that doesn't translate to the university for a decade or more and that means that people who are practicing often don't have the most contemporary information available to them because it's Just they don't have the time to keep [00:41:34] appraised and and hopefully, we can continue to push that.

But, as it relates to implicit associations and attitudes around knee OA, yeah I do think that there probably are too many people practicing who also hold these beliefs that are not necessarily aligned with contemporary evidence for how we think knee OA works. And so I. I tend to put a preference, a preface when I give talks on knee OA, or even when I'm teaching my students I'll mention I'm going to talk about some things that your other lecturers might disagree with because they don't, work in this very niche area very regularly.

At conferences, it can get a little dicey because I'll talk about things that are not necessarily common knowledge yet. They're well evidence based, but they're not necessarily common. One of the common ones is that knee OA is not very well the idea that bone on bone is a reflection of knee OA is not very well evidence [00:42:34] based.

Despite being a common belief when we actually look at knee OA, and this is challenging because radiographic evidence is the main way to diagnose knee oA. If you actually look at any a knee that has away, there's never, it's never bone on bone. It's never bone on bone. There's always some cartilage left and Let's complicate things even further.

That cartilage can regenerate, even in cases of pretty severe OA. There are some, there's some really interesting but complex and not finished research showing that the gut microbiome has some really important implications for regeneration of knee tissue. I don't know why, but it's cool. And also the big one is that more than anything, knee osteoarthritis is probably largely driven by a low grade body wide inflammation, not just.

Knee inflammation. And I think that to [00:43:34] me is the most optimistic and hopeful area of study in this field because it means that there are body wide targets to reduce that inflammation and hopefully improve the outcome for the condition. But again, this is very contemporary research. This is very recent, so we don't have translational evidence for all of this about how we actually make this happen in the clinic.

In the context of belief. We know from some research in, particularly in back pain, J. P. Canero's work and some of Peter O'Sullivan's work, that physios have those similar implicit beliefs that bending with a rounded back is dangerous, bending with a straight back is comparatively safe. I suspect, but have not yet confirmed, that we will find something similar.

In people with, or in physios as it relates to knee pain. I suspect we will see a similar finding for knee pain, but that's yet to come. We'll see how we go. But regardless, I [00:44:34] do always preface when I talk about learning in this context, I rarely use the term patient because we're all learning about pain.

We're all learning about about treatment for this condition. And so the same rules apply to clinicians. So the idea that that information must be important to the learner. The source of information must be compelling to the learner. Synthetic or misconceptions must be, bothersome to the learner.

All of this applies to physios as much or even more than it applies to patients. And so I'm very fortunate as a researcher to spend all of my time questioning myself, wait, hang on, does that make sense with what I learned yesterday? Hang on, does this paper actually fit in the context of this other paper?

Do these things that I said on that podcast yesterday make sense with what I've learned today? So that kind of thing, I think we all need to be a little bit reflective [00:45:34] because that's the only way that we truly learn and we are susceptible when we're interested in a topic to a confirmation bias, a different kind of bias where we might be more keen to believe the things that we think are most aligned with what we believe.

We've been studying for a while now. And so if we're interested in pain science and we've been studying pain science for a while now, we're probably going to be more keen to agree and, focus on the things that confirm that bias over time. And knowing that, I think, gives us an edge to to try to highlight pain science.

new information as it comes out and and question those biases as they as they change over time.

[00:46:16] Mark Kargela: There are just a lot of things that humans deal with that make it hard to shift beliefs. Just like it's hard to shift beliefs with patients, clinicians face the same thing. We're all humans that fall victim to biases and confirmation bias and all the things that make it hard to shift. Cognitive [00:46:34] dissonance.

I remember when people were threatening my, comfort zone. I think we all try to group into a thought process that gives us comfort that, Hey, I know what I'm doing and I'm helping people, dang it. And don't you dare pull my security blanket out from under me. I want to get into some other things, but we did have an audience question that I want to throw at you.

It was on blue sky, one of the new apps, social media apps. If you're on there, check we'll put some links to that out. The question was in the frame within a framework of fear avoidance. Can we identify patients who have genuine mechanical reasons to be cautious slash protective of movement and those who don't then possibly could we stratify to psychological versus physiological approaches based on this distinction?

And do you think that's a possibility?

[00:47:12] Brian Pulling: That's interesting. I think we all have I think we all need to be, aware of potential physiological harm and risk of injury, for example. And I think that's one of the key thing for, so for example the fear model, cognitive functional therapy, which primarily utilizes that model tries to acknowledge people [00:47:34] and put people in.

Emotionally or attitudinally triggering positions, physical positions or circumstances when it is known by the clinician that is a safe movement for them to be in. And so that requires clinical expertise. You just have to know that based on, expected healing tissue healing times and disease progression and the state of the tissue that it's perfectly acceptable for a person to do this.

Thanks. simple activity like bending over or moderately squatting or something like that. But that the individual might not feel that way based on their experience. So one of the issues with cognitive functional therapy and the fear avoidance model is what's the limit of fear? What's the acceptable limit of of fear that individual can tolerate without going the other direction, without worsening and, furthering that cycle of fear avoidance through what is essentially catastrophizing.

And so I don't know that it's as straightforward as separating [00:48:34] out the physical and the psychological, or in this case, the implicit and the explicit. I, and again, this is an example of something that comes up a lot with my students. We teach the bio-psychosocial model and a lot of people's first instinct when talking about that model is, okay, we're gonna learn about the biological and we're gonna pay attention to that in our sessions.

We're gonna evaluate the psychological and we're gonna ask questions about that. And we're gonna consider this social and the sociological as it relates to this person's, welfare and experience. And those are not three separate domains. They were never intended to be three separate domains. They are wholly overlapping.

They are not separate things that you can stratify just because they are, separate components of the term. The reality is we are whole human beings. And while historically we've had a biomedical model of healthcare a truly contemporary biopsychosocial approach to treatment [00:49:34] cannot differentiate between those three because they are so entwined that they rely on each other to facilitate a person's experience.

The same is true in the context of how we learn and understand our own health. my work is primarily focused on conceptual framework theory, where we pull together lots of different elements of experience. And so these are things like a person's knowledge, a person's beliefs, expectations, experiences, as they all relate to that person's pain or health more generally.

You can't really separate those things out, which makes assessment a nightmare because assessment wants one thing, that questionnaire better be about one thing. Because statistically, we can't really validate a questionnaire that's about lots of different things unless we have an overarching or really underpinning theory for why those things would contribute to one thing.

And in this case, the one thing [00:50:34] is their overlapping conceptual framework, and that requires a whole different set of statistical modeling that, that hopefully you'll see in this paper soon. But historically, we've had a whole mess of assessment tools that look at one little piece of a person's experience.

So they look at the knowledge. Or the catastrophizing beliefs, or the kinesiophobia, or the expectations for exercise, or, the expectations for treatment and then we try to pile them up together to see, how a person is experiencing their health, which works okay in research because we have time to do lots of different assessments and it's completely impractical in the clinic because they just take a certain amount of time.

And so then you have to pick which are the most important to your method of treatment to your clinical practice. And that is a really difficult decision for for clinicians. I think you're right to pick something like the Womack because it's very practical. I think it's Very pragmatic for getting straight [00:51:34] into how's this person experiencing their pain?

What can or can what can they do or cannot do? But ideally, we would have a comprehensive assessment that or maybe set of assessments that would allow us to. to quickly gain a better understanding of this person's experience so that we know what to target through education, through, maybe it's counseling through acceptance and commitment therapy or cognitive behavioral therapy.

Maybe it's what do we expose them to in a cognitive functional therapy or what scientific concepts do we prioritize in a pain sciences? Education or therapeutic neuroscience education framework these are not really separate things, but they all rely on different information. And ideally, we could get a lot of that information quickly.

So that's what we tried to do. I don't think, to circle all the way back to the question, I don't think we can easily stratify these concepts, and I'm talking about that from a statistical [00:52:34] perspective. I do think that more information about, for example, the explicit and the implicit, gives clinicians useful information when they're having conversations, when they're facilitating those difficult moments where the individual is just clearly stuck.

So as you mentioned, When the person doesn't see the dissonance that they're experiencing, you might be able to say, okay, so exercise is good for you. Let's do this implicit association test. Now, based on your score, happily, the test gives you a score as soon as you've completed it, so that's pretty cool.

Based on your score to this test, it seems like implicitly, deep down, you have this knee jerk reaction to associating physical activity with danger. Why do you think that might be? Let's talk about that, and let's see if we can investigate that further, and that might help someone who's not gonna have a eureka moment, they're not gonna have a lightbulb moment where everything just clicks all at once, but it might get them [00:53:34] thinking in between this session and the next session and again, to the session after that.

[00:53:39] Mark Kargela: Yeah, no, I agree. I think again, it comes back to just creating clinical scenarios where the patient can start chiseling away. And I always find it just can I create a clinical scenario each time where they challenged their own beliefs, right? Where we put that front and center where they see their beliefs and they see their behavior, what happens in reality.

And they can kind of, and then you have that discussion. What do you make of that? So this is what you've been telling me you think would happen if we've squatted or stepped up this step or whatever it may be Yet, this is what we're seeing but I think you're right.

It's that epiphany Eureka moments, although they when they do occur They're awesome, but they're a very rare thing to see in clinic And again, I think sometimes too when you want to gather data, you know being really good to interviewer to get to the nuts and bolts of a patient, to ask questions, pull some of these questions from a PCS tool or a fear avoidance model.

Obviously, if we have time and we can do some of these, [00:54:34] assessments, but sometimes, like you said, clinically, it's not a realistic thing. thing Brian, I could talk for hours more about this stuff, but I would love to know what kind of burning questions are out there that you are all looking to answer when it comes to taking this further, as far as, this around Knee OA, or maybe you're looking into other areas of the body.

[00:54:51] Brian Pulling: Yeah, the biggest question for me is, does implicit association relate to behavior? So we know that That implicit association does not correlate well to explicit associations, which is actually a good thing, because it means that the implicit association is telling us something that existing assessment tools like the PCS, like other explicit assessment tools, don't tell us.

So it's offering new information. That's really cool. But does it tell us something about what a person's behavior is going to be? So for example, do people who, score such that activity is dangerous, do less activity? That's the key question [00:55:34] for me. If if people who are scoring that physical activity is dangerous, but then are going off and running 10 Ks.

The tool doesn't do a whole lot of good except that it's interesting and might facilitate other research or, qualitative studies. But but really we need to get at that key question of how does it relate to physical activity? And then if it does relate to physical activity, can we change the implicit association such that physical activity changes?

So that's where we're headed next.

[00:56:03] Mark Kargela: That makes complete sense, and I'm excited to see the results because, in clinic, we try to do these experiments, our N=1 of how do we shift this behavior? And I'll be interested to see what you all come up with because your group amongst others are some of the top out there that are doing some great work.

And we all appreciate the time because I do know, especially trying to get that study rolling through COVID. I've spoke to a few researchers who had to navigate a pretty immensely challenging time when COVID came and made research an extra challenging endeavor for folks. So thanks again for your time and thanks for all the amazing work you're [00:56:34] doing.

[00:56:34] Brian Pulling: Thanks so much for having me, Mark.

[00:56:36] Mark Kargela: For those of you listening, if you could subscribe, wherever you're listening, or if you're on YouTube, if you subscribe, that would be great. Leave a review. And if somebody you know is a clinician struggling to manage OA or having some questions on what's going on with some of their patients with a knee osteoarthritis, maybe share this episode with them.
 
We'll leave it there this week. We will talk to you all next week.