![[Physio Explained] Rehabilitation of hip related pain in circus athletes with Dr Charlotte Ganderton](https://cdn-images-3.listennotes.com/podcasts/physio-network/physio-explained-tIKv2fPGO4x-oZnCU8OQLpA.1400x1400.jpg "[Physio Explained] Rehabilitation of hip related pain in circus athletes with Dr Charlotte Ganderton")
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Should we progress hip rehabilitation based on time or based on what the person can or can't do?
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And what role does posture really play in hip-related pain?
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And when we focus on biomechanics, what other important contributors to pain might we be missing?
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Today we cover all of this and more.
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To do this, we are joined by Dr.
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Charlotte Ganderton.
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Charlotte has a PhD in hip pain and is a physiotherapist, senior lecturer and clinical researcher at La Trobe University with extensive experience across the lead sport and the performing arts.
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She currently works with Tennis Australia, Ice Hockey Australia, and the Australian Parrot Table Tennis, and has previously worked with Cirque de Soleil, Matilda the Musical, Six the Musical, and Elton John's Farewell Yellow Brick Road Tour.
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Charlotte has published more than 50 scientific papers with her research focusing on hip pain, including femoracetabular impingement, hip dysplasia and gluteal tendinopathy, as well as shoulder instability.
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Today we'll be discussing her recent research investigating exercise rehab for full-time circus arts performers experiencing hip-related pain.
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You're going to love today's episode.
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I'm Sarah Yule, and this is Physio Explained.
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Charlotte, thank you so much for joining us on today's podcast and welcome.
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Thank you very much.
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I'm looking forward to it.
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I'd love to start with the paper that prompted part of today's conversation.
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You've published a study looking at exercise rehab to improve hip-related pain and quality of life in full-time student circus arts performers.
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Before we get into today's talking points, can you just set the scene for us?
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Why circus performers?
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What problem were you trying to solve?
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Absolutely.
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So, in effect, the circus performer population was a bit of a sample of convenience, but also of great interest to myself, having worked in performing arts, specifically Sector Soleil and Musical Theatre.
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And we thought we might trial it in this group of individuals that have, I use a high level of function, but equally we wanted to implement a program that was not necessarily technical, but it stepped them through a step-by-step process over a 12-week period and it progressed them at the level that they were at.
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So some of them were more entry-level student circus performers, and some were at the end of their degree where they'd be looking to join a circus troupe in more of a professional capacity.
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So the idea was that we grouped together some expert clinicians in the area of hip pain, as well as looked at the evidence around what had been produced in the literature for hip-related pain.
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And we established a step-by-step protocol across four stages that included some postural education strategies and also exercises that targeted all directions of hip motion.
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And we did it in a sort of a step-by-step approach where each section of the protocol had little goals that they needed to achieve with respect to repetitions, sets, and weights and/or resistance bands before they could then move on.
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So, in terms of the number of people looking at, it were, as I said, it was a sample of convenience.
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We didn't set out to have necessarily a perfect number.
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It was a pilot trial, but we ended up with 18 females and 10 males.
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And for the most part, they did have some underlying hip dysplasia.
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So a situation where they had less bony support to their hip.
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And it's quite common in, it's a bit like self-selection, really.
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The people who do have a flexibility and the ability to move their leg towards their head tend to go into these sorts of sports like gymnastics, ballet, circus.
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So we did have a, I guess, a skewed population in the sense that they did have lots of mobility, but equally they needed to be strong through that mobility.
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And surprisingly, a lot of them lacked strength that they needed to perform their sport.
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It's a great observation, isn't it?
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That whole idea of the athlete choosing the sport or the sport choosing the athlete.
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Yeah, absolutely.
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And I think it's it makes sense.
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If a liberal kid has the ability to do the splits, then they're more likely to head towards these types of sports.
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And if they can't, they'll likely choose something else.
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As much as these mobility potentially has issues, it also is such a positive attribute to have.
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It's just we need to make sure that young individuals that that enter sport have the stability and the strength to cope with the sport demands.
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In this case, the performing arts demands, of course.
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I'd love to talk about what you've already alluded to, which is progressing rehab based on impairment rather than time.
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As you said, in this study, progression was based more on the individual impairments and what they were actually capable of doing.
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Can you talk us through that approach and why you might favor progressing rehab based on this more so than time?
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Yeah, absolutely.
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So, in terms of the way we set up the stages of the protocol, we I guess every individual got some form of a summary on the happiest place for the hip to be and usually set it up saying the hip likes to be nourished.
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It likes to be get the nutrition it needs by sitting right central in the cup.
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And some people stand in positions that don't optimize that nourishment of the hip.
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And this is particularly prevalent in circus performers or any performer.
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You can see even at the end of like a gymnastics routine when they pop their arms right up in the air and almost shump their pelvis forward for an aesthetically pleasing end.
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You're really hanging off the passive structures.
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And it's okay to do here and there, but it's not ideal for the hip to be at all, for any joint to be at its very much its end of range for a duration of time or a long duration of time.
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So it was about educating the individual that within their sport, we may not be able to necessarily control the position of their hip, but it's all of the other things that they do during the day, like sleeping, sitting, studying, those sorts of things that have an influence on then what their capacity or then what they're able to do in their sport.
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So it wasn't about trying to change their routines or their training schedule.
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We were trying to implement a program that sort of gap-filled what they needed.
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And there were times that we had to say, oh, is there a way that you could change this particular pose or position or technique?
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But we didn't fundamentally we didn't really change anything to do with their circus training.
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It was all about, okay, what do you need?
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How can we reduce their hip pain and symptoms through some postural modifications initially, and then couple that with some really targeted exercises?
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So in stage one, we focused on that postural education.
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We focused on hip extension.
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Hip extension is something that's often lost early in hip pathology.
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We see it written up in hip osteoarthritis, we see it in lateral hip pain presentations, and we know that that's the direction of movement loss comes quite early with hip pain.
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So we focused on hip extension, we focused on hip abduction and hip rotation in a really controlled manner.
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But we didn't push sort of end of range.
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We only, we only got them to do it within the range that they couldn't control, the range where there was no symptoms.
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And then we set thresholds.
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So we need these muscles to be really, I guess, on a lot of the time.
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When you stand on one leg, we need really good control of our rotators and our abductors.
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So we keep that that position, that strong position of the of the pelvis.
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So we were hoping to get them up to a higher number of reps.
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So we aim for two sets of 15 repetitions when it came to rotation and abduction.
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Same with hip extension, so just introducing a double leg bridge early on.
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And of course, we allowed them to load that.
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So some of them were too good for just a standard body weight bridge.
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So we allowed them to load that accordingly with some weights or a barbell across their pelvis.
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And then we did some abdominal work, so a power press, for example.
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Meanwhile, we were always saying, okay, during your rehab, really take note of where you're where you're standing.
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Are your hips in line with your knees and sort of the heels or the back of the feet so that they weren't hanging their pelvis forward in that real sway back position?
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So then we would allow them to progress to the next set of exercises once they'd achieved the little goals that we'd set them.
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But I think what was unique about this particular protocol that we put together was that they could progress to different stages in the movement directions.
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So just because they increased or moved to stage two of hip abduction, it didn't mean that they had to be at stage two of hip extension, for example.
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So they could progress through different, I guess, hip movements and associated stages.
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So it gave, it meant that although it was a protocol that everyone did, it was nuanced for the individual and where they were at.
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Probably something, I guess, to note is that we tended to introduce internal rotation a little bit later in the protocol and also adduction a little bit later.
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So hip internal rotation and adduction, yeah, and hip flexion was the other one we tended to bring in a little bit later.
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Why did we do that?
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It was so that we had an incremental increase in the loading of the hip rather than having sort of everything in one go.
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But also we know that often aggravators of hip pain involve flexion internal rotation and adduction.
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So we decided just to layer those on later, once they'd established their, oh, they'd got to their goals for abduction, external rotation, extension, and abdominals.
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So it was interesting actually, because we had four stages, and really that last stage was much higher level activity.
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So right through to say the Copenhagen hip adduction, shortened and long lever.
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But almost no one got to that level.
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So despite the fact they were really high-level, what we would think high-level athletes, these individuals still were not actually able to hit that point.
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And it demonstrates really that we can see these exercises being used in the literature, but application of those needs to be with significant caution because that can actually really flare up someone's hip.
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And this is evident, like this is evidence in this protocol where a lot of the individuals didn't actually get to stage four of our exercises, which tells us that this protocol could be applied to lots of different populations.
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And it doesn't necessarily have to be a high-level athlete that does this, because even the higher-level athletes need some basic exercises at times.
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Absolutely.
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I feel like I've got a few questions that have fallen out of that, but I'm curious, what were those little goals that qualified for progression?
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Were you looking at I know you said repetition tags of two sets of 15.
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And within that, are you looking at movement quality and symptom response?
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And what's called what was the qualifying factor to have them progress to the next level?
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So, in terms of, I guess, the research protocol, we looked at sets and repetitions.
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But in practice, when they were obviously they were supervised during the group exercises, and then they then practiced those in their the home environment to extra two additional times per week.
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During that time where they were observed by the physio, they needed to have really good quality movement that had no elevation in their discomfort.
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So that might mean that they spent a lot longer on it on a particular stage of the program because they may, within that same exercise, they may have had a really small range of motion initially with a really light band, say a red zero band, and then they might progress to a slightly larger range and then progress to their green band.
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So potentially they might spend weeks on that stage one exercise for rotation or whatever it is, but within that, they're having the ability to do more with less discomfort.
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We were happy for them to have some level of discomfort, but the exercise was not to change that in the sense that of worsening it.
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So if they came in at a two out of ten pain, that's okay.
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Because oftentimes performers perform with discomfort.
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So had we said no, you're not to have any pain, we wouldn't have been able to start them in the program.
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So it was really about can we deliver an exercise program that can be pragmatically inserted into a working active circus school with one session a week where they were supervised in a group environment and two sessions at home where they really had targeted exercises for their presentation?
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That's a great summary.
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Lastly, I'd love to talk around recognizing the limitations of what this project was designed to investigate.
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And it obviously had a strong focus on biomechanics and physical impairments, as we've discussed, but we also know someone's pain experience extends beyond that.
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What was this project able to tell us?
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And then what wasn't it designed to answer?
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What hasn't it told us?
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It's a really good point because we know that pain is far more than tissue damage.
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We know that there's such a significant need for psychosocial contributors to be addressed in paying presentations.
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And oftentimes in, and I wouldn't like to blanket say this, but in the performing arts, there is a pressure on aesthetics and participating.
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And oftentimes in the circumstances, they might have 10 shows a week.
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So it's just go, go, go without stepping back off the accelerator pedal.
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You're right.
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This study did not have a target or have an intervention to target psychosocial contributors to their paying presentation.
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It was very much looking at their anatomy from a radiology perspective and determining if they had the presence of sort of a CAM morphology in more of an FAI presentation or undercoverage with dysplasia or, in fact, a combined picture of the both.
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I would love to investigate the some sort of intervention for the psychosocial aspects.
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But I think what was really interesting about this study is where we did see a statistically significant improvement was actually on the Hagos quality of life subscale.
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And for me, that was so critical because it told us that whatever we did, altering their pain, altering their feeling of disability, we changed their quality of life.
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And I guess as a clinician, an active clinician, as well as a researcher, my go-to is also always what impact does this symptom that a patient's presenting with have on their quality of life?
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It's that whole discussion around surgery.
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I've got terrible osteoarthritis.
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Should I have surgery?
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Should I not?
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Well, what impact has this hip or is this hip having on their quality of life?
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Are they able to contribute to the community?
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Are they able to participate in their social settings?
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And if that's what's limiting them, then go and do something about it.
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And I think for these people, they have this perceived really high level of function.
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So it's almost a bit distorted what their requirements are, because if they presented in a standard physio clinic along with old Betty who loves doing playing bowls once a week or something, I don't mean to stereotype there, but you obviously see a huge spectrum of different patients, right?
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Just basic ADLs is not good enough for someone who wants to swing with one leg on a trapeze.
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So I think the fact that we had a change in their quality of life for people who have such a large requirement of their sport and really employment in the end, it did show a change.
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We also had significant changes between baseline and three months of the eye hot, but we didn't see a lot of change on the other subscales of significance.
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However, this trended in a positive direction in terms of reducing pain and disability, but in terms of the fact it was a pilot, perhaps limited the effectiveness.
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Fabulous summary.
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I think one of the key messages from our chat today that I'm hearing as well is really to not make assumptions about someone's rehab needs based on a timeline or even how functioning that person or athlete appears to be.
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Instead, assess the impairments in front of you and progress the rehab according to what the individual actually needs and can do.
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Really appreciate you coming on to the podcast today and giving a fantastic summary of that study as well.
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Yeah, you're absolutely welcome.
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And I think what's nice for listeners is this particular study also has lots of supplementary files and does provide a really detailed view of all of the exercises we implemented.
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And I think that's nice because it means that in other populations or hip pain presentations, people can go back to those stage one exercises and see is this applicable for the patient in front of me?
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They're not a circus performer, but they do have hip-related pain and they do have deficits in abductor strength or rotator strength.
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This is what I could try to implement something that doesn't elevate their discomfort levels and gives them a little bit more function back.
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That's a wonderful resource.
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Thank you so much, Charlotte.
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Much appreciated.
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You're welcome.
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Should we progress hip rehabilitation based on time or based on what the person can or can't do?
00:00:12.000 --> 00:00:15.199
And what role does posture really play in hip-related pain?
00:00:15.359 --> 00:00:21.039
And when we focus on biomechanics, what other important contributors to pain might we be missing?
00:00:21.199 --> 00:00:23.039
Today we cover all of this and more.
00:00:23.280 --> 00:00:24.879
To do this, we are joined by Dr.
00:00:24.960 --> 00:00:26.320
Charlotte Ganderton.
00:00:26.480 --> 00:00:37.359
Charlotte has a PhD in hip pain and is a physiotherapist, senior lecturer and clinical researcher at La Trobe University with extensive experience across the lead sport and the performing arts.
00:00:37.520 --> 00:00:52.320
She currently works with Tennis Australia, Ice Hockey Australia, and the Australian Parrot Table Tennis, and has previously worked with Cirque de Soleil, Matilda the Musical, Six the Musical, and Elton John's Farewell Yellow Brick Road Tour.
00:00:52.560 --> 00:01:04.879
Charlotte has published more than 50 scientific papers with her research focusing on hip pain, including femoracetabular impingement, hip dysplasia and gluteal tendinopathy, as well as shoulder instability.
00:01:05.120 --> 00:01:13.200
Today we'll be discussing her recent research investigating exercise rehab for full-time circus arts performers experiencing hip-related pain.
00:01:13.439 --> 00:01:15.120
You're going to love today's episode.
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I'm Sarah Yule, and this is Physio Explained.
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Charlotte, thank you so much for joining us on today's podcast and welcome.
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Thank you very much.
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I'm looking forward to it.
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I'd love to start with the paper that prompted part of today's conversation.
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You've published a study looking at exercise rehab to improve hip-related pain and quality of life in full-time student circus arts performers.
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Before we get into today's talking points, can you just set the scene for us?
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Why circus performers?
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What problem were you trying to solve?
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Absolutely.
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So, in effect, the circus performer population was a bit of a sample of convenience, but also of great interest to myself, having worked in performing arts, specifically Sector Soleil and Musical Theatre.
00:02:00.000 --> 00:02:20.159
And we thought we might trial it in this group of individuals that have, I use a high level of function, but equally we wanted to implement a program that was not necessarily technical, but it stepped them through a step-by-step process over a 12-week period and it progressed them at the level that they were at.
00:02:20.800 --> 00:02:32.319
So some of them were more entry-level student circus performers, and some were at the end of their degree where they'd be looking to join a circus troupe in more of a professional capacity.
00:02:32.479 --> 00:02:45.840
So the idea was that we grouped together some expert clinicians in the area of hip pain, as well as looked at the evidence around what had been produced in the literature for hip-related pain.
00:02:46.000 --> 00:02:58.240
And we established a step-by-step protocol across four stages that included some postural education strategies and also exercises that targeted all directions of hip motion.
00:02:58.400 --> 00:03:13.599
And we did it in a sort of a step-by-step approach where each section of the protocol had little goals that they needed to achieve with respect to repetitions, sets, and weights and/or resistance bands before they could then move on.
00:03:13.840 --> 00:03:20.319
So, in terms of the number of people looking at, it were, as I said, it was a sample of convenience.
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We didn't set out to have necessarily a perfect number.
00:03:23.919 --> 00:03:29.039
It was a pilot trial, but we ended up with 18 females and 10 males.
00:03:29.199 --> 00:03:34.159
And for the most part, they did have some underlying hip dysplasia.
00:03:34.319 --> 00:03:38.960
So a situation where they had less bony support to their hip.
00:03:39.120 --> 00:03:42.560
And it's quite common in, it's a bit like self-selection, really.
00:03:42.639 --> 00:03:52.479
The people who do have a flexibility and the ability to move their leg towards their head tend to go into these sorts of sports like gymnastics, ballet, circus.
00:03:52.639 --> 00:04:00.800
So we did have a, I guess, a skewed population in the sense that they did have lots of mobility, but equally they needed to be strong through that mobility.
00:04:00.960 --> 00:04:06.319
And surprisingly, a lot of them lacked strength that they needed to perform their sport.
00:04:06.639 --> 00:04:08.319
It's a great observation, isn't it?
00:04:08.479 --> 00:04:13.039
That whole idea of the athlete choosing the sport or the sport choosing the athlete.
00:04:13.280 --> 00:04:14.159
Yeah, absolutely.
00:04:14.240 --> 00:04:16.160
And I think it's it makes sense.
00:04:16.319 --> 00:04:24.160
If a liberal kid has the ability to do the splits, then they're more likely to head towards these types of sports.
00:04:24.399 --> 00:04:27.279
And if they can't, they'll likely choose something else.
00:04:27.519 --> 00:04:36.800
As much as these mobility potentially has issues, it also is such a positive attribute to have.
00:04:37.120 --> 00:04:46.399
It's just we need to make sure that young individuals that that enter sport have the stability and the strength to cope with the sport demands.
00:04:46.639 --> 00:04:49.920
In this case, the performing arts demands, of course.
00:04:50.560 --> 00:04:56.959
I'd love to talk about what you've already alluded to, which is progressing rehab based on impairment rather than time.
00:04:57.199 --> 00:05:03.839
As you said, in this study, progression was based more on the individual impairments and what they were actually capable of doing.
00:05:04.160 --> 00:05:11.519
Can you talk us through that approach and why you might favor progressing rehab based on this more so than time?
00:05:11.920 --> 00:05:12.879
Yeah, absolutely.
00:05:13.120 --> 00:05:30.800
So, in terms of the way we set up the stages of the protocol, we I guess every individual got some form of a summary on the happiest place for the hip to be and usually set it up saying the hip likes to be nourished.
00:05:30.959 --> 00:05:35.759
It likes to be get the nutrition it needs by sitting right central in the cup.
00:05:36.000 --> 00:05:41.600
And some people stand in positions that don't optimize that nourishment of the hip.
00:05:41.759 --> 00:05:47.040
And this is particularly prevalent in circus performers or any performer.
00:05:47.199 --> 00:05:58.319
You can see even at the end of like a gymnastics routine when they pop their arms right up in the air and almost shump their pelvis forward for an aesthetically pleasing end.
00:05:58.639 --> 00:06:02.639
You're really hanging off the passive structures.
00:06:02.879 --> 00:06:15.600
And it's okay to do here and there, but it's not ideal for the hip to be at all, for any joint to be at its very much its end of range for a duration of time or a long duration of time.
00:06:15.920 --> 00:06:37.439
So it was about educating the individual that within their sport, we may not be able to necessarily control the position of their hip, but it's all of the other things that they do during the day, like sleeping, sitting, studying, those sorts of things that have an influence on then what their capacity or then what they're able to do in their sport.
00:06:37.759 --> 00:06:43.680
So it wasn't about trying to change their routines or their training schedule.
00:06:43.839 --> 00:06:49.519
We were trying to implement a program that sort of gap-filled what they needed.
00:06:49.680 --> 00:06:57.680
And there were times that we had to say, oh, is there a way that you could change this particular pose or position or technique?
00:06:58.000 --> 00:07:03.360
But we didn't fundamentally we didn't really change anything to do with their circus training.
00:07:03.519 --> 00:07:06.399
It was all about, okay, what do you need?
00:07:06.560 --> 00:07:16.879
How can we reduce their hip pain and symptoms through some postural modifications initially, and then couple that with some really targeted exercises?
00:07:17.199 --> 00:07:21.759
So in stage one, we focused on that postural education.
00:07:21.920 --> 00:07:24.079
We focused on hip extension.
00:07:24.240 --> 00:07:29.839
Hip extension is something that's often lost early in hip pathology.
00:07:30.000 --> 00:07:40.639
We see it written up in hip osteoarthritis, we see it in lateral hip pain presentations, and we know that that's the direction of movement loss comes quite early with hip pain.
00:07:40.800 --> 00:07:48.959
So we focused on hip extension, we focused on hip abduction and hip rotation in a really controlled manner.
00:07:49.120 --> 00:07:51.439
But we didn't push sort of end of range.
00:07:51.600 --> 00:07:57.040
We only, we only got them to do it within the range that they couldn't control, the range where there was no symptoms.
00:07:57.199 --> 00:07:58.800
And then we set thresholds.
00:07:59.040 --> 00:08:04.639
So we need these muscles to be really, I guess, on a lot of the time.
00:08:04.800 --> 00:08:09.279
When you stand on one leg, we need really good control of our rotators and our abductors.
00:08:09.360 --> 00:08:13.600
So we keep that that position, that strong position of the of the pelvis.
00:08:14.160 --> 00:08:18.639
So we were hoping to get them up to a higher number of reps.
00:08:18.720 --> 00:08:24.240
So we aim for two sets of 15 repetitions when it came to rotation and abduction.
00:08:24.399 --> 00:08:28.720
Same with hip extension, so just introducing a double leg bridge early on.
00:08:28.879 --> 00:08:31.439
And of course, we allowed them to load that.
00:08:31.600 --> 00:08:35.120
So some of them were too good for just a standard body weight bridge.
00:08:35.200 --> 00:08:41.120
So we allowed them to load that accordingly with some weights or a barbell across their pelvis.
00:08:41.360 --> 00:08:45.679
And then we did some abdominal work, so a power press, for example.
00:08:45.919 --> 00:08:52.320
Meanwhile, we were always saying, okay, during your rehab, really take note of where you're where you're standing.
00:08:52.480 --> 00:09:01.759
Are your hips in line with your knees and sort of the heels or the back of the feet so that they weren't hanging their pelvis forward in that real sway back position?
00:09:02.000 --> 00:09:09.039
So then we would allow them to progress to the next set of exercises once they'd achieved the little goals that we'd set them.
00:09:09.200 --> 00:09:19.279
But I think what was unique about this particular protocol that we put together was that they could progress to different stages in the movement directions.
00:09:19.440 --> 00:09:29.200
So just because they increased or moved to stage two of hip abduction, it didn't mean that they had to be at stage two of hip extension, for example.
00:09:29.440 --> 00:09:37.360
So they could progress through different, I guess, hip movements and associated stages.
00:09:37.519 --> 00:09:45.200
So it gave, it meant that although it was a protocol that everyone did, it was nuanced for the individual and where they were at.
00:09:45.440 --> 00:09:56.720
Probably something, I guess, to note is that we tended to introduce internal rotation a little bit later in the protocol and also adduction a little bit later.
00:09:56.960 --> 00:10:03.840
So hip internal rotation and adduction, yeah, and hip flexion was the other one we tended to bring in a little bit later.
00:10:04.080 --> 00:10:05.360
Why did we do that?
00:10:05.600 --> 00:10:12.480
It was so that we had an incremental increase in the loading of the hip rather than having sort of everything in one go.
00:10:12.879 --> 00:10:20.399
But also we know that often aggravators of hip pain involve flexion internal rotation and adduction.
00:10:20.639 --> 00:10:34.080
So we decided just to layer those on later, once they'd established their, oh, they'd got to their goals for abduction, external rotation, extension, and abdominals.
00:10:34.399 --> 00:10:41.840
So it was interesting actually, because we had four stages, and really that last stage was much higher level activity.
00:10:42.000 --> 00:10:46.799
So right through to say the Copenhagen hip adduction, shortened and long lever.
00:10:47.279 --> 00:10:49.600
But almost no one got to that level.
00:10:49.840 --> 00:10:59.200
So despite the fact they were really high-level, what we would think high-level athletes, these individuals still were not actually able to hit that point.
00:10:59.360 --> 00:11:11.759
And it demonstrates really that we can see these exercises being used in the literature, but application of those needs to be with significant caution because that can actually really flare up someone's hip.
00:11:11.919 --> 00:11:27.120
And this is evident, like this is evidence in this protocol where a lot of the individuals didn't actually get to stage four of our exercises, which tells us that this protocol could be applied to lots of different populations.
00:11:27.200 --> 00:11:35.039
And it doesn't necessarily have to be a high-level athlete that does this, because even the higher-level athletes need some basic exercises at times.
00:11:35.440 --> 00:11:38.240
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00:11:38.480 --> 00:11:41.440
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00:11:56.960 --> 00:11:57.519
Absolutely.
00:11:57.679 --> 00:12:05.039
I feel like I've got a few questions that have fallen out of that, but I'm curious, what were those little goals that qualified for progression?
00:12:05.200 --> 00:12:10.000
Were you looking at I know you said repetition tags of two sets of 15.
00:12:10.320 --> 00:12:14.000
And within that, are you looking at movement quality and symptom response?
00:12:14.159 --> 00:12:19.120
And what's called what was the qualifying factor to have them progress to the next level?
00:12:19.440 --> 00:12:25.039
So, in terms of, I guess, the research protocol, we looked at sets and repetitions.
00:12:25.200 --> 00:12:36.320
But in practice, when they were obviously they were supervised during the group exercises, and then they then practiced those in their the home environment to extra two additional times per week.
00:12:36.559 --> 00:12:45.360
During that time where they were observed by the physio, they needed to have really good quality movement that had no elevation in their discomfort.
00:12:45.840 --> 00:13:08.000
So that might mean that they spent a lot longer on it on a particular stage of the program because they may, within that same exercise, they may have had a really small range of motion initially with a really light band, say a red zero band, and then they might progress to a slightly larger range and then progress to their green band.
00:13:08.159 --> 00:13:22.159
So potentially they might spend weeks on that stage one exercise for rotation or whatever it is, but within that, they're having the ability to do more with less discomfort.
00:13:22.399 --> 00:13:31.200
We were happy for them to have some level of discomfort, but the exercise was not to change that in the sense that of worsening it.
00:13:31.360 --> 00:13:34.720
So if they came in at a two out of ten pain, that's okay.
00:13:34.960 --> 00:13:38.639
Because oftentimes performers perform with discomfort.
00:13:38.799 --> 00:13:44.480
So had we said no, you're not to have any pain, we wouldn't have been able to start them in the program.
00:13:44.720 --> 00:14:06.240
So it was really about can we deliver an exercise program that can be pragmatically inserted into a working active circus school with one session a week where they were supervised in a group environment and two sessions at home where they really had targeted exercises for their presentation?
00:14:06.559 --> 00:14:08.080
That's a great summary.
00:14:08.399 --> 00:14:15.759
Lastly, I'd love to talk around recognizing the limitations of what this project was designed to investigate.
00:14:16.000 --> 00:14:24.559
And it obviously had a strong focus on biomechanics and physical impairments, as we've discussed, but we also know someone's pain experience extends beyond that.
00:14:25.279 --> 00:14:28.240
What was this project able to tell us?
00:14:28.320 --> 00:14:30.720
And then what wasn't it designed to answer?
00:14:30.879 --> 00:14:32.159
What hasn't it told us?
00:14:32.480 --> 00:14:38.559
It's a really good point because we know that pain is far more than tissue damage.
00:14:38.799 --> 00:14:45.919
We know that there's such a significant need for psychosocial contributors to be addressed in paying presentations.
00:14:46.080 --> 00:14:56.559
And oftentimes in, and I wouldn't like to blanket say this, but in the performing arts, there is a pressure on aesthetics and participating.
00:14:56.639 --> 00:15:00.559
And oftentimes in the circumstances, they might have 10 shows a week.
00:15:00.720 --> 00:15:06.080
So it's just go, go, go without stepping back off the accelerator pedal.
00:15:06.320 --> 00:15:06.879
You're right.
00:15:07.039 --> 00:15:15.279
This study did not have a target or have an intervention to target psychosocial contributors to their paying presentation.
00:15:15.440 --> 00:15:32.159
It was very much looking at their anatomy from a radiology perspective and determining if they had the presence of sort of a CAM morphology in more of an FAI presentation or undercoverage with dysplasia or, in fact, a combined picture of the both.
00:15:32.320 --> 00:15:37.759
I would love to investigate the some sort of intervention for the psychosocial aspects.
00:15:38.000 --> 00:15:48.159
But I think what was really interesting about this study is where we did see a statistically significant improvement was actually on the Hagos quality of life subscale.
00:15:48.320 --> 00:15:59.840
And for me, that was so critical because it told us that whatever we did, altering their pain, altering their feeling of disability, we changed their quality of life.
00:16:00.000 --> 00:16:11.840
And I guess as a clinician, an active clinician, as well as a researcher, my go-to is also always what impact does this symptom that a patient's presenting with have on their quality of life?
00:16:12.000 --> 00:16:14.159
It's that whole discussion around surgery.
00:16:14.639 --> 00:16:16.320
I've got terrible osteoarthritis.
00:16:16.399 --> 00:16:17.120
Should I have surgery?
00:16:17.279 --> 00:16:17.759
Should I not?
00:16:17.919 --> 00:16:22.720
Well, what impact has this hip or is this hip having on their quality of life?
00:16:22.960 --> 00:16:25.600
Are they able to contribute to the community?
00:16:25.759 --> 00:16:29.039
Are they able to participate in their social settings?
00:16:29.279 --> 00:16:33.440
And if that's what's limiting them, then go and do something about it.
00:16:33.600 --> 00:16:38.480
And I think for these people, they have this perceived really high level of function.
00:16:38.720 --> 00:16:57.200
So it's almost a bit distorted what their requirements are, because if they presented in a standard physio clinic along with old Betty who loves doing playing bowls once a week or something, I don't mean to stereotype there, but you obviously see a huge spectrum of different patients, right?
00:16:57.440 --> 00:17:03.919
Just basic ADLs is not good enough for someone who wants to swing with one leg on a trapeze.
00:17:04.079 --> 00:17:17.119
So I think the fact that we had a change in their quality of life for people who have such a large requirement of their sport and really employment in the end, it did show a change.
00:17:17.359 --> 00:17:26.880
We also had significant changes between baseline and three months of the eye hot, but we didn't see a lot of change on the other subscales of significance.
00:17:27.119 --> 00:17:38.880
However, this trended in a positive direction in terms of reducing pain and disability, but in terms of the fact it was a pilot, perhaps limited the effectiveness.
00:17:39.279 --> 00:17:40.319
Fabulous summary.
00:17:40.480 --> 00:17:51.920
I think one of the key messages from our chat today that I'm hearing as well is really to not make assumptions about someone's rehab needs based on a timeline or even how functioning that person or athlete appears to be.
00:17:52.079 --> 00:17:59.279
Instead, assess the impairments in front of you and progress the rehab according to what the individual actually needs and can do.
00:17:59.519 --> 00:18:06.079
Really appreciate you coming on to the podcast today and giving a fantastic summary of that study as well.
00:18:06.319 --> 00:18:07.759
Yeah, you're absolutely welcome.
00:18:07.920 --> 00:18:21.359
And I think what's nice for listeners is this particular study also has lots of supplementary files and does provide a really detailed view of all of the exercises we implemented.
00:18:21.519 --> 00:18:32.240
And I think that's nice because it means that in other populations or hip pain presentations, people can go back to those stage one exercises and see is this applicable for the patient in front of me?
00:18:32.400 --> 00:18:39.680
They're not a circus performer, but they do have hip-related pain and they do have deficits in abductor strength or rotator strength.
00:18:39.759 --> 00:18:47.839
This is what I could try to implement something that doesn't elevate their discomfort levels and gives them a little bit more function back.
00:18:48.079 --> 00:18:49.680
That's a wonderful resource.
00:18:49.920 --> 00:18:51.440
Thank you so much, Charlotte.
00:18:51.519 --> 00:18:52.640
Much appreciated.
00:18:52.799 --> 00:18:54.160
You're welcome.
